1016 — Treatment Decisions for Complex Patients: Differences between Primary Care Physicians and Mid-level Providers

Klamerus ML (VA Ann Arbor HSR&D Center of Excellence (COE)), Kerr EA (VA Ann Arbor HSR&D COE), Zikmund-Fisher BJ (VA Ann Arbor HSR&D COE), Subramanian U (Roudebush VAMC, Indianapolis), Hofer TP (VA Ann Arbor HSR&D COE)

Objectives:
The role of mid-level providers (nurse practitioners [NPs], physician assistants [PA]) in VA primary care has expanded. Few studies have examined differences in decision-making between physicians and mid-level providers for patients with multiple chronic conditions. We examined whether treatment change for diabetic patients presenting with an elevated blood pressure [BP] differed between physicians and mid-level providers.

Methods:
We enrolled 1,169 diabetic patients of 92 primary care providers (PCPs) in nine Midwest VA facilities. Patients were enrolled if their triage BP prior to a PCP visit was > =140/90. PCPs completed a baseline survey that assessed BP management practice style and an enrollment survey on BP medication changes and issues discussed at the visit. BP values and follow-up plans were obtained from the medical record and automated data. Using two-level logistic regression models, we examined the association of provider type (physician vs. mid-level) with treatment change (BP medication intensification at the visit or planned prompt follow-up to reassess BP). In the first model, we controlled for enrollment visit BP and mean SBP in the prior year. In the second model, we also controlled for patient factors (e.g., number of chronic conditions, issues discussed at visit) and provider factors (e.g., BP goals, provider propensity to intensify) that could explain differences by provider type. We calculated predicted probabilities of treatment change by provider type, holding other variables constant at their means.

Results:
Among the PCPs, 64 were physicians, 21 were NPs, and 7 were PAs. Patients cared for by physicians and mid-level providers did not differ in their mean enrollment BP, number of chronic conditions, or age. Controlling for current and past BPs, physicians were significantly more likely to initiate a treatment change (55% vs. 37%, p < .001). After adding other patient and provider factors, physicians were still more likely to initiate a treatment change (51% vs. 38%, p=.023).

Implications:
Mid-level providers were significantly less likely to change BP treatment for diabetic patients with multiple chronic conditions.

Impacts:
Given the expanded role of mid-level providers in VA primary care clinics, greater attention needs to be paid to supporting appropriate clinical decision-making for complex patients.