Provider Teams Outperform Solo Providers In Managing Chronic Diseases And Could Improve The Value Of Care

Abstract

Scope-of-practice regulations, including prescribing limits and supervision requirements, may influence the propensity of providers to form care teams. Therefore, policy makers need to understand the effect of both team-based care and provider type on clinical outcomes. We examined how care management and biomarker outcomes after the onset of three chronic diseases differed both by team-based versus solo care and by physician versus nonphysician (that is, nurse practitioner and physician assistant) care. Using 2013-18 deidentified electronic health record data from US primary care practices, we found that provider teams outperformed solo providers, irrespective of team composition. Among solo providers, physicians and nonphysicians exhibited little meaningful difference in performance. As policy makers contemplate scope-of-practice changes, they should consider the effects of not only provider type but also team-based care on outcomes. Interventions that may encourage provider team formation, including scope-of-practice reforms, may improve the value of care.

Exhibit 1:. Adjusted diagnosis rates for patients with new onset of type 2 diabetes, hyperlipidemia, or hypertension by team-based care and provider type, 2013–2018

Source: Authors’ analysis of de-identified electronic health record data from 2013 to 2018 for adults with a new chronic disease as identified by an abnormal biomarker (N = 22,874 for type 2 diabetes, N = 24,510 for hyperlipidemia, and N = 28,078 for hypertension). Notes: Colored bars indicate the predicted values from a regression of a claims-based diagnosis indicator on provider, including organization fixed effects as well as patient and disease severity covariates as described in the text. Error bars represent 95% confidence intervals. p-values for team total vs. solo total were as follows: diabetes, <0.001; hyperlipidemia, 0.595; hypertension, <0.001.. Non-physician providers are physician assistants and nurse practitioners. A mixed team is composed of both physician and non-physician providers.

Exhibit 2.. Adjusted prescription rates for patients with new onset of type 2 diabetes, hyperlipidemia, or hypertension by team-based care and provider type, 2013–2018

Source: Authors’ analysis of de-identified electronic health record data from 2013 to 2018 for adults with a new chronic disease as identified by an abnormal biomarker (N = 22,874 for type 2 diabetes, N = 24,510 for hyperlipidemia, and N = 28,078 for hypertension). Notes: Colored bars indicate the predicted values from a regression of an indicator for a patient receiving at least two disease-appropriate prescription orders (including refills) within one year on provider, including organization fixed effects as well as patient and disease severity covariates as described in the text. Error bars represent 95% confidence intervals. p-values for team total vs. solo total were as follows: diabetes, <0.001; hyperlipidemia, <0.001; hypertension, <0.001. Non-physician providers are physician assistants and nurse practitioners. A mixed team is composed of both physician and non-physician providers.

Exhibit 3.. Adjusted lab monitoring rates for patients with new onset of type 2 diabetes or hyperlipidemia by team-based care and provider type, 2013–2018

Source: Authors’ analysis of de-identified electronic health record data from 2013 to 2018 for adults with a new chronic disease as identified by an abnormal biomarker (N = 22,874 for type 2 diabetes, and N = 24,510 for hyperlipidemia). Notes: Colored bars indicate the predicted values from a regression of an indicator for a patient having at least one disease-appropriate lab result within one year (i.e., hemoglobin A1c for type 2 diabetes and LDL cholesterol for hyperlipidemia) on provider, including organization fixed effects as well as patient and disease severity covariates as described in the text. Error bars represent 95% confidence intervals. p-values for team total vs. solo total were as follows: diabetes, <0.001; hyperlipidemia, <0.001. Non-physician providers are physician assistants and nurse practitioners. A mixed team is composed of both physician and non-physician providers. This outcome was not examined for hypertension since blood pressures are routinely taken during visits and thus may not be informative of active hypertension monitoring.

Exhibit 4.. Adjusted biomarker-based disease control outcomes for patients with new onset of type 2 diabetes, hyperlipidemia, and hypertension by team-based care and provider type, 2013–2018

Source: Authors’ analysis of de-identified electronic health record data from 2013 to 2018 for adults with a new chronic disease as identified by an abnormal biomarker (N = 22,874 for type 2 diabetes, N = 24,510 for hyperlipidemia, and N = 28,078 for hypertension). Notes: Colored bars indicate the predicted values from a regression of disease control, as measured by disease-specific biomarker levels below guideline-concordant biomarker targets within one year, on provider, including organization fixed effects as well as patient and disease severity covariates as described in the text. Error bars represent 95% confidence intervals. p-values for team total vs. solo total were as follows: diabetes, <0.001; hyperlipidemia, <0.001; hypertension, <0.001. Non-physician providers are physician assistants and nurse practitioners. A mixed team is composed of both physician and non-physician providers.