To meet the health care needs of low-income, underinsured, and underserved individuals in the U.S., midlevel providers such as nurse practitioners (NPs) and physician assistants (PAs) are now providing a range of services that were once within the sole domain of physicians.

The idea of utilizing NPs to perform many types of procedures has gained widespread support. The Planned Parenthood Federation of America (PPFA) has long championed efforts to expand the scope of practice of NPs in many aspects of women's health care. In many PPFA facilities, NPs provide most, if not all, of the family planning services and routine care for women.

Managed care organizations, seeking to improve efficiency and cost-effectiveness, are also calling for expanded utilization of qualified midlevel clinicians. And recently the U.S. Congress authorized expanded Medicare/Medicaid reimbursement of services provided by NPs.

Boards of nursing in many U.S. states are supportive of expanded practice for nurses, relying on nurses' "track record" in areas where their autonomy is already in evidence. For example, in some states NPs are able to provide treatment independently, while in others they provide services under the supervision of a physician. Numerous studies have indicated high levels of client satisfaction with services provided by NPs, citing greater access to services, provider-client interaction, and emphasis on health education and prevention.

Improving Access to Vasectomy

A project in the Pacific Northwest has been utilizing midlevel providers to improve access to vasectomy services by low-income and underserved men. The pilot project was launched in November 1996 in Alaska, Idaho, Oregon, and Washington to train NPs and PAs in the no-scalpel vasectomy (NSV) technique.

Modeled after a smaller pilot effort in Washington in 1995, the project is a collaborative effort of AVSC, the U.S. Public Health Services, and the National Association of Nurse Practitioners in Reproductive Health. The Center for Health Training in Seattle, WA, coordinated the training.

Midlevel providers were teamed with physicians in training efforts. Under the project, 12 clinicians were trained to perform NSV in 1997.

The final training of the project was conducted in Anchorage, Alaska, last October. Before the training began, about 25 staff from area clinics attended a day-long workshop on sterilization counseling and male involvement in reproductive health decision-making.

Using an NSV curriculum and other training materials developed by AVSC, two physicians trained two nurse-physician teams in the NSV technique. Several AVSC staff and many local providers observed the training process to help plan future training activities.

The training teams performed a total of 11 vasectomies over the course of the two-day training. The clients who underwent the procedure either had signed up for it while visiting publicly funded clinics in the Anchorage area or had responded to advertisements for the training. The State of Alaska's Bureau of Maternal-Child Health provided funding for these procedures and plans to fund up to 200 more for low-income men who have no insurance coverage.

Evaluation Under Way

During the eight- to 12-month period following the training, the team members will be evaluated on their NSV skills.

Using data-collection forms they received at the training, they will record the outcomes of their first 50 NSV cases. This will help identify any surgical problems they may encounter, the need for consultation or assistance, and future issues that may arise.

When these records are completed, the project coordinator will review them and reinterview the team members about the problems they had. At the end of the project, they will be interviewed again and asked to provide constructive criticism of the project.

Once the providers feel more confident about their expertise in the NSV technique, they will invite providers from the surrounding areas to refer clients to them for NSV services. This will further expand access to the services in the area, since none of the Anchorage-area physicians who are already trained in NSV are affiliated with publicly funded clinics.

A Positive Response

While the outcome of the project is pending, the idea of utilizing midlevel providers in this way has generated much discussion and enthusiasm in the health care community. Some concerns about using midlevel providers to perform these kinds of services have been raised, and issues such as professional regulation of services, licensing, and insurance coverage will need to be addressed as more creative solutions for expanding service provision are implemented.

So far, reactions to the project have been very positive. The project staff and coordinator have received many inquiries from NPs about how to replicate the project, where additional training opportunities may be found, and how such training efforts might affect the practices of midlevel providers.

Chris Knutson, a nurse practitioner, is a clinical consultant and trainer at The Center for Health Training in Seattle, WA, and served as one of the coordinators of the NSV training.