Nurse Practitioners and Physician Assistants: Primary Care Roles and Outcomes

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Anticipated Impact on Veterans' Healthcare: This project will describe and compare outcomes of Veterans Health Administration (VHA) nurse practitioner (NP), physician assistant (PA), and physician roles in primary care of patients with diabetes. Results will inform patient aligned care team (PACT) role implementation so that NPs and PAs can maximally contribute to quality and cost of veteran care. For example, results will compare NP, PA, and physician care outcomes for clinically complex patients. Intermediate study results, such as how number and type of patient visits correlate with assigned primary care provider, can rapidly aid VHA workforce planning and evaluation. The project expands methods for characterizing VHA NP and PA roles utilizing secondary data that can be adapted for future VHA research addressing how to best utilize NP and PA skills. Background: Expected primary care provider shortfalls threaten access to care in both the Veterans Health Administration (VHA) and the U.S. healthcare system. Meanwhile, deficiencies in quality and efficiency of primary care demand new approaches such as patient-aligned care team models. Expanded use of NPs and PAs is key to addressing these access, quality, and cost issues. Although the VHA has been a pioneer in adopting expansive roles for nonphysician providers and VHA PACTs can be led by NPs and PAs, there is limited information about how the work of patient care is divided among VHA providers or about how this division of labor affects care outcomes and costs. Because of potential differences in care provided by NPs and PAs, our study assesses each profession separately. Because most non-VHA national datasets under-represent NP and PA care, the VHA provides the only national data that allow for valid comparisons of care provided by different provider types. Building on our previous work, we will use diabetes as a tracer condition to evaluate care. Diabetes is prevalent (>24% of VA patients) and costly to the VHA, and treatment of patients with diabetes calls for services representative of the wide range of clinical skills and tasks required of primary care providers. Objectives: The project purpose is to examine clinical roles of NPs, PAs, and physicians in VHA primary care of patients with diabetes and to assess the association of these roles with care outcomes and costs. Aim 1. Characterize role patterns for allocation of patient care work among NPs, PAs, and physicians in the care of patients with diabetes in VHA primary care clinics. Aim 2. Compare quality of care outcomes for patients with diabetes across usual provider of care (UPC) types and NP & PA roles, controlling for organizational characteristics and patient health status. We will examine intermediate patient-level clinical outcomes (i.e. hemoglobin A1c, blood pressure, and low- density lipoprotein cholesterol) and patient-level clinical processes that are more proximal to the provider (i.e. receipt of a diabetic eye exam and new participation in the MOVE! Weight Management Program). Aim 3. Evaluate health resource utilization and costs for patients with diabetes across UPC types and NP & PA roles, controlling for initial health and organizational characteristics. We will evaluate utilization of: 1) outpatient care (primary and total); 2) emergency department care; and 3) inpatient care (ambulatory care sensitive condition admissions and total) and total patient-level costs. Methods: This is a retrospective cross-sectional study using secondary VHA data combined with previously collected VHA facility survey data. We will describe the roles of NPs, PAs, and physicians (usual provider vs. supplemental provider; type of care provided, and complexity of patients) by patient and organizational characteristics. We will then utilize hierarchical linear modeling (patients clustered within providers clustered within facilities) to examine the association between provider roles and intermediate clinical, process and economic outcomes, controlling for patient and organizational factors described above.