2017 HSC Section 2 - Practice Management

TABLE I. Distribution of Medical Providers Seen for Otolaryngologic Office Visits, 2008 and 2009.

Medical Provider Seen

No.

SE

% of Visits*

SE

Physician

37,647,017

3,742,272

97.5

1.1

Physician assistant

1,770,980

702,253

4.6

1.9

Nurse practitioner

659,674

359,556

1.7

0.9 7.6

RN/LPN

9,669,216

3,500,089

25.1

No. represents number of visits. *Provider seen is not mutually exclusive (i.e., patient may have seen both physician and nurse practitioner) thereby sum totals > 100%. SE ¼ standard error; RN ¼ registered nurse; LPN ¼ licensed practical nurse.

visit rate vs. 23.3%). Less than 0.5% of ambulatory otola- ryngologic visits involved care provided by a RN alone (i.e., without concurrent physician-level care). Tables II and III present the top 10 diagnoses asso- ciated with an APC- or RN-related ENT visit, as well as physician-alone visits. Disorders associated with the external and middle ear (i.e., otitis externa, cerumen impaction, acute otitis media) were the most common diseases with and APC and/or an RN component to the encounters. With respect to patient visit type, for 7.2 6 2.3% of established patient visits, an APC was involved in the outpatient visit. In contrast, for new patient visit types, an APC was involved in the outpatient visit less frequently, 4.3 6 1.8% of the time ( P ¼ .080) DISCUSSION There is little question that APCs are increasingly becoming part of the core healthcare providership in the United States. As the US population ages and with pre- dicted increases in chronic conditions such as obesity, diabetes, and allergic diseases, it is further likely that care provided by physician extenders will increase across multiple medical specialties. Given that recent work sug- gests a increasing volume of patients who will require otolaryngologic care in the upcoming decades, coupled with a relatively aging otolaryngologic physician work- force, a significant penetration of APCs into ambulatory otolaryngologic care is likely. 2,9 As a specialty, otolaryn- gology–head and neck surgery will need to recruit, train, and supervise these nonphysician providers. For

reporting period. During this period, data for a systematic ran- dom sample of visits are recorded by the physician on an encounter form provided for that purpose. It is estimated that 84% of all ambulatory visits in the United States fall within the NAMCS sampling frame, and the survey has been previously validated in comparison to direct observation with very good ac- curacy with respect to the provision of health services. 4 We and others have previously used this data set to examine care pro- vided for a number of otolaryngologic conditions including chronic rhinosinusitis, otitis media, and otologic diagnoses in the elderly. 5–8 The study was reviewed and received an institutional review board exemption. From the combined years data set, office visits to ambulatory ear, nose, and throat (ENT) practices were extracted including diagnosis codes, patient demographic data, and provider data. Each visit contains provider data related to type of providers seen: physician, physician assistant (PA), nurse practitioner (NP), and registered nurse (RN)/li- censed practical nurse (LPN). For purposes of evaluation, physician assistants and nurse practitioners were grouped to- gether as APCs. From the ENT office visits, the types of providers seen were tabulated. Next, for patients seen by a PA, NP, or RN, the fraction of patients seen by the auxiliary personnel alone (visit independent of physician) and auxiliary personnel with physi- cian (collaborative visit) were determined. Furthermore, the top 10 visit diagnoses were determined and tabulated for each of the auxiliary personnel: physician, NP, and RN. Last, the rela- tionship between auxiliary personnel and type of office visit (office new patient vs. established patient) was determined and tabulated. Because the NAMCS design uses clustering, stratifi- cation, random sampling, and weighting, appropriate statistical methods that incorporate these study design elements into sta- tistical calculations for complex samples were used. Statistical significance was set at P ¼ .05. RESULTS For combined calendar years 2008 and 2009, an estimated 38.6 6 3.73 million outpatient office visits to an ENT provider/practice (raw sample, 2714 visits) were identified for analysis. The distribution of providers seen at these office visits are presented in Table I. In Table I, the providers seen are not mutually exclusive (i.e., at a given outpatient visit, the patient may have seen both a physician and an NP). In 6.3 6 2.0% of office visits, an APC (PA or NP) was seen. A nurse (RN/LPN) was involved in 25.1 6 7.6% of ENT office visits. Figure 1 demonstrates the joint versus independent visit rate for APCs and RNs with respect to collaborating physicians. NPs were more likely to see patients independent of a physician when compared to PAs (47.7% independent

Fig. 1. Distribution of joint versus independent office visits in oto- laryngology for physician assistants, nurse practitioners, and nurses. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

Laryngoscope 122: May 2012

Bhattacharyya: Physician Extenders in Otolaryngology

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