Quality of Diabetes Care in Family Medicine Practices: Influence of Nurse-Practitioners and Physician's Assistants

Abstract

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician's assistants (PAs), or neither, and which practice attributes contribute to any differences in care.METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identifi ed by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs. RESULTSCompared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A 1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤.005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A 1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P ≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P = .03) and had larger total staff (P <.001) than physician-only practices.CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear. Ann Fam Med 2008;6:14-22. DOI: 10.1370/afm.758. INTRODUCTIONI ncreasingly, nurse-practitioners (NPs) and physician's assistants (PAs) serve as a primary point of contact for patients within primary care practices.1,2 Bolstering this trend is the development of new models of primary care practice advocating collaborative teams of diverse clinicians.3-5 Yet, among family physicians, some uncertainty and unease persists about the use of these clinicians, [6][7][8] particularly with regard to quality of care, 9,10 patient satisfaction, 11,12 and fi nancial effi ciency. 13,14 Most randomized clinical trials and observational studies have focused on comparing the quality of care between physicians and NPs, with relatively little published research comparing PAs with either physicians or NPs. 9,[15][16][17][18] For example, in a study comparing NP and physician performance in the care and attainment of outcomes for patients with diabetes, Lenz et al 19 found signifi cant differences in documentation but not in patient outcomes. Some have argued that NPs may enhance primary care because they are trained specifi cally for health promotion and education. 2,20,21 In fact, Hopkins et al 22 found that compared with physicians, NPs performed better at secondary prevention, assessment, and counseling. QU A L I T Y O F DIA BE T ES C A R E W I T H NP s A ND PA sSakr et al 16 found that patients cared for by NPs received more inf...

Investigating the contribution of physician assistants to primary care in England: a mixed-methods study

“…140,144,154,155,168,169,174 While evidence was mainly positive regarding the appropriateness of care, some less favourable comparisons with other providers were also reported. 155,175 It is noteworthy that most of these studies were concerned with care for people with chronic conditions, for example diabetes; however, the evidence suggests that this patient group are in the minority in the PA workload.…”

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

“…Physician organizations often state that substituting APNs for physicians may put patients at risk for poorer outcomes despite a lack of evidence to support this claim. Stakeholder acceptability might be fostered by emphasizing evidence supporting the ability of APNs to provide care that is as safe as the care provided by physicians (Fairman, 2008;Groth, Norsen, & Kitzman, 2010;Hatem et al, 2008;Hogan et al, 2010;Horrocks, Anderson, & Salisbury, 2002;Hughes, 2010;Laurant et al, 2005;Dulisse & Cromwell, 2010;Newhouse et al, 2011;Laurant et al, 2009;Jackson et al, 2011;Ohman-Strickland et al, 2008;Lenz et al, 2004). Establishing a consensus-based minimum standard for clinical experience before an APN is granted full practice authority, as New York State has done, will likely be critical to facilitating stakeholder acceptability.…”

Clinical Discoveries: A New Feature of the Annals

“…12 The study by Ohman-Strickland generated interesting discussion of the potential role of nurse-practitioners in diabetes quality of care. [13][14][15][16][17][18][19][20][21][22][23][24][25] One commenter appropriately noted that the use of the word "infl uence" in the title implies causation. Whereas the rest of the article makes it clear that the causal direction of the observed associations cannot be known from the crosssectional design, the editors regret that this word in the title was allowed to make it through the editing process, and appreciate the commenter's pointing this out for the record.…”