Durham Veterans Affairs Health Care System and Duke University, Durham, North Carolina (G.L.J., V.A.S., D.E., C.C.H.).
Durham Veterans Affairs Health Care System, Durham, North Carolina (S.L.W., T.S.B., B.S.W.).
Ann Intern Med. 2018 Dec 18;169(12):825-835. doi: 10.7326/M17-1987. Epub 2018 Nov 20.
Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages.
To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs).
Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record.
568 VA primary care facilities.
368 481 adult patients with diabetes treated pharmaceutically.
The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively.
The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant.
Most VA patients are men who receive treatment in a staff-model health care system.
No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs.
VA Health Services Research and Development.
初级保健由执业护士（NP）和医师助理（PA）提供，这被认为是解决预期劳动力短缺的一种解决方案。
检查患者中医生、NP 和 PA 初级保健提供者（PCP）的糖尿病中期结果的潜在差异。
使用美国退伍军人事务部（VA）电子健康记录中的数据进行队列研究。
568 个 VA 初级保健设施。
368481 名接受药物治疗的成年糖尿病患者。
根据 2013 年测量值的平均值，检查 PCP（患者在 2012 年就诊最多的医生）的专业与血红蛋白 A1c（HbA1c）、收缩压（SBP）和低密度脂蛋白胆固醇（LDL-C）的连续和二分控制之间的关系。使用 PCP 类型的逆概率来平衡队列特征。使用分层线性混合模型和逻辑回归模型分别分析连续和二分结果。
PCP 分别为医生（n=3487）、NP（n=1445）和 PA（n=443），分别占患者的 74.9%、18.2%和 6.9%。与医生相比，NP 的 HbA1c 值差异为-0.05%（95%CI，-0.07%至-0.02%），PA 为 0.01%（CI，-0.02%至 0.04%）。对于 SBP，NP 的差值为-0.08mmHg（CI，-0.34 至 0.18mmHg），PA 为 0.02mmHg（CI，-0.42 至 0.38mmHg）。对于 LDL-C，NP 的差值为 0.01mmol/L（CI，0.00 至 0.03mmol/L）（0.57mg/dL[CI，0.03 至 1.11mg/dL]），PA 为 0.03mmol/L（CI，0.01 至 0.05mmol/L）（1.08mg/dL[CI，0.25 至 1.91mg/dL]）。这些差异均无临床意义。
大多数 VA 患者为男性，在员工模式医疗保健系统中接受治疗。
在糖尿病结果方面，3 种 PCP 类型之间没有发现具有临床意义的差异，这表明医生、NP 和 PA 可以实现相似的慢性病结果。
VA 医疗保健服务研究与发展。
