Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: Implications for care under the Affordable Care Act.
BACKGROUND
The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between advanced practice providers (APPs) and physicians in a primary care setting.


METHODS
We identified diabetes (n=1,022,588) and CVD (n=1,187,035) patients receiving primary care between October 2013 and September 2014 in 130 Veterans Affairs facilities. We compared glycemic control (hemoglobin A1c <7%) in diabetic patients, blood pressure (BP) <140/90 mmHg in diabetic or CVD patients, cholesterol control (low-density lipoprotein cholesterol<100 mg/dL, receiving a statin) in diabetic or CVD patients, and those receiving a β-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians and APPs. We also compared the proportion meeting composite measure (glycemic, BP, and cholesterol control in diabetic patients; BP, cholesterol control, and receipt of β-blocker among eligible CVD patients).


RESULTS
Diabetic patients receiving care from APPs were statistically more likely to have glycemic (50% vs 51.4%, odds ratio [OR] 1.06 [1.05-1.08]) and BP control (77.5% vs 78.4%, OR 1.04 [1.03-1.06]), whereas patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% vs 66.5%, OR 0.94 [0.93-0.95]) in adjusted models, although these differences are not clinically significant. Similar results were seen in CVD patients. Few patients met the composite measure (27.1% and 27.6% of diabetic and 54.0% and 54.8% of CVD patients receiving care from physicians and APPs, respectively).


CONCLUSIONS
Diabetes and CVD care quality was comparable between physicians and APPs with clinically insignificant differences. Regardless of provider type, there is a need to improve performance on eligible measures in diabetes or CVD patients.
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, TX; Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX; Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX. Electronic address: virani@bcm.edu.
Salim S
SS
Virani
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, TX.
Julia M
JM
Akeroyd
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, TX.
David J
DJ
Ramsey
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, TX.
Winston J
WJ
Chan
The University of Texas Health Science Center at Houston (UTHealth) School of Nursing, Houston, TX.
Lorraine
L
Frazier
Center for Healthcare Advancement & Outcomes at Baptist Health South Florida, Miami, FL; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD.
Khurram
K
Nasir
Division of Management, Policy and Community Heath, School of Public Health, University of Texas - Health Science Center at Houston, Houston, TX.
Suja
S
S Rajan
Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX; Center for Cardiovascular Disease Prevention, Methodist DeBakey Heart and Vascular Center, Houston, TX.
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, TX.
Laura A
LA
Petersen
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000553:Ambulatory Care / Q000379:methods; D001786:Blood Glucose / Q000378:metabolism; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000378:metabolism / Q000628:therapy*; D008078:Cholesterol, LDL / Q000378:metabolism; D003695:Delivery of Health Care / Q000379:methods*; D003920:Diabetes Mellitus / Q000378:metabolism / Q000628:therapy*; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D009722:Nurse Practitioners; D058991:Patient Protection and Affordable Care Act; D010823:Physician Assistants; D058007:Physicians, Primary Care; D011320:Primary Health Care / Q000592:standards*; D011787:Quality of Health Care; D014481:United States; D014493:United States Department of Veterans Affairs
D000319:Adrenergic beta-Antagonists; D001786:Blood Glucose; D008078:Cholesterol, LDL; D006442:Glycated Hemoglobin; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; C517652:hemoglobin A1c protein, human