Mafi John N, Wee Christina C, Davis Roger B, Landon Bruce E
Ann Intern Med. 2016 Aug 16;165(4):237-44. doi: 10.7326/M15-2152. Epub 2016 Jun 21.
Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value.
To compare use of low-value services among U.S. APCs and physicians.
Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP).
National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011.
Patients presenting with upper respiratory infections (URIs), back pain, or headache.
Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions).
12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting.
NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs.
APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions.
U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.
许多医生认为高级执业临床医生（APCs，即执业护士和医师助理）提供的医疗服务价值相对较低。
比较美国APCs和医生使用低价值服务的情况。
在对患者和提供者特征以及年份进行调整后，评估了3种情况下初级保健就诊后的服务使用情况。排除有基于指南的警示信号的患者，并按门诊与住院就诊、急性与非急性表现以及临床医生是否自认为是患者的初级保健提供者（PCP）进行分层分析。
1997年至2011年的国家门诊医疗调查（NAMCS）和国家医院门诊医疗调查（NHAMCS）。
出现上呼吸道感染（URIs）、背痛或头痛的患者。
使用不符合指南的抗生素（用于URIs）、X线摄影（用于URIs和背痛）、计算机断层扫描（CT）或磁共振成像（MRI）（用于头痛和背痛）以及转诊至其他医生（用于所有3种情况）。
共识别出12170次医生门诊就诊和473次APCs门诊就诊，以及13359次医生住院就诊和2947次APCs住院就诊。虽然门诊临床医生诊治的患者相似，但住院的APCs诊治的患者更年轻（平均年龄42.6岁对45.0岁；P<0.001），且在城市环境中执业的频率低于住院医生（就诊比例为49.7%对81.7%；P<0.001）。未经调整和调整后的结果显示，在这两种情况下APCs开具抗生素、CT或MRI、X线摄影以及转诊的频率与医生相同。分层分析表明，在住院环境中，自认为是PCP的APCs比PCP医生开具的服务更多。
NHAMCS反映的是住院APCs的医疗服务情况；NAMCS对医生执业情况进行抽样，可能低估了门诊APCs的情况。
APCs和医生提供的低价值医疗服务数量相当，消除了医生认为在这些常见病症中APCs提供的医疗服务价值低于医生的看法。
美国卫生服务与研究管理局、佐佐川良一奖学金基金和美国国立卫生研究院。
