Diabetes care best in teams with NPs, PAs

Patient population, practice goals important to consider when defining nurse practitioner and physician assistant roles in primary care teams.

Diabetes care best in teams with NPs, PAs
Diabetes care best in teams with NPs, PAs

HealthDay News -- For patients with diabetes, health outcomes were generally equivalent when the treating clinician was nurse practitioner (NP), physician assistant (PA) or physician, researchers found.

NP/PA-provided patient care was equivalent to physician-provided care on 13 outcomes, with health outcomes even exceeding those yielded via physician-only care on four patient outcome measures, Christine Everett, PhD, of Duke University School of Medicine in Durham, N.C., and colleagues reported in Health Affairs.

"The capacity of these clinicians to fill a variety of roles argues for increased support for new and existing state and federal policies that encourage flexible approaches to provider roles and team design," the researchers wrote.

However, outcomes on three specific measures, particularly in scenarios involving clinically complex patients, were generally more favorable for patients who received physician-only care.

"This suggests that implementation of roles for primary care team members such as NPs and PAs may require thoughtful consideration of local factors such as the population served and [individual practices'] identified goals," the researchers noted.

Although existing research shows that NPs and PAs can perform 85% to 90% of primary care services traditionally provided by physicians, no study to date has compared the effectiveness of NP and PAs head to head with physician-only care among patients with chronic illness.

So Everett and colleagues analyzed Medicare claims and electronic health record data from a large physician group to compare outcomes for adult Medicare patients with diabetes who were cared for by teams that included PAs and NPs or physicians only. The analysis included data from 2,576 Medicare patients with a mean age of 72 years who received care from the provider group in 2008.

Among the 261 primary care panels in the group, 55% had team in which NPs or PAs provided care. Overall, 39% of patients received physician-only care, whereas only 5% of patients received NP or PA only care. 

Different patterns in the measure of the quality of diabetes care and use of health care services were associated with specific PA and NP roles, the researchers found. However, no role was best for all outcomes.

For example, NPs and PAs who did not treat highly complex patients and did not deliver chronic care experienced a 30% lower rate of ED visits compared with physician-only teams (odds ratio [OR] for emergency visits 0.70, 95% CI 0.56-0.93). However, those NP/PA care teams that did treat highly complex patients experienced a 50% higher rate of ED visits (OR 1.5, 95% CI 1.06-2.03), the researchers found.

Outcome variability by team type was also observed on measures of glycemic control. Teams that included NPs and PAs that did not treat highly complex patients were 54% less likely to have poor versus good glycemic control (OR 0.46, 95% CI 0.22-0.97). However, teams with NPs and PAs that treated complex patients showed a 1.8 times greater odds of having poor versus good glycemic control (95% CI: 1.21-2.67).

A key takeaway from the study is that determining the proper role for NPs and PAs within primary care teams "will require an even more nuanced approach than that taken in the current analysis," according to the researchers. "Training and policy should continue to support role flexibility for these health professionals."

References

  1. Everett C et al. Health Aff. 2013; doi:10.1377/hlthaff.2013.0506.
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