Comparison of primary care visits to physicians and non-physician

Comparison of primary care visits to
physicians and non-physician
providers in Community Health
Centers and Hospital Outpatient
Departments
Health Resources and Services
Administration (HRSA), NORC at the
University of Chicago,
Chicago University of Chicago
Chicago,
National Center for Health Statistics (NCHS)
AcademyHealth 2014 Annual
Research Meeting
g
June 10, 2014
Goal of broader study
y
• To better understand the healthcare services
being provided in federally funded health centers
• How care at health centers compares to other primary
care settings
• How health centers are using their workforce to
provide services
p
2
Introduction
• This
Thi study
t d compares healthcare
h lth
services
i
ordered
d d
or provided by primary care physicians and nonphysician
h i i providers
id
iin:
• Federally-funded community health centers (CHCs)
• Hospital outpatient departments (OPDs)
• Non-physician providers include nurse
practitioners, physician assistants, and certified
nurse midwives
3
METHODS
Description
p
of Data Source
• NAMCS & NHAMCS collect data on ambulatory
care visits
Data Source
Setting
Provider type visit data
collected
National Ambulatory Medical Care
S
Survey
(NAMCS)
CHCs
Physician and non-physician
providers
id
POs
Physicians (non-physician
providers not sampled)
OPDs
Physician and non-physician
providers
National Hospital Ambulatory Medical
Care Survey (NHAMCS)
• Combined 2008-2010 data
5
Exclusion criteria
• Focus on primary care visits
• OPD sample restricted to primary care visits using
approach described by Forrest & Whelan1
• Comparison
p
of p
physician-only
y
y visits and nonphysician provider-only visits (NPs, PAs, CNMs
combined))
• Excluded small number of visits involving both
physicians and non
non-physician
physician providers and visits
involving only other types of providers
1. Forrest,
1
Forrest C
C.B.
B and Whelan
Whelan, E
E.M.
M 2000
2000. "Primary
Primary Care Safety-Net
Safety Net Delivery Sites
in the United States." Journal of the American Medical Association, 284(16):2077-2083.
6
Description
p
of Data
• Visit
Vi it d
data
t iinclude:
l d
• patient demographic characteristics
• visit characteristics
–
–
–
–
–
Reason for the visit
Diagnoses
Services ordered or provided
Medications & immunizations ordered or continued
Recommended follow up from the visit
• Type of provider seen at the visit
7
Studyy Design
g
• Assessed
A
d relationship
l ti
hi b
between
t
provider-type
id t
(predictor variable) and key outcome variables
• Bivariate analysis
• Chi
Chi-squared
squared tests of association
• Multivariate analysis
• Negative binomial model and logistic regression
• Controlled for patient and visit characteristics
8
Outcomes
Outcome Variable (service(s) ordered or provided at the visit)
Total number of services
up to 54 distinct services (includes up to 8 medications)
Any mental health service
mental health counseling, stress management,
psychotherapy and depression screening
psychotherapy,
Any health education service education for asthma, diet/nutrition, exercise,
growth/development, injury prevention, stress management,
tobacco use/exposure, weight reduction, and other health
education services provided
y women’s health
Any
screening or preventive
health service
Any preventive service
mammography,
g p y, p
pelvic exam,, p
pap
p smear,, bone density,
y, and
HPV DNA test
cholesterol, glucose, Hba1c, PSA, bone density,
mammography,
h pelvic
l i exam, d
depression
i screening,
i
chlamydia test, HPV DNA test, pap smear, and
sigmoidoscopy or colonoscopy
9
Results
Bivariate Results - CHCs
• At CHCs,
CHCs approx.
approx 56% of visits were to physicians and
40% were to non-physician providers
• At OPDs,
OPDs 73% of visits were to physicians and 16% were
to non-physician providers
• Non
Non-physician
physician providers saw more patients living in less
dense areas than physicians in both CHCs and OPDs
• At CHCs,, a larger
g p
proportion
p
of non-physician
p y
p
provider
visits had the reason for the visit cited as preventive care
(35% compared to 28%), while a larger proportion of
physician visits were for a chronic issue or surgery (33%
compared to 26%)
11
Multivariate Results - CHCs
Visit Characteristics
Total Number of Services, Average
Adjusted Incidence Rate Ratio
Visit Involved Any Mental Health Service
Adjusted Odds Ratio
Visit with Female Patients Involved Any
Women's Preventive Health Service
Adjusted Odds Ratio
Visit Involved Any Health Education Service
Adjusted Odds Ratio
Visit Involved Any Preventive Health Service
Adjusted Odds Ratio
95% confidence interval
Physician Only
Non-Physician Only
4.8
5.4
reference
1.15*
4%
10%
reference
2.34*
14%
24%
reference
1 33
1.33
39%
56%
reference
1.88*
25%
35%
reference
1.51*
*Statistically significant (p-value ≤ 0.001)
12
Multivariate Results - OPDs
Visit Characteristics
Total Number of Services, Average
Adjusted Incidence Rate Ratio
Visit Involved Any Mental Health Service
Adjusted Odds Ratio
Visit with Female Patients Involved Any
Women's Preventive Health Service
Adjusted Odds Ratio
Visit Involved Any Health Education Service
Adjusted Odds Ratio
Visit Involved Any Preventive Health Service
Adjusted Odds Ratio (95% CI)
95% confidence interval
Physician Only
Non-Physician Only
5.6
5.4
reference
1.03
5%
6%
reference
1.15
17%
16%
reference
1.02
47%
50%
reference
1.08
28%
25%
reference
1.00
Note: None of the results are statistically significant.
13
Summary
y
• Findings suggest non
non-physician
physician providers are playing an
important role in the delivery of primary care services by
providing more care in rural areas of the country
• Non-physician providers at CHCs are ordering/providing
more services overall and more mental health,, preventive
p
care, and health education at each visit
• At CHCs, a greater proportion of non-physician visits are
with patients coming in for preventive care.
• At OPDs, there were no differences found between
services provided at physician and non-physician visits,
indicating comparable care.
14
Implications
p
for Policy
y
• Some experts project a shortage of primary care
physicians, suggest that non-physician providers could
play an increased role as primary care providers, often in
collaboration with physicians
• Scope of practice policies for non-physician providers
i
impact
t th
the extent
t t to
t which
hi h they
th can serve as primary
i
care
providers
• We may be seeing more rural visits to non-physician
non physician
providers because of the lack of sufficient physicians in
these areas
15
Authors
• Sarah Downie,
Downie NORC at the University of Chicago
• Yue Gao, University of Chicago
• Erin
E i Tanenbaum,
T
b
NORC att the
th University
U i
it off Chicago
Chi
• Petry Ubri, NORC at the University of Chicago
• Marie
M i Dreyer,
D
NORC att the
th University
U i
it off Chicago
Chi
• Elbert Huang, University of Chicago
• Adil Moiduddin,
M id ddi NORC at the
h U
University
i
i off Chi
Chicago
• Ravi Sharma, Bureau of Primary Health Care
• Esther Hing, National Center for Health Statistics
• Amanda Tzy-Chyi Yu, previously at NORC at the
U i
University
it off Chicago
Chi
Insert Presentation Title and Any Confidentiality Information
16
Questions
Q
ti
and
d
Discussion
HCIA Evaluation - Disease Specific