21 Jun Physician Extenders Utilize Similar Rates of Low Value Services as Primary Care Physicians
MedicalResearch.com Interview with:
Dr. John Mafi
John N. Mafi, MD, MPH
Assistant Professor of Medicine
Division of General Internal Medicine and Health Services Research
UCLA David Geffen School of Medicine
Los Angeles, CA 90024
Affiliated Adjunct in Health Policy
RAND Corporation
Santa Monica, CA 90401
MedicalResearch.com: What is the background for this study? What are the main findings?
Dr. Mafi: The U.S. healthcare system faces a looming shortage of primary care physicians, with some estimates as high as 20,000 physicians by the year 2020. In addition, fewer and fewer trainees enter primary care careers because of the harder work and lower salaries. Combine this with the passage of the Affordable Care Act and the millions of newly insured patients looking for a primary care provider, and you have created a perfect storm where timely access to primary care becomes essentially unachievable.
Many advocate for expanding the role of nurse practitioners and physician assistants to mitigate the physician shortage. But this is controversial as most doctors believe nurse practitioners provide inferior care to doctors and many feel that expanding their role would worsen the value and efficiency of the U.S. healthcare system.
While studies suggest they provide similar quality of care to physicians, few have actually evaluated whether they provide greater amounts of inefficient or low value care. Low value care is important because it can harm patients (antibiotics for colds don’t help patients and have harmful side effects) and they can raise healthcare costs. In this context, we used a large national database on ambulatory visits to compare the quality and efficiency of care among nurse practitioners, physician assistants, and physicians in the U.S. primary care setting.
In our 15 year analysis of nearly 29,000 patients who saw either a nurse practitioner, physician assistant, or a physician, we found similar rates of inappropriate antibiotic use for colds, unnecessary imaging (such as x-rays, CT scans, and MRI scans) for back pain and headache, and potentially necessary referrals to specialists for these same three conditions.
MedicalResearch.com: What should readers take away from your report?
Dr. Mafi: Nurse practitioners, physician assistants, and physicians provide similar amounts of low value care, dispelling physicians’ perceptions that they provide lower value care than physicians for these three common conditions in primary care.
While we are not advocating that nurse practitioners replace physicians, these findings are reassuring in light of recent efforts to expand nurse practitioners and physician assistants scope of practice, and while the primary care provider workforce continues to rapidly shrink.
We believe nurse practitioners and physicians assistants can and should expand their scope of practice in primary care, particularly for relatively straightforward conditions with clearly defined guidelines, much like the ones we studied.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Dr. Mafi: As nurse practitioners and physician assistants continue to expand their scope of practice, we need more research to measure their diagnostic accuracy and whether they can practice safely in more independent settings (e.g. with minimal physician input) compared with physicians. This is particularly salient as the Veterans Administration considers granting full practice authority to all VA nurse practitioners, which has generated controversy in recent days. Given the VA’s dangerous access to care problems, we believe expanding the scope of practice of nurse practitioners makes sense, particularly for highly protocolized conditions like the ones we studied. Ultimately, some care is certainly better than no care at all. Nonetheless, we suggest that the VA studies these questions (e.g., diagnostic accuracy and practicing without physician input) by randomizing the expansion in some regions and not in others. We also suggest that the VA to better define how nurse practitioners will fit into a collaborative team-based environment.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Citation:
Rich EC. Advanced Practice Clinicians and Physicians in Primary Care: Still More Questions than Answers. Ann Intern Med. [Epub ahead of print 21 June 2016] doi:10.7326/M16-1326
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Last Updated on June 21, 2016 by Marie Benz MD FAAD