Comparing Use of Low-Value Health Care Services Among US Advanced Practice Clinicians and Physicians
Comparing Use of Low-Value Health Care Services Among US Advanced Practice Clinicians and Physicians
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DOI：
10.7326/m15-2152
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发表时间：
2016-08-16
影响因子：
39.2
通讯作者：
Landon, Bruce E.
中科院分区：
文献类型：
--
作者：
Mafi, John N.;Wee, Christina C.;Landon, Bruce E.
背景资料：许多医生认为，先进的实践临床医生（APC [执业护士和医师助理]）提供的护理相对较低的value.Objective：To比较使用低价值的服务之间的美国APC和physics.Design：初级保健访问后的服务使用进行了评估，为3个条件调整后的患者和供应商的特点和年。根据指南的危险信号的患者被排除，分析按门诊与住院就诊、急性与非急性表现以及临床医生是否自认为是患者的初级保健提供者（PCP）进行分层。设置：1997年至2011年国家门诊医疗调查（NAMCS）和国家医院门诊医疗调查（NHAMCS）患者：患有上呼吸道感染（URI）、背痛或头痛的患者。使用指南不一致的抗生素（用于URI），放射摄影（用于URI和背痛）、计算机断层扫描（CT）或磁共振成像（MRI）结果：确定了12 170名医生和473名APC办公室就诊和13 359名医生和2947名APC医院就诊。尽管诊所的临床医生看到的患者相似，但医院的APC看到的患者更年轻（平均年龄，42.6 vs. 45.0岁; P < 0.001），并且在城市环境中执业的频率低于医院医生（49.7% vs. 81.7%; P < 0.001）。未经调整和调整的结果显示，APC在这两种情况下都与医生一样经常使用抗生素，CT或MRI，X线摄影和转诊。分层表明，自我认定的PCP APC订购更多的服务比PCP医生在hospital-based setting.Limitation：NHAMCS反映了医院为基础的APC护理; NAMCS样本医生的做法，并可能underrepresented办公室为基础的APCs.Conclusion：APC和医生提供了等量的低价值的医疗服务，消除医生的看法，APC提供低价值的护理比医生为这些常见的条件。
Background: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value.Objective: To compare use of low-value services among U.S. APCs and physicians.Design: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office-versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP).Setting: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011Patients: Patients presenting with upper respiratory infections (URIs), back pain, or headache.Measurements: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions).Results: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting.Limitation: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs.Conclusion: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions.