CVD Care Among Physicians vs Nonphysician Clinicians 'Comparable but Low' in VA Study

Deborah Brauser

May 04, 2015

HOUSTON, TX — Although both physicians and nonphysician clinicians in a primary-care setting provide comparable quality of overall care to outpatients with cardiovascular disease (CVD), the scores are actually quite low for both groups, new research from a Veterans Affairs (VA) population suggests[1].

A review of more than 1.1 million CVD patients who made a primary-care visit to one of 130 VA facilities from October 2013 to September 2014 showed that only 54.8% of those receiving care from nonphysicians, such as nurse practitioners and physician assistants, and 54.0% receiving care from doctors underwent all three performance measures, which included BP monitoring, cholesterol monitoring, and receiving a beta-blocker.

Patients who were seen by nonphysicians were more likely to have their BP controlled, whereas those who saw physicians were significantly more likely to receive a beta-blocker or to have cholesterol control through LDL-C monitoring or use of statins.

"These were very important factors to be modified, and one group may do better than the other on certain measures. But both categories of providers have a lot of work to do," lead author Dr Salim S Virani (DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX) told heartwire from Medscape.

"I think in the future, a model with physicians and nonphysicians working together will be good, especially for patients with a lot of chronic disease that will require management," added Virani.

The study results had been scheduled to be presented in a poster session last week at the American Heart Association Quality of Care and Outcomes Research (QCOR) 2015 Scientific Sessions in Baltimore, MD. However, as reported earlier by heartwire , the meeting was canceled in the wake of rioting in the city that followed the funeral of Freddie Gray.

Shortage Calls for Solutions

"With the Affordable Care Act (ACA) implementation, the current number of physicians will not be sufficient to accommodate 30 to 40 million Americans receiving healthcare access," write the investigators in their poster, noting that using nurse practitioners and physician assistants for chronic disease had been a proposed solution to this shortage.

Although past studies have shown that physicians and nonphysicians provide comparable CVD care in cardiology settings, the researchers sought to examine this issue in primary-care settings.

They assessed data for 934,950 CVD outpatients (defined as those with ischemic heart disease or with cerebrovascular or peripheral artery disease) who received care from physicians (98.1% men; mean age 71.8 years) and 252,085 who received care from nonphysicians (97.7% men; mean age 72.4 years).

Interestingly, the participants who received nonphysician care were significantly less likely to receive that care in a teaching facility, as well as less likely to have a primary-care provider visit in the previous year and a history of diabetes, hypertension, or "overall burden of illness" than those receiving physician care (P<0.0001 for all comparisons).

The nonphysician care group was also more likely to have BP <140/90 mm Hg compared with the physician care group (80.3% vs 78.8%, respectively).

However, the physician care group was more likely than the nonphysician care group to have an LDL-C lower than 100 mg/dL (73.1% vs 72.2%, respectively) or to receive a statin (70.4% vs 68.3%) or moderate- to high-intensity statin therapy (37.4% vs 36.3%). Those in the physician care group who had an MI in the previous 2 years were also more likely than their counterparts in the nonphysician care group to receive a beta-blocker (72.9% vs 69.3%).

"Because we had over one million participants, even a one-percentage-point difference will come out statistically significant," said Virani.

"Need to Improve Global Performance"

Overall, the findings show that "a collaborative care delivery model" using both physicians and nonphysicians may be beneficial, write the investigators. But even more important, "there is a need to improve global performance on all eligible measures in CVD patients."

Virani noted that this study examined only effectiveness of care and not how resource utilizations or safety measures differed between the two groups.

"Because those aspects were not evaluated, we don't know if physicians and nonphysicians use the same amount of healthcare resources to get their patients to where they are right now. It could be that one category used more of these resources: sending them to more specialists or doing more testing," he said. "We also have to be cognizant that we were looking at really basic measures, not at urgent cardiac issues and not at inpatient measures."

Virani added that the investigators are now assessing these additional measures and plan to present them at a future meeting.

The study was funded by a beginning grant-in-aid from the American Heart Association, by an American Diabetes Association Clinical Science and Epidemiology Award, and by a Houston VA Health Services Research and Development Service (HSR&D) Center of Innovation grant. Virani reports being supported by an HSR&D Career Development Award. Disclosures for the coauthors are listed in the abstract.

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