Clinician Care Team Composition and Health Care Utilization.

OBJECTIVE: To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization. PATIENTS AND METHODS: We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions. RESULTS: The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = -0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians. CONCLUSION: Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Association of Primary Care Team Composition and Clinician Burnout in a Primary Care Practice Network.

OBJECTIVE: To determine the relationship of the emotional exhaustion domain of burnout with care team composition in a Midwestern primary care practice network. PARTICIPANTS AND METHODS: We studied 420 family medicine clinicians (253 physicians and 167 nurse practitioners/physician assistants [NP/PAs]) within a large integrated health system throughout 59 Midwestern communities. The observational cross-sectional study utilized a single-question clinician self-assessment of the emotional exhaustion domain of burnout on a scale of 0 (never) to 6 (daily) conducted between March 1 and April 2, 2018, and administrative data collected between January 1, 2017, and December 31, 2017. We used a multivariable linear mixed model for data analysis, adjusted for clinical- and team-level factors, including clinician sex, panel size and complexity, clinician type (physician or NP/PA), clinician full-time equivalent (FTE), total care team panel size, and number of clinicians on the care team. RESULTS: Among 217 survey respondents (51.7%), the median frequency of the emotional exhaustion domain of burnout was once per week. Adjusted analyses revealed that a greater proportion of physician FTE on the care team was associated with a lower emotional exhaustion domain of burnout among individual clinicians (P=.05). Female clinicians had a higher emotional exhaustion domain of burnout than male clinicians (P=.05). None of the other variables in the model were associated with emotional exhaustion. CONCLUSION: Primary care teams containing both physicians and NP/PAs had lower levels of emotional exhaustion with increasing proportion of physician FTE. More work is needed to explore what other variables may be associated with burnout in primary care team-based practices.

Nurse practitioners and physician assistants are complements to family medicine physicians.

Controlling the overall cost of medical care requires controlling the number of physician visits. Nurse practitioners and physician assistants (NPs/PAs) may function as lower-cost substitutes for physicians or they may complement physician services. The association between NP/PA and physician visits when NPs/PAs are not working as primary care providers (PCPs) has not been thoroughly studied. A sample of 400 family medicine patients drawn from 1 large multisite practice was studied using multiple logistic regression analysis. NPs/PAs did not function as PCPs during the study period. Patients were defined as outliers if they visited physicians more than 5 times in a year. Patients who visited NPs/PAs in non-retail clinics were significantly more likely to be physician visit outliers. Visits to NPs/PAs in retail clinics were not related to physician visits. NP/PA visits in standard medical office settings complement physician visits when the NPs/PAs were not working as PCPs in this large multisite practice. Health care reform proposals relying on increased use of NPs/PAs may be more cost-efficient if NPs/PAs are located in retail settings or function as PCPs.