Treatment decisions for complex patients: differences between primary care physicians and mid-level providers

OBJECTIVES: To examine whether treatment change for diabetic patients presenting with elevated blood pressure (BP) differed between physicians and midlevel providers (nurse practitioners [NPs] and physician assistants [PAs]) and to determine reasons for any observed differences. METHODS: Analyses were part of a prospective cohort study of 1169 diabetic patients with scheduled visits to 92 primary care providers (PCPs) in 9 Midwest Veterans Health Administration facilities presenting with a triage BP of > or =140/90 mm Hg. We analyzed predicted probabilities of treatment change by provider type. RESULTS: The PCPs included 64 physicians, 21 NPs, and 7 PAs. Patients treated by physicians and midlevel providers did not differ in their mean visit BP, number of chronic conditions, age, or number of BP medications. Controlling for current and past BP readings and patient characteristics, physicians were significantly more likely than midlevel providers to initiate a treatment change for elevated BP at a visit (53.8% vs 36.4%; P = .001). After controlling for additional visit-specific factors, practice style, measurement, and organizational factors, physicians were still more likely to initiate a treatment change (52.5% vs 37.5%; P = .02). CONCLUSIONS: Midlevel providers were significantly less likely than physicians to change BP treatment for diabetic patients with multiple chronic conditions presenting with elevated BP at a single visit. We could not find good explanations for this difference. Given the expanding role of midlevel providers in delivering primary care to complex patients, we need to understand whether these treatment change differences lead to long-term differences in BP control.

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