VA Diabetes and Cardiovascular Care Quality Comparable between Physicians and Advanced Practice Providers
The United States has fewer primary care physicians (PCPs) per capita than any other industrialized country, and it is estimated that the U.S. will face a shortage of 45,000 PCPs by 2020, which will increase to 65,000 by 2025. A possible solution to this shortage has been to expand the scope of practice laws to advanced practice providers (APPs, including nurse practitioners and physician assistants) to perform their clinical duties independently. However, questions remain about whether the quality of chronic disease care delivered by physicians and APPs is comparable. This study assessed the effectiveness of diabetes and cardiovascular disease (CVD) care provided to Veterans in VA primary care by APPs compared to physicians. Using VA data, investigators identified Veterans who received primary care for diabetes or CVD from VA in FY2014 in 130 VAMCs. The diabetes cohort included 1,022,588 Veterans: 811,872 who received care from a physician, and 210,716 who received care from an APP. The CVD cohort included 1,187,035 Veterans: 934,950 who received care from a physician, and 252,085 who received care from an APP. Investigators then compared quality of care for various performance measures separately for Veterans with diabetes and CVD receiving care from a physician or APP. For Veterans with diabetes, outcomes included glycemic, blood pressure (BP), and lipid control. For Veterans with CVD, outcomes included BP control, proportion with myocardial infarction (in the last two years) receiving beta-blocker therapy, and lipid control.
- The quality of diabetes and CVD care delivered in VA primary care settings was mostly comparable between physicians and APPs. However, a majority of Veterans with diabetes and CVD – irrespective of their provider type – did not meet performance measures geared toward control of multiple risk factors. Only 27% and 28% of Veterans with diabetes and 54% and 55% of Veterans with CVD receiving care from physicians and APPs, respectively, met all eligible measures.
- Results suggest that a care delivery model with more expansion of the role for APPs could address some healthcare access issues without compromising basic quality of CVD and diabetes care delivery. However, regardless of provider type, there is a need to improve performance on all eligible measures among these Veterans.
- Investigators could not account for care received by Veterans outside the VA health care system. In addition, results only apply to outpatient non-urgent clinical care.
- This study evaluated only one aspect of quality (i.e., effectiveness) and did not examine other factors that help define good quality of care, such as safety, timeliness, equity, patient-centeredness, and efficiency.
This study was partly by HSR&D. Drs. Virani, Ramsey, Petersen and Ms. Akeroyd are part of HSR&D's Center for Innovations, Quality, Effectiveness and Safety (IQuESt) in Houston, TX.
Virani S, Akeroyd J, Ramsey D, et al. 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. American Heart Journal. November 2016;181:74-82.