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IIR 13-063
Nurse Practitioners and Physician Assistants: Primary Care Roles and Outcomes
George Lee Jackson, PhD MHA Durham VA Medical Center, Durham, NC Durham, NC Funding Period: July 2014 - June 2017 |
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BACKGROUND/RATIONALE:
Expected primary care provider shortfalls threaten access to care in both the Veterans Health Administration (VHA) and the United States healthcare system. Meanwhile, deficiencies in quality and efficiency of primary care demand new approaches such as patient-aligned care team models. Expanded use of nurse practitioners (NPs) and physician assistants (PAs) offers a potential mechanism for addressing access, quality, and cost issues. Although the VHA has been a pioneer in adopting expansive roles for non-physician providers and VHA patient-aligned care teams (PACTs) can be led by NPs and PAs, there is limited information about how the work of patient care is divided among VHA providers and about how this division of labor affects care outcomes and costs. Because of potential differences in care provided by NPs and PAs, our study assessed each profession separately. We used diabetes as a tracer condition to evaluate care provided by primary care NPs, PAs, and physicians. OBJECTIVE(S): The project's purpose was to examine clinical roles of NPs, PAs, and physicians in VHA primary care of patients with diabetes and to assess the association of these roles with care outcomes and costs. The first aim characterized role patterns for allocation of patient care work among NPs, PAs, and physicians in the care of patients with diabetes in VHA primary care clinics. Secondly, we sought to compare quality of care outcomes for patients with diabetes across usual provider of care (UPC) types and NP & PA roles, controlling for organizational characteristics and patient health status. Third, we evaluated patient-level health resource utilization and costs for patients with diabetes across UPC types and NP & PA roles, controlling for initial health and organizational characteristics. METHODS: Using retrospective analyses of secondary data, we examined the care of adult, pharmaceutically-treated diabetes patients receiving care at primary care locations within the Veterans Affairs (VA) healthcare system in 2012 and 2013. A patient's usual provider of care was defined as the primary care provider most often visited in the primary care clinic in 2012. This analysis included patients with the same PCP in 2012 and 2013. We described the patterns of care and roles (usual provider vs. supplemental provider; type of care provided, and complexity of patients) of NPs, PAs, and physicians by patient and organizational characteristics. We examined associations between the profession and roles of the UPC and intermediate diabetes outcomes and control, healthcare utilization, and healthcare costs. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes respectively. These analyses accounted for patient and organizational level characteristics potentially associated with diabetes outcomes. FINDINGS/RESULTS: Based on data from the VA Corporate Data Warehouse, there were 710,267 patients who met inclusion criteria including 1) an ICD-9 code for diabetes; 2) at least 1 pharmacy fill for diabetes medication in FY 12; 3) at least 2 outpatient visits (or at least 1 inpatient visit) in FY12; 3) at least 1 outpatient visit in FY13; and 4) at least 1 primary care encounter with an MD, NP, or PA in FY12. These Veterans received the largest portion of their primary care from 840 VA clinic locations meeting inclusion criteria. The most frequent primary care providers for patients in the VHA in FY 12 (defined as the primary care provider most frequently seen in that year) were attending physicians (76% of patients), NPs (16% of patients), PAs (6% of patients), and resident physicians (2% of patients). Among the findings, no clinically significant differences were observed between outcomes of patients for physicians, NPs, and PAs. Compared to physicians: 1) mean HbA1c differences were -0.05% (-0.07:-0.03) for NPs and 0.01% (95%CI=-0.02:0.03) for PAs; 2) mean SBP differences were -0.26mmHg (-0.45:-0.07) for NPs and -0.25mmHg (-0.50:0.01) for PAs; and 3) mean LDL-C differences were 1.03mg/dl (0.59:1.48) for NPs and 1.77mg/dl (1.18:2.37) for PAs. IMPACT: Both the VHA and broader healthcare system in the United States are seeking ways to expand access to primary care. There has long been debate over the potential roles of non-physician primary care providers in addressing access issues. The VHA has recently expanded the clinical duties of nurse practitioners and continues to consider appropriate clinical roles of physician assistants. The results of this study provided important expanded evidence that NP and PA providers can achieve similar diabetes outcomes among their patients as physicians. As a result, it added to the body of evidence that NPs and PAs can and do have extensive roles in treating patients with chronic illness in primary care settings. External Links for this ProjectNIH ReporterGrant Number: I01HX001325-01A1Link: https://reporter.nih.gov/project-details/8676365 Dimensions for VA Dimensions for VA is a web-based tool available to VA staff that enables detailed searches of published research and research projects. Learn more about Dimensions for VA. VA staff not currently on the VA network can access Dimensions by registering for an account using their VA email address. Search Dimensions for this project PUBLICATIONS:Journal Articles
DRA:
Health Systems, Diabetes and Other Endocrine Disorders
DRE: none Keywords: none MeSH Terms: none |
