Nurse Practitioners Match Doctors in Study
To those patients who are convinced a doctor always knows best, Columbia University nursing school researchers would argue that isn’t necessarily so.
When it comes to the common, everyday concerns of medical care, from managing diabetes to controlling high blood pressure, nurse practitioners are as effective as physicians and as well-liked by patients, according to the first large study to compare the merits of the two approaches.
Nurse practitioners are registered nurses with additional training in diagnostics and use of drugs. They are licensed in all 50 states to operate independently of doctors and can write prescriptions, although Pennsylvania, Georgia, Michigan and Ohio require a physician to co-sign the order. There are an estimated 65,000 nurse practitioners in the United States, compared with 760,000 doctors.
The study is particularly relevant because of the renewed surge in health-care costs and the continued search by managed-care organizations to find less expensive ways to deliver health care.
Critics, however, noted that the study was very short, covering only six months, and that the population was a healthy one. No study has yet documented how the two professions compare over the long term, or while caring for a patient population with higher levels of illness or more serious problems.
A team from the Columbia University School of Nursing in New York City randomly assigned 3,397 primary-care patients to one of four clinics operated by physicians or to one operated by nurse practitioners. The subjects were primarily poor immigrants from the Dominican Republic with a mean age of 45.9 years, and the visits were typically paid for by Medicare.
The team reported in Wednesday’s Journal of the American Medical Assn. that at the end of six months, no significant differences in the patients’ health statuses were observed.
Both diabetes and asthma were equally well-controlled in the two groups, for example. Patients with hypertension treated by the nurse practitioners actually had slightly lower blood-pressure levels. The referral rate to specialists was also the same in the two groups. And, finally, those who visited nurses were as satisfied with their care as those who visited doctors.
Same Blood Pressure, Different Death Rates
High blood pressure is more dangerous to men in the United States and northern Europe than to those in Japan and southern Europe, a finding that is probably related to differences in diet and lifestyle, according to Dutch researchers.
Hypertensive men in the U.S. and northern Europe are three times as likely to die of a heart attack as Japanese or Italian men with the same blood pressures, the team reported in Thursday’s New England Journal of Medicine.
A team headed by Dr. Peggy C.W. van den Hoogen of the National Institute of Public Health and the Environment in Bilthoven coordinated researchers in seven countries who enrolled 12,761 men, ages 40 to 59, between 1958 and 1964. The men have been studied since.
Overall, they found that the risk of death rose 28% for each 10-point increase in systolic blood pressure (the first number in a blood pressure reading) or each five-point increase in the diastolic pressure (the second number).
But the number of deaths varied widely from place to place. Among men with a systolic blood pressure of 140, for example, there were about 70 heart attack deaths per 10,000 person-years in northern Europe and the U.S., compared with 20 deaths in Japan and the Mediterranean. The researchers attribute the difference, in part, to the Mediterranean diet, which included less red meat and dairy products, but more olive oil, fish, fruits and vegetables.
Ultrasound Used to Diagnose Fetal Anemia
Ultrasound can detect anemia in pre-term fetuses, such as that caused by Rh incompatibility, sparing the woman and the child the need for invasive medical procedures otherwise necessary for diagnosing the problem, according to researchers from Yale University. Such anemia occurs, for example, when the mother’s blood is Rh-negative and the fetus’ is Rh-positive, leading the fetal red blood cells to be destroyed. Screening for Rh factor is nearly universal, and a simple treatment is available if it is detected early, but many pregnant women slip through the cracks.
If the anemia becomes too severe, a blood transfusion may be required for the fetus. The severity of anemia is now assessed by a process called cordocentesis, in which a needle is inserted through the mother’s uterus and into the umbilical cord to withdraw fetal blood. An estimated 14,000 pregnant women undergo repeated cordocentesis each year in the United States, even though no more than 20% of the fetuses require a transfusion.
Dr. Giancarlo Mari and his colleagues found that, as anemia develops, the fetus’ heart pumps faster in an effort to keep oxygen flowing to the brain. Mari’s group reported in Thursday’s New England Journal of Medicine that ultrasound measurements could identify the faster blood flow resulting from the increased pumping rate. They found that the technique was 100% effective in detecting moderate or severe fetal anemia.
Snoring in Pregnancy Linked to Hypertension
Women who snore during pregnancy have an increased risk of hypertension and of giving birth to underweight babies, according to Swedish researchers. Snoring is a sign of increased upper airway resistance and is known to be associated with arterial hypertension and coronary artery disease.
Dr. Karl Franklin and his colleagues at Umea University Hospital studied more than 500 pregnant women and reported in the January issue of Chest that 24% had begun snoring or increased their snoring during pregnancy. Fourteen percent who snored had pregnancy-induced hypertension, compared with only 6% of those who didn’t snore. More than 7% of the snoring mothers gave birth to an undersized child, compared with 2.6% of the non-snorers. The paper is available at https://www.chestjournal.org.
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Reach Thomas H. Maugh II at thomas.maugh@latimes.com.
