NPs, PAs as effective as primary care docs in outpatient setting

Patients at high risk of cardiovascular events received equivalent care, whether from a primary care physician or a nonphysician, in a study that compared the effectiveness of outpatient care. But both groups showed room for improvement.

“Irrespective of where these patients are getting care, whether from a physician or nonphysician provider, there is a lot of opportunity to improve care for the measures we are looking at,” Salim Virani, MBBS, PhD, said in an interview with Cardiovascular Business. Virani is a staff cardiologist at the Michael E. DeBakey VA Medical Center and associate professor at Baylor College of Medicine, both in Houston.

The Affordable Care Act has expanded the number of Americans who receive coverage for healthcare, which is expected to increase the burden on primary care physicians. While the patient rolls are growing, the number of available physicians is expected to contract as doctors retire. Given that scenario, Virani and his colleagues wanted to explore whether nonphysicians such as nurse practitioners (NPs) and physician assistants (PAs) might fill the gap in a nonacute primary care setting.

They focused on one aspect of quality—effectiveness—using key performance measures for patients at risk of a repeat cardiovascular event: blood pressure less than 140/90 mmHg; low-density lipoprotein cholesterol of less than 100 mg/dL; receiving statin therapy; receiving moderate- to high-intensity statin therapy; and beta-blocker use for patients with a previous MI in the past two years.

To assess effectiveness, they identified patients who completed a primary care visit for ischemic heart disease, cerebrovascular disease or peripheral artery disease at one of 130 Veterans Affairs facilities between 2013 and 2014. “These are patients who already have established cardiovascular disease,” Virani said. “They are high risk. How are we going to manage their risk factors to prevent a second event?”

They identified 934,950 patients whose care was provided by a physician and 252,085 who received care from a nonphysician. The proportion of patients who met the targets was similar for both groups for all measures. For blood pressure, for instance, 78.8 percent of patients seen by a physician were in the target range vs. 80.3 percent in the nonphysician group.

“The results are reassuring as far as effectiveness of care is concerned,” Virani said. But he emphasized that effectiveness is only one spoke in quality care. Their study did not look at efficiency, safety, equitableness, resource utilization or timeliness of care, and included only stable patients. “At a very basic level, for a patient with cardiovascular disease … that quality did not differ clinically between physician and nonphysician providers.”

But only about a third of patients in either group received moderate- to high-intensity statin therapy and 54 percent of the physician group and 54.8 percent of the nonphysician group met all three measures for blood pressure control, statin therapy and beta-blocker therapy if they had an MI. “All of the groups have a lot of ground to cover in terms of improving care for their patients,” he said.

Patient factors such as nonadherence to medications and lifestyle changes or drug intolerance could affect the findings as well, he noted.  

The results were scheduled to be presented on May 1 at the American Heart Association’s annual Quality of Care and Outcomes Research conference in Baltimore. The conference was canceled because of unrest in the city. Virani and his colleagues are completing a manuscript on the study for publication, he said.