Collaborative, Physician-Only Care Models Similar on CV Quality Measures in Analysis

Veronica Hackethal, MD

October 26, 2015

HOUSTON, TX — A national study in the US has found that cardiovascular care managed by both physicians and advanced practice practitioners (APPs), the latter including nurse practitioners and physician assistants, provides comparable quality of outpatient cardiovascular care as do physicians on their own[1]. But regardless of care model, quality of care for coronary artery disease (CAD) fell far short of meeting performance measures. The study was published in the October 20, 2015 issue of the Journal of the American College of Cardiology.

"Our results indicate that apart from minor differences, a collaborative-care delivery model employing both physicians and advanced practice providers may deliver an overall comparable quality of outpatient, nonacute cardiovascular care compared with a physician-only model," first author Dr Salim Virani (Michael E DeBakey Veterans Affairs Medical Center, Houston, TX) told heartwire from Medscape.

APPs could improve access to cardiovascular care by covering many of the functions normally provided by physicians. Questions have been raised, though, about whether the quality of cardiovascular care would differ based on provider type. But, of note, "compliance with global CAD performance measures was low for both provider categories," according to Virani.

"Team-based cardiovascular disease care has the potential to improve access for patients with CVD and improve the efficiency of the system," he said. "This will require a conscious effort by both physicians and APPs to work toward a common goal of improving access and quality. The collaborative spirit of one provider type asking the other for their opinion on how to treat a particular patient will need to continue for this model to remain effective."

Practice Innovation and Clinical Excellence Registry

In the study, researchers used the American College of Cardiology's Practice Innovation and Clinical Excellence (PINNACLE) registry to identify outpatient visits for 2012. Using data from 648,909 patients seen in 90 practices by 1234 providers, they assessed compliance to quality measures that have been demonstrated to improve cardiovascular morbidity and mortality for CAD, atrial fibrillation, and heart failure. Measures included beta-blocker use in patients with a history of heart attack, smoking screening and intervention, cardiac-rehabilitation referral, use of ACE inhibitors, angiotensin-receptor blockers, lipid-lowering therapy, blood-pressure monitoring, and, in atrial fibrillation, anticoagulants.

The analysis included 883 providers (716 physicians, 167 APPs) working in 41 practices and caring for 459,669 patients, of which 43,531 were seen by APPs and 416,138 were seen by physicians.

APPs and physicians had similar compliance with most CAD, heart-failure, and atrial-fibrillation quality measures. Both groups, though, had low compliance with CAD quality measures (12.1% and 12.2%, respectively). Only about one in 10 patients with CAD received care that complied with all quality measures, irrespective of provider type.

Analyses adjusted for other factors associated with quality of CVD care showed that APPs who cared for CAD patients had higher compliance with smoking-cessation screening and intervention (adjusted rate ratio 1.14, 95% CI 1.03–1.26) and referral to cardiac rehabilitation (rate ratio 1.40, 95% CI 1.16–1.70), with a rate ratio >1, suggesting better performance on the quality measures.

APPs and physicians also had similar compliance with performance measures for atrial fibrillation and heart failure. In addition, a secondary analysis found no differences in compliance with quality measures in practices with both physicians and APPs (41 practices, 459,669 patients), compared with physician-only practices (49 practices, 189,240 patients).

"Several Limitations Worth Noting'

"Although these data are generally supportive of team-based care using collaborative models between APPs and physicians, there are several limitations worth noting as important for future research to address," write Drs Robert A Harrington and Paul A Heidenreich (Stanford University School of Medicine, in) an editorial[2]. They contend that:

  • The results do not allow for evaluating different approaches used in delivering team care.

  • The study did not include enough nurse practitioners and physician assistants to allow for direct comparison of these two groups, especially given their different educations and different state regulations applied to them.

  • The study could not evaluate the link between process-of-care quality measures and patient outcomes.

  • Economic analyses will need to look at changes in cost related to team care and changes in patient outcome.

  • The US needs a more integrated system for sharing electronic medical records, rather than relying on disease-specific registries.

  • Finally, they underscored the very low percentage of patients whose CAD care met all quality measures.

Nevertheless, they conclude, "Team-based cardiovascular care, delivered in collaborative models with a diverse group of healthcare professionals all working at the top of their education and training, can offer the United States expanded access to high-quality, evidenced-based care."

Virani is supported by a Department of Veterans Affairs Health Services research and development service career development award, American Heart Association beginning grant-in-aid, and the American Diabetes Association clinical science and epidemiology award. Disclosures for the coauthors are listed in the paper. Harrington and Heidenreich report no relevant financial relationships.

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