Download Characteristics of Primary Care Office Visits to Physician Assistants

Characteristics of Primary Care Office Visits to Physician Assistants, Nurse
Practitioners, and Physicians in the VA , 2005-2010
Perri Morgan1 •David H. Abbott2• Rebecca McNeill2 • Deborah A. Fisher2,3
1Duke Department of Community and Family Medicine
2 Durham VA HSRD • 3 Duke Department of Medicine
We examine whether primary
care provider types are
occupying patient care niches
within the VA. We also examine
the assumption that PAs and NPs
see patients who are less
medically complex than those
seen by physicians.
METHODS
RESEARCH
QUESTIONS
2. How do patient and patient
encounter characteristics vary
among provider types?
RESULTS
Primary Care Visits by Provider Type,
2005-2010
80
20
45
18
40
16
35
30
25
PAs
20
NPs
15
PAs + NPs
10
5
0
Variable
PA
NP
Mean age (years)
62.8
61.1
61.7
Male (%)
93.4
93.3
90.0
21.0
20.9
20.4
African American
5.8
5.0
6.0
Hispanic
2/7
1.1
1.8
Other
0.3
0.2
0.3
70.1
72.8
71.7
92.4
85.7
90.3
Unscheduled visit
4.2
5.3
4.5
Physical exam to determine
compensation and pension
eligibility
3.4
9.0
5.2
50
Physicians
Physician assistants
Nurse practitioners
Missing
Purpose of visit (%)
10
Scheduled clinic visit
0
2005
2006
2007
2008
2009
2010
PAs and NPs attend 28-30% of VA primary care
visits, with NPs attending twice as many visits
as PAs.
10
8
Physicians
6
PAs
NPs
4
0
Physician
60
30
12
Use of PAs and NPs in varies widely by region.
Inter-facility variation may also be large.
White
40
14
2
1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23
Veterans Integrated Service Network (VISN) number
Race/ethnicity (%)
70
Comparison of primary encounter diagnoses, 2010
50
Comparison of VA primary care encounter
characteristics, 2010
20
This project uses national data
from the Veterans Administration
to compare characteristics of
primary care patients and patient
encounters attended by PAs, NPs
or physicians .
% of Primary Care Visits
Variation in Number of VA Primary Care Visits
to PAs and NPs by Region, 2010
1. What are the trends in use of
PAs and NPs in VA primary care
between 2005 and 2010?
% of primary care visits
The U.S. Department of Veterans
Affairs has been a frontrunner in
utilization of physician assistants
(PAs) and nurse practitioners
(NPs). Evaluation of the roles
and impact of PAs and NPs in the
VA is critical to ensuring optimal
care for American veterans and
may inform best practices for use
of PAs and NPs in other settings.
% of primary visit diagnoses
BACKGROUND
Comparison of primary visit procedure codes, 2010
Diagnosis categories were created from the encounter primary diagnosis ICD-9 codes.
Diagnoses present in >.02% of visits are categorized above. Nearly 30% of visits have ICD-9 diagnoses
present in <.02% of visits. These will be categorized in future work, and could change to proportions
above slightly..
*Symptoms without diagnoses include headache, dizziness, chest pain, edema, abdominal pain,
convulsions, and shortness of breath.
FINDINGS
1. A substantial proportion (28-30%) of VA
primary care encounters are attended by
PAs and NPs. This proportion was stable
from 2005-2010.
2. Nurse practitioners attend approximately
twice as many VA primary care
encounters as PAs.
3. Most VA primary care encounters record
only one provider type.
40
Physician assistant
Nurse practitioner
% of visits with physician listed
as a second provider
0.75
0.52
30
25
5. Characteristics of patients and encounters
are similar for physicians, PAs, and NPs
in VA primary care clinics.
20
15
10
PAs
5
NPs
Established patient
E/M* codes
New patient E/M*
codes
Other
Preventive medicine
Lifestyle counselling
Disability evaluations
Immunizations
Comprehesive mod-hi severity
Mod-hi severity problem
Moderate severity problem
Low-moderate severity problem
Comprehesive mod-hi severity
Mod-hi severity problem
Low-moderate severity problem
0
Minor problem
Very few (<1%) visits to NPs and PAs list a
physician as a second provider. It is possible that
physicians were involved in some of these visits,
but not coded as providers.
Physicians
Minimal problem
• Veterans Administration
electronic medical record data
from 2005-2010
• 11 million primary care
encounters in 2010
• Physicians: 7,700,000
• NPs:
2,000,000
• PAs:
890,000
Provider type
% of visits
DATA SOURCE
4. Use of PAs and NPs in VA primary care
varies widely by region.
35
Other
Categories were created from encounter CPT codes.
*E/M= Evaluation and management.
IMPLICATIONS
1. VA data is a promising source for
research on care by PAs and NPs.
2. Other sources show recent growth
in VA employment of PAs and
NPs. Since we did not find an
increase in numbers of primary
care PA and NP visits, these new
employees may be working in
specialty care.
3. PAs , NPs, and physicians seem to
fill similar roles in VA primary
care clinics. Additional research
is needed to examine whether this
is the most effective and efficient
division of labor.
FUTURE WORK
• Person-level analysis comparing
patient characteristics by assigned
primary care provider type.
• Analysis of primary care team
composition and division of labor.
• Comparison of patient-level
continuity of care, resource use,
and health outcomes by assigned
primary care provider type.
6. PAs perform more general medical
exams for purposes of determining
disability than do physicians or NPs.
Contact information: [email protected]