Abstract
BackgroundTeam care improves processes and outcomes of care, especially for patients with complex medical conditions that require coordination of care. This study aimed to compare the processes and outcomes of care provided to older patients with diabetes by primary care teams comprised of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs).MethodsWe studied 3,524 primary care practices identified via social network analysis and 306,741 patients ≥66 years old diagnosed with diabetes in or before 2015 in Medicare data. Guideline-recommended diabetes care included eye examination, hemoglobin A1c test, and nephropathy monitoring. High-risk medications were based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Preventable hospitalizations were defined as hospitalizations for a potentially preventable condition.ResultsCompared with patients in the PCP only teams, patients in the team care practices with NPs or PAs received more guideline-recommended diabetes care (annual eye exam: adjusted odds ratio (aOR): 1.04 (95% CI: 1.00–1.08), 1.08 (95% CI: 1.03–1.13), and 1.10 (95% CI: 1.05–1.15), and HbA1C test: aOR: 1.11 (95% CI: 1.04–1.18), 1.11 (95% CI: 1.02–1.20), and 1.15 (95% CI: 1.06–1.25) for PCP/NP, PCP/NP/PA, and PCP/PA teams). Patients in the PCP/NP and the PCP/PA teams had a slightly higher likelihood of being prescribed high-risk medications (aOR: 1.03 (95% CI: 1.00–1.07), and 1.06 (95% CI: 1.02–1.11), respectively). The likelihood of preventable hospitalizations was similar among patients cared for by various types of practices.ConclusionThe team care practices with NPs or PAs were associated with better adherence to clinical practice guideline recommendations for diabetes compared to PCP only practices. Both practices had similar outcomes. Further efforts are needed to explore new and cost-effective team-based care delivery models that improve process, outcomes, and continuity of care, as well as patient care experiences.
Highlights
Diabetes mellitus has become epidemic and poses a great challenge to the economy and public health in the US [1]
Compared with patients in the primary care physicians (PCPs) only teams, patients in the team care practices with nurse practitioners (NPs) or physician assistants (PAs) received more guideline-recommended diabetes care (annual eye exam: adjusted odds ratio: 1.04, 1.08, and 1.10, and HbA1C test: aOR: 1.11, 1.11, and 1.15 for PCP/NP, PCP/NP/PA, and PCP/PA teams)
Due to primary care physician (PCP) shortage, more primary care for patients with diabetes is being delivered by nurse practitioners (NPs) and physician assistants (PAs), most of whom work with PCPs in a team care model to manage clinically-complex conditions such as diabetes mellitus in older patients [5]
Summary
Diabetes mellitus has become epidemic and poses a great challenge to the economy and public health in the US [1]. Optimal primary care access and continuity are especially important for achieving guidelinerecommended care [3] in older patients with diabetes, a population at higher risk of complications from diabetes, polypharmacy, and adverse drug events. These risks reflect at least in part the age-related decline in drug metabolism and the use of multiple concomitant medications to manage the multiple comorbid diseases found in this population [4]. Due to primary care physician (PCP) shortage, more primary care for patients with diabetes is being delivered by nurse practitioners (NPs) and physician assistants (PAs), most of whom work with PCPs in a team care model to manage clinically-complex conditions such as diabetes mellitus in older patients [5]. This study aimed to compare the processes and outcomes of care provided to older patients with diabetes by primary care teams comprised of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs)
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