Can patients receive similar quality of care outcomes from Nurse Practitioners (NPs) and Physician Assistants (PAs) as they would from Primary Care MDs (PCMDs)? In a healthcare landscape moving towards greater independence of and more reliance on advanced practice providers such as NPs, questions have been raised about the standard of care they can deliver compared to primary care MDs. In a recent study, results seemed to show that NPs and PAs didn’t just deliver equal quality of care as PCMDs – they delivered even better care.
The study, limited in its analysis to community health centers, created a list of several patient-level outcomes to measure. Results demonstrated that NPs and PAs had equal outcomes to PCMDs on all fronts, except that both were more likely to provide a greater number of health counseling services, and NPs were more likely to provide smoking cessation counseling.
However, the internal validity of these “quality of care” metrics is questionable. How did the authors determine what outcomes to measure? First, they divided the scope of primary care services into three categories: prevention and early detection, treatment of common acute and chronic illnesses, and medical management. Then, they simply looked at the most prevalent presentation in each of these categories, which turned out to be smoking cessation counseling, depression treatment, and hyperlipidemia management, respectively.
Thus, countless examples of PCMDs providing advanced but necessary care were thrown out of this dataset. Patients with a borderline tumor that would need diagnosis and referral. Patients with rare illnesses that finally get diagnosed. Patients whose medication interactions require a more thoughtful approach. All these patients and their stories are not included in this study’s dataset. Instead, a few prevalent presentations are explored for a narrowly defined primary care scope, and from this, generalizations are attempted.
The idea that NPs and PAs can provide equal care to physicians, at a fraction of the cost, is tempting to administrators as well as legislators looking to cut healthcare costs. But, we should not forget to take overly-simplified quality metrics with a healthy dose of skepticism. Because of that hidden complexity, I suggest the end of the primary care doctor is not yet here.
This Policy Prescriptions® review is written by Abraham Akbar as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine. Mr. Akbar is a first year medical student.
BACKGROUND: Under the Affordable Care Act, the number and capacity of community health centers (HCs) is growing. Although the majority of HC care is provided by primary care physicians (PCMDs), a growing proportion is delivered by nurse practitioners (NPs) and physician assistants (PAs); yet, little is known about how these clinicians’ care compares in this setting.
OBJECTIVES: To compare the quality of care and practice patterns of NPs, PAs, and PCMDs in HCs.
RESEARCH DESIGN: Using 5 years of data (2006-2010) from the HC subsample of the National Ambulatory Medical Care Survey and multivariate regression analysis, we estimated the impact of receiving NP-delivered or PA-delivered care versus PCMD-delivered care. We used design-based and model-based inference and weighted all estimates.
SUBJECTS: Primary analyses included 23,704 patient visits to 1139 practitioners-a sample representing approximately 30 million patient visits to HCs in the United States.
MEASURES: We examined 9 patient-level outcomes: 3 quality indicators, 4 service utilization measures, and 2 referral pattern measures.
RESULTS: On 7 of the 9 outcomes studied, no statistically significant differences were detected in NP or PA care compared with PCMD care. On the remaining outcomes, visits to NPs were more likely to receive recommended smoking cessation counseling and more health education/counseling services than visits to PCMDs (P?0.05). Visits to PAs also received more health education/counseling services than visits to PCMDs (P?0.01; design-based model only).
CONCLUSIONS: Across the outcomes studied, results suggest that NP and PA care were largely comparable to PCMD care in HCs.