The Family Practice and diabetes treatment

By Charles Bankhead, Staff Writer, MedPage Today
Published: January 15, 2008
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine.

PISCATAWAY, N.J., Jan. 15 -- Patients with diabetes fare better in family practices that employ a nurse practitioner than in practices with a physician's assistant or those without a mid-level provider, investigators here found.
Action Points

* Explain to patients that family practices with nurse practitioners appear to provide higher quality diabetes care.

* Point out that the study was observational and cannot conclude causation from any associations.

* Note also that the researchers could not explain the differences they observed.

Monitoring, treatment, and treatment success were significantly better in practices with NPs than in those with PAs (P?0.005), Pamela A. Ohman-Strickland, Ph.D., of the University of Medicine and Dentistry of New Jersey, and colleagues, reported in the January/February issue of Annals of Family Medicine.

Practices with NPs were also significantly more likely than physician-only practices to assess hemoglobin A1c levels and lipid levels (P?0.007 for each).

"These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems," the authors wrote.

"With the burgeoning use of PAs and NPs in attempts to cut costs and try different models of clinical care, these results point to a need for additional research to confirm these associations and to explore their causes," they added.

Several studies have suggested that NPs and physicians perform certain types of care equally well. Others have identified aspects of care in which NPs might perform better than physicians. However, little data exist to compare the care provided by PAs with either physicians or NPs in primary care.

Prior studies frequently focused on specific skills or skill sets. In this study, Dr. Ohman-Strickland and colleagues examined the effectiveness of practices that employ NPs or PAs. They sought to determine at the practice level the effect of NPs and PAs on quality of care.

The researchers performed a cross-sectional analysis of data from a quality improvement trial conducted in family medicine practices. Specifically, they examined practices' adherence to American Diabetes Association guidelines for testing and treatment.

The study included 46 family medicine practices and 846 patients with diabetes. Nine practices had NPs, and nine employed PAs. The remaining 28 practices had physicians only.

As compared with the practices that employed PAs, those with NPs were significantly (P?0.005) more likely to:

* Measure hemoglobin A1c (66% versus 33%)
* Measure lipid levels (80% versus 58%)
* Measure urinary microalbumin (32% versus 6%)
* Treat high lipid levels (77% versus 56%)
* Attain lipid targets (54% versus 37%)

In comparison with physician-only practices, those with NPs were significantly (P?0.007) more likely to assess hemoglobin A1c (66% versus 49%) and lipid levels (80% versus 68%).

Practices with PAs or NPs were perceived as busier (P=0.03) and had larger total staffs (P<0.001) than did physician-only practices.

The number of PAs and NPs per physician did not differ significantly among practices, nor did the number of physicians.

The researchers acknowledged a number of limitations to the study, including the relatively small number of practices with either NPs or PAs and the fact that their findings may not be generalizable. They also said that measuring additional variables may have provided "more hints as to the reason for the differences found."

"In addition," they said, "we may not have measured components of care that are potentially most affected by collaboration with a diverse clinician base."

Although the observational study cannot prove causality and the study design precluded connection of patients with particular clinicians, the authors noted that previous randomized trials have done such matching and have found similar results for NPs. The findings indicate a need for further studies to determine how "teams of clinicians that include mid-level practitioners can be used more effectively and efficiently in primary care practice," the authors concluded.


Additional source: Annals of Family Medicine
Source reference:
Ohman-Strickland, PA et al "Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants" Ann Fam Med 2008; 6: 14-22.

The study was supported by the National Heart, Lung, and Blood Institute, the American Academy of Family Physicians, and the Cancer Institute of New Jersey's Primary Care Research.

The authors reported no conflicts of interest.