The proportion of physician practices with nurse practitioners (NPs) and physician assistants (PAs) increased by 22% in specialty practices and by 24% in primary care practices from 2008 to 2016, according to a study published in JAMA Internal Medicine.

Grant R. Martsolf, PhD, MPH, from the School of Nursing at the University of Pittsburgh, and colleagues sought to characterize levels of and changes in advanced practice clinician employment across different physician practices in the United States in 2008 and 2016, with a particular focus on specialty practices. The research team identified the 2008 and 2016 SK&A outpatient provider files for the analyses.

Specialty practices were identified as single medical or single surgical specialty practices. The team conducted analysis on the 3 largest categories of primary care practices: family medicine, internal medicine, and pediatrics, as well as supplementary analyses for the top 10 specialties by practice counts across all years. The proportion of practices with an advanced practice clinician (overall and by NPs and PAs) and the percentage change between 2008 and 2016 were calculated for each practice type.

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In 2016, approximately 28% of all specialty practices employed advanced practice clinicians. Multispecialty practices were most likely (49%) and surgical specialties least likely (21%) to employ advanced practice clinicians. Among the top 10 specialties, advanced practice clinicians were employed in at least a quarter of practices in the following specialties: cardiology, obstetrics-gynecology, dermatology, gastroenterology, and orthopedic surgery.

Specialty practices were more likely to employ NPs than PAs, with the exception of surgical practices, which relied more on PAs. Overall, from 2008 to 2016, there was a 22% increase in specialty practices employing advanced practice clinicians. There has been a 24% increase in advanced practice clinician use among primary care practices, as 35% of these practices had at least 1 advanced practice clinician by 2016. Employment of NPs in specialty practices increased faster compared with the rate among PAs (33% vs 20% increase).

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About 1 in 4 specialty practices employ advanced practice clinicians, compared with 1 in 3 primary care practices. Because the NP role was historically developed to focus on primary care and most advanced practice clinicians are NPs, it would be expected that advanced practice clinicians would have a greater presence in primary care practices, noted the study authors.

“Overall growth in advanced practice clinicians may be driven by recent increases in graduates from advanced practice clinician programs, the emergence of value-based purchasing models that are incentivizing team-based care, and downward price pressure from public and private payers—making the lower costs of advanced practice clinician employment more attractive,” the researchers concluded. “Advanced practice clinicians may also be increasingly moving into specialty practices as specialist physicians embrace new roles for advanced practice clinicians.”


Martsolf GR, Barnes H, Richards MR, Ray KN, Brom HM, McHugh MD. Employment of Advanced Practice Clinicians in Physician Practices. JAMA Intern Med. Published online April 30, 2018. doi:10.1001/jamainternmed.2018.1515