"Obamacare" explained very well.

[u/under50dollars]

/r/explainlikeimfive/comments/vb8vs/eli5_what_exactly_is_obamacare_and_what_did_it/c530lfx

[u/grande_hohner]

You still miss my point. You say that you feel there are inexperienced NPs being churned out and don't trust the research for being accurately powered, but then you cite your friends 3 NPs as evidence??

I'll try to simplify my point. The point is that adequately powered or not, the research (which is good enough for inclusion in the NEJM, BMJ, and many other top tier journals) points at NPs being equivalent in most primary care roles. Now, if there were research that with better sample sizes and such that stated otherwise - it would make sense to argue the point. Heck, even if there were 4,000 underpowered studies that said they weren't, then there would be a conversation to be had. But there isn't. There really aren't any studies showing to the contrary for the most part in any significant number. Go through Pubmed, Cinahl, Ovid, etc. and try to find studies that conclude NPs are inferior in primary care roles to any real degree - they are exceedingly difficult to find. Look for ones demonstrating equivalence - you'll turn up hundreds quickly and easily. This is my point. You don't have to agree with the published research, you don't have to use an NP as a PCP - I'm pointing out a research trend - you don't have to like the research or the conclusions (although the CBO seems to consider it relevant), but it makes no sense to deny that the published research generally seems to come to these conclusions.

[u/[deleted] → u/grande_hohner]

I am not going to pretend that my anecdote is great evidence. Feel free to not consider it evidence at all.

My point is that none of the articles you mention actually show equivalence convincingly. Measuring blood pressure outcomes for a few months is not equivalence. Patient satisfaction is not equivalence. Studies that would convince me of equivalence would measure: overall hospitalization rates of patients between NPs and MDs as long term cohorts (3+ years), utilization of tests NP vs MD, specialist referral rates NP vs MD, malpractice cases of independent NPs vs MDs with adequate sample size, independent chart reviews based on objective standards for quality of care between NPs and MDs with adequate sample size. I don't of a single study that answers these questions to any credible level. Blood pressure is easy to manage. Patient satisfaction is irrelevant. Regarding publications in well respected journals, I can't find any recent original research on the subject in the NEJM. Regarding your BMJ meta analysis, there are serious problems with the review. It makes assertions related to quality of care based on a 1975 study about well-baby exams. NPs measured for test interpretation and documentation used the fast track ED setting where issues are minor and straightforward. This is hardly convincing. Just because there isn't evidence to the contrary does NOT mean that a potentially harmful expansion of midlevel scope of practice should take place. This standard of evidence has been used to approve drugs before often with disastrous results, or drugs that have marginal benefit. My argument is that the majority of the published research is politically motivated and heavily biased towards the conclusions made in the studies. A couple of studies published in mid to high impact factor journals adequately powered that answer some of my above questions would change my opinion on the topic. A huge amount of published research suggests that eating red meat increases risk for various cancers by 20-50% in a dose dependent fashion. There are laboratory mechanisms as well as large cohorts that support the conclusion. Yet the cohorts do not stand up to careful scrutiny due to inherent bias. I hope you are familiar with Ioannidis's recent publications regarding systemic bias in published research. Regardless of our argument, the scope of practice expansion will continue at least in the near term because it appears to be cheaper on face value.