In the Journals

Nurse practitioners, physician assistants effectively manage chronic conditions

Nurse practitioners and physician assistants provided care to patients with chronic conditions, including diabetes, that led to similar health outcomes to that of physicians, according to research published in Annals of Internal Medicine.

“The role of nonphysician primary care providers (PCPs) continues to expand. However, concerns have long been expressed as to whether the outcomes achieved by nurse practitioners (NPs) and physician assistants (PAs) are equivalent to those of physicians. Further, few studies have compared chronic illness outcomes of primary care provided by PAs versus NPs or physicians,” George L. Jackson, PhD, MHA, health care epidemiologist at Durham Veterans Affairs Health Care System and assistant professor in the division of general internal medicine at Duke University, and colleagues wrote.

Jackson and colleagues analyzed data from the U.S. Department of Veterans Affairs electronic health record to investigate whether intermediate diabetes outcomes differ among patients cared for by three types of PCPs: physicians, NPs and PAs.

A total of 368,481 patients with diabetes being treated with pharmaceutical medications were included in the analysis. About 75% of patients were cared for primarily by physicians (n = 3,487), while 18.2% were cared for by NPs (n = 1,445) and 6.9% were cared for by PAs.

The researchers measured patients’ continuous and dichotomous control of HbA1c, systolic BP and LDL cholesterol and compared these outcomes by type of PCP.

Compared with physicians, the difference in HbA1c levels for NPs was –0.05% (95% CI, –0.07 to –0.02) and for PAs was 0.01% (95% CI, –0.02 to 0.04). The difference in systolic BP was –0.08 mm Hg (95% CI, –0.34 to 0.18) for NPs and 0.02 mm Hg (95% CI, –0.42 to 0.38) for PAs, compared with physicians. The difference in LDL cholesterol was 0.01 mmol/L (95% CI, 0-0.03) for NPs and 0.03 mmol/L (95% CI, 0.01-0.05) for PAs, compared with physicians.

These differences were not clinically significant, the researchers noted.

“This study provides further evidence that using NPs and PAs as PCPs may represent a mechanism for expanding access to primary care while maintaining quality standards,” Jackson and colleagues concluded.

In a related editorial, Anne L. Peters, MD, professor of medicine at Keck School of Medicine of the University of Southern California, wrote that the findings by Jackson and colleagues are not surprising.

She argued that of more importance was that the study highlights the changing definition of the PCP and the role of PCPs in managing diabetes.

“The time has come to embrace many different approaches to providing primary care, particularly for persons with a chronic disease, such as diabetes,” Petters wrote. “Given the right system — with resources to provide education and support, along with referral to an endocrinologist or a diabetes team if needed, and including more innovative programs, such as telehealth, online programs, and device-based data transfer and support — persons with diabetes can achieve their goals.”

“Moreover, it is time to stop calling NPs and PAs ‘midlevel’ providers, as is common in certain systems,” she added. “Nurse practitioners and PAs are competent PCPs in their own right and should be fully accepted as such.” – by Alaina Tedesco

 

Disclosures: Jackson reports receiving grants from the VA. Please see study for all other authors’ relevant financial disclosures. Peters reports receiving grants from Astra Zeneca, Dexcom and Mannkind; and personal fees from Abbott Diabetes Care, BI, Eli Lilly, Lexicon, Livongo, Merck, NovoNordisk, Omada Health and Sanofi.

Nurse practitioners and physician assistants provided care to patients with chronic conditions, including diabetes, that led to similar health outcomes to that of physicians, according to research published in Annals of Internal Medicine.

“The role of nonphysician primary care providers (PCPs) continues to expand. However, concerns have long been expressed as to whether the outcomes achieved by nurse practitioners (NPs) and physician assistants (PAs) are equivalent to those of physicians. Further, few studies have compared chronic illness outcomes of primary care provided by PAs versus NPs or physicians,” George L. Jackson, PhD, MHA, health care epidemiologist at Durham Veterans Affairs Health Care System and assistant professor in the division of general internal medicine at Duke University, and colleagues wrote.

Jackson and colleagues analyzed data from the U.S. Department of Veterans Affairs electronic health record to investigate whether intermediate diabetes outcomes differ among patients cared for by three types of PCPs: physicians, NPs and PAs.

A total of 368,481 patients with diabetes being treated with pharmaceutical medications were included in the analysis. About 75% of patients were cared for primarily by physicians (n = 3,487), while 18.2% were cared for by NPs (n = 1,445) and 6.9% were cared for by PAs.

The researchers measured patients’ continuous and dichotomous control of HbA1c, systolic BP and LDL cholesterol and compared these outcomes by type of PCP.

Compared with physicians, the difference in HbA1c levels for NPs was –0.05% (95% CI, –0.07 to –0.02) and for PAs was 0.01% (95% CI, –0.02 to 0.04). The difference in systolic BP was –0.08 mm Hg (95% CI, –0.34 to 0.18) for NPs and 0.02 mm Hg (95% CI, –0.42 to 0.38) for PAs, compared with physicians. The difference in LDL cholesterol was 0.01 mmol/L (95% CI, 0-0.03) for NPs and 0.03 mmol/L (95% CI, 0.01-0.05) for PAs, compared with physicians.

These differences were not clinically significant, the researchers noted.

“This study provides further evidence that using NPs and PAs as PCPs may represent a mechanism for expanding access to primary care while maintaining quality standards,” Jackson and colleagues concluded.

In a related editorial, Anne L. Peters, MD, professor of medicine at Keck School of Medicine of the University of Southern California, wrote that the findings by Jackson and colleagues are not surprising.

She argued that of more importance was that the study highlights the changing definition of the PCP and the role of PCPs in managing diabetes.

“The time has come to embrace many different approaches to providing primary care, particularly for persons with a chronic disease, such as diabetes,” Petters wrote. “Given the right system — with resources to provide education and support, along with referral to an endocrinologist or a diabetes team if needed, and including more innovative programs, such as telehealth, online programs, and device-based data transfer and support — persons with diabetes can achieve their goals.”

“Moreover, it is time to stop calling NPs and PAs ‘midlevel’ providers, as is common in certain systems,” she added. “Nurse practitioners and PAs are competent PCPs in their own right and should be fully accepted as such.” – by Alaina Tedesco

 

Disclosures: Jackson reports receiving grants from the VA. Please see study for all other authors’ relevant financial disclosures. Peters reports receiving grants from Astra Zeneca, Dexcom and Mannkind; and personal fees from Abbott Diabetes Care, BI, Eli Lilly, Lexicon, Livongo, Merck, NovoNordisk, Omada Health and Sanofi.