George L. Jackson, PhD, MHA; Valerie A. Smith, DrPH; David Edelman, MD, MHS; Sandra L. Woolson, MPH; Cristina C. Hendrix, DNS, GNP-BC; Christine M. Everett, PhD, MPH, PA-C; Theodore S. Berkowitz, MS; Brandolyn S. White, MPH; Perri A. Morgan, PhD, PA-C
Disclaimer: The views expressed in this article are those of the authors and do not reflect the position or policy of the VA or the U.S. government.
Grant Support: Funding was provided through a peer-reviewed grant (IIR 13-063) from the VA Health Services Research and Development (HSR&D) Service. This work was also supported by the Center of Innovation for Health Services Research in Primary Care (CIN 13-410) at Durham VA Medical Center.
Disclosures: Drs. Jackson and Edelman report grants from the VA during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M17-1987.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Available from Dr. Jackson (e-mail, email@example.com). Statistical code: Information on the statistical code that could not lead to identification of individual patients is available from Dr. Jackson upon consultation with study statisticians. Data set: The data set, with information obtained from national VA databases originating in the VA-EHR, is not available. Use of underlying national VA databases is subject to VA rules and regulations. Further information relating to specific national VA data sets used for this study is available from Dr. Jackson upon consultation with study statisticians.
Corresponding Author: George L. Jackson, PhD, MHA, Durham VA Medical Center, HSR&D Service (152), 508 Fulton Street, Durham, NC 27705; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Jackson: Durham VA Medical Center, HSR&D Service (152), 508 Fulton Street, Durham, NC 27705.
Drs. Smith and Edelman, Ms. Woolson, Mr. Berkowitz, and Ms. White: Durham VA Medical Center, Center for Health Services Research in Primary Care (152), 508 Fulton Street, Durham, NC 27705.
Dr. Hendrix: Duke University School of Nursing, 307 Trent Drive, Durham, NC 27710.
Drs. Everett and Morgan: DUMC 104780, Duke University Medical Center, Durham, NC 27710.
Author Contributions: Conception and design: G.L. Jackson, V.A. Smith, D. Edelman, C.C. Hendrix, C.M. Everett, P.A. Morgan.
Analysis and interpretation of the data: G.L. Jackson, V.A. Smith, D. Edelman, S.L. Woolson, C.C. Hendrix, C.M. Everett, T.S. Berkowitz, P.A. Morgan.
Drafting of the article: G.L. Jackson, V.A. Smith, D. Edelman, S.L. Woolson, C.C. Hendrix, C.M. Everett.
Critical revision for important intellectual content: V.A. Smith, D. Edelman, C.C. Hendrix, C.M. Everett, P.A. Morgan.
Final approval of the article: G.L. Jackson, V.A. Smith, D. Edelman, S.L. Woolson, C.C. Hendrix, C.M. Everett, T.S. Berkowitz, B.S. White, P.A. Morgan.
Provision of study materials or patients: B.S. White.
Statistical expertise: V.A. Smith, T.S. Berkowitz.
Obtaining of funding: G.L. Jackson, D. Edelman, P.A. Morgan.
Administrative, technical, or logistic support: G.L. Jackson, S.L. Woolson, C.C. Hendrix, B.S. White.
Collection and assembly of data: S.L. Woolson, T.S. Berkowitz, P.A. Morgan.
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.
Jackson GL, Smith VA, Edelman D, Woolson SL, Hendrix CC, Everett CM, et al. Intermediate Diabetes Outcomes in Patients Managed by Physicians, Nurse Practitioners, or Physician Assistants: A Cohort Study. Ann Intern Med. [Epub ahead of print 20 November 2018]169:825–835. doi: 10.7326/M17-1987
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Published: Ann Intern Med. 2018;169(12):825-835.
Published at www.annals.org on 20 November 2018
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, High Value Care.
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