Physicians, advanced practice clinicians may order similar amounts of low-value care for certain conditions, study finds
Advanced practice clinicians were not significantly more likely than physicians to order antibiotics, CT/MRI, or radiography, or to refer patients to other physicians for upper respiratory infections, back pain, or headache.
Physicians and advanced practice clinicians may utilize comparable amounts of guideline-discordant and low-value tests and treatments for 3 conditions commonly seen in primary care, a recent study found.
Researchers used National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey data from 1997 to 2011 to compare the management of upper respiratory infections, back pain, and headache by physicians and advanced practice clinicians (nurse practitioners and physician assistants). Results were published online on June 20 by Annals of Internal Medicine.
The study included 28,949 primary care visits for the 3 conditions (25,529 physician visits and 3,420 advanced practice clinician visits). About 90% of the data came from physicians' office visits, and the rest came from clinicians practicing in hospital-based outpatient clinics. Office-based clinicians saw similar patients, whereas hospital-based advanced practice clinicians treated younger patients (mean age, 42.6 vs. 45.0 years; P<0.001) and delivered care in an urban setting less frequently (49.7% vs. 81.7% of visits; P<0.001) compared with their physician counterparts.
In both settings, advanced practice clinicians were not significantly more likely than physicians to order antibiotics, CT/MRI, or radiography, or to refer patients to other physicians for the 3 conditions, according to unadjusted analyses. Practice patterns in both settings remained consistent after researchers adjusted for multiple variables. Hospital-based advanced practice clinicians did order more antibiotics (52.8% vs. 46.0%; P= 0.043) and made more referrals (11.8% vs. 8.3%; P= 0.018) than hospital-based physicians, although only referral differences remained significant after a sensitivity analysis.
The study authors noted limitations to their analysis, such as how the data samples may exclude visits to more independent advanced practice clinicians (thereby underrepresenting their care) and how some “low-value” care may have been justified. They also lacked longitudinal patient data and could not account for variations in state-level scope-of-practice laws.
The study raises questions in light of previous research, which has suggested that advanced practice clinicians are more likely than primary care physicians to order tests or refer to specialists, according to an accompanying editorial. “Of course, it is plausible that any greater clinical expertise conferred by the physician's additional training and clinical experience is not relevant to efficient and appropriate care of these common health concerns,” the editorialist wrote. “However, it also may be the case that the numerous other sources of variation in use of low-value services are sufficient to render underlying differences due to training and experience undetectable in these data.”