Nurse practitioners and physicians offer similar care, study finds

Dr. John Mafi

Do nurse practitioners and physician assistants provide the same level of care as doctors? That’s the question to keep in mind amid a growing controversy over proposals to expand the role of nurse practitioners and physician assistants in doctors’ offices due to a shortage of primary care physicians. A new study could either help provide an answer to that question – or fuel the debate.

Most recently, in a move to address staffing shortages, the Department of Veterans Affairs announced last month that it wants to grant full practice authority to its advanced practice registered nurses, permitting them to assess and diagnose patients, prescribe medications and interpret tests. They would do this without a physician’s supervision – in other words, they would get full autonomy in these areas.

The news prompted a less than happy response from the American Medical Association, which argued that the proposal would “significantly undermine the delivery of care within the VA,” and that physicians, with thousands of hours of education and training behind them, are best qualified to provide this care. Besides, physicians and physician groups say, nurse practitioners and physician assistants – also called advanced practice clinicians – are more apt than doctors to order costly and unnecessary tests, treatments and referrals, collectively known as low-value health services.

As it turns out, however, UCLA-led research published June 21 in the Annals of Internal Medicine finds that physicians and advanced practice clinicians provide similar amounts of these needless services. It’s one of the largest national studies to date on this issue.

“Contrary to physician perceptions, [advanced-practice clinicians] provide an equivalent amount of low-value care where the risk of harm is greater than the benefit,” Dr. John Mafi, assistant professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA, and the study’s lead author, said in an interview with

Low-value health services are defined as services for which the risks typically exceed the benefits—for example, antibiotics against the cold virus don’t help cure the illness and can cause harmful side-effects.

The researchers used data from Jan. 1, 1997, through Dec. 31, 2011, from the National Ambulatory Medical Care Survey (12,170 physicians and 473 advanced practice clinicians) and the National Hospital Ambulatory Medical Care Survey (13,359 physician and 2,947 advanced practice clinicians). They examined three outcomes commonly considered to be low value health services: use of antibiotics for upper respiratory infections, X-rays for upper respiratory infections and back pain, and advanced imaging such as magnetic resonance imaging and computed tomography for back pain and headache. They also looked at physician referrals to specialists, which generally are not required for these routine and straightforward conditions.

They found no significant differences between physicians and advanced practice clinicians in either office-based or hospital-based primary care settings.

Here are the rates of low-value services ordered by physicians and advanced practice clinicians in primary care practice:

  Physicians Advanced Practice Clinicians
Office-based 48.7 percent 51.9 percent
Hospital-based 46.0 percent 52.8 percent
Office-based 5.7 percent 3.0 percent
Hospital-based 7.1 percent 6.4 percent
Office-based 10.0 percent 10.9 percent
Hospital-based 10.5 percent 11.1 percent
Referrals to other physicians
Office-based 7.6 percent 7.8 percent
Hospital-based 8.3 percent 11.8 percent

The findings were roughly similar among patients with acute vs. chronic symptoms, though there was a suggestion that hospital-based advanced practice clinicians who were the patient’s own primary care provider ordered more services than physicians.

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