GA Scope of Practice Bill Sparks Debate About APRNs

The American Medical Association and the Medical Association of Georgia (MAG) are speaking out against proposed state legislation that would expand scope of practice for advanced practice registered nurses (APRNs) and allow them to order radiographic imaging.

The bill in question, SB 321, calls to create parity between physician assistants (PAs) and APRNs, including the specific change about ordering imaging tests. The bill passed handily in both the Georgia House and Senate, coming in at a 137 to 14 vote and 46 to 5 vote, respectively. It is now awaiting signature from Georgia Governor Brian Kemp, whose veto AMA and MAG are lobbying for.

Currently, APRNs are only allowed to order radiographic images in life-threatening situations. If signed, the bill would allow APRNs to order such tests in situations that are not life-threatening when it adheres to the practice agreement between the APRN and supervising physician. This is already a part of PA scope of practice.

According to the United Advanced Practice Registered Nurses of Georgia (UAPRN), Georgia is the only state in the US that does not allow APRNs to order imaging tests during situations that are not life-threatening.

Bills expanding scope of practice for advance practice providers like APRNs usually aim to improve patient access to care because they increase the number of clinicians who are able to provide a certain type of treatment.

But according to AMA and MAG, the bill could result in an increased number of ordered imaging tests, which could subsequently lead to waste and high healthcare costs.

“The AMA is concerned such expansion will increase health care costs and threatens the health and safety of patients in Georgia,” the groups wrote in a letter to Georgia Governor Brian Kemp, who is the sole policymaker who could stop this already-passed bill from coming into law. “For these reasons we strongly encourage you to veto S.B. 321.”

The organizations cited previous studies indicating that nurse practitioners, a type of APRN, who have been given this level of practice authority tend to order imaging tests more often than physicians.

One such study, published in the Journal of the American College of Radiology, found the rate at which NPs ordered skeletal x-rays increased by over 400 percent between 2003 and 2015 (although NPs still trail far behind physicians in ordering skeletal x-rays). Another study in JAMA Internal Medicine found NPs ordered imaging after an outpatient appointment more often than physicians, even after controlling for imaging orders from specialists.

The organizations also reiterated the long-held stance that physicians should be the leaders of the clinical care team.

“All health care professionals play a critical role in providing care to patients; however, their skillsets are not interchangeable with that of fully trained physicians,” AMA and MAG wrote. “While nurse practitioners are valuable members of the health care team, with only two to three years of education, no residency requirement and approximately 500-720 hours of clinical training, they are not trained to practice independently.”

Physicians are required to complete four years of medical school, as well as between three and seven years of residency training and between 10,000 and 16,000 hours of clinical training.

To be clear, APRNs usually have to have completed a four-year bachelor’s program to become a registered nurse before applying for a two- or three-year advanced degree, totaling to between six and seven years of education. According to the American Association of Nurse Practitioners (AANP), NPs receive more than six years of education and must complete national board certification and state NP licensure.

AMA and MAG are not the only organizations speaking out against this bill. The Georgia Chapter of the American Academy of Pediatrics echoed many of the sentiments offered by AMA and MAG.

“Also, on the negative, was a bill, SB 321 that would give nurse practitioners the unfettered right to order ‘radiographic imaging’ for all patients, including children,” the organization wrote in a July update of the Georgia General Assembly. “We opposed this bill and will now make an appeal to Governor Kemp to veto it. For without a veto, this bill will needlessly endanger children with imaging ordered by those with far less training and expertise in pediatric care.”

But the bill also has its proponents. UAPRN, for example, pointed out the bill gets rid of the final step for ordering imaging tests.

“At this time, we can only order these tests in an emergency,” Michelle A. Nelson, PhD, RN, MS, FNP-BC, UAPRN president, said in a statement. “We are already determining the need for these tests in many cases but must take an unnecessary step of seeking the signature of a supervising physician. We are certified, educated, licensed and trained to order them. Not allowing APRNs to order these tests results in delays in care and increased costs for our patients.”

Correction 11/15/2021: A previous version of this article misstated that NPs order skeletal x-rays 400 percent more often than physicians. It has been corrected to reflect that the rate at which NPs order skeletal x-rays increased by over 400 percent between 2003 and 2015.