Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians

Abstract

Background: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value.

Objective: To compare use of low-value services among U.S. APCs and physicians.

Design: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP).

Setting: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011.

Patients: Patients presenting with upper respiratory infections (URIs), back pain, or headache.

Measurements: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions).

Results: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting.

Limitation: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs.

Conclusion: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions.

Primary funding source: U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

Appendix Figure 1

NAMCS missing data procedures. Some missing data were imputed by randomly assigning a value from a patient record survey form with similar characteristics. Imputations were based on physician specialty, geographic region, and 3-digit ICD-9-CM codes for primary diagnosis. ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; NAMCS = National Ambulatory Medical Care Survey.

Appendix Figure 2

NHAMCS outpatient department missing data procedures. Some missing data were imputed by randomly assigning a value from a patient record survey form with similar characteristics. Imputations were based on outpatient department volume by clinic type, geographic region, and 3-digit ICD-9-CM codes for primary diagnosis. ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; NHAMCS = National Hospital Ambulatory Medical Care Survey.