Study Finds Nurse Practitioners Use Low-Value Care at Comparable or Lower Rates, With Key Implications for Coverage Oversight
A cross-sectional analysis of 2021 outpatient claims in Arizona, Nevada, and New Mexico suggests that primary care nurse practitioners (NPs) deliver some of the most common low-value care (LVC) services at rates comparable to or lower than other providers, adding evidence to support the cost-effectiveness and clinical quality of NP-led care. However, one area—antibiotic prescribing for acute upper respiratory infections (aURI)—remains a concern for payers and policymakers alike.
The study examined 3 common LVC services, lumbar x-rays for uncomplicated pain, antibiotics for aURI, and routine electrocardiograms (ECGs) in low-risk patients, among 14 579 adult beneficiaries drawn from the 2021 Merative MarketScan Commercial and Medicare databases.
NPs ordered low-value lumbar x-rays in 13% of cases and routine ECGs in 6%, both rates lower or similar to previously reported benchmarks for the general clinician population. In contrast, low-value antibiotic prescribing for aURI remained high at 42%. Although this is lower than the American Academy of Family Physicians’ reported 80% rate for sinusitis, the study’s disaggregated analysis of acute sinusitis alone still showed a 64% prevalence.
“Even after accounting for the possibility of misclassified antibiotic prescriptions, low-value antibiotic use for aURI among NPs remains high,” the authors noted.
For payers, these findings offer reassurance regarding the clinical value delivered by NPs in primary care, particularly for imaging and ECG services. Given the increasing reliance on NPs to expand access and reduce costs, the relatively lower rates of LVC utilization could support broader inclusion of NP services in value-based care models.
The persistently high rate of aURI antibiotic prescribing does raise concern. Coverage policies could incorporate more granular utilization tracking or promote stewardship programs targeting this specific prescribing behavior. Tailored interventions—such as prescribing audits, decision support tools, or continuing education—may help deimplement this form of LVC without compromising access or satisfaction.
Importantly, the study found no statistically significant association between LVC use and patient sex, practice location (urban vs rural), or younger age, variables that have traditionally been linked to overuse. This finding may influence future policy decisions around population-based risk adjustments or resource allocations in NP-managed care.
The study further highlights the need for exploring NP-specific drivers of LVC. Variables such as years of experience, education background, and psychosocial determinants could inform more nuanced deimplementation strategies.
This baseline assessment of NP-led LVC patterns adds valuable insight for managed care stakeholders seeking to balance cost control with evidence-based practice. While low-value lumbar x-rays and ECGs appear well-managed, high antibiotic prescribing for aURI warrants attention. The study reinforces the importance of examining both clinical behavior and systemic factors in LVC reduction initiatives.
“NP LVC use in primary care was lower or relatively similar compared with the general clinician population,” the authors concluded, pointing toward a need for targeted, rather than sweeping, policy responses.
Reference
Nugent SB, Lavin RP, Lee J, Horn BP, Holmes Damron BI. An assessment of nurse practitioner low-value care use in primary care. Am J Manag Care. 2025;31(10):In Press.
