Team-based care outcomes
Team-based care involving PAs and advanced practice RNs (APRNs) is one strategy for improving access and quality of care. PAs and APRNs perform a variety of roles; however, limited research describes the relationship between their role and patient outcomes. This study examined outcomes associated with primary care PA and APRN roles using a cross-sectional survey analysis of adult respondents to the 2010 US Health Tracking Household Survey. PA and APRN role was categorized as physician only (no PA or APRN) visits; usual provider (PA or APRN provide majority of primary care visits) or supplemental provider (physician as usual provider, PA or APRN provide a subset of visits). Compared with people with physician-only care, patients with PAs or APRNs as usual providers and as supplemental providers had increased risk of having five or more primary care visits. Patients reporting PAs or APRNs as supplemental providers had increased risk of ED use and lower satisfaction. No differences were seen for hospitalizations or when asked if they had unmet need. Healthcare use patterns and satisfaction varied between adults with PAs or APRNs in different roles, but reported unmet need did not. These findings suggest a wide range of outcome should be considered when identifying the best PA or APRN role on primary care teams.1
Commentary by Anthony A. Miller: Outcomes data are critical to solidifying how PAs are vital to the healthcare system, especially in primary care. The authors examined data through a phone survey and reported findings of increased ED visits without hospitalization and lower satisfaction scores when PAs or APRNs are in a supplemental role; these findings are concerning and many questions are unanswered. Although these findings were statistically significant, only 8% of the sample (N=6,894) had two or more ED visits without hospitalizations and only 3% reported they were very dissatisfied with healthcare. It also appears that patients have higher use of primary care visits when the PA or APRN is the primary provider—but why? The authors suggest several explanations including that the PA or APRN may be seeing sicker patients, and reducing underuse of primary care. Patients who see a PA or NP are more likely to be uninsured and less likely to see the same provider at the usual place of care.2 What is known is that PA use varies widely by level of experience, specialty, geographic location, and other factors. Also, PA and APRN data continue to be intermingled. Although in many settings PA and APRN roles may be indistinguishable, their education and philosophy regarding practice vary. Another possibility in the 2010 Health Tracking Household Survey is that some respondents may have confused the roles of an APRN with an RN or licensed practical nurse providing higher-level care at the clinic site.
Everett CM, Morgan P, Jackson GL. Primary care physician assistant and advance practice nurses roles: patient healthcare utilization, unmet need, and satisfaction. Healthc (Amst). [e-pub July 19, 2016].
2. Hooker RS, Benitez JA, Coplan BH, Dehn RW. Ambulatory and chronic disease care by physician assistants and nurse practitioners. J Ambul Care Manage. 2013;36(4):293–301.
What are the prescribing trends of PAs, NPs, and physicians?
Little is known about PAs' and NPs' prescribing of medications for chronic disease. This study assessed prescribing data on all NPs, PAs, and primary care physicians for anticoagulants, antihypertensives, oral hypoglycemics, and HMG-Co-A reductase inhibitors pre- and postintroduction of five new drugs in these classes that varied in novelty (dabigatran, aliskiren, sitagliptin, saxagliptin, and pitavastatin). Three measures of prescriber adoption during the 15-month post-FDA approval period were used: any prescription of the medication, proportion of prescriptions in the class for the medication, and time to adoption (first prescription) of the medication. From 2007 to 2011, the proportion of antihypertensives prescribed by NPs or PAs about doubled. Similar trends were found for anticoagulants, oral hypoglycemics, and HMG-Co-A reductase inhibitors. By 2011, more primary care physicians had prescribed each of the newly approved medications than NPs and PAs (for example, 44.3% of physicians, 18.5% of NPs, and 20% of PAs had prescribed dabigatran). Across all medication classes, the newly approved drugs accounted for a larger share of prescriptions in the class for primary care physicians, followed by PAs, then NPs. Mean time-to-adoption for the newly approved medications was shorter for primary care physicians compared with NPs and PAs. Primary care physicians were more likely to prescribe each of the newly approved medications per each measure of drug adoption, regardless of drug novelty. Differences in the rate and speed of drug adoption among prescribers may have important implications for care and overall costs at the population level as NPs and PAs continue taking on larger roles in prescribing.1
Commentary by Melissa Murfin: Jumping on the prescribing bandwagon when a newly approved drug becomes available has the potential for benefits and risks for patients. Medications such as dabigatran may be worthwhile due to improvements over current standard of care, but choosing a me-too drug such as pitavastatin offers no significant advantage over current treatment options. Medication cost is always an issue with new drugs but may ultimately prove cost-effective if the result is significantly improved patient outcomes. This preliminary study offers a look into differences between primary care physicians, PAs, and NPs in prescription of five new medications. Comparing which providers choose new medications more often and attempting to draw conclusions based on raw numbers of prescriptions raises additional questions for further study. Patient acuity and comorbidities, prescriber's practice setting, patients' insurance status, and formulary restrictions all factor into what is prescribed. More depth in future studies is needed to adequately assess why primary care physicians prescribe more new medications than PAs or NPs before definitive conclusions on patient care and overall cost can be drawn.
1. Marcum ZA, Bellon JE, Li J, et al New chronic disease medication prescribing by nurse practitioners, physician assistants, and primary care physicians: a cohort study. BMC Health Serv Res. 2016;16:312.
PAs, NPs, and inappropriate antibiotic prescribing
This study assessed whether the presence of a PA or NP was associated with antibiotic prescribing for all ambulatory care visits and visits for acute respiratory tract infections. Visits involving patients of all ages were divided into NP or PA and physician-only visits and compared for antibiotic prescribing. The proportion of visits involving NPs or PAs more than doubled across all ambulatory care settings between 1998 and 2011 (3.9% to 9%). Visits in which NPs or PAs were present more frequently resulted in an antibiotic prescription compared with physician-only visits (17% versus 12%). This pattern persisted for visits involving acute respiratory tract infections (61% versus 54%). In a multivariable model, the presence of an NP or PA at visits was independently associated with higher odds of antibiotic prescribing (OR=1.31). Ambulatory care visits involving an NP or PA are increasing and more likely to result in an antibiotic prescription compared with physician-only visits. Antibiotic stewardship messages should target NPs and PAs.1
Commentary by Teri Moser Woo: The estimated prevalence of inappropriate antibiotic prescriptions written for common respiratory infections in the outpatient setting is 30%.1 This study found that NPs and PAs prescribe antibiotics at a higher rate for all visits, including common respiratory conditions. What cannot be discerned is why: Could it be due to the type of practice they are employed in? Or due to practice laws that restrict independent prescribing in many states, leading to NPs or PAs prescribing under protocol or based on the preference of their supervising or collaborating physician? The study's findings are not consistent with other recent studies of NP and PA prescribing.2 Klein compared NP and physician prescribing for patients with attention-deficit hyperactivity disorder and found that NPs prescribed in same pattern as the same-specialty physician.3 Levy and colleagues found that NPs and PAs prescribe opioids at the same rate as general practice providers.4 Others found lower rates of opioid prescribing by NPs in states with independent prescribing.5 Although inappropriate antibiotic prescribing is pervasive and a public safety concern, research must determine the practice factors that affect the prescribing behavior before interventions are targeted toward a group of providers such as NPs or PAs.
1. Sanchez GV, Hersh AL, Shapiro DJ, et al Outpatient antibiotic prescribing among United States nurse practitioners and physician assistants. Open Forum Infect Dis. 2016;3(3):ofw168.
2. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA. 2016;315(17):1864–1873.
3. Klein TA, Panther S, Woo T, et al Childhood attention-deficit/hyperactivity disorder prescribing by prescriber type and specialty in Oregon Medicaid. J Child Adolesc Psychopharmacol. 2016;26(6):548–554.
4. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007-2012. Am J Prev Med. 2015;49(3):409–413.
5. Schirle L, McCabe BE. State variation in opioid and benzodiazepine prescriptions between independent and nonindependent advanced practice registered nurse prescribing states. Nurs Outlook. 2016;64(1):86–93.
Malpractice reports per capita for PAs, NPs, and physicians
This study examined trends in malpractice awards and adverse actions (such as revocation of provider license) following an act or omission constituting medical error or negligence. The National Practitioner Data Bank was used to compare rates of malpractice reports and adverse actions for physicians, PAs, and NPs. From 2005 through 2014, malpractice payment reports ranged from 9.9 to 16.6 per 1,000 physicians, 1.40 to 2.35 per 1,000 PAs, and 1.09 to 1.43 per 1,000 NPs. In percentage terms, 11.4% of physicians, 3.3 % of PAs, and 1.3% of NPs would likely have made a malpractice payment during the study period. Physician median payments ranged from 1.56 to 2.31 times higher than those of PAs and NPs. Malpractice allegations associated with diagnosis varied by provider type, with physicians having significantly fewer reports (31.8%) than PAs (52.8%) or NPs (40.6%). Significant trends may reflect policy enactments to decrease liability.1
Commentary by Richard Rohrs: Amid an ever-declining misconception that PAs and NPs are a malpractice risk to physicians and other employers, the authors put forth another piece of strong evidence that debunks this theory. Following several other studies that addressed the topic using similar resources, the authors went one step further and included reportable adverse actions in addition to malpractice payments. The addition of this aspect gives a clearer picture of the total scope of potential risk by class of provider. The study again demonstrates that PAs and NPs, adjusted per capita, have fewer malpractice awards and adverse actions than their physician counterparts. Many variables might contribute to these outcomes but in comparison to previous studies, the disparity persists despite the increase in the number of events for PAs and NPs. As the number of PAs and NPs increases and their autonomy and role diversity expand, this type of analysis must be performed at regular intervals to reflect how such actions might affect these outcome measures.
Brock DM, Nicholson JG, Hooker RS. Physician assistant and nurse practitioner malpractice trends. Med Care Res Rev. [e-pub July 25, 2016]
PAs in maxillofacial surgery
A prospective study of patients was undertaken to determine the effects on time, cost, and complication rates of integrating PAs into an outpatient oral-maxillofacial surgery practice. Subjects were separated into PA and No PA groups. Process maps captured activities from room preparation to patient discharge, and all activities were timed. A time-driven activity-based costing method calculated the times and costs from the provider's perspective. In total, the process time did not differ significantly between groups, but the average procedure cost decreased by $75.08 after PAs were introduced. Surgeon procedure time decreased by 19.2 minutes (mean) following the introduction of PAs. The addition of PAs into the procedural components of an outpatient oral-maxillofacial surgery practice reduced costs while complication rates remained constant. The increased availability of the surgeon allowed for more patients to be seen, increasing efficiency and revenue.1
Commentary by Richard W. Dehn: After 50 years of observation, it is evident that almost any use of a PA or NP can improve the throughput of a surgical procedure because of skill and labor cost. Orthopedics, interventional radiology, and cardiovascular surgery stand out because of documentation but anecdotal observations in procedures involving other organs are abundant.2,3 The economic theories for this increased use are embedded in substitution, complement, team-based care, and division of labor. Recognizing that postgraduate trained physicians are in short supply at the same time that demand is being driven by an expanding population (including a greater proportion of older adults), chronic disease sustainability, and new technology, it is only logical that the world turns to PAs and NPs for a wide variety of roles. Oral-maxillofacial surgery, the focus of this study, is only the latest to awaken to this fact. However, the use of time-motion studies to document the efficiency added with a PA to this practice is a creative and important observational enhancement.
1. Resnick CM, Daniels KM, Flath-Sporn SJ, et al Physician assistants improve efficiency and decrease costs in outpatient oral and maxillofacial surgery. J Oral Maxillofac Surg. 2016;74(11):2128–2135.
2. Hiza EA, Gottschalk MB, Umpierrez E, et al Effect of a dedicated orthopaedic advanced practice provider in a level I trauma center: analysis of length of stay and cost. J Orthop Trauma. 2015;29(7):e225–e230.
3. Duszak R Jr, Walls DG, Wang JM, et al Expanding roles of nurse practitioners and physician assistants as providers of nonvascular invasive radiology procedures. J Am Coll Radiol. 2015;12(3):284–289.