key: cord-0706022-bwppob95
authors: Hohman, Jessica A.; Patel, Aditi; Parikh, Parth; Rothberg, Michael B.
title: Comparing Encounter Characteristics Among Advanced Practice Clinicians and Physicians for Adult Same-Day Visits in Primary and Urgent Care
date: 2021-03-03
journal: J Gen Intern Med
DOI: 10.1007/s11606-021-06669-w
sha: 7de513a3c9b5af4adedf7f82176c532c6ce277e9
doc_id: 706022
cord_uid: bwppob95

nan

We performed a retrospective cross-sectional analysis of adult same-day visits to primary and urgent care from December 2014 to August 2015 within our integrated health system. A total of 1200 unique patient encounters were randomly selected for chart review from 52 academic and community practice sites in urban, suburban, and rural settings. Two physicians classified reason for visit (acute complaint, stable chronic condition follow-up, exacerbation of chronic condition, preventive care, or other), encounter complexity (simple algorithmic v. complex diagnostic), complaint acuity (acute v. chronic), number of additional problems addressed, medication changes, and diagnostic interventions, including consultations, imaging, and labs (Table 1) . Patient and clinician demographics were extracted from the electronic medical record. The Cleveland Clinic Institutional Review Board approved this study.

For patient and encounter measures, we reported frequencies (percentages) and measures of central tendency by provider type. We also described differences between physicians and APCs, using chi-square and t tests. We modeled odds of prescription receipt, medication de-prescribing, and addressing additional concerns using mixed-effects logistic regression models, accounting for clustering by clinician. Models included provider, patient, and encounter characteristics.

Our sample included 393 physician and 807 APC visits ( Table 2 ). Patients seeing APCs were more likely to be female (68.9% v. 60.0%, p=0.002) and non-Caucasian (19.6% v. 9.4%, p<.0001). APC visits were more often for simple algorithmic complaints than physician visits (67.7% v 55.0%, p<.0001). Physicians more frequently addressed additional problems (0.62 v. 0.38, p=0.0003). The number of new medications prescribed was similar (1.26 v. 1.24, p=0.68), but physicians de-prescribed more medications (0.48 v. 0.34, p=0.02). There was no difference in the number of diagnostic interventions (2.89 v. 2.84, p=0.84), including specialty consultations (1.24 v. 1.21, p=0.74). There was no difference in seeing an APC v. physician by setting (data not shown).

In the adjusted models, addressing additional complaints (aOR 1.80, 95% CI 1.27-2.57) and de-prescribing (aOR 1.44, 95% CI 1.07-1.93) were associated with seeing a physician v. an APC.

In this observational review of 1200 cases, we found small differences in practice between APCs and physicians. APCs more often saw simple, algorithmic complaints, while physicians were more likely to address additional health concerns or de-prescribe medications. Both prescribed medications and ordered diagnostic interventions at similar rates. To our knowledge, our study is the first to examine differences in APC and physician practice content.

Prior studies finding similar quality of care between APCs and physicians did not assess the complexity of decisionmaking, 6 focusing instead on diagnoses amenable to algorithmic care, such as low-back pain and sinusitis. [1] [2] [3] [4] [5] [6] Although our system employs no formal triage process, physicians saw a higher proportion of visits requiring diagnostic acumen. Physicians also added value by de-prescribing and addressing additional complaints.

Limitations include the single institution sample, which may not be representative. We also did not assess diagnostic accuracy or longitudinal outcomes.

Given primary care shortages and rising care demand, it may be tempting to replace physicians with APCs. Our findings suggest that they often do similar work, but physicians may add value in unmeasured ways. Systems are needed to ensure that work is divided between physicians and APCs in ways that maximize efficiency through the use of each practitioner's particular skills. Publisher's Note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Mean number of current medication subtypes or supplements provided for those patients endorsing taking at least one medication prior to encounter Bold values are statistically significant at p < 0.05

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