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NPs, PAs increasingly provide care to specialists’ patients

From 2001 to 2013, there was an increase in the involvement of nurse practitioners and physician assistants in the care of patients visiting specialist physicians; however, growth has slowed in recent years and these visits remain a minor percentage of overall specialty visits, according to a research letter published in JAMA Internal Medicine.

“Nurse practitioners (NPs) and physician assistants (PAs) play key roles in expanding access to primary care, but their involvement in specialty care is not well described,” Kristin N. Ray, MD, MS, from the University of Pittsburgh School of Medicine, and colleagues wrote. “Given concerns about the limited supply of specialist physicians, increasing incorporation of NPs and PAs into collaborative specialist practices could be a strategy for improving access.”

The researchers noted that there is a lack of knowledge of the trends in specialist physician visits in which NPs and PAs provide care. To address this gap, they identified visits to specialist physicians using data from the National Ambulatory Medical Care Survey, which included a nationally representative sample of outpatient care office visits (n = 473,132) from 2001 to 2013. Visits were categorized as visits to surgical and medical specialist physicians.

The researchers used multiyear intervals to evaluate unadjusted trends in the percentage of visits with NP or PA involvement from 2001 to 2013. They also used a logistic regression model to determine the adjusted percentages of visit characteristics associated with higher likelihood of NP or PA involvement during the study period.

The percentage of visits to surgical and medical specialist physicians involving an NP increased from 3.3% in 2001 to 2003 to 6.9% in 2010 to 2013 (P=.001), while visits involving a PA increased from 2.4% in 2001 to 2003 to 5.8% in 2010 to 2013 (P<.001). Among visits with an NP or PA, new and return visits and all visit reasons increased similarly. The percentage of visits involving NPs or PAs in which the patient did not also see a physician grew from 12.3% to 21.4% (P=.004)

After adjustment for other visit and patient factors, the researchers found that among the proportion of visits with an NP or PA, there was significant variation by visit reason (4.9% of routine chronic visits vs. 9.3% of presurgical and postsurgical visits), patient comorbidity (10.6% of visits among patients with 4 chronic conditions vs. 5.6% with no chronic conditions) and region (4% of visits in the Midwest vs. 9.6% in the Northeast). In addition, there was a variation across specific specialties in the adjusted proportion of visits with an NP or PA, ranging from 4% (general surgery) to 8.5% (otorhinolaryngology).

“NPs or PAs were disproportionately involved in care of patients with greater medical complexity, requiring further work to understand if this reflects team-based care, coding artifact, or other explanations,” Ray and colleagues concluded. “These findings are particularly notable given that NPs and PAs in specialty care receive shorter formal training than specialist physicians, with specialty-specific training entirely on-the-job in some fields.”

“Our findings have implications for the specialty workforce, and the impact on access to specialty care and its quality should be evaluated,” they added. – by Alaina Tedesco

Disclosure: The researchers report funding from the Agency for Healthcare Research and Quality.