Trends in Midlevel Provider Utilization

Abstract

Physician assistants and nurse practitioners have become an increasingly common part of emergency department (ED) care. As described by Menchine and colleagues,1 12.7% of all U.S. ED visits in 2006 were seen by a midlevel provider (MLP). The authors, and the accompanying editorial by Haley and Kellermann,2 discuss the practical and financial reasons for the increasing utilization of MLPs and potential implications for the quality of ED care. Menchine and colleagues expressed concerns about the scope of practice and level of supervision of MLPs, while Haley and Kellermann reassured readers that MLPs cannot replace emergency physicians (EPs). Unfortunately, in hundreds of EDs, this substitution has already occurred. We recently reported that 4.8% of U.S. ED visits in 2005 were seen by MLPs, mostly physician assistants, without any evidence of direct physician involvement.3 That is, for approximately 6 million ED visits, MLPs had essentially replaced EPs. Additionally, the role of MLPs has extended beyond minor ED presentations—37% of patients seen only by MLPs were of urgent or emergent acuity, and 3% were admitted to the hospital. Clearly, there are not enough personnel or funds to fully staff EDs with physicians, let alone with emergency medicine (EM) residency–trained and board-certified EPs. While MLPs are important collaborators in emergency care and can improve efficiency and productivity, their role is intended as an extension, not replacement, of EPs. Indeed, physician assistants by definition “assist” the physician and thus require supervision. These providers usually train for 2 years before practicing in the ED. As Haley and Kellermann2 suggest, this cannot replace training from 4 years of medical school and 3 to 4 years of EM residency training. Although nurse practitioners have different training and supervision requirements than physician assistants, the concept of collaboration, rather than replacement, is widely held in EM. The 2006 Institute of Medicine report on the future of emergency care highlighted that alternative options will be required to adequately staff all EDs with competent clinicians.4 However, EP workforce shortages and ED financial difficulties have led to increased reliance on MLPs, often without physician supervision and without evaluation on the impact of this change on quality care and patient safety. Menchine and colleagues1 voiced concerns that widespread employment of MLPs may compromise the quality of ED care; Haley and Kellermann2 noted that “they offer no proof to support these misgivings.” We have new evidence to address this issue.5 In an analysis of 4,029 visits for acute asthma in 63 U.S. EDs, we found that unsupervised MLPs had a much lower quality of ED asthma care, compared to physician-supervised MLPs and to physicians alone; the latter groups provided care of very similar quality. While this is a single study of one condition, these data support concerns that MLPs should collaborate with, rather than substitute for, EPs. ED-based MLPs may improve the financial bottom line, but we need to remain focused on quality care and patient safety, particularly for MLPs practicing without physician supervision.