Author + information
- Robert A. Harrington, MD∗ ( and )
- Paul A. Heidenreich, MD, MS
- ↵∗Reprint requests and correspondence:
Dr. Robert A. Harrington, Department of Medicine, Stanford University, 300 Pasteur Drive, S-102, Stanford, California 94305.
By 2030, >40% of the U.S. population will suffer from some form of cardiovascular disease (CVD), according to analyses from the American Heart Association, and both direct and indirect costs associated with the care of patients with CVD will increase substantially (1). With such a high burden of disease and associated comorbidities, management of chronic CVD, including coronary artery disease (CAD), heart failure, and atrial fibrillation, will require coordinated efforts to ensure maximal adherence to guideline-based clinical care in a population health strategy that is increasingly risk-capitated. At the same time, more research will need to be done and more attention paid to better understand which patients will benefit from increasingly complex regimens of medical therapies designed to improve clinical outcomes (precision health/medicine).
Meeting these care delivery obligations while ensuring the highest possible level of quality care delivered in a personalized, patient-centric way, and doing it all in a cost-effective manner will severely strain an increasingly understaffed cardiovascular workforce (2). The American College of Cardiology (ACC) has taken 2 actions to help the medical community achieve these care delivery obligations: it has committed substantial resources to better understand the quality of care delivery across the United States by establishing the National Cardiovascular Data Registries (3); and it has formally acknowledged the importance of nonphysician professionals, such as physician assistants and nurse practitioners, in cardiovascular care delivery by creating a new membership category, the Cardiovascular Care Team (4).
In this issue of the Journal, Virani et al. (5) use data from the National Cardiovascular Data Registries PINNACLE (Practice Innovation and Clinical Excellence) Registry to compare adherence to outpatient quality measures by physicians and advanced practice providers (APPs), specifically physician assistants and nurse practitioners. They focused on quality measures in CAD, heart failure, and atrial fibrillation during 2012 among nearly 900 clinicians (716 physicians and 167 APPs) in 41 practices that provided care for >450,000 patients. There was no formal quantitative hypothesis on the basis of data equivalence or noninferiority but rather the study was designed to examine what the authors called “clinically meaningful” differences in the delivery of care by the APPs compared with the physicians in these practices.
For most measures of quality care, adjusted analyses (for both provider and patient characteristics) revealed no differences between the 2 groups of providers. Two exceptions were that CAD patients were more likely to receive smoking cessation screening/intervention and referral to cardiac rehabilitation when APPs delivered their care. Secondary analyses found consistent results when comparing practices that had both physicians and APPs with those that had only physicians. The authors conclude that collaborative models of team-based care for common CVDs in an outpatient setting deliver quality care when using accepted performance measures from the ACC. They note that these findings may have important implications for expanding access to the cardiovascular workforce in response to the Affordable Care Act. Of note, neither group of providers fares well when looking at the likelihood that CAD patients are compliant/adherent to all the reported quality measures (approximately 12% for both physicians and APPs).
Both the authors and the ACC should be congratulated for reporting on these observations because the results have important and broad policy implications for an increasingly aging population and the need for expanding access for the prevention and management of chronic disease, including CVD. Recently, the ACC published a health policy document on cardiovascular team-based care and the role of APPs (4), in which the authors explore the training, qualifications, and roles of team members; discuss models of team care; and offer up opportunities to improve, including APP education and state regulations. Being able to explore the implications of these policy statements by analyzing large practice-based registries, such as PINNACLE, is an enormous asset for U.S. cardiovascular practices. The current paper is one example of what has been deemed the “cycle of quality” (6).
The demonstration of quality care delivery by APPs compared with physicians is consistent with prior observations in primary care and will be important data to support expanding opportunities for APPs and access for patients throughout the United States, most specifically in regions with a more limited physician workforce. Although these data are generally supportive of team-based care using collaborative models between APPs and physicians, there are several limitations worth noting as important for future research to address.
First, these data do not allow an assessment of different approaches to team care delivery. For example, are there preferred systems of organization of the team or models of oversight by physician leaders of the care team? How do teams get organized to take advantage of the diversity of perspective that differently trained professionals bring to patient care? It is interesting to note that the APPs performed better than physicians in delivering behavioral interventions around smoking and cardiac rehabilitation to their patients. How should systems be designed so that all patients benefit from this diversity of perspective and experience? Health systems should set aside a small fraction of their clinical budgets to allow for rigorous evaluations of any new approach to team care. With careful planning, inexpensive cluster randomized trials of team care strategies can provide unbiased and generalizable knowledge that cannot be obtained through typical before and after analyses.
Second, there are insufficient numbers of nurse practitioners and physician assistants to directly compare these professionals to understand potential differences in quality of care. The educational models are very different for these 2 groups as are the state regulations that govern their practices. Do these differences translate into important differences in quality? Future research should address this, because the country needs to make decisions about future investments in education and training of APPs.
Third, data on quality beyond processes of care are needed. Although process of care measures are valuable, a direct link between care and patient outcome is needed, given the societal investment into the care of patients with CVD. The experience of care is another dimension of quality that is important to patients and may be improved or harmed with implementation of team care. Further investment into research on the topic is needed.
Fourth, economic analyses should be done to compare the change in cost with team care with changes in patient outcome. Such analyses should include the cost of educational investments to guide policy makers as they consider major societal investments in health professional education and training programs.
Fifth, the United States needs a more integrated system for sharing electronic data across health systems instead of relying on disease-specific registries to gain insights into these major public health questions. Efforts by the Patient Centered Outcomes Research Institute to create such integrated data networks are noteworthy (7).
Finally, although it is encouraging to note the similarities between the APPs and physicians, it is very disappointing to see that only 12% of CAD patients fully adhere to all quality measures. These data are consistent with observations from the MI FREEE (Post-Myocardial Infarction Free Rx Event and Economic Evaluation) trial (8) and point out the complexities and limitations of current strategies of chronic disease management.
Team-based cardiovascular care, delivered in collaborative models with a diverse group of health care professionals all working at the top of their education and training, can offer the United States expanded access to high-quality, evidenced-based care. Continuing to collect, analyze, and disseminate data around cardiovascular practices has become foundational to contemporary cardiovascular medicine. In a similar way, health policy makers must be obliged to incorporate strong evidence into the deliberations and decisions that ultimately govern medical practice. Cardiovascular medicine can lead these efforts to strengthen the nation’s health care delivery enterprise (9).
The authors thank Rhonda L. Larsen, PA-C, MHS, for her thoughtful review and insights, and Penny Hodgson for her expert editorial assistance.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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