Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma

Abstract

Objective: The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians.

Methods: We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay).

Results: Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled beta-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (-6 points; 95% CI, -9 to -3 points). Supervised MLPs provided similar quality of care to that of physicians.

Conclusions: The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.