Low-Value Back Imaging in the Care of Medicare Beneficiaries: A Comparison of Nurse Practitioners and Physician Assistants

Abstract

Little is known about practice pattern differences between nurse practitioners (NPs) and physician assistants (PAs). We compared the rates of low-value back images ordered by NPs and PAs. For this comparison, we used 2012-2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions and a measure of low-value back imaging from the Choosing Wisely recommendations. Models included a random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician type, the emergency department setting, and region. NPs (N = 234) order low-value back images significantly less than PAs (N = 204) (NPs 25.5% vs. PAs 39.2%, p < .0001). Controlling for relevant factors, NPs are 10.0 percentage points (p < .0001) less likely to order a low-value back image than PAs. NPs and PAs have distinct patterns of low-value back imaging, which is likely a reflection of their different practice settings.

Keywords

nurse practitioner physician assistant low-value imaging Medicare

Get full access to this article

View all access options for this article.

References

Agency for Healthcare Research and Quality. (2018). The number of nurse practitioners and physician assistants practicing primary care in the United States. Rockville, MD: Author. https://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html

American Board of Internal Medicine. (2014, May 1). Unnecessary tests and procedures in the health care system: What physicians say about the problem, the causes and the solutions. Results from a national survey of physicians. http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf

American Board of Internal Medicine. (2018). Choosing Wisely: Facts and figures. http://www.choosingwisely.org/our-mission/facts-and-figures/

American College of Radiology. (2016). Choosing Wisely: Ten things physicians and pateints should question. http://www.choosingwisely.org/societies/american-college-of-radiology/

Association of American Medical Colleges. (2017). Workforce data and reports. https://www.aamc.org/data/workforce/reports/

Auerbach

Staiger

Buerhaus

(2018). Growing ranks of advanced practice clinicians—Implications for the physician workforce. New England Journal of Medicine, 378, 2358-2360.

Brown

S. R.

Brown

(2011). Why do physicians order unnecessary preoperative tests? A qualitative study. Family Medicine, 43, 338-343.

Buerhaus

P. I.

DesRoches

C. M.

Dittus

Donelan

(2015). Practice characteristics of primary care nurse practitioners and physicians. Nursing Outlook, 63, 144-153. doi:10.1016/j.outlook.2014.08.008

Centers for Medicare & Medicaid Services. (2019). Draft ICD-10-CM/PCS MS-DRGv31.0 definitions manual. https://www.cms.gov/icd10manual/version31-fullcode-cms/P0001.html

10.

Charles

Gafni

Whelan

(1999). Decision-making in the physician–patient encounter: Revisiting the shared treatment decision-making model. Social Science & Medicine, 49, 651-661. doi:10.1016/S0277-9536(99)00145-8

11.

Claxton

Rae

Levitt

Cox

(2018). How have healthcare prices grown in the U.S. over time? Peterson-Kasier Health System Tracker. https://www.healthsystemtracker.org/chart-collection/how-have-healthcare-prices-grown-in-the-u-s-over-time/-item-start

12.

Colla

C. H.

Mainor

A. J.

Hargreaves

Sequist

Morden

(2016). Interventions aimed at reducing use of low-value health services: A systematic review. Medical Care Research and Review, 74, 507-550. doi:10.1177/1077558716656970

13.

Colla

C. H.

Morden

N. E.

Sequist

T. D.

Schpero

W. L.

Rosenthal

M. B.

(2015). Choosing wisely: Prevalence and correlates of low-value health care services in the United States. Journal of General Internal Medicine, 30, 221-228. doi:10.1007/s11606-014-3070-z

14.

Dartmouth Institute for Health Policy and Clinical Practice. (1996). The Dartmouth Atlas of Health Care. https://www.dartmouthatlas.org/downloads/atlases/96Atlas.pdf

15.

Dietrich

Leroux

Santiago

Helgeson

Richard

Koehlmoos

(2018). Assessing practice pattern differences in the treatment of acute low back pain in the United States Military Health System. BMC Health Services Research, 18(1), 720. doi:10.1186/s12913-018-3525-8

16.

Edwards

Hayden

Asbridge

Gregoire

Magee

(2017). Prevalence of low back pain in emergency settings: A systematic review and meta-analysis. BMC Musculoskeletal Disorders, 18(1), 143. doi:10.1186/s12891-017-1511-7

17.

Elixhauser

Steiner

Harris

D. R.

Coffey

R. M.

(1998). Comorbidity measures for use with administrative data. Medical Care, 36, 8-27.

18.

Ford

(1979). A nurse for all settings: The nurse practitioner. Nursing Outlook, 27, 516-521.

19.

Fraher

E. P.

Morgan

Johnson

(2016). Specialty distribution of physician assistants and nurse practitioners in North Carolina. Journal of the American Academy of Physician Assistants, 29(4), 38-43.

20.

Gidwani

Sinnott

Avoundjian

Asch

Barnett

(2016). Inappropriate ordering of lumbar spine magnetic resonance imaging: Are providers Choosing Wisely? American Journal of Managed Care, 22, e68-e76.

21.

Han

P. K.

Klabunde

C. N.

Noone

A. M.

Earle

C. C.

Ayanian

J. Z.

Ganz

P. A.

. . .Potosky

A. L.

(2013). Physicians’ beliefs about breast cancer surveillance testing are consistent with test overuse. Medical Care, 51, 315-323. doi:10.1097/MLR.0b013e31827da908

22.

Holt

(1998). “Confusion’s masterpiece”: The development of the physician assistant profession. Bulletin of the History of Medicine, 72, 246-278.

23.

Hong

A. S.

Ross-Degnan

Zhang

Wharam

J. F.

(2017). Clinician-level predictors for ordering low-value imaging. JAMA Internal Medicine, 177, 1577-1585. doi:10.1001/jamainternmed.2017.4888

24.

Hoy

Bain

Williams

March

Brooks

Blyth

. . .Buchbinder

(2012). A systematic review of the global prevalence of low back pain. Arthritis Rheum, 64, 2028-2037. doi:10.1002/art.34347

25.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academies Press. https://www.nap.edu/read/10027/chapter/1

26.

Institute of Medicine. (2010). The future of nursing: Focus on scope of practice. Washington, DC: National Academies Press. http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief-Scope-of-Practice.aspx

27.

Institute of Medicine. (2012). Best care at lower cost: The path to continuously learning health care in America. Washington, DC: National Academies Press. https://www.nap.edu/catalog/13444/best-care-at-lower-cost-the-path-to-continuously-learning

28.

Institute of Medicine. (2013). Variation in health care spending: Target decision making, not geography. Washington, DC: National Academies Press. https://www.nap.edu/catalog/18393/variation-in-health-care-spending-target-decision-making-not-geography

29.

Mafi

J. N.

Wee

C. C.

Davis

R. B.

Landon

B. E.

(2016). Comparing use of low-value health care services among U.S. advanced practice clinicians and physicians. Annals of Internal Medicine, 165, 237-244. doi:10.7326/m15-2152

30.

Martsolf

G. R.

Barnes

Richards

M. R.

Ray

K. N.

Brom

H. M.

McHugh

M. D.

(2018). Employment of advanced practice clinicians in physician practices. JAMA Internal Medicine, 178, 988-990. doi:10.1001/jamainternmed.2018.1515

31.

Medicare Payment Advisory Commission. (2016, March). Report to the Congress: Medicare payment policy. http://www.medpac.gov/docs/default-source/reports/march-2016-report-to-the-congress-medicare-payment-policy.pdf?sfvrsn=0

32.

Medicare Payment Advisory Commission. (2019a, January 17-18). Assessing payment adequacy and updating payments: Physicians and other health professional services; and Medicare payment policies for advanced practice registered nurses and physician assistants. Paper presented at the Public Meeting, Washington, DC.

33.

Medicare Payment Advisory Commission. (2019b). Improving Medicare’s payment policies for Advanced Practice Registered Nurses and Physician Assistants. MedPAC Blog. http://medpac.gov/-blog-/the-commission-recommends-aprns-and-pas-bill-medicare-directly-/2019/02/15/improving-medicare%27s-payment-policies-for-aprns-and-pas

34.

Mills

A. M.

Raja

A. S.

Marin

J. R.

(2015). Optimizing diagnostic imaging in the emergency department. Academic Emergency Medicine, 22, 625-631. doi:10.1111/acem.12640

35.

National Committee for Quality Assurance. (2014). Appropriate imaging for acute back pain. Washington, DC: Author. https://www.qualityforum.org/

36.

National Governors Association. (2012). The role of nurse practitioners in meeting increasing demand for primary care. https://www.nga.org/center/issues/health-issues/the-role-of-nurse-practitioners-in-meeting-increasing-demand-for-primary-care/

37.

Newhouse

J. P.

Gardner

(2013). Geographic variation in Medicare services. New England Journal of Medicine, 368, 1465-1468.

38.

Office of the Assistant Secretary for Planning and Evaluation. (2015). Impact of state scope of practice laws and other factors on the practice and supply of primary care nurse practitioners. https://aspe.hhs.gov/sites/default/files/pdf/167396/NP_SOP.pdf

39.

O’Reilly-Jacob

Perloff

Buerhaus

(2019). Comparing the rates of low-value back images ordered by physicians and nurse practitioners for Medicare beneficiaries in primary care. Nursing Outlook, 67(6), 713-724. https://doi.org/10.1016/j.outlook.2019.05.005

40.

Pittman

Leach

Everett

Han

McElroy

(2018). NP and PA privileging in acute care settings: Do scope of practice laws matter? Medical Care Research and Review. Advance online publication. doi:10.1177/107755871876033

41.

Schwartz

A. L.

Landon

B. E.

Elshaug

A. G.

Chernew

M. E.

McWilliams

J. M.

(2014). Measuring low-value care in Medicare. JAMA Internal Medicine, 174, 1067-1076. doi:10.1001/jamainternmed.2014.1541

42.

Schwartz

A. L.

Zaslavsky

A. M.

Landon

B. E.

Chernew

M. E.

McWilliams

J. M.

(2018). Low-value service use in provider organizations. Health Services Research, 53, 87-119. doi:10.1111/1475-6773.12597

43.

Segal

J. B.

Bridges

J. F.

Chang

H. Y.

Chang

Nassery

Weiner

Chan

K. S.

(2014). Identifying possible indicators of systematic overuse of health care procedures with claims data. Medical Care, 52, 157-163. doi:10.1097/mlr.0000000000000052

44.

Smith-Bindman

Miglioretti

D. L.

Johnson

Lee

Feigelson

H. S.

Flynn

. . .Williams

A. E.

(2012). Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA, 307, 2400-2409. doi:10.1001/jama.2012.5960

45.

Tan

Zhou

Kuo

Y. F.

Goodwin

J. S.

(2016). Variation among primary care physicians in the use of imaging for older patients with acute low back pain. Journal of General Internal Medicine, 31, 156-163. doi:10.1007/s11606-015-3475-3

46.

U.S. Department of Veterans Affairs. (2016, December 14). VA grants full practice authority to advance practice registered nurses. https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847