- Email: [email protected]
Consumer-Driven Health Care: Nurse Practitioners Making History
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 31
Consumer-Driven Health Care: Nurse Practitioners Making History Kenneth Miller
ABSTRACT
Consumer-driven health care has spawned an industry of convenient care clinics that offer accessible, quality care at a reasonable price.The primary health care providers at these clinics are family nurse practitioners. Since their debut, these clinics have provided a niche for people who do not want to spend hours in emergency departments for minor illnesses and uninsured people who cannot afford the high costs of health care.This article reviews the history behind convenient care clinics and offers some prognostication for the future. Keywords: accessibility, convenient care clinics, nurse practitioners, quality care, retail clinics
www.npjournal.org
The Journal for Nurse Practitioners - JNP
31
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 32
onsumers in search of accessible, quality health ROLE OF NURSE PRACTITIONERS care at a reasonable price have turned their Since their debut, the primary providers of care in the attention and their health care dollars to the CCCs have been family NPs (FNPs). Based on both their convenient care industry.This relatively new approach to scope of practice, coupled with the scope of services that treatment of minor ailments has provided a new venue CCCs offer, this group of health care providers seems to for provision of care by nurse practitioners (NPs). Drug be the best fit for this new model of care. Studies have stores, discount shopping centers, grocery stores, and repeatedly shown that NPs provide care that is equivalent other retail outlets are the geographic locales for these to, or better than, that provided by family practice physinew convenient care clinics (CCCs), which are staffed cians.4-7 NPs are cost-effective health care providers who, primarily by NPs, although some are also staffed by within the CCCs, can help relieve the burden of “nonphysician assistants (PAs) and urgent” visits to overly burphysicians.The “convenience” dened emergency departments. label for these clinics evolves not It is entirely possible that these By treating these less only from the geographic closeCCCs serve a surrogate role as ness to the patients’ homes but “safety net providers” for complex cases, NPs are also to the fact that the clinics are patients who would otherwise freeing up both emergency open 7 days a week, with easy have gone untreated, or inapdepartments and family propriately used an emergency convenient parking.The waiting practice physicians to treat department for a minor illness.8 times are such that patients can Additionally, some of these be in and out in less time than in more complex cases. non-urgent conditions, if not a primary care office.Additiontreated in a timely fashion, ally, the time they might have to could progress to become more serious in nature, thus wait to have their prescriptions filled can easily be spent involving a more costly treatment modality. shopping for needed household goods.The purpose of Ninety percent of all CCC visits involve just 10 comthis paper is to detail the rapidly expanding history of this plaints, specifically: upper respiratory infections, sinusitis, “consumer dream.” bronchitis, pharyngitis, immunizations, otitis media, otitis externa, conjunctivitis, urinary tract infections, and EARLY HISTORY screening labs or blood pressure checks.8 All of these conConvenient care clinics made their debut in 2000, when ditions or procedures are well within the scope of practhe first in-store clinics appeared in Minneapolis-St. Paul, tice of NPs. It is the role of the NPs in these clinics to operated by QuickMedx.1 The meteoric rise from less than 50 clinics in 2005 to over 1095 in 2008 bears mute assess, diagnose, and treat the illnesses that are within the 2,3 testimony to this new health care venue. The key to the scope of services that the particular CCC provides.Typisuccess of these clinics is not only their accessibility in cally, patients are seen within 15 to 20 minutes after havretail outlets, along with the provision of quality care at a ing signed in to the clinic on computers provided in the reasonable price, but also the economics associated with patient waiting area. Each chief complaint has a comsuch a venture. puter-generated protocol that the practitioner uses to Investment dollars are plentiful, as both public and diagnose and treat the patient. If the diagnosis falls outprivate investors seek a piece of this ever-burgeoning pie. side the protocol and enters a more complex realm of However, both small and large companies have faltered signs and symptoms that require additional treatment, due to economic decline. Some sought too rapid an these cases are referred to a list of local health care expansion, while others neglected to consider the overproviders who have agreed to take referrals from the head costs of employing a more costly workforce. For CCC, or the patient is referred to the nearest emergency example, a large privately owned Las Vegas company department, depending on the urgency of presenting recently removed itself from the industry.The speculation signs and symptoms.An additional safety net is that each is that the overhead associated with physician staffing was clinic has a collaborating physician with whom the NP more than had been anticipated.2 can discuss a particular case. In general, by treating these
C
32
The Journal for Nurse Practitioners - JNP
January 2009
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 33
less complex cases, NPs are freeing up both emergency departments and family practice physicians to treat more complex cases. A question that is frequently entertained by both the NPs who work in these clinics and those who support this consumer-driven movement is: why would an NP want to work in a setting in which the scope of services is far less than what the practitioner could otherwise do in another setting? The answer to that question is as varied as the practitioners who work in the CCCs. Conversations with NPs in these clinics indicate that there are multiple reasons for wanting to work in CCCs. Some like the “independence” of the role, others like the hours, the benefits, the collegiality, the ability to enhance their expertise by working with a limited number of medical conditions, and having time to provide preventive education. More experienced practitioners have indicated that they enjoy the less hectic pace of the CCC as compared to a busy family practice clinic, as it provides them time to provide some education to the patient. Given that the NPs are dealing with a limited number of conditions to treat, there are very few obstacles in their practice.A consulting physician is only a phone call away, and the regional NP who oversees the clinic is also available for consultation. The evolution and rapid rise of CCCs has not been without its detractors. Both the American Medical Association (AMA) and the American Academy of Pediatrics (APA) have opposed CCCs primarily on the issues of continuity of care, coordination of care, and economic issues.9-11 However, recent research by the Rand Corporation has provided some data to respond to these concerns.8 The disruption of primary care relationships has proven to be a non-issue. The study found that 60% of those visiting a CCC did not have a primary care provider (PCP); hence, there was no relationship to disrupt.The majority of patients using a CCC are in the 18to 44-year-old range (Table 1), who otherwise might not have sought care until a more serious set of symptoms developed, thus adding to the increased costs of treatment.The second concern revolved around the potential exacerbation of communication problems between the patient and the PCP.Yet all clinics provide the patient with either a written summary of the visit, or if the patient requests, the clinic will fax a copy of the record to the PCP’s office. Either way, the communication problem is resolved.
www.npjournal.org
Table 1. Age and Percentage of Patients Who Visited Convenient Care Clinics Between 2002 and 2005 (N =1.35 million) Age (years)
Percent
<2
0.2
2-5
6.3
6-17
20.3
18-44
43.0
45-64
22.6
> 65
7.5
Total
100
Adapted from Mehrota A, Wange MA, Lave JR, Adams J, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patient visits. Health Affairs 2008;5:1277.
Finally, the potential financial impact to the PCPs by loss of simple acute visits was also addressed.The study noted that, while it is possible that the PCP might have fewer visits per hour of the simple acute cases, this is potentially offset by the filling of that time with more complex cases, whose reimbursement rates are higher than that of the simple acute cases. Another perspective that the study did not note was the potential of referrals from the CCCs for more complex cases that fall outside the scope of services that the clinics offer. The issues raised by the AMA and AAP have been addressed by the standards of care developed by the Convenient Care Industry (CCI). CCCs do not see children under the age of 18 months. Electronic medical records (EMRs) provide ready access to visit summaries for PCPs. And all complex cases are referred to appropriate local health care providers from lists that the CCCs maintain. The CCCs and the quality health care that they provide are not going away.They have become an integral part of our health care landscape, and the NPs and the other health care providers who work in these clinics are helping to meet the crisis of too few primary care providers that currently exists.The Rand study has merely scraped the surface of the types of studies that need to be done to show the positive outcomes of these CCCs.Additionally, studies need to be done to clearly show that the clinics offer accessible and quality care at a reasonable price.
The Journal for Nurse Practitioners - JNP
33
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 34
From an historical perspective, NPs are negotiating new modes of care delivery while being groomed into the eventual role of assuming responsibility for becoming the gateway to primary care in this country.This is a result of 2 historical events. First, data over the past 10 years reveal a steady decline in the number of family practice physicians who elect primary care as their specialty.The most recent data from the 2008 National Resident Matching Program show that 2,636 family practice residencies were offered, yet only 2,387 were filled.12 Of the number that were filled, less than half were filled by U.S. seniors; the other 52% were graduates of medical schools outside the country. However, these declining physician numbers are offset by an increasing number of FNP graduates. In 2007-2008, some 4041 FNPs graduated from schools around the country.This represents 3.5 times the number of U.S. medical school graduates who elected family practice as their specialty.13 Given these data, it is certainly feasible that in the next 5 years, FNPs will indeed be the gateway for primary care in the United States.An integral part of this evolution will be the services provided by CCCs. The greatest contribution of the CCI has been their clear articulation of the role of the NP. No other organization has done so much for NPs in terms of clarifying and enhancing their visibility to the public. Just as Johnson and Johnson have become the marketers for the general nursing community, so too, has the CCI become the marketer for NPs.What was once the best-kept secret in the health care industry has now become the most visible and viable safety net in the health care industry. FUTURE ROLE OF THE CCCs The CCCs are now a monument on the health care landscape.They offer a viable alternative to once more costly services that were rendered in primary care provider offices and emergency departments.They have established themselves as an industry complete with standards of care, evaluation tools, and satisfaction surveys. In 2008, they launched their own newspaper, and held an inaugural Retail Clinician Education Congress, which proved to be the first of what will become an annual conference. It is possible that the future will also hold an enhancement to their scope of services, especially in the arena of prevention.What better venue to provide education than within a CCC, where NPs and
34
The Journal for Nurse Practitioners - JNP
pharmacists can work collaboratively to provide the latest information not only on drugs, but also on ways to prevent some of the more common diseases such as heart disease, diabetes, hypertension, obesity, and depression.The opportunities will be endless. And NPs who were there at the inauguration of this industry will be there making history through the provision of accessible, quality care at a reasonable price. References 1. Hansen-Turton T, Ryan S, Miller K, Counts M, Nash D. Convenient care clinics: the future of accessible healthcare. Dis Manage. 2007;10:61-73. 2. Kolar R. A consumer revolution in retail medicine: where is it heading? Healthcare Financial Manage. 2008;62:46-48. 3. Convenience care in the United States. Available at: www.merchant medicine.com. Accessed October 26, 2008. 4. Sox HC. Quality of patient care by nurse practitioners and physician assistants: a ten-year perspective. Ann Intern Med. 1979;91:459-468. 5. Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington randomized trial of the nurse practitioners. New Engl J. Med. 1974;290:251-256. 6. Lenz ER, Mundinger M, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61:332-351. 7. Lenz ER, Mundinger MO, Hopkins SC, Lin SX, Smolowitz JL. Diabetes care processes and outcomes in patients treated by nurse practitioners or physicians. Diabetes Educ. 2002;28:590-598. 8. Mehrota A, Wange MA, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patient visits. Health Affairs. 2008;5:1272-1278. 9. Corwin RM, Francis AB, McInerny TK, Ponzi JW, Reuben MS, et al. AAP principles concerning retail based clinics. Pediatrics. 2006;118:2561-2562. 10. Berman S. Continuity, the medical home and retail-based clinics. Pediatrics. 2007;120:1123-1125. 11. AMA takes on retail-based clinics. Available at: http://archives.chicago tribune.com/2007/jun/25/business/chi-clinics_bizjun25. Accessed November 4, 2008. 12. Results and data: 2008 main residency match. Available at: www.nrmp.org. Accessed October 26, 2008. 13. Fang D, Htut A, Bednash GD. 2007-2008 enrollment in baccalaureate and graduate programs in nursing. Washington, D.C.: American Association of Colleges of Nursing; 2008.
Kenneth P. Miller, PhD, RN, CFNP, FAAN, is director of the School of Nursing at the University of Delaware in Newark. He can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2009 American College of Nurse Practitioners doi:10.1016/j.nurpra.2008.11.002
January 2009
12/17/08
4:15 PM
Page 31
Consumer-Driven Health Care: Nurse Practitioners Making History Kenneth Miller
ABSTRACT
Consumer-driven health care has spawned an industry of convenient care clinics that offer accessible, quality care at a reasonable price.The primary health care providers at these clinics are family nurse practitioners. Since their debut, these clinics have provided a niche for people who do not want to spend hours in emergency departments for minor illnesses and uninsured people who cannot afford the high costs of health care.This article reviews the history behind convenient care clinics and offers some prognostication for the future. Keywords: accessibility, convenient care clinics, nurse practitioners, quality care, retail clinics
www.npjournal.org
The Journal for Nurse Practitioners - JNP
31
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 32
onsumers in search of accessible, quality health ROLE OF NURSE PRACTITIONERS care at a reasonable price have turned their Since their debut, the primary providers of care in the attention and their health care dollars to the CCCs have been family NPs (FNPs). Based on both their convenient care industry.This relatively new approach to scope of practice, coupled with the scope of services that treatment of minor ailments has provided a new venue CCCs offer, this group of health care providers seems to for provision of care by nurse practitioners (NPs). Drug be the best fit for this new model of care. Studies have stores, discount shopping centers, grocery stores, and repeatedly shown that NPs provide care that is equivalent other retail outlets are the geographic locales for these to, or better than, that provided by family practice physinew convenient care clinics (CCCs), which are staffed cians.4-7 NPs are cost-effective health care providers who, primarily by NPs, although some are also staffed by within the CCCs, can help relieve the burden of “nonphysician assistants (PAs) and urgent” visits to overly burphysicians.The “convenience” dened emergency departments. label for these clinics evolves not It is entirely possible that these By treating these less only from the geographic closeCCCs serve a surrogate role as ness to the patients’ homes but “safety net providers” for complex cases, NPs are also to the fact that the clinics are patients who would otherwise freeing up both emergency open 7 days a week, with easy have gone untreated, or inapdepartments and family propriately used an emergency convenient parking.The waiting practice physicians to treat department for a minor illness.8 times are such that patients can Additionally, some of these be in and out in less time than in more complex cases. non-urgent conditions, if not a primary care office.Additiontreated in a timely fashion, ally, the time they might have to could progress to become more serious in nature, thus wait to have their prescriptions filled can easily be spent involving a more costly treatment modality. shopping for needed household goods.The purpose of Ninety percent of all CCC visits involve just 10 comthis paper is to detail the rapidly expanding history of this plaints, specifically: upper respiratory infections, sinusitis, “consumer dream.” bronchitis, pharyngitis, immunizations, otitis media, otitis externa, conjunctivitis, urinary tract infections, and EARLY HISTORY screening labs or blood pressure checks.8 All of these conConvenient care clinics made their debut in 2000, when ditions or procedures are well within the scope of practhe first in-store clinics appeared in Minneapolis-St. Paul, tice of NPs. It is the role of the NPs in these clinics to operated by QuickMedx.1 The meteoric rise from less than 50 clinics in 2005 to over 1095 in 2008 bears mute assess, diagnose, and treat the illnesses that are within the 2,3 testimony to this new health care venue. The key to the scope of services that the particular CCC provides.Typisuccess of these clinics is not only their accessibility in cally, patients are seen within 15 to 20 minutes after havretail outlets, along with the provision of quality care at a ing signed in to the clinic on computers provided in the reasonable price, but also the economics associated with patient waiting area. Each chief complaint has a comsuch a venture. puter-generated protocol that the practitioner uses to Investment dollars are plentiful, as both public and diagnose and treat the patient. If the diagnosis falls outprivate investors seek a piece of this ever-burgeoning pie. side the protocol and enters a more complex realm of However, both small and large companies have faltered signs and symptoms that require additional treatment, due to economic decline. Some sought too rapid an these cases are referred to a list of local health care expansion, while others neglected to consider the overproviders who have agreed to take referrals from the head costs of employing a more costly workforce. For CCC, or the patient is referred to the nearest emergency example, a large privately owned Las Vegas company department, depending on the urgency of presenting recently removed itself from the industry.The speculation signs and symptoms.An additional safety net is that each is that the overhead associated with physician staffing was clinic has a collaborating physician with whom the NP more than had been anticipated.2 can discuss a particular case. In general, by treating these
C
32
The Journal for Nurse Practitioners - JNP
January 2009
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 33
less complex cases, NPs are freeing up both emergency departments and family practice physicians to treat more complex cases. A question that is frequently entertained by both the NPs who work in these clinics and those who support this consumer-driven movement is: why would an NP want to work in a setting in which the scope of services is far less than what the practitioner could otherwise do in another setting? The answer to that question is as varied as the practitioners who work in the CCCs. Conversations with NPs in these clinics indicate that there are multiple reasons for wanting to work in CCCs. Some like the “independence” of the role, others like the hours, the benefits, the collegiality, the ability to enhance their expertise by working with a limited number of medical conditions, and having time to provide preventive education. More experienced practitioners have indicated that they enjoy the less hectic pace of the CCC as compared to a busy family practice clinic, as it provides them time to provide some education to the patient. Given that the NPs are dealing with a limited number of conditions to treat, there are very few obstacles in their practice.A consulting physician is only a phone call away, and the regional NP who oversees the clinic is also available for consultation. The evolution and rapid rise of CCCs has not been without its detractors. Both the American Medical Association (AMA) and the American Academy of Pediatrics (APA) have opposed CCCs primarily on the issues of continuity of care, coordination of care, and economic issues.9-11 However, recent research by the Rand Corporation has provided some data to respond to these concerns.8 The disruption of primary care relationships has proven to be a non-issue. The study found that 60% of those visiting a CCC did not have a primary care provider (PCP); hence, there was no relationship to disrupt.The majority of patients using a CCC are in the 18to 44-year-old range (Table 1), who otherwise might not have sought care until a more serious set of symptoms developed, thus adding to the increased costs of treatment.The second concern revolved around the potential exacerbation of communication problems between the patient and the PCP.Yet all clinics provide the patient with either a written summary of the visit, or if the patient requests, the clinic will fax a copy of the record to the PCP’s office. Either way, the communication problem is resolved.
www.npjournal.org
Table 1. Age and Percentage of Patients Who Visited Convenient Care Clinics Between 2002 and 2005 (N =1.35 million) Age (years)
Percent
<2
0.2
2-5
6.3
6-17
20.3
18-44
43.0
45-64
22.6
> 65
7.5
Total
100
Adapted from Mehrota A, Wange MA, Lave JR, Adams J, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patient visits. Health Affairs 2008;5:1277.
Finally, the potential financial impact to the PCPs by loss of simple acute visits was also addressed.The study noted that, while it is possible that the PCP might have fewer visits per hour of the simple acute cases, this is potentially offset by the filling of that time with more complex cases, whose reimbursement rates are higher than that of the simple acute cases. Another perspective that the study did not note was the potential of referrals from the CCCs for more complex cases that fall outside the scope of services that the clinics offer. The issues raised by the AMA and AAP have been addressed by the standards of care developed by the Convenient Care Industry (CCI). CCCs do not see children under the age of 18 months. Electronic medical records (EMRs) provide ready access to visit summaries for PCPs. And all complex cases are referred to appropriate local health care providers from lists that the CCCs maintain. The CCCs and the quality health care that they provide are not going away.They have become an integral part of our health care landscape, and the NPs and the other health care providers who work in these clinics are helping to meet the crisis of too few primary care providers that currently exists.The Rand study has merely scraped the surface of the types of studies that need to be done to show the positive outcomes of these CCCs.Additionally, studies need to be done to clearly show that the clinics offer accessible and quality care at a reasonable price.
The Journal for Nurse Practitioners - JNP
33
31-34_TJNP775_Miller_CP
12/17/08
4:15 PM
Page 34
From an historical perspective, NPs are negotiating new modes of care delivery while being groomed into the eventual role of assuming responsibility for becoming the gateway to primary care in this country.This is a result of 2 historical events. First, data over the past 10 years reveal a steady decline in the number of family practice physicians who elect primary care as their specialty.The most recent data from the 2008 National Resident Matching Program show that 2,636 family practice residencies were offered, yet only 2,387 were filled.12 Of the number that were filled, less than half were filled by U.S. seniors; the other 52% were graduates of medical schools outside the country. However, these declining physician numbers are offset by an increasing number of FNP graduates. In 2007-2008, some 4041 FNPs graduated from schools around the country.This represents 3.5 times the number of U.S. medical school graduates who elected family practice as their specialty.13 Given these data, it is certainly feasible that in the next 5 years, FNPs will indeed be the gateway for primary care in the United States.An integral part of this evolution will be the services provided by CCCs. The greatest contribution of the CCI has been their clear articulation of the role of the NP. No other organization has done so much for NPs in terms of clarifying and enhancing their visibility to the public. Just as Johnson and Johnson have become the marketers for the general nursing community, so too, has the CCI become the marketer for NPs.What was once the best-kept secret in the health care industry has now become the most visible and viable safety net in the health care industry. FUTURE ROLE OF THE CCCs The CCCs are now a monument on the health care landscape.They offer a viable alternative to once more costly services that were rendered in primary care provider offices and emergency departments.They have established themselves as an industry complete with standards of care, evaluation tools, and satisfaction surveys. In 2008, they launched their own newspaper, and held an inaugural Retail Clinician Education Congress, which proved to be the first of what will become an annual conference. It is possible that the future will also hold an enhancement to their scope of services, especially in the arena of prevention.What better venue to provide education than within a CCC, where NPs and
34
The Journal for Nurse Practitioners - JNP
pharmacists can work collaboratively to provide the latest information not only on drugs, but also on ways to prevent some of the more common diseases such as heart disease, diabetes, hypertension, obesity, and depression.The opportunities will be endless. And NPs who were there at the inauguration of this industry will be there making history through the provision of accessible, quality care at a reasonable price. References 1. Hansen-Turton T, Ryan S, Miller K, Counts M, Nash D. Convenient care clinics: the future of accessible healthcare. Dis Manage. 2007;10:61-73. 2. Kolar R. A consumer revolution in retail medicine: where is it heading? Healthcare Financial Manage. 2008;62:46-48. 3. Convenience care in the United States. Available at: www.merchant medicine.com. Accessed October 26, 2008. 4. Sox HC. Quality of patient care by nurse practitioners and physician assistants: a ten-year perspective. Ann Intern Med. 1979;91:459-468. 5. Spitzer WO, Sackett DL, Sibley JC, et al. The Burlington randomized trial of the nurse practitioners. New Engl J. Med. 1974;290:251-256. 6. Lenz ER, Mundinger M, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Med Care Res Rev. 2004;61:332-351. 7. Lenz ER, Mundinger MO, Hopkins SC, Lin SX, Smolowitz JL. Diabetes care processes and outcomes in patients treated by nurse practitioners or physicians. Diabetes Educ. 2002;28:590-598. 8. Mehrota A, Wange MA, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patient visits. Health Affairs. 2008;5:1272-1278. 9. Corwin RM, Francis AB, McInerny TK, Ponzi JW, Reuben MS, et al. AAP principles concerning retail based clinics. Pediatrics. 2006;118:2561-2562. 10. Berman S. Continuity, the medical home and retail-based clinics. Pediatrics. 2007;120:1123-1125. 11. AMA takes on retail-based clinics. Available at: http://archives.chicago tribune.com/2007/jun/25/business/chi-clinics_bizjun25. Accessed November 4, 2008. 12. Results and data: 2008 main residency match. Available at: www.nrmp.org. Accessed October 26, 2008. 13. Fang D, Htut A, Bednash GD. 2007-2008 enrollment in baccalaureate and graduate programs in nursing. Washington, D.C.: American Association of Colleges of Nursing; 2008.
Kenneth P. Miller, PhD, RN, CFNP, FAAN, is director of the School of Nursing at the University of Delaware in Newark. He can be reached at [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/$ see front matter © 2009 American College of Nurse Practitioners doi:10.1016/j.nurpra.2008.11.002
January 2009