Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act

Virani, Salim S.; Akeroyd, Julia M.; Ramsey, David J.; Chan, Winston; Frazier, Lorraine; Nasir, Khurram; Rajan, Suja S.; Ballantyne, Christie M.; Petersen, Laura A.

doi:10.1016/j.ahj.2016.07.020

Cited by 59 publications

(45 citation statements)

References 22 publications

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“…Details of cohort development have been described previously. 5,10,11 For each patient, the team first identified his/her primary care visit in VA FY 2014. If a patient had multiple primary care visits during VA FY 2014, then the most recent visit in the VA system was used as that patient's index primary care visit.…”

Section: Cohort Development and Study Populationmentioning

confidence: 99%

“…As described previously, 5,10,11 patients with CVD were defined as those with a prior history of ischemic heart disease, peripheral artery disease (PAD), or ischemic cerebrovascular disease and were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedure, or current procedural terminology codes (see Supplementary Table S1;…”

Section: Cohort Development and Study Populationmentioning

confidence: 99%

“…A greater use of advanced practice providers (APPs) (nurse practitioners [NPs] or physician assistants) has been proposed to address these shortages, especially for chronic disease care delivery. 2 In prior studies performed in small practices 3 and recent studies performed in large national cohorts of patients, 4,5 it has been shown that the effectiveness of outpatient delivery of cardiovascular disease (CVD) and diabetes care is comparable among patients receiving care from physicians or APPs. 5 Although effectiveness of routine outpatient CVD and diabetes care delivery has shown to be comparable between physicians and APPs, 5 it is not clear whether this comes at the price of increased health care resource utilization by APPs compared with physicians.…”

Section: Introductionmentioning

confidence: 99%

“…2 In prior studies performed in small practices 3 and recent studies performed in large national cohorts of patients, 4,5 it has been shown that the effectiveness of outpatient delivery of cardiovascular disease (CVD) and diabetes care is comparable among patients receiving care from physicians or APPs. 5 Although effectiveness of routine outpatient CVD and diabetes care delivery has shown to be comparable between physicians and APPs, 5 it is not clear whether this comes at the price of increased health care resource utilization by APPs compared with physicians. Prior studies on the topic were performed in small academic settings [6][7][8] and did not compare these findings in large health care systems in a ''real-world'' primary care setting.…”

Section: Introductionmentioning

confidence: 99%

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Health Care Resource Utilization for Outpatient Cardiovascular Disease and Diabetes Care Delivery Among Advanced Practice Providers and Physician Providers in Primary Care

Virani

Akeroyd

Ramsey

et al. 2018

Population Health Management

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Although effectiveness of diabetes or cardiovascular disease (CVD) care delivery between physicians and advanced practice providers (APPs) has been shown to be comparable, health care resource utilization between these 2 provider types in primary care is unknown. This study compared health care resource utilization between patients with diabetes or CVD receiving care from APPs or physicians. Diabetes (n = 1,022,588) or CVD (n = 1,187,035) patients with a primary care visit between October 2013 and September 2014 in 130 Veterans Affairs facilities were identified. Using hierarchical regression adjusting for covariates including patient illness burden, the authors compared number of primary or specialty care visits and number of lipid panels and hemoglobinA1c (HbA1c) tests among diabetes patients, and number of primary or specialty care visits and number of lipid panels and cardiac stress tests among CVD patients receiving care from physicians and APPs. Physicians had significantly larger patient panels compared with APPs. In adjusted analyses, diabetes patients receiving care from APPs received fewer primary and specialty care visits and a greater number of lipid panels and HbA1c tests compared with patients receiving care from physicians. CVD patients receiving care from APPs received more frequent lipid testing and fewer primary and specialty care visits compared with those receiving care from physicians, with no differences in the number of stress tests. Most of these differences, although statistically significant, were numerically small. Health care resource utilization among diabetes or CVD patients receiving care from APPs or physicians appears comparable, although physicians work with larger patient panels.

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Section: Cohort Development and Study Populationmentioning

confidence: 99%

Section: Cohort Development and Study Populationmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Health Care Resource Utilization for Outpatient Cardiovascular Disease and Diabetes Care Delivery Among Advanced Practice Providers and Physician Providers in Primary Care

Virani

Akeroyd

Ramsey

et al. 2018

Population Health Management

Self Cite

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show abstract

“…Advanced practice providers (APPs) may provide an opportunity to fill this vital gap in the healthcare delivery team to both expand access and relieve some burden from primary‐care managers . The appropriate utilization of APPs in a primary‐prevention, subspecialty clinic population has the possibility to positively impact adherence to guideline‐directed therapy, as it has been shown to do in secondary‐prevention, diabetes mellitus (DM), and heart failure populations previously …”

Section: Introductionmentioning

confidence: 99%

Treatment in a preventive cardiology clinic utilizing advanced practice providers effectively closes atherosclerotic cardiovascular disease risk‐management gaps among a primary‐prevention population compared with a propensity‐matched primary‐care cohort: A team‐based care model and its impact on lipid and blood pressure management

Fentanes

Hei

Holuby

et al. 2018

Clinical Cardiology

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Background Advanced practice providers (APPs) can fill care gaps created by physician shortages and improve adherence/compliance with preventive ASCVD interventions. Hypothesis APPs utilizing guideline‐based algorithms will more frequently escalate ASCVD risk factor therapies. Methods We retrospectively reviewed data on 595 patients enrolled in a preventive cardiology clinic (PCC) utilizing APPs compared with a propensity‐matched cohort (PMC) of 595 patients enrolled in primary‐care clinics alone. PCC patients were risk‐stratified using Framingham Risk Score (FRS) and coronary artery calcium scoring (CACS). Results Baseline demographics were balanced between the groups. CACS was more commonly obtained in PCC patients (P < 0.001), resulting in reclassification of 30.6% patients to a higher risk category, including statin therapy in 26.6% of low‐FRS PCC patients with CACS ≥75th MESA percentile. Aspirin initiation was higher for high and intermediate FRS patients in the PCC (P < 0.001). Post‐intervention mean LDL‐C, non–HDL‐C, and triglycerides (all P < 0.05) were lower in the PCC group. Compliance with appropriate lipid treatment was higher in intermediate to high FRS patients (P = 0.004) in the PCC group. Aggressive LDL‐C and non–HDL‐C treatment goals (<70 mg/dL, P = 0.005 and < 130 mg/dL, P < 0.001, respectively), were more commonly achieved in high‐FRS PCC patients. Median post‐intervention SBP was lower among intermediate and low FRS patients (P = 0.001 and P < 0.001, respectively). Cumulatively, this resulted in a reduction in median post‐intervention PCC FRS across all initial FRS risk categories (P < 0.001 for all). Conclusions APPs within a PCC effectively risk‐stratify and aggressively manage ASCVD risk factors, resulting in a reduction in post‐intervention FRS.

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Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease

et al. 2021

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IMPORTANCEThere is a paucity of data regarding secondary prevention care disparities in women with premature and extremely premature atherosclerotic cardiovascular disease (ASCVD), defined as an ASCVD event at 55 years or younger and 40 years or younger, respectively.OBJECTIVE To evaluate sex-based differences in antiplatelet agents, any statin, high-intensity statin (HIS) therapy, and statin adherence in patients with premature and extremely premature ASCVD. DESIGN, SETTING, AND PARTICIPANTSThis was a cross-sectional, multicenter, nationwide VA health care system-based study with patients enrolled in the Veterans With Premature Atherosclerosis (VITAL) registry. The study assessed patients who had at least 1 primary care visit in the Veterans Affairs (VA) health care system from October 1, 2014, to September 30, 2015. Participants included 147 600 veteran patients with premature ASCVD, encompassing ischemic heart disease (IHD), ischemic cerebrovascular disease (ICVD), and peripheral arterial disease (PAD).EXPOSURES Women vs men with premature and extremely premature ASCVD.MAIN OUTCOMES AND MEASURES Antiplatelet use, any statin use, HIS use, and statin adherence (proportion of days covered [PDC] Ն0.8). RESULTSWe identified 10 413 women and 137 187 men with premature ASCVD (age Յ55 years) and 1340 women and 8145 men with extremely premature (age Յ40 years) ASCVD. Among patients with premature and extremely premature ASCVD, women represented 7.1% and 14.1% of those groups, respectively. When compared with men, women with premature ASCVD had a higher proportion of African American patients (36.1% vs 23.8%) and lower proportions of Asian patients (0.5% vs 0.7%) and White patients (56.1% vs. 68.1%). In the extremely premature ASCVD group, women had a comparatively higher proportion of African American patients (36.8% vs 23.2%) and lower proportion of White patients (55.0% vs 67.8%) and Asian patients (1.3% vs 1.5%) than men. Among patients with premature IHD, women received less antiplatelet (adjusted odds ratio [AOR], 0.47, 95% CI, 0.45-0.50), any statin (AOR, 0.62; 95% CI, 0.59-0.66), and HIS (AOR, 0.63; 95% CI, 0.59-0.66) therapy and were less statin adherent (mean [SD] PDC, 0.68 [0.34] vs 0.73 [0.31]; β coefficient: −0.02; 95% CI, −0.03 to −0.01) compared with men. Similarly, women with premature ICVD and premature PAD received comparatively less antiplatelet agents, any statin, and HIS. Among patients with extremely premature ASCVD, women also received less antiplatelet therapy (AOR, 0.61; 95% CI, 0.53-0.70), any statin therapy (AOR, 0.51; 95% CI, 0.44-0.58), and HIS therapy (AOR, 0.45; 95% CI, 0.37-0.54) than men. There were no sex-associated differences in statin adherence among patients with premature ICVD, premature PAD, or extremely premature ASCVD. CONCLUSIONS AND RELEVANCEThis cross-sectional study revealed that women veterans with premature ASCVD and extremely premature ASCVD receive less optimal secondary prevention cardiovascular care in comparison with men. Women with premature ASCVD, particularly those...

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Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act

Cited by 59 publications

References 22 publications

Health Care Resource Utilization for Outpatient Cardiovascular Disease and Diabetes Care Delivery Among Advanced Practice Providers and Physician Providers in Primary Care

Health Care Resource Utilization for Outpatient Cardiovascular Disease and Diabetes Care Delivery Among Advanced Practice Providers and Physician Providers in Primary Care

Sex-Related Disparities in Cardiovascular Health Care Among Patients With Premature Atherosclerotic Cardiovascular Disease

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