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Nurse Practitioners Play an Increasing Role in Primary Care

Jaime Rosenberg
Between 2008 and 2016, primary care providers increasingly relied on nurse practitioners amidst a shortage of doctors, especially in rural areas.
With approximately 234,000 nurse practitioners licensed in the United States, they are increasingly playing a key role in both rural and nonrural primary care practices, according to study results published in Health Affairs. Increases were especially significant in rural practices, with the number of practices with nurse practitioners increasing from 35% in 2008 to 45.5% in 2016.

In primary care, nurse practitioners can perform most services that physicians provide, often at a lower cost. The use of nurse practitioners in primary care has been implemented at a growing rate as a way to address growing patient demand and improve care delivery.

“The number of physicians choosing primary care careers remains insufficient to replace those retiring,” wrote the authors of the study. “This concern is especially acute in rural areas with long-standing provider shortages. Thus, it is plausible that practices will increase the use of providers other than physicians, such as nurse practitioners.”

The increased amount of newly insured people seeking care due to Medicaid expansion has also highlighted the need for more providers in the primary care workforce, according to the authors. However, despite the growing need, little evidence exists on how nurse practitioners have been incorporated into primary care practices in recent years.

Researchers compiled data from SK&A, a commercial data set that includes practice-level characteristics of office-based physician practices in all states and the District of Columbia. These data were then combined with data from the Area Health Resources Files to determine each practice’s rurality.

There was a significant increase in the presence of nurse practitioners among rural practices from 2008 to 2016, jumping from 17.6% to 25.2%. Although physicians continuously accounted for the largest proportion of providers in rural areas, they saw a relative decrease in the presence, from 69.4% to 60.5%.

With regard to the presence of nurse practitioners in nonrural settings, there was an increase from 15.9% in 2008 to 23% in 2016. At the same time, the presence of physicians decreased from 75.2% to 66.3%.

The researchers also examined the increase in the percentage of practices with nurse practitioners and the average number of nurse practitioners per practice. Compared with nonrural practices, a significant amount of rural practices employed at least 1 nurse practitioner. During the study period, the presence of nurse practitioners increased from 31.4% to 43.4% in rural practices and from 18.3% to 26.5% in nonrural practices. The average number of nurse practitioners increased in both rural (1.34 to 1.64) and nonrural (1.47 to 1.67) practices.

“Adding nurse practitioners is a useful way for practices to align themselves with contemporary efforts to improve access and performance,” concluded the authors. “Our findings imply that primary care practices are embracing a more diverse provider configuration, which may strengthen healthcare delivery overall.”


Barnes H, Richards M, McHugh M, Martsolf G. Rural and nonrural primary care physician practices increasingly rely on nurse practitioners. Health Aff (Millwood). 2018;37(6):908-914. doi: 10.1377/hlthaff.2017.1158.

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