Provider Type and Quality of Outpatient Cardiovascular Disease Care: Insights From the NCDR PINNACLE Registry.
BACKGROUND
The current number of physicians will not be sufficient to accommodate 30 to 40 million Americans expected to secure health coverage with Affordable Care Act implementation. One proposed solution is to use advanced practice providers (APPs) (nurse practitioners and physician assistants).


OBJECTIVE
This study sought to determine whether there were clinically meaningful differences in the quality of care delivered by APPs versus physicians in a national sample of cardiology practices.


METHODS
Within the American College of Cardiology's PINNACLE Registry, we compared quality of coronary artery disease (CAD), heart failure, and atrial fibrillation care delivered by physicians and APPs for outpatient visits between January 1, 2012, and December 31, 2012. We performed hierarchical regression adjusting for provider sex; panel size; duration of participation in registry; and patient's age, sex, insurance, number of outpatient visits, history of hypertension, diabetes, myocardial infarction, and percutaneous coronary intervention or coronary artery bypass grafting in the preceding 12 months.


RESULTS
We included 883 providers (716 physicians and 167 APPs) in 41 practices who cared for 459,669 patients. Mean number of patients seen by APPs (260.7) was lower compared with that seen by physicians (581.2). Compliance with most CAD, heart failure, and atrial fibrillation measures was comparable, except for a higher rate of smoking cessation screening and intervention (adjusted rate ratio: 1.14; 95% confidence interval: 1.03 to 1.26) and cardiac rehabilitation referral (rate ratio: 1.40; 95% confidence interval: 1.16 to 1.70) among CAD patients receiving care from APPs. Compliance with all eligible CAD measures was low for both (12.1% and 12.2% for APPs and physicians, respectively) with no significant difference. Results were consistent when comparing practices with both physicians and APPs (n = 41) and physician-only practices (n = 49).


CONCLUSIONS
Apart from minor differences, a collaborative care delivery model, using both physicians and APPs, may deliver an overall comparable quality of outpatient cardiovascular care compared with a physician-only model.
Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Cardiovascular Disease Prevention, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas. Electronic address: virani@bcm.edu.
Salim S
SS
Virani
Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado; Division of Cardiology, University of Colorado Denver, Denver, Colorado.
Thomas M
TM
Maddox
Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri, Kansas City, Missouri.
Paul S
PS
Chan
Saint Luke's Mid America Heart Institute, Kansas City, Missouri.
Fengming
F
Tang
Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.
Julia M
JM
Akeroyd
American College of Cardiology, Washington, DC.
Samantha A
SA
Risch
American College of Cardiology, Washington, DC.
William J
WJ
Oetgen
Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
Anita
A
Deswal
Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas; Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas.
Biykem
B
Bozkurt
Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Center for Cardiovascular Disease Prevention, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas.
Christie M
CM
Ballantyne
Health Policy, Quality & Informatics Program, Michael E. DeBakey Veterans Affairs Medical Center Health Services Research and Development Center for Innovations, and Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas.
Laura A
LA
Petersen
D000328:Adult; D000553:Ambulatory Care / Q000592:standards; D002309:Cardiology; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D009722:Nurse Practitioners; D010348:Patient Care Team; D058991:Patient Protection and Affordable Care Act; D010823:Physician Assistants; D010820:Physicians / Q000600:supply & distribution; D011787:Quality of Health Care; D012042:Registries
cardiovascular disease; chronic disease care; nurse practitioners; performance measures; physician assistants; physicians