All Fail to Consistently Meet Performance Measures

By Brenda L. Mooney


Nurse practitioner Jyoti Desai (right) and nurse Barbara Murphy see an older primary care patient at the Philadelphia VA Medical Center. VA photo by Tommy Leonardi

HOUSTON — Cardiac patients and even some medical staff might assume they will receive the best ongoing care when they see a physician, not an advanced practice provider such as a physician assistant or nurse practitioner.

It turns out that isn’t true at all. A VA-funded study published in the Journal of the American College of Cardiology found that care for coronary artery disease, heart failure and atrial fibrillation is comparable, no matter which of those professionals is providing it.1

The more serious concern, according to study authors from the Michael E. DeBakey VAMC in Houston, is that none of the providers met all performance measures.

Using the American College of Cardiology’s PINNACLE Registry, the researchers compared the quality of care for coronary artery disease (CAD), heart failure and atrial fibrillation delivered by physicians and advanced practice providers (APPs) during outpatient visits between Jan. 1, 2012, and Dec. 31, 2012. Included in the study were 716 physicians and 167 APPs in 41 practices, caring for 459,669 patients.

The mean number of patients seen by APPs (260.7) was lower compared with that seen by physicians (581.2). Compliance with most CAD, heart failure and atrial fibrillation measures was comparable, except the NPs and PAs were more likely than physicians to urge smoking cessation screening and intervention (adjusted rate ratio: 1.14) and cardiac rehabilitation referral (rate ratio: 1.40) among CAD patients.

Yet, none of the healthcare professionals had high compliance with all eligible CAD measures, according to the results, with 12.1% for APPs and 12.2% for physicians. The results didn’t vary when the 41 physician practices with APPs were compared to the 49 practices without.

“Apart from minor differences, a collaborative care delivery model, using both physicians and APPs, may deliver an overall comparable quality of outpatient cardiovascular care compared with a physician-only model,” study authors concluded.


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“Our findings indicate that a collaborative care delivery model which employs both physicians and advanced practice providers appears to provide a care quality that is comparable to a physician-only model,” lead author Salim S. Virani, MD, PhD, said in an American College of Cardiology press release.

“Our results also have health care policy implications,” Virani pointed out. “It should be reassuring that the quality of care for uncomplicated outpatient cardiovascular disease is at least equivalent between advanced practice providers and physicians, even in states with independent scope of practice laws for advanced practice providers and between practices with both advanced practice providers and physicians compared with physician-only practices.”

Study authors pointed out that nurse practitioners and physician assistants are taking on a larger role as initiatives such as the Affordable Care Act add millions to the health insurance rolls. Their study sought to determine if care provided by those professionals differed meaningfully from physicians in cardiology practices.

How well it succeeded is up for debate.

“I am uncertain that these findings can be generalized across the varied health systems of the United States,” added Valentin Fuster, MD, PhD, editor-in-chief of the Journal of the American College of Cardiology. “However, I am certain that team-based delivery models will provide the basis of the highest quality care.”

In an accompanying editorial, Robert A. Harrington, MD, Arthur L. Bloomfield professor and chairman of the department of medicine at Stanford University, said the study generally supported team-based care between advanced practice providers and physicians, but he pointed out several limitations.

Harrington called for future studies about the organization of the care delivery teams and nurse practitioners and physician assistants to provide more insight about potential differences in quality of care.2

1 Virani SS, Maddox TM, Chan PS, Tang F, Akeroyd JM, et. al. Provider Type and Quality of Outpatient Cardiovascular Disease Care: Insights From the NCDR PINNACLE Registry. J Am Coll Cardiol. 2015 Oct 20;66(16):1803-12. doi: 10.1016/j.jacc.2015.08.017. PubMed PMID: 26483105.

2 Harrington RA, Heidenreich PA. Team-Based Care and Quality: A Move Toward Evidence-Based Policy. J Am Coll Cardiol. 2015 Oct 20;66(16):1813-5. doi: 10.1016/j.jacc.2015.08.016. PubMed PMID: 26483106.