title: Treatment decisions for complex patients: differences between primary care physicians and midlevel providers.
abstract: OBJECTIVE
  To examine whether treatment change for diabetic patients presenting with elevated blood pressure (BP) differed between physicians and midlevel providers (nurse practitioners [NPs] and physician assistants [PAs]) and to determine reasons for any observed differences.
  
  
  METHODS
  Analyses were part of a prospective cohort study of 1169 diabetic patients with scheduled visits to 92 primary care providers (PCPs) in 9 Midwest Veterans Health Administration facilities presenting with a triage BP of > or =140/90 mm Hg. We analyzed predicted probabilities of treatment change by provider type.
  
  
  RESULTS
  The PCPs included 64 physicians, 21 NPs, and 7 PAs. Patients treated by physicians and midlevel providers did not differ in their mean visit BP, number of chronic conditions, age, or number of BP medications. Controlling for current and past BP readings and patient characteristics, physicians were significantly more likely than midlevel providers to initiate a treatment change for elevated BP at a visit (53.8% vs 36.4%; P = .001). After controlling for additional visit-specific factors, practice style, measurement, and organizational factors, physicians were still more likely to initiate a treatment change (52.5% vs 37.5%; P = .02).
  
  
  CONCLUSIONS
  Midlevel providers were significantly less likely than physicians to change BP treatment for diabetic patients with multiple chronic conditions presenting with elevated BP at a single visit. We could not find good explanations for this difference. Given the expanding role of midlevel providers in delivering primary care to complex patients, we need to understand whether these treatment change differences lead to long-term differences in BP control.
authors.affiliation: Roudebush VA Medical Center, 250 University Blvd, IF 122, Indianapolis, IN 46202, USA. subrama@iupui.edu
authors.forename: Usha
authors.initials: U
authors.lastname: Subramanian
authors.forename: Eve A
authors.initials: EA
authors.lastname: Kerr
authors.forename: Mandi L
authors.initials: ML
authors.lastname: Klamerus
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Zikmund-Fisher
authors.forename: Robert G
authors.initials: RG
authors.lastname: Holleman
authors.forename: Timothy P
authors.initials: TP
authors.lastname: Hofer
mesh_terms: D000368:Aged; D001794:Blood Pressure / Q000187:drug effects; D015331:Cohort Studies; D003657:Decision Making; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015146:Midwestern United States; D010821:Physicians, Family; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies