Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma.
OBJECTIVE
The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians.


METHODS
We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and 2 outcome-of-care measures (admission and ED length of stay).


RESULTS
Of the 4029 patients included in this analysis, 3622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled beta-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (-6 points; 95% CI, -9 to -3 points). Supervised MLPs provided similar quality of care to that of physicians.


CONCLUSIONS
The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.
Tsai
Chu-Lin
CL
Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA. cltsai@post.harvard.edu
Sullivan
Ashley F
AF
Ginde
Adit A
AA
Camargo
Carlos A
CA
D000208:Acute Disease; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001249:Asthma / Q000628:therapy*; D002983:Clinical Competence / Q000592:standards; D016001:Confidence Intervals; D004636:Emergency Service, Hospital / Q000592:standards; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D015999:Multivariate Analysis; D009722:Nurse Practitioners / Q000592:standards*; D016017:Odds Ratio; D010823:Physician Assistants / Q000592:standards*; D010820:Physicians / Q000592:standards; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care / Q000592:standards*; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D000078329:Workforce; D055815:Young Adult
D000305:Adrenal Cortex Hormones; D018927:Anti-Asthmatic Agents; D000900:Anti-Bacterial Agents
Ann Intern Med. 1974 Feb;80(2):137-42
4811789
N Engl J Med. 1996 Sep 26;335(13):966-70
8782507
J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138
17983880
CJEM. 2008 Jul;10(4):355-63
18652728
JAMA. 2000 Jan 5;283(1):59-68
10632281
J Trauma. 2007 Jul;63(1):128-34
17622880
Am J Emerg Med. 2004 Nov;22(7):516-21
15666252
Ann Emerg Med. 1995 Aug;26(2):130-2
7618773
Am J Emerg Med. 1997 May;15(3):229-32
9148974
Nurse Pract. 1997 Apr;22(4):175-8, 183, 187
9128885
J Allergy Clin Immunol. 2008 Aug;122(2):313-8
18538382
Am J Public Health. 1989 Mar;79(3):340-9
2916724
Acad Emerg Med. 2007 Dec;14(12):1182-9
18045895
J Allergy Clin Immunol. 2009 Feb;123(2):354-61
19070357
J Trauma. 1990 Jun;30(6):660-3; discussion 663-5
2112612
Lancet. 1999 Oct 16;354(9187):1321-6
10533859
BMJ. 2002 Apr 6;324(7341):819-23
11934775