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Physicians More Likely than Mid-Level Providers to Initiate Treatment Change for Veterans with Diabetes and Elevated Blood Pressure


Incorporating mid-level providers - nurse practitioners (NPs) or physician assistants (PAs) - into primary care practice is an effective way to improve patient access to care and give physicians more time to see patients with complex conditions. Over the past decade, VA increased mid-level providers by 200%. This prospective cohort study sought to examine whether treatment change for Veterans with diabetes and elevated blood pressure (BP) differed between physicians and mid-level providers (NPs, PAs), and to determine reasons for any observed differences. Investigators analyzed data, including patient and provider surveys, for 1169 Veterans with diabetes and 92 primary care providers from nine Midwest VA facilities. The main variable measured was whether or not there was a treatment change by the provider in response to elevated BP.

Findings show that mid-level providers were significantly less likely than physicians to change BP treatment for Veterans with diabetes and multiple chronic conditions, even after controlling for a number of patient, provider, and organizational characteristics. For example, after controlling for visit factors, provider practice style, measurement and organizational factors, mid-level providers were still less likely than physicians to initiate treatment change (37.5% vs. 52.5%) for elevated BP. Investigators also note that a fairly comprehensive set of potential explanatory variables did not account for any of the differences between physicians and mid-level providers. Given the expanding role of mid-level providers in delivering primary care to complex patients, the authors suggest seeking a better understanding of differences in BP treatment change.

PubMed Logo Subramanian U, Kerr E, Klamerus M, Zikmund-Fisher B, Holleman R, and Hofer T. Treatment decisions for complex patients: Differences between primary care physicians and mid-level providers. American Journal of Managed Care June 2009;15(6):373-80.

This study was partly funded by HSR&D. Dr. Subramanian is part of the Roudebush VA Medical Center in Indianapolis; all other authors are part of HSR&D's Center for Clinical Management Research in Ann Arbor.

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HSR&D requires notification by HSR&D-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR&D and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR&D based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR&D published articles. Visit the HSR&D citations database for a complete listing of HSR&D articles and presentations.