Quality of Diabetes Care in Family Medicine Practices: Influence of Nurse-Practitioners and Physician’s Assistants

Yes, we agree that a limitation of this study was our inability to directly link patients with specific providers.

Our informal experience is that NPs and PAs worked in much the same capacity as physicians, on a day to day basis, with some assigned to see more acute care cases.

We did find that practices with NPs and particularly those with PAs were larger than physician only practices and the analyses were controlled for size of practice as total number of staff. It is possible that this was not a good measure of size of practice or that size of practice interacted with another variable to affect the process outcomes.

Unfortunately, in the development of the chart audit, numerous physicians and consultants on our team felt that some of the other diabetes care processes (e.g., foot exams) would not be well documented in charts and would result in poor quality information such that it was not worth collecting this information. Patient surveys or observation of patient pathways would have been a much better way to collect this information, but were not feasible in this study.

Thank you for your input.

Competing interests:   None declared

In 2004, the Institute of Medicine published a report, Keeping Patients Safe: Transforming the Work Environment of Nurses, which recommends substantial changes in the nursing work environment to mitigate threats to patient safety (1). Since that report, a number of publications further describe associations between nurses and patient safety and health care outcomes (2).

In Ohman-Strickland et al., the authors describe the influence of nurse practitioners (NPs) on diabetes care. Their findings are consistent with what the nursing profession has known for years—that: · in public opinion polls conducted by Gallup, nurses are consistently rated the most honest and ethical professional outperforming physicians, clergy, college teachers, and public safety workers; · the composition and size of the nursing workforce directly affect important inpatient outcomes such as failure to rescue, pressure ulcer prevalence, and falls with injury (3); · nurse practitioners have been found to deliver timely, effective, and patient-centered care (4); and · patients’ perceptions about hospital quality are intrinsically associated with their relationship to nurse (5).

Surprisingly, though, little action has occurred since the IOM published its 2004 report. This new study places an additional spotlight on immediate policy directions that should be considered: · As value-based purchasing programs are implemented, nurses who demonstrate a key contribution to quality, should be included in incentive plans. Among high performing provider organizations that are paid bonuses, these payments should be shared with—or at least a portion designated to—nurses who contribute to those performance results. · Threats to the nursing workforce are quantifiable and sustained. Recruitment, retention, and preparation of the nursing workforce should be continually examined and reevaluated in the context of goals for patient safety and quality. · These associations should continue to be vigorously investigated and substantiated. An agenda for research should include the affect NPs have on quality for other conditions, in other settings, and among additional outcomes (e.g., patient satisfaction, cost).

The science-base that describes nurses’ influence on quality is substantial and growing. Yet, the burden of proof for demonstrating a business case for nursing quality appears to be set higher than for other professions. An ongoing agenda must be established that details the primacy of nursing’s contribution to improving care as demonstrated by gains that offset any investment. Without this business case, it doesn’t appear as if the evidence we have accumulated over the last two decades will have any meaningful influence on improvements that are needed by the system and deserved by all patients.

(1) Institute of Medicine (IOM). Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.

(2) Needleman J, Kurtzman ET, Kizer KW. Performance measurement of nursing care: state of the science and the current consensus. Med Care Res Rev. 2007 Apr;64(2 Suppl):10S-43S.

(3) Needleman J, et al. Nurse-staffing levels and the quality of care in hospitals. NEJM. 2002; 346:1715–1722.

(4) Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002 April 6; 324(7341): 819–823.

(5) Sofaer S, Crofton C, Goldstein E, et al. What do consumers want to know about the quality of care in hospitals? Health Serv Res. 2005 Dec;40(6 Pt 2):2018-36.

Competing interests:   None declared

The article on diabetes care provided by different practices is a good example of how quality care studies can be conducted to evaluate the team model of care. In today’s economic and health care environment, no provider is an island. It takes a team of professionals – whether employed by the practice or referred to by the primary health care provider – to provide comprehensive care.

To insinuate in the title of the article that NPs or PAs “influenced” the quality of diabetes care is a misstatement, though. The presence of a PA or NP in the practices studied was a co-occurrence. What evidence is there supporting that the PAs or NPs had any influence on the use of the guidelines?

For the authors to also state that NPs “may add new perspectives” to care because of their “emphasis on the well-being of the whole patient” is disrespectful to the work of physicians, PAs, and other providers who do not limit themselves to addressing just the immediate medical needs. I am also concerned that statements such as “practices wishing to improve quality of care or adhere to a more holistic approach may tend to hire NPs” only perpetuate stereotypical behavior hyperbole among health professionals. The inclusion of unsubstantiated assumptions about the utilization of one provider over the other within the team has already become the “take away message” of this article. (“Family Practices with NPs Provide Better Diabetes Care,” MedPage Today)

The authors’ unsupported conclusions attributed the differences in adherence to practice guidelines to the presence or absence of a particular provider type, despite noting that “the study design precludes connection of patients to particular clinicians.” The data presented does not identify the role, if any, of the PAs or NPs in providing treatment or case management to diabetic patients in the practices studied.

The article presents a well thought-out study on practice adherence to guidelines by a team of providers, and therefore the discussion and conclusions should have focused solely on the team. It is the organization and processes of the clinical team that are relevant here. What is the antecedent to guidelines adherence by the practices? What was the patient risk stratification? Did race characteristics of the patients and providers influence which tests were conducted? What percentage of the patient population had health insurance that paid for the tests? Some may consider increased monitoring without statistically significant results a financially wasteful practice.

What we learn from this study is there is tremendous variability in the capability of practices to provide care to diabetic patients, nothing about the individual providers. One needs a stable point of comparison between practices before the author can assess the members of the practice team.

Studies on team practice of care need to be conducted on a variety of health issues to help guide providers to develop effective models of interdisciplinary care. But the authors of such studies should not try and twist the results to fit preconceived intentions.

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It is always interesting to hear about differences in practice from clinicians and researchers in family medicine throughout the country. I am not aware of PAs in New Jersey and Pennsylvania being on ER duty, although I have not done exhaustive investigation on this. Thank you for bringing up the fact that the responsibilities (and experience) of the various clinicians may differ depending on where you are in the country. I'm sure that they differ from practice to practice as well. We were not able to document consistent differences in responsibilities for the practices in our study.

Yes, unfortunately, family medicine practitioners seem to be among those most affected by the reimbursement system of healthcare within the US today. And, yes, “busy” often translates into disorganized. We have informally observed within our family medicine network that it is very difficult for a practice that is disorganized to turn around and develop efficient processes, due to all of the competing financial and patient care demands and workforce turnover. It is hoped that ULTRA and other intervention projects underway will begin to develop ways for practices to find the time and space necessary to make the changes that will eventually lead to improved patient care.

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Thank you for your comments. We had some qualitative data; however, the interview questions were not intended to get at issues related to the incorporation of NPs and PAs into family medicine practices. Thus, this secondary analysis was not able to glean enough information from the pre- transcribed interviews to get good information on backgrounds and attitudes toward guidelines of diverse clinicians within the study practices.

I agree that an “us versus them” attitude is not helpful; that was not the intent of this article. I think all clinicians would like to provide quality care to their patients and that is the ultimate goal of most of the research we do as well. By documenting that there may be some important differences, we hope to elucidate where efforts for improvement may be directed as well as encourage practice teams to understand the skills and interests of those they work with and to develop ways to take advantage of those strengths. Often we can’t learn how to work together well until we learn how we are different and how we are alike. In order to do this within the family medicine practice setting, one needs to develop a cooperative attitude in working with a wide variety of professionals.

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This article is most interesting in that it is one of the first that compared outcomes of practices with NPs, PAs and MDs at the practice level. Earlier studies have focused on distinguishing differences between primary care providers and generally found few. As the authors indicate, why these findings occurred is not clear from the methods used. NPs and PAs are educated in different models of care and build on different bases to form the primary care training. Was it the differences in this philosophy of care that lead to these differences in outcome? The data here do not tell us that story.

A strength of this study is that the outcome measurements included in analysis should not be highly influenced by the scope of practice allowed or supervision required by the two different states for NPs or PAs. Again, the measures were at the aggregate level and were practice (not practitioner) characteristics

In the past several years there has been substantial discussion focused on interdisciplinary approaches to care. This article provides some small evidenced that care might be improved when providers with different theoretical backgrounds work together to deal with complex problems such as diabetes.

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I appreciate your comments. We have had numerous discussions about the importance and meaning of "adherence to guidelines." It was an oversight on my part that the issue about the correspondence between adherence to guidelines and good care was not mentioned in the Discussion of this paper; it should have been. Although there may be some discrepancy about whether strict adherence to guidelines is necessary for all patients, this paper does point out that, on average, practices with NPs are doing more than physician only practices and practices with PAs. This is particularly notable in the assessment and treatment of lipids, where low rates of assessment and treatment seem to translate into low rates in achievement of lipid targets as well. Control of lipids is particularly important, as Grover SA, et al. (2003) have estimated that controlling lipid levels can have the effect of adding 3.0 to 3.4 years of life to the average patient with diabetes.

Whether "adherence to guidelines" is an optimal measure of diabetes care quality is an certainly appropriate issue for discussion and one that is difficult to study. There are also other aspects of diabetes care that were not included in this study, such as foot exams, physical activity counseling, etc.

Grover SA,et al. Evaluating the benefits of treating dyslipidemia: the importance of diabetes as a risk factor. Am J Med 2003; 115:122-8.

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The principal problem with this study is that it did not follow whether a particular provider (or type of provider) followed this patient. Therefore the study cannot comment on whether a particular type of provider provided better care.

Also when examining non-physician providers the study carried across two different states. Each state has different practice acts for PAs and NPs which may influence provider encounters. In addition the geographical spread of the study means that different practices may have different payor mixes which may limit a practices ability to order the laboratory tests examined in the study. Neither the practice act or the payor mix was discussed in this study leading to the possibility of error.

An alternative explanation to the findings in the study is that the presence of an NP in the practice was a surrogate marker for size of practice. There was no difference in outcomes, only in processes. Therefore the alternative explanation is that smaller practices are better at adhering to processes (at least the ones measured).

It is also tremendously disappointing that the study focused on a few biochemical markers when good diabetes practice requires much more effort and process formation.

David Carpenter, PA-C

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I am a PA who has been practicing medicine over 30 years. I have worked with a high number of NPs and PAs and found that once out of school a few years the differences regarding the quality and type of of care both professions provide are negligible. I wonder about this study, as it really says that PAs and physicians did not follow the American Diabetes Association guidelines as well as NPs did. The real question here is why this is so? Possibly an interview was needed to discover a bit more about why? Do PAs or MDs generally not follow guidelines as closely as NPs do? Were the nurses nurse educators or diabetic specialists before becoming NPs? Is it the nursing background that makes NPs feel that guidelines are more important? Is it even a question of the MD or PA feeling they are less important? I think the more important question is how are both PAs, NPs and even physicians going to benefit by these types of "us against them" studies? We all need to learn as a group and elevate the quality of our practices as a group, all learning from each other. I am not sure how the study results actually get applied to the practices of all three professions unless it is to say that all of us must insure that we practice with knowlege of the newest guidelines in an evidence based manner. Still and all interesting. Dave

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I am in a rural setting. I have practiced with PA/NP midlevels for over ten years. Over that time I have seen some differences in approach to the provision of health care. My n number is too small so this is anecdotal and possibly my own stereotype. I like that this study used the ADA diabetes guidlines to assess "better performance" If you ordered a test suggested "then it was better performance". In my experience the PA's applied the recomendations or protocols more appropriatly given the patients clinical and personal situation than the NPs ex If a diabetic also was being treated for HTN with an ACE or ARB do you need a microalbumin as often or at all as suggested by the ADA? (even nurse diabetic teachers in our area don't understand this question) The NP's tended to order that kind of test regardless of what they would do with the result. We are confronted with many under insured patients so what test and when to order it is modulated by other issues besides what I call "the guidelines." The PAs seem more comfortable managing the patients without all the routine tests than the NPs. I would submit that that might actually represent better patient care if not that at least more flexibility. I currently have an NP in my employ, no PA. Thank you for this interesting study. It is helping me understand the people that I depend on to help me serve this comunity. DC

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