Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians

Abstract

Background Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. Objective To compare use of low-value services among U.S. APCs and physicians. Design Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office-versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient’s primary care provider (PCP). Setting National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. Patients Patients presenting with upper respiratory infections (URIs), back pain, or headache. Measurements Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). Results 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. Limitation NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. Conclusion APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians’ perceptions that APCs provide lower-value care than physicians for these common conditions. Primary Funding Source U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

“…APPs are viewed as a key component of primary care delivery, in which substantial data suggests that APPs provide care equivalent in quality to MDs . A randomized controlled trial comparing nurse practitioners practicing independently versus physicians in primary care showed no differences in mortality or other important health outcomes .…”

“…Most patients with cirrhosis are not co‐managed by a gastroenterology‐trained or hepatology‐trained specialist . Previous studies have demonstrated that advanced practice providers (APPs) provide care that is equivalent in quality to medical doctors (MDs) in both primary care and specialty care when their practice is focused on one condition . However, data are lacking regarding quality metric performance for APPs in patients with cirrhosis.…”

Association of Primary Care Practice Location and Ownership With the Provision of Low-Value Care in the United States

“…Missing data are rare (e.g., answers to the survey question, “Have you or anyone in this practice seen this patient before?” are missing 2.9% of the time), and multiple imputation techniques are used for missing data. 1 …”

“…1,15 Based on prior research, we chose three episodic conditions that are frequently associated with low value care: (1) upper respiratory infections (URIs, such as acute bronchitis and pharyngitis), (2) back pain, and (3) headache, which are commonly treated by generalists or in general medical clinics and based on prior research. 1,6,7 …”

“…Our analyses adjusted for potential confounders, including age (measured as a continuous variable in years), sex, race/ethnicity (defined as a single, four-level variable including white, black, Hispanic, and other), insurance status, modified Charlson disease count, 1,21 urban vs. rural location, geographic region (one of four quadrants in the U.S.), and calendar year.…”