Lawrence Herman, MPA, PA-C, DFAAPA
A recent study presented at the annual scientific sessions of the American Diabetes Association in San Francisco compared outcomes in patients with diabetes who were treated within the Veterans Administration healthcare system. Presenter Dr. Lawrence S. Phillips said the study of 19,238 patients treated over 4 years compared changes in hemoglobin A1C levels and found that management performed by PAs and NPs is “as good as that provided by physicians.”
The VA is the single largest employer of PAs and NPs in the country, and diabetes affects more than one in five VA patients, so this is not trivial. Dr. Phillips and colleagues analyzed VA data to identify patients who saw a physician, NP, or PA for more than 50% of healthcare visits since a new diagnosis of diabetes in 2008-2012.
Researchers analyzed average A1C levels at the time of diabetes diagnosis, at the initiation of medications, and during follow-up years. They found that after adjusting for patient characteristics, average A1C levels did not differ significantly between provider groups. Dr. Phillips, a professor of medicine at Emory University in Atlanta and a well-respected endocrinologist, also found that patient populations treated by all three groups were statistically comparable.
According to the study, patient demographics were similar between provider groups, with a mean age of 69 years, 95% male, and mean body mass index of 32.4 kg/m2. The cohort seen by physicians had a statistically smaller percentage of white patients (77%) than did the cohort seen by physician assistants (81%).
Results revealed that baseline A1C levels were 7.2%, 7.14%, and 7.18% for patients seen by physicians, PAs, and NPs, respectively. By the end of the study in 2012, those levels had dropped to 6.78%, 6.75%, and 6.75%, not statistically significant.
Similarly so, patient comorbidity levels, as measured by the Charlson Comorbidity Index, were virtually identical in each provider group. The proportion of patients on any diabetes therapy was similar between groups: 81% with physicians, 79% with PAs, and 80% with nurse practitioners.
This is not a perfect study and there are potentially confounding variables. As an example, a physician (perhaps an endocrinologist) may have seen the same patient for a minor percentage of visits and actually directed the patient care plan. Clearly, this could have affected outcomes. And statistically significant differences were found in some data. Specifically, the study found a significantly smaller proportion of patients seeing PAs were on insulin (12%), compared with those seeing physicians (15%) or NPs (14%). PAs also referred a significantly smaller proportion of patients to diabetes specialists (5%), compared with physicians (8%) or NPs (7%).
This was a very large cohort of patients seen over a fairly lengthy period of time primarily by one of three different groups of providers. So this study does provide yet another piece of data indicating that, at least in this setting and with the diagnosis of diabetes, outcomes for patients who see PAs and NPs are comparable to those who see physicians. Furthermore and perhaps just as significant, it may be another piece of evidence that PAs and NPs are educated to treat not simply colds and runny noses but at least some of the most complicated patient populations with multiple comorbidities and with comparable outcomes.
Lawrence Herman is an associate professor and chair of the Department of Physician Assistant Studies at the New York Institute of Technology in Old Westbury, N.Y., and chair of the board of directors immediate past president of AAPA. The views expressed in this blog post are those of the author and may not reflect AAPA policies.