Prescribing Patterns of Nurse Practitioners

Prescribing

Patterns of Nurse Practitioners Laurie Scudder ABSTRACT Nurse practitioners have gradually achieved broad-scale prescribing authority that is integral to the full implementation of the role. However, where they practice, under what circumstances they prescribe medications, and the specifics of their drug prescriptions have not been fully described.This special feature for The Journal for Nurse Practitioners sheds valuable light on these prescriptive practices of nurse practitioners.

Keywords: Drug samples, drugs, prescribing data. prescriptions, prescriptive practice 98

The role of the nurse practitioner (NP) in the United States continues to flourish. Anecdotal references and a variety of research studies suggest that NPs are recognized and accepted health care providers to an ever-growing percentage of the population.1 The Bureau of Health Professions, Division of Nursing, Seventh National Sample Survey of Registered Nurses conducted in 2000 and published in early 2002 reported there were 102,829 NPs in the United States practicing in a variety of primary and acute care settings.1 The need to provide prescriptions to their patients has resulted in NPs gaining some degree of prescriptive authority in 49 states; Georgia is the lone state still struggling to obtain full prescriptive authority. (Although NPs in Georgia are able to call in drug orders to pharmacists, they cannot write prescriptions.2) Although prescribing is an important component of the NP role, there is a paucity of accurate information on NP practice and prescribing. Most published data come from relatively small studies conducted in the 1980s.3-6 Later studies contributed some additional information about February 2006

prescriptive practices, particularly in specialty areas.7-15 The escalating numbers of NPs in primary care settings and the newer role for NPs in acute care areas make these older data largely irrelevant and not reflective of current prescribing patterns. The pharmaceutical industry has established mechanisms to collect detailed information about physician prescribing practice but has devoted little attention to the prescribing patterns of NPs. A whole new industry has developed devoted to pharmacy data collection and analysis with regard to the ways that clinicians prescribe. However, those data are inherently flawed. Because no provisions have been made to break out the prescribing data from the more than 100,000 NPs and more than 45,000 physician assistants (PAs), prescriptions written by these providers are ascribed to the physicians with whom they work or the providers are erroneously classified as physicians. As a result, NP and PA prescribing activities are consistently underestimated, whereas physician prescribing is artificially inflated by these invalid data collection methods. Our own observation has been that, on the few occasions that industry has attempted to collect data about NP prescribing, a small, underpowered sample has been used and the results then generalized to the entire NP universe without recognition of the vast differences in prescribing patterns necessary for NPs who practice in different settings and specialties (eg, adult vs pediatric NPs). The obfuscation of NP and PA practice information that has resulted from faulty data collection methods practiced by the insurance and pharmaceutical industries has led to these providers being labeled “shadow providers.”This status has obscured the major contributions that NPs make to health care services and their vast untapped potential in meeting the goals laid out in Healthy People 2010.The resultant misinformation conveyed to pharmaceutical company executives about who is prescribing their products has contributed to the difficulty the profession has had in convincing pharmaceutical companies to support NP organizations, gear continuing education offerings toward NPs, and use more provider-neutral language in their advertising.Thus, additional data about this prescribing group are overdue. This article summarizes data collected in 2004 and 2005 and is the most recent iteration of a longitudinal study begun in 1996; it is the longest descriptive study of NP prescribing practice of its kind. Data were collected every 2 years by using the same basic methodology and questions, although updates were made as indicated by www.npjournal.org

“The misinformation conveyed to pharmaceutical companies about who is prescribing their products has contributed to the difficulty in convincing them to support NP organizations” changes in the NP role and changes in drug availability. Participants were drawn from a convenience sample of attendees at national and regional NP conferences. In addition to questionnaires, different numbers of NPs were interviewed, and this anecdotal information illustrates many of the statistical conclusions. Because the sample represents NPs from throughout the United States, the respondents represent a cross-section of clinicians who practice in the different legal environments of many states. SAMPLE DEMOGRAPHICS This most recent sample was drawn from NPs who attended the 2005 American College of Nurse Practitioner Clinical Conference held in Palm Springs, Calif. Of the 1200 NPs who attended the conference, 224 completed a usable questionnaire. Reference comparisons are made to data from previous surveys, including the 2004 sample of 800 NPs who attended 2 regional NP conferences that year. Descriptive statistics demonstrated that more than 50% of the 2004 sample had fewer than 10 years of experience as NPs; in 2005, that percentage had 99

Table 1. Settings of Nurse Practitioner Practice PRACTICE SETTINGS

2004

2005

Inpatient

17.6%

19.5%

Outpatient clinic

50%

47.3%

Health maintenance organization

4%

2.1%

Nursing home or home health

3%

5.4%

Corrections facility

0%

0.4%

School/college health

5%

3.3%

Occupational health Other

3%

3.3%

14.7%

17.8%

Table 2. Types of Patients Seen By Nurse Practitioner Sample* TYPES OF PATIENTS

2004

2005

Geriatric

18.7%

20.7%

Adult

50.0%

60.6%

Women’s health

18.0%

15.8%

Pediatric

15.3%

8.7%

Family

38.5%

31.5%

Psychiatric

No report

7.5%

*Multiple responses possible.

Table 3. Characteristics of Nurse Practitioner Practice* Rural

17.4%

Urban

37.8%

Suburban

32.8%

International Practice

8.7%

State of Federal Facility

4.6%

Other

3.7%

*Multiple responses possible.

increased to 76%, an increase that is presumed to reflect the population of NPs that choose to attend national NP conferences. Anecdotal comments collected from previous samples suggest that many NPs who have been in practice for this length of time have developed subspecialties and often elect to attend medical conferences. In the current sample, 78.8% indicated that they are currently clinically practicing full time as an NP and that 15.4% are in part-time clinical practice. Many of these part-time practitioners are faculty, administrators, or NP researchers. Although information about educational preparation was not collected this year, 89.4% of those surveyed in 2004 held a master degree or higher, thus continuing a gradual upward trend toward preparation at this level. 100

Most NPs in this survey (62.7%) were practicing in ambulatory settings, including health maintenance organizations, school health, and private clinics or offices.A growing number of NPs describes their practice site as a hospital inpatient setting, with 19.5% of the 2005 sample practicing in these settings, an increase from 17.6% just 1 year previously.This is not unexpected because of the growing trend toward acute care roles for NPs. However, a surprising number of respondents (17.8%) selected “other” as their practice setting, clearly pointing to the flexibility of the NP role and the need to obtain more specific details about these settings in future years (Table 1). Although most NPs (60%) in this survey reported seeing adult patients, a growing number of NPs reports practicing in family practice settings. One significant change in this year’s survey was the 7.5% of respondents who reported psychiatric/mental health as their area of practice, an anticipated increase that most likely reflects the penetration of formal NP psychiatric/mental health programs and the availability of credentialing examinations in that area (Table 2). Characteristics of the NP practice sample are listed in Table 3. NP practice sites may be limited by the practice sites of physicians. Due to state mandated requirements for collaboration it may be difficult for NPs to practice in rural settings because of the dearth of physicians in those communities. Each year the survey has documented a small but increasing number of NPs practicing in independent settings. NPs are also employed in a growing number of state and federal facilities, which may place some constraints on the role (eg, maintain a strict drug formulary, not allow drug samples, or not require Drug Enforcement Administration [DEA] numbers, such as in military settings,Veterans Administration settings, or correctional facilities). NP PRODUCTIVITY So what do we know about NPs and their prescription writing behaviors? Do NPs prescribe similarly to physicians? Do they prescribe the same drugs? The same volume? Only some of these questions can be answered. Table 4 lists the average number of patient encounters per day. Consistent with findings in previous years, a very small number of respondents (3.5%) saw fewer than 5 patients per day.We speculate that these NPs are predominantly in home care or hospice practices, where the intensity of the client encounter and the need for travel restrict their ability to see larger numbers. In contrast, February 2006

Table 4. Number of Patient Encounters per Day NUMBER OF ENCOUNTERS

2004

<5

3.1%

Table 8. Percentage of Patients Requiring a Change in Therapy*

2005 3.5%

PATIENTS REQUIRING CHANGE IN THERAPY

% 2.6

6-10

16.7%

17%

0%

11-15

27.8%

26.3%

1%-25%

31.4

16-20

31.2%

25.4%

26%-50%

31.4

>20

21.1%

25%

51%-75%

24.7

>30

0%

76%-100%

9.8

2.7%

* Additional prescription or result of new diagnosis.

Table 5. Patients Seen for an Acute, Self-Limiting, or Episodic Table 9. Average Number of Prescriptions in a Typical Day

Health Problem PATIENTS SEEN FOR ACUTE HEALTH PROBLEM

2004

2005

0%

11.4%

6%

1%-25%

23.9%

30.4%

26%-50%

30.6%

29.5%

51%-75%

18.0%

17.1%

76%-100%

16.1%

17.1%

NUMBER OF PRESCRIPTIONS 1-5

Table 6. Patients Seen for a Chronic Health Problem PATIENTS SEEN FOR CHRONIC PROBLEM 0%

1996

2004

2005

0%

5.9%

4.3%

1%-25%

38.8%

34.4%

26.8%

26%-50%

43%

23.8%

30.1%

51%-75%

13.7%

18.4%

19.6%

Table 7. Patients Seen for Health Maintenance Activities* HEALTH MAINTENANCE ACTIVITY

2004

2005

0%

34.1%

36.9%

1%-25%

38.4%

42.5%

26%-50%

16.5%

14.5%

51%-75%

6.7%

3.3%

76%-100%

4.3%

2.8%

* For routine physical, Papanicolaou smear, or immunization.

27.7% of respondents in this year’s survey reported seeing more than 20 patients per day. Tables 5 through 8 present the types of patient encounters in an average NP practice, thus illustrating the wide variety of care provided by NPs and the continuing relevance of the health promotion component of their role. In 2004, more than 50% of NPs reported that 76% to 100% of their patient encounters required them to engage in patient education, counselwww.npjournal.org

0

2004

2005

3.5%

2.8%

15.7%

33.3%

6-15

35.4%

37.5%

16-25

27.6%

15.7%

>25

17.8%

10.6%

ing, and teaching.This sequence of tables demonstrates a notable, steady, albeit small, increase over the 9 years of this survey in the number of patients seen for chronic health conditions such as asthma, hypertension, and diabetes. In contrast, there has been a significant increase in the number of NPs who report that they do not see any patients for routine health maintenance (17.1% in 1996 vs 36.9.1% in 2005), most likely a result of the increased numbers of NPs practicing in acute care settings. NP PRESCRIBING ACTIVITY Asked to recall a typical day, respondents were queried about numbers of prescriptions written, over-the-counter drug recommendations made, and specific medications prescribed.The results record in very clear terms the breadth and depth of medications prescribed by NPs and underscores the importance of accurate and timely continuing education in this area. It is notable that the numbers of medications prescribed by NPs have remained remarkably consistent over the 9 years of this survey.The 2005 data do indicate some change from that stable pattern, but it cannot be determined whether this is a mere statistical blip or indicative of a true change in prescribing patterns and will require followup (Table 9). The survey did not query participants about the numbers of prescriptions written per patient. In future years, this question will be added to the survey. Previous research has documented that NPs typically see fewer patients and write fewer prescriptions than do other prescribers, with the conclusion that the clinical focus for most NPs, which emphasizes nonpharmacologic strategies, might lead them to explore other options before ordering a medication.16 101

Table 10. Number of Prescriptions Provided or Prescribed by Physician per Patient NUMBER OF PRESCRIPTIONS

%

Respondents were queried about numbers

0

34.8

1

26.1

of prescriptions written, over-the-counter

2

15.0

drug recommendations made, and

3

7.7

4

5.1

5

3.4

6

2.6

7

1.4

8

3.8

specific medications prescribed.

Data from the 2005 National Ambulatory Medical Care Survey.17

Table 11. Average Number of OTC* Products NPs Recommended in a Typical Day OTC PRODUCTS RECOMMENDED 0

% 6.1

1-25

67.0

26-50

21.7

51-75

4.2

76-100

0.9

* OTC indicates over-the-counter.

Table 12. Prescription and Nonprescription Products Recommended by Brand Name by NPs* NUMBER OF PRESCRIPTIONS RECOMMENDED 0%

NPs (%) 8.3

1%-25%

32.8

26%-50%

26.9

51%-75%

20.9

76%-100%

11.1

* NP indicates nurse practitioner.

In related data (Table 10), the National Ambulatory Medical Care Survey published in 2005 indicates that primary care and specialty physicians prescribe medications in 65.2% of all patient visits.16 In many cases, multiple prescriptions were given to the patient by the physician.Whether this is the same for NPs is not known. It is also not clear if this national study was truly limited to only physician practice or if NPs were included under the physician category, as they so often are in government-sponsored research. If NPs were excluded from this research, it is an illustration of the continuing effect of the shadow status of NPs. 102

The 2004 survey asked NPs to indicate types of medications prescribed by category.The results span the gamut of agents, reflecting the wide variety of settings in which NPs practice. It is clear that NPs prescribe legend and controlled substances and recommend over-thecounter products, often by brand name, after being asked about drugs by their patients (Tables 11 to 13). The 2005 survey presented the participant with a list of 139 specific medications taken from the top 2004 bestselling branded medications or popular generic products and asked them to identify specific drugs that they prescribed. Some notable conclusions follow: • Every agent on the list was prescribed by a segment of the respondents, although frequency (ie, number of times they actually prescribed that product) cannot be determined. • Surprisingly, there was no overall correlation between years of experience and numbers of drugs prescribed, with the novice and expert NP employing the same sized repertoire of drugs. • When some specific drugs were compared by the number of years of NP experience, there seemed to be a correlation between prescribing of that product and experience. For example, drugs linked to a specialty, such as cardiac agents or antiepileptics, appeared to be prescribed more commonly by NPs with more experience. Although a statistically valid conclusion cannot be drawn, this trend could be explained by experienced primary care providers moving into subspecialty practice over time. • The results do not allow conclusions to be drawn for use of generic versus branded products, overuse of products such as antibiotics, or prescribing patterns of novice and experienced NPs for all agents. OTHER PRESCRIBING PATTERNS As the NP role has matured, many clinicians have developed specific expertise, often creating specialty practices February 2006

Table 13. Categories of Medications Prescribed by Nurse Practitioners in 2004 MEDICATION CATEGORY

RESPONSE NUMBER

%

Anti-infective

695

89.6

Antineoplastic

45

4.8

Central nervous system

347

44.7

Diuretic, cardiac

521

67.1

Gastrointestinal

579

74.5

Hormones, including OCPs

508

65.5

NSAIDS, analgesics, antipyretics

683

88.0

Respiratory

591

76.2

Topicals

647

83.4

Vitamins, nutritionals

530

68.3

NSAIDs indicates nonsteroidal anti-inflammatory drugs; and OCPs, oral contraceptive products.

Table 14. Subspecialty Practices of 2005 Nurse Practitioner Sample SUBSPECIALTY EXPERTISE

%

Obesity

4.8

AIDS/HIV*

4.8

Mental health Smoking cessation Cardiovascular disease/hypertension

20.6 6.3 63.5

* AIDS/HIV indicates acquired immunodeficiency syndrome/human immunodeficiency virus.

within a primary care setting. For the first time in 2005, the survey queried participants about specific subspecialty expertise. In this sample, 26% noted that they had developed a specialty and indicated, from a list of choices, what that specialty was.Table 14 lists this information; however, on anecdotal feedback, NPs pointed out that the options did not cover all the specialty areas in which NPs currently practice. Most state laws allow NPs to write for legend drugs and controlled substances. Over the 9 years of this survey, there has been a consistent increase in the numbers of NPs reporting that they have their own DEA numbers. In 2005, 73% of the sample of NPs reported they had their own DEA numbers, the largest percentage ever recorded (Table 15). In 2005, 78% of NPs saw drug representatives in their offices; 22% reported that they do not see drug representatives.These numbers have been almost identical every year of the survey. However, the number of NPs distributing product samples to patients has varied. Only 30% of this survey group reported never giving product samples. www.npjournal.org

However, it must be noted that there are some practice settings that prohibit the distribution of samples (ie, military settings, schools, or prison populations;Table 16). One issue that has appeared to affect the ability of NPs to provide their patients with drug samples is the requirement mandated by the Pharmaceutical Drug Manufacturers Act of 1987 that pharmaceutical representatives document that clinicians are valid drug prescribers before providing them with samples.Although a bill originally enacted with the goal of decreasing the misuse of samples, this bill has created unforeseen problems for NPs.Although licensure information for physicians is released by state boards of medicine, many state boards of nursing have refused to distribute this information, even when such disclosure is required by law. Because NPs in many states do not have independent prescriptive authority, the pharmaceutical industry has deemed them to have delegated authority from the physician with whom they practice.This determination forces industry representatives to validate the license statuses of the NP and the physician with whom they collaborate. Anecdotally, this has led to clashes between pharmaceutical representatives and NPs who do not understand the regulatory background of this requirement and are angered by barriers that appear to be supported by industry and discriminatory. Some NPs have reported they are so upset about the process that they refuse to complete the industry-mandated forms and forego their ability to receive drug samples. Another recent trend that has affected NPs is the mandate by some health maintenance organizations or insurance programs that their members use selected mail-order pharmacies to refill their prescriptions.This has led to denial of NP-written prescriptions in many instances, 103

Table 15. Percentage of NPs Who Have Own DEA Number* NPs WITH DEA NUMBERS

1996

2004

2005

NP has own DEA number

30%

69%

73%

Use physician’s DEA number

29%

11%

11%

Do not prescribe drugs requiring DEA number

41%

20%

16%

* DEA indicates Drug Enforcement Administration; and NPs, nurse practitioners.

Table 16. Percentage of Nurse Practitioners Who Distribute Product Samples to Patients PROVIDES PRODUCT SAMPLES

1996

2005

Frequently

55.6%

50%

Occasionally

23.1%

20%

Never

21.3%

30%

Table 17. Have Your Patients Reported Problems Filling NP*Written Prescriptions at Mail-Order Pharmacies? REPORTED PROBLEMS

NPs (%)

No problems reported

54.4

No mail order experience

14.9

Yes, do not accept any NP prescriptions

14.1

Yes, deny schedule II prescriptions

1.7

Yes, denial, reason unknown

8.7

* NPs indicates nurse practitioners.

Table 18. Billing of NP* Services Under Physician’s Name NP BILLING DONE IN PHYSICIAN’S NAME IN 2005 (%)

%

0

37.1

1-25

10.4

26-50

10.0

51-75

8.6

76-100

33.9

* NP indicates nurse practitioner.

often as a result of confusion about what is legally authorized and the variances in state law between states in which the prescriptions are written and the state in which the pharmacy is located.The American College of Nurse Practitioners has been working with the largest mail-order prescription houses to resolve these issues. An authorized prescriber in 1 state should be able to have prescriptions filled in another state unless specific legislation prevents this.To date,Texas is the only state with such restrictive legislation.Table 17 summarizes the experience that NPs in this sample have had with mail-order drugstores. 104

In 1996, only 26% of NPs reported that they had the ability to bill in their own name. In 2004, that number had increased to 42.3%. In the 2005 survey, the question was expanded to focus on the percentage of NPs who were actually using this ability to bill in their own name. Only 37.1% of NPs said that they were not billing at least some of their patient encounters and 33.9% were billing 76% to 100% of their patient charges in their own names. This is a very dramatic change over the years. Federal legislation mandates direct reimbursement to NPs for Medicaid patients, but it is unknown what percentage of this direct billing is a result of billing for Medicaid. Although the trend over the 9 years of the survey is positive,Table 18 documents the reality that NPs are still financially tethered to physicians. The variability in state law in the area of independent prescriptive authority has created some confusion for industry representatives, legislators, and health care organizations concerning how NPs make prescribing decisions. Even in those states with very broad nurse practice acts, institutional policies may place restrictions on how independently an NP may prescribe. As 1 NP commented, “Nurses have always consulted with physicians about important decisions—it’s good practice. It’s just like physicians talk things over with each other.The only difference is some state laws try to force us to consult with physicians more than we might need to do.” Despite the financial dependence on physicians, most patient encounters are managed independently with little physician consultation. As noted in Table 19, 13.7% of NPs did not consult with a physician for any patient encounters; the remainder consulted to varying degrees. Other research suggests that how independently an NP may function is likely dependent on several factors:18 1. The relative restrictiveness of an individual state nurse practice act. 2. Length of practice as an NP. 3. The complexity and diversity of patients seen in an individual practice. February 2006

Table 19. Patient Encounters Managed Without Physician Consulation INDEPENDENT PATIENT ENCOUNTERS

1996

0%

17%

2.4%

3.7%

1%-25%

83%

5.6%

5%

26%-50%

0%

10.3%

11.4%

51%-75%

0%

20.2%

15.1%

61.5%

51.1%

Not asked

13.7%

76%-99% All

2004

0% Not asked

2005

Table 20. Marketing to NPs by Pharmaceutical Companies ISSUE

NPs WHO AGREE

Most company representatives detail to NPs*

44.4%

Some company representatives ignore NPs

43.2%

Some drug companies do not support NPs

24.5%

Many drug reps think NPs and PAs are the same

48.5%

I hate “see your doctor” advertisements

47.3%

Most drug representatives do not know what drugs NPs prescribe

23.2%

Some companies require signing a form to receive drug samples

59.8%

*NPs indicates nurse practitioners; and PAs, physician assistants.

Table 21. Ways Drug Companies Show Support for NPs* WAYS TO SHOW SUPPORT

NPs WHO AGREE

Sponsoring CE activities

85.1%

Supporting NP professional associations

54.4%

Advertising in NP journals

55.2%

Advertising “see health care provider”

49.4%

Utilizing NPs on focus/advisory groups

36.9%

Using NPs on speaker panels

55.2%

*CE indicates continuing education; and NPs, nurse practitioners.

Table 22. Primary Sources of Drug Product Information for Nurse Practitioners SOURCES

%

Colleagues

57.3

Conferences/seminars

75.1

Professional journals

66.8

Pharmaceutical labels/drug representatives

54.8

Internet

28.6

In addition, it is increasingly recognized that the physician may not be at the same site where the NP practices. NP RELATIONSHIPS WITH PHARMACEUTICAL COMPANIES In interviews with NPs about pharmaceutical representatives, it is clear that NPs have very strong opinions.The www.npjournal.org

NPs interviewed at national conferences often describe being invisible to the industry.They note the generous industry support for physician conferences and continuing education and contrast that with support for NPs. NPs report concerns with product literature and directto-consumer advertising that uses “ask your doctor” 105

terminology that leads to patient confusion and undermines the credibility of the NP. Use of provider-neutral language is strongly desired by NPs. In an attempt to quantify these perceptions, for the first time in 2005, respondents were asked about specific pharmaceutical industry practices.Tables 20, 21, and 22 present NP responses to different statements regarding drug companies or drug company products. Although the response of this small sample of NPs cannot be generalized to the profession as a whole, it will be interesting to monitor responses to these same statements with other groups over the years. Conclusion A notable finding over the 9 years of data collection is the remarkable stability of NP practice patterns.Through this period of significant changes in the profession, legislatively, educationally, and in practice, NPs have continued to treat the same types of patients, place the same importance on preventive issues, and use the same types of medications, although increasingly they have broadened their role from primary care settings to provide those same services in acute care settings, including emergency rooms, urgent care settings, and outpatient surgical centers. The ability for NPs to prescribe medications for their patients has been an important component of the role that required legislative action in every state. Clearly by 2005 NPs have well integrated this activity into the care they provide for patients in an increasingly broad and independent manner.The fact that their ability to prescribe these medications remains such a well-hidden secret because of their invisible prescriber status makes a compelling argument for continued research.

References 1. US Department Health and Human Services. Findings from the National Sample Survey of Registered Nurses. The registered nurse population; 2000. Available at: bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/rnss1.htm. Accessed December 6, 2005. 2. Phillips S. Annual update on how each state stands on legislative issues affecting advanced nursing practice: a survey of legal authority, reimbursement status, and prescriptive authority. Nurse Pract Am J Primary Care. 2005;30(1):14-47. 3. Batey MV, Holland JM. Prescribing practices among nurse practitioners in adult and family health. Am J Public Health. 1985;75(3):258-261. 4. Batey MV, Holland MJM, Dawson K. Nurse practitioner prescribing patterns: drug therapy and client health problems. J Ambulatory Care Manage. 1985;9(3):44-53. 5. Munroe D, Pohl J, Gardner H, Bell R. Prescribing patterns of nurse practitioners. Am J Nurs. 1982;10:1538-1542. 6. Rosenaur J, Stanford D, Morgan W, Curtin B. Prescribing behaviors of primary care nurse practitioners. Am J Public Health. 1984;74(1):10-13. 7. Flenniken MC. Psychotropic prescriptive patterns among nurse practitioners in nonpsychiatric settings. J Am Acad Nurse Pract. 1997;9(3):117-121. 8. Glod CA, Manchester A. Prescribing patterns of advanced practice nurses: contrasting psychiatric mental health CNS and NP practice. Nurse Pract. 2002;27(1):22-29. 9. MacEachern L. Providers issue brief: scope of practice and prescriptive authority: year end report-2003. Issue Brief Health Policy Track Serv. 2003; Dec 31:1-29. 10. Mahoney DF. Employer resistance to state authorized prescriptive authority for NPs. Results from a pilot study. Nurse Pract. 1995;20(1):58-61. 11. Mayes M. A study of prescribing patterns in the community. Nurs Stand. 1996;10(29):34-37. 12. Pan S, Straub LA, Geller JM. Restrictive practice environment and nurse practitioners’ prescriptive authority. J Am Acad Nurse Pract. 1997;9(1):9-15. 13. Pulcini J, Vampola D. Tracking NP prescribing trends. Nurse Pract. 2002;27(10):38-43. 14. Shell RC, Smith PL, Moody NB. Antidepressant prescribing practices of nurse practitioners. Clin Excell Nurs Pract. 1998;2(5):273-278. 15. Goolsby MJ. 2004 AANP national nurse practitioner sample survey, Part II: nurse practitioner prescribing. J Amer Acad Nurse Practitioners. 2005;17:506-511. 16. Avorn J, Everitt DE, Baker MW. The neglected medical history and therapeutic choices for abdominal pain. Arch Intern Med. 1991;151(4):694-698. 17. Hing E, Cherry D, Woodwell DA. Advance Data, Centers for Disease Control and Prevention, National Center for Health Statistics, No 365. October 4, 2005, p 32. Available at: www.cdc.gov/nchs/data/ad/ad365.pdf. Accessed January 21, 2006. 18. Safriet BJ. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale J Regul. 1992;9(417):434-485.

Laurie Scudder, MS, NP, is co-owner of Nurse Practitioner Alternatives, Inc., in Ellicott City, Md. She can be reached at [email protected]. 1555-4155/06/$ see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.nurpra.2005.12.019

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