Non-physician clinicians aren’t responsible for more low-value imaging utilization than docs are

Contrary to popular physician perception, advanced practice clinicians (APCs)—primarily nurse practitioners and physician assistants—don’t spur more low-value imaging orders, antibiotic prescriptions or specialist referrals than physicians do.

The study behind the finding was published online June 21 in Annals of Internal Medicine.

John Mafi, MD, MPH, of the David Geffen School of Medicine at UCLA and colleagues evaluated ordering patterns following primary-care visits for three common conditions: upper respiratory infections (URIs), back pain and headache.

The researchers focused on guideline-discordant orders for, specifically, antibiotics for upper-respiratory infections (URIs), X-rays for URIs and back pain, CT or MRI for headache and back pain, and referrals to other physicians for all of the above.

They reviewed 12,170 physician and 473 APC office-based visits and 13,359 physician and 2,947 APC hospital-based visits as recorded in the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 to 2011.

After excluding patients with guideline-based red flags, the team found that unadjusted and adjusted results revealed APCs ordering antibiotics, imaging and referrals as often as physicians in both settings.

They additionally observed that, although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years) and practiced in urban settings less frequently (49.7 percent vs. 81.7 percent of visits) than hospital-based physicians.

Among the limitations in study design that the authors acknowledge is the fact that NAMCS probably underrepresents office-based APCs.

“Many physicians believe that advanced practice clinicians provide care of relatively lower value,” write Mafi et al. That perception appears not to be based on reality, they suggest, as APCs and physicians “provided an equivalent amount of low-value health services, dispelling physicians’ perceptions that APCs provide lower-value care than physicians for these common conditions.”