Low-Value Care Rates Similar for Physicians and NPs/PAs

Marcia Frellick

July 06, 2016

Advanced practice clinicians (APCs, which include nurse practitioners and physician assistants) and physicians order similar levels of low-value care for some of the most common conditions in primary care in both hospital- and office-based settings, according to data from a new study published online June 21 in the Annals of Internal Medicine.

John N. Mafi, MD, MPH, from the Division of General Internal Medicine and Health Services Research at the Ronald Reagan University of California, Los Angeles, Medical Center, and colleagues say the findings dispel a common misperception.

"According to a recent national survey, most physicians believe that APCs provide lower-quality care than they do, and nearly one quarter think that expanding nurse practitioners' roles in U.S. practice would decrease the efficiency and value of health care," the authors explain.

Comparing Treatment for Three Conditions

The researchers used national data on ambulatory visits to compare the use of potentially low-value health services between APCs and physicians in how they managed common conditions, including upper respiratory infections (URIs), back pain, and headache.

The services or treatments, which have been widely identified in previous studies or guidelines as low value in most cases, are use of antibiotics for URIs, plain radiography for URIs and back pain, and advanced imaging (both magnetic resonance imaging and computed tomography for back pain and headache) and referrals to other physicians for all three conditions.

The authors write: "Our finding that APCs order antibiotics, [computed tomography] or [magnetic resonance imaging], radiography, and referrals as frequently as physicians is reassuring given recent efforts to expand the number of APCs, as well as their role, to meet the increasing demand for primary care while the primary care physician workforce continues to shrink."

The researchers used the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2011. They looked at 12,170 physician and 473 APC office-based visits and 13,359 physician and 2947 APC hospital-based visits.

In an accompanying editorial, Eugene C. Rich, MD, from the Center on Health Care Effectiveness Mathematica Policy Research in Washington, DC, points out some questions not resolved in the study.

He notes that patients were not randomly assigned to NPs or PAs or physicians, and patients may have had varying needs or expectations for care not detectable through the risk adjustment factors. The study also was not able to account for financial incentives for productivity and high-value care.

"If the more limited breadth and depth of training required of APCs is sufficient to efficiently manage some common conditions, how does this translate into care for the much broader range of conditions and concerns commonly seen in primary care? A better understanding of these issues may guide more informed ascertainment of the competencies required for skillful primary care in different settings and patient populations," Dr Rich writes.

He says that although he agrees with the authors that it is reassuring that this study finds that NP and PA treatment of these three conditions does not show a lowering of healthcare value, given their expanding role, questions remain about more comprehensive treatment.

"[H]ealth professions educators, practice leaders, and policymakers still are faced with substantive questions regarding how to assure the ready availability of the deeper clinical competencies required for correct diagnosis and more comprehensive care for primary care patients who are, or prove to be, more medically complex," he writes.

Regardless of who provides it, low-value care is an important problem to address, as an estimated 30% of US healthcare spending is wasteful, the authors say, citing a previous Medicare spending study. Much of this waste is driven by the use of low-value health services, they note.

Dr Mafi reports support from the US Health Services and Research Administration and the Ryoichi Sasakawa Fellowship Fund. Coauthors report support from the National Institutes of Health. Dr Rich has disclosed no relevant financial relationships.

Ann Intern Med. Published online June 21, 2016. Article abstract, Editorial extract

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