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No significant differences were noted in terms of the number of stress tests per year.


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Table 4. For example, patients receiving care from APPs in this sample have on average 0. Analyses for the number of lipid panels and number of stress tests further adjusted for the number of specialty care visits. Analyses stratified by patient's illness burden above or below the median for DCG RRS for each of the 2 cohorts [see Supplementary Tables S3—S6 ] were consistent with the results of the main analyses.

Sensitivity analyses also were performed after excluding 7. The results remained consistent with the main analyses see Supplementary Tables S7—S8. In this national cohort of patients with diabetes and CVD receiving care throughout the VA health care system, the study team made the following observations. First, physicians work with larger patient panels than APPs. Second, the overall illness burden of diabetes or CVD patients receiving care from APPs is comparable to patients receiving care from physicians.


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Third, although there are small statistically significant differences in health care resource utilization among patients with diabetes or CVD receiving care from APPs compared with physicians less frequent primary care and specialty care visits but more frequent lipid panels and HbA1c tests , most of these differences are numerically small and likely clinically insignificant. These results are broadly comparable to those from prior studies. In a study performed in an urban medical center, patients assigned to a physician or an NP after an urgent care or emergency department visit had similar health care resource utilization at 6 months and 1 year.

A 2-year follow-up showed similar results with no differences in health care resource utilization between patients assigned to NPs or physicians.

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In contrast, no differences were found in number of prescriptions, return consultations, or referrals. These results are important in the context of the study team's recent studies performed both within and outside the VA health care system, which show that the effectiveness of health care delivery eg, blood pressure control, diabetes control, lipid control is comparable among patients receiving care from APPs and physicians.

Taken together, these findings are important from a health care system's perspective and indicate that a greater use of APPs for chronic care disease delivery in primary care will maintain the effectiveness of care. Furthermore, this does not come at a price of increased health care resource utilization or a greater use of specialist providers. Therefore, a greater use of APPs in primary care is an efficient option for routine chronic disease care delivery, especially when encountering an increase in the number of patients with chronic disease seeking care in the face of physician shortages.

The observation that physicians work with larger patient panels is important, and prior studies have noted this in primary care 5 and in specialty care. Despite this, the team believes that the issue of whether effectiveness of care and health care resource utilization between physicians and APPs remains comparable if APPs are allowed to practice with a larger panel size will need to be formally tested in future studies.

This study has limitations, which must be accounted for while interpreting these results.

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These results represent health care resource utilization among primary care patients and, therefore, these results cannot be generalized to specialty care. Emergency room visits and hospitalizations were not evaluated, as the focus was on health care resource utilization in routine delivery of outpatient diabetes and CVD care. In addition, these measures can be tracked back to a health care provider versus an emergency room visit or a hospitalization, which may or may not be preventable by a provider. This study was performed in the VA health care system, where patient demographics and dynamics of care could be different than in other health care systems.

Although this might be the case, these results represent one of the largest studies to date on this topic involving patients with diabetes or CVD.

Given the national scope of this project, the analyses included a large number of women patients 42, with diabetes and 23,with CVD. Because the study team measured health care resource utilization in the days prior to a patient's index primary care visit, the team performed sensitivity analyses after excluding 7. A switch in provider category following a patient's index primary care visit therefore would not affect health care resource utilization as described in these analyses. Lastly, the study team is not able to identify whether the lipid panels, HbA1c tests, or stress tests were ordered by primary care or specialty providers.

Although tests ordered by specialists would bias the results toward null, the team further adjusted for the number of specialty care visits when evaluating the number of lipid panels, HbA1c tests, and stress tests. In addition, this phenomenon should not affect other health care resource utilization measures eg, number of primary care or specialty care visits.

In conclusion, health care resource utilization for diabetes or CVD care delivery among patients receiving care from APPs is comparable to that of those receiving care from physicians, although physicians work with larger patient panels. These results indicate that a greater use of APPs for chronic disease care delivery does not come at a cost of increased health care resource utilization.

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The other authors declare that there are no conflicts of interest. The opinions expressed reflect those of the authors and not necessarily those of the Department of Veterans Affairs, the US government, or Baylor College of Medicine. Login to your account Username.

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