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Nurse practitioner and physician adherence to standing orders criteria for consultation or referral.

L O Watkins and E H Wagner

The degree to which nurse-practitioners (NPs) and physicians (MDs) follow the mutually agreed-upon rules for their practice and the effects of any deviations are unknown. This study assessed whether NPs adhered to consultation/referral (C/R) criteria in NP standing orders for hypertension, whether MDs adhered to the task-delegation intent expressed in standing orders, and the relationship between adherence and blood-pressure (BP) control. A sample of 161 patients from a practice of five MDs and four NPs in a rural primary care clinic was studied over 16 months. Patient characteristics associated with provider non-adherence were identified by discriminant analysis. NPs failed to obtain consultation or referral for 22 of 66 patients (33 per cent) with conditions requiring C/R. MDs retained 17 of the 43 patients (40 per cent) without C/R conditions. NP non-adherence was associated with care by a single NP, presence of few non-hypertension problems, and need for dietary alteration (p less than .05). MD non-adherence was associated with males and presence of severe non-hypertensive disease (p less than .005). Diastolic BP control (less than or equal to 90 mm Hg) was similar in NP patient groups without C/R conditions, retained by NPs despite C/R conditions and shared with MDs by C/R. Control in the shared group was better than in the MD-treated group with C/R conditions (p less than .025). Although in this setting NPs frequently did not adhere to C/R criteria for hypertension, this did not affect acceptable BP control.

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