Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care
Open accessAbstract
Objective: To examine whether nurse practitioner (NP)‐assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)‐assigned patients. Data Sources: Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012. Study Design: We applied a difference‐in‐difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment. Principal Findings: Compared to MD‐assigned patients, NP‐assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. Conclusions: Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost‐effective approach to addressing anticipated shortages of primary care physicians.
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The literature generally reports similar or marginally lower costs for nurse-led services.
“This literature generally reports similar27,34-37 or marginally lower29,38-41 costs for nurse-led services.”
From Evaluating the cost of NP-led vs. GP-led primary care in British Columbia (2024) · cites this paper as [36]
Cites
Charlson, M. E., Pompei, P., Ales, K. L., & MacKenzie, C. R. (1987) · Journal of Chronic Diseases · doi:10.1016/0021-9681(87)90171-8 · Cited by 49,742 · see citing works
Comorbidity measures for use with administrative data.
Elixhauser, A., Steiner, C., Harris, D. R., & Coffey, R. M. (1998) · Medical Care · doi:10.1097/00005650-199801000-00004 · Cited by 9,921 · see citing works
Instrumental Variables Regression with Weak Instruments
Staiger, D., & Stock, J. H. (1997) · Econometrica · doi:10.2307/2171753 · Cited by 7,081 · see citing works
The Association of American Medical Colleges
ZAPFFE, F. C. (1938) · Academic Medicine · doi:10.1097/00001888-193801000-00007 · Cited by 5,527 · see citing works
Austin, P. (2009) · Communications in statistics. Simulation and computation · doi:10.1080/03610910902859574 · Cited by 2,323 · see citing works
Two-stage residual inclusion estimation: Addressing endogeneity in health econometric modeling
Terza, J. V., Basu, A., & Rathouz, P. J. (2008) · Journal of Health Economics · doi:10.1016/j.jhealeco.2007.09.009 · Cited by 1,728 · see citing works
Horrocks, S., Anderson, E., & Salisbury, C. (2002) · BMJ · doi:10.1136/bmj.324.7341.819 · Cited by 1,235 · see citing works
Estimating log models: to transform or not to transform?
Manning, W. G., & Mullahy, J. (2001) · Journal of Health Economics · doi:10.1016/s0167-6296(01)00086-8 · Cited by 1,145 · see citing works
A combined comorbidity score predicted mortality in elderly patients better than existing scores
Gagne, J. J., Glynn, R. J., Avorn, J., Levin, R., & Schneeweiss, S. (2011) · Journal of Clinical Epidemiology · doi:10.1016/j.jclinepi.2010.10.004 · Cited by 995 · see citing works
Substitution of doctors by nurses in primary care
Laurant, M. G. H., Reeves, D., Hermens, R., Braspenning, J., Grol, R. P. T. M., & Sibbald, B. (2005) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd001271.pub2 · Cited by 961 · see citing works
Goodness of Link Tests for Generalized Linear Models
Pregibon, D. (1980) · Journal of the Royal Statistical Society Series C (Applied Statistics) · doi:10.2307/2346405 · Cited by 764 · see citing works
Austin, P. C. (2007) · Journal of Thoracic and Cardiovascular Surgery · doi:10.1016/j.jtcvs.2007.07.021 · Cited by 589 · see citing works
Venning, P. (2000) · BMJ · doi:10.1136/bmj.320.7241.1048 · Cited by 494 · see citing works
Dunn, A., Grosse, S. D., & Zuvekas, S. H. (2018) · Health Services Research · doi:10.1111/1475-6773.12612 · Cited by 494 · see citing works
A Comparison of Alternative Models for the Demand for Medical Care
Duan, N., Manning, W. G., Morris, C. N., et al. (1983) · Journal of Business and Economic Statistics · doi:10.2307/1391852 · Cited by 421 · see citing works
A Meta-Analysis of Nurse Practitioners and Nurse Midwives in Primary Care
Brown, S. A., & Grimes, D. E. (1995) · Nursing Research · doi:10.1097/00006199-199511000-00003 · Cited by 326 · see citing works
Implementation of the Patient-Centered Medical Home in the Veterans Health Administration
Nelson, K. M., Helfrich, C. D., Sun, H., Hebert, P. L., Liu, C., Dolan, E. D., Taylor, L., Wong, E. S., Maynard, C. C., Hernandez, S. E., et al. (2014) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2014.2488 · Cited by 319 · see citing works
Self-citationKaton, W., Von Korff, M., Lin, E., & Simon, G. (2001) · General Hospital Psychiatry · doi:10.1016/s0163-8343(01)00136-0 · Cited by 313 · see citing works
Substitution of physicians by nurses in primary care: a systematic review and meta-analysis
Martínez-González, N. A., Djalali, S., Tandjung, R., Huber-Geismann, F., Markun, S., Wensing, M., & Rosemann, T. (2014) · BMC Health Services Research · doi:10.1186/1472-6963-14-214 · Cited by 310 · see citing works
Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians
Bodenheimer, T. S., & Smith, M. D. (2013) · Health Affairs · doi:10.1377/hlthaff.2013.0234 · Cited by 302 · see citing works
Primary Care Outcomes in Patients treated by Nurse Practitioners or Physicians: Two-Year Follow-Up
Lenz, E. R., Mundinger, M. O., Kane, R. L., Hopkins, S. C., & Lin, S. X. (2004) · Medical Care Research and Review · doi:10.1177/1077558704266821 · Cited by 278 · see citing works
Litaker, D. G., Mion, L. C., Planavsky, L. A., Kippes, C. M., Mehta, N., & Frolkis, J. P. (2003) · Journal of Interprofessional Care · doi:10.1080/1356182031000122852 · Cited by 276 · see citing works
Equivalence of two healthcare costing methods: bottom-up and top-down
Chapko, M. K., Liu, C., Perkins, M., Li, Y., Fortney, J. C., & Maciejewski, M. L. (2009) · Health Economics · doi:10.1002/hec.1422 · Cited by 256 · see citing works
Self-citationPractice characteristics of primary care nurse practitioners and physicians
Buerhaus, P. I., DesRoches, C. M., Dittus, R. S., et al. (2014) · Nursing Outlook · doi:10.1016/j.outlook.2014.08.008 · Cited by 210 · see citing works
The Impact of Nonphysician Clinicians
Laurant, M., Harmsen, M., Wollersheim, H., Grol, R., Faber, M., & Sibbald, B. (2009) · Medical Care Research and Review · doi:10.1177/1077558709346277 · Cited by 166 · see citing works
Kuo, Y., Loresto, F., Rounds, L. R., & Goodwin, J. S. (2013) · Health Affairs · doi:10.1377/hlthaff.2013.0072 · Cited by 161 · see citing works
Morgan, P., Smith, V. A., Berkowitz, T. S. Z., Edelman, D. E., Houtven, C. H. V., Woolson, S., Hendrix, C. C., Everett, C. M., White, B. S., & Jackson, G. L. (2019) · Health Affairs · doi:10.1377/hlthaff.2019.00014 · Cited by 137 · see citing works
Systematic review of recent innovations in service provision to improve access to primary care.
Chapman, J., Zechel, A., Carter, Y. H., & Abbott, S. (2004) · Europe PMC (PubMed Central) · Cited by 127 · see citing works
Substitution of doctors by nurses in Primary Care
Laurant, M. G. H., Sergison, M., & Sibbald, B. (1998) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd001271 · Cited by 125 · see citing works
Charlton, I., Charlton, G., Broomfield, J., et al. (1991) · PubMed · Cited by 124 · see citing works
Hughes, D. R., Jiang, M., & Duszak, R. (2014) · JAMA Internal Medicine · doi:10.1001/jamainternmed.2014.6349 · Cited by 122 · see citing works
Ohman‐Strickland, P., Orzano, A. J., Hudson, S. V., Solberg, L. I., DiCicco‐Bloom, B., O’Malley, D. M., Tallia, A. F., Balasubramanian, B. A., & Crabtree, B. F. (2008) · The Annals of Family Medicine · doi:10.1370/afm.758 · Cited by 121 · see citing works
Choosing between the Sample-Selection Model and the Multi-Part Model
Duan, N., Manning, W. G., Morris, C. N., et al. (1984) · Journal of Business and Economic Statistics · doi:10.2307/1391711 · Cited by 113 · see citing works
Do Veterans Health Administration Enrollees Generalize to Other Populations?
Wong, E. S., Wang, V., Liu, C., Hebert, P. L., & Maciejewski, M. L. (2015) · Medical Care Research and Review · doi:10.1177/1077558715617382 · Cited by 95 · see citing works
Self-citationFalsification Testing of Instrumental Variables Methods for Comparative Effectiveness Research
Pizer, S. D. (2015) · Health Services Research · doi:10.1111/1475-6773.12355 · Cited by 89 · see citing works
(2006) · PubMed Central · Cited by 86 · see citing works
Lovink, M. H., Persoon, A., Koopmans, R. T. C. M., Van Vught, A. J. A. H., Schoonhoven, L., & Laurant, M. G. H. (2017) · Journal of Advanced Nursing · doi:10.1111/jan.13299 · Cited by 83 · see citing works
Diabetes Care Processes and Outcomes in Patients Treated by Nurse Practitioners or Physicians
Lenz, E. R., Mundinger, M. O., Hopkins, S. C., Lin, S. X., & Smolowitz, J. L. (2002) · The Diabetes Educator · doi:10.1177/014572170202800413 · Cited by 80 · see citing works
2SLS versus 2SRI : A ppropriate methods for rare outcomes and/or rare exposures
Basu, A., Coe, N. B., & Chapman, C. G. (2018) · Health Economics · doi:10.1002/hec.3647 · Cited by 79 · see citing works
Hebert, P. L., Liu, C., Wong, E. S., Hernandez, S. E., Batten, A. J., Lo, S., Lemon, J. M., Conrad, D. A., Grembowski, D. E., Nelson, K. M., et al. (2014) · Health Affairs · doi:10.1377/hlthaff.2013.0893 · Cited by 77 · see citing works
Self-citationMartínez-González, N. A., Tandjung, R., Djalali, S., Huber-Geismann, F., Markun, S., & Rosemann, T. J. (2014) · PLoS ONE · doi:10.1371/journal.pone.0089181 · Cited by 76 · see citing works
Measuring Performance Directly Using the Veterans Health Administration Electronic Medical Record
Goulet, J. L., Erdos, J., Kancir, S., Levin, F. L., Wright, S. M., Daniels, S. M., Nilan, L., & Justice, A. C. (2006) · Medical Care · doi:10.1097/01.mlr.0000244510.09001.e5 · Cited by 67 · see citing works
Morgan, P., Abbott, D. H., McNeil, R. B., & Fisher, D. A. (2012) · Human Resources for Health · doi:10.1186/1478-4491-10-42 · Cited by 56 · see citing works
Perloff, J. N., Clarke, S. P., DesRoches, C. M., O’Reilly-Jacob, M., & Buerhaus, P. I. (2017) · Medical Care Research and Review · doi:10.1177/1077558717732402 · Cited by 54 · see citing works
Jackson, G. L., Smith, V. A., Edelman, D. E., Woolson, S., Hendrix, C. C., Everett, C. M., Berkowitz, T. S. Z., White, B. S., & Morgan, P. (2018) · Annals of Internal Medicine · doi:10.7326/m17-1987 · Cited by 52 · see citing works
Evidence Brief: The Quality of Care Provided by Advanced Practice Nurses
McCleery, E., Christensen, V., Peterson, K., Humphrey, L. L., & Helfand, M. (2014) · Europe PMC (PubMed Central) · Cited by 51 · see citing works
Importance of health system context for evaluating utilization patterns across systems
Burgess, J. F., Maciejewski, M. L., Bryson, C. L., et al. (2010) · Health Economics · doi:10.1002/hec.1588 · Cited by 41 · see citing works
Liu, C., Batten, A. J., Wong, E. S., et al. (2018) · Health Services Research · doi:10.1111/1475-6773.13029 · Cited by 40 · see citing works
Self-citationA comparison of resource utilization in nurse practitioners and physicians.
Hemani, A., Rastegar, D. A., Hill, C., & Al-Ibrahim, M. S. (1999) · PubMed · Cited by 34 · see citing works
Nurse Practitioners as Primary Care Providers Within the VA
Fletcher, C. E., Copeland, L. A., Lowery, J. C., & Reeves, P. J. (2011) · Military Medicine · doi:10.7205/milmed-d-10-00329 · Cited by 34 · see citing works
Nurse practitioners and physician assistants as primary care providers in institutional settings.
Jacobson, P., Parker, L. E., & Coulter, I. D. (1999) · PubMed · Cited by 23 · see citing works
Improving the care of veterans
Hobson, A., & Curtis, A. C. (2017) · Journal of the American Association of Nurse Practitioners · doi:10.1002/2327-6924.12506 · Cited by 10 · see citing works
Advanced Practice Clinicians and Physicians in Primary Care: Still More Questions than Answers
Rich, E. C. (2016) · Annals of Internal Medicine · doi:10.7326/m16-1326 · Cited by 9 · see citing works
Friedberg, M. W., Martsolf, G. R., White, C., et al. (2016) · Rand health quarterly · doi:10.7249/rhq-06-04-08 · Cited by 9 · see citing works
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Karo, M., Simorangkir, L., Daryanti Saragih, I., Suarilah, I., & Tzeng, H. (2024) · Journal of Nursing Scholarship · doi:10.1111/jnu.12941 · Cited by 20 · see citing works
Evaluating the cost of NP-led vs. GP-led primary care in British Columbia
Contandriopoulos, D., Bertoni, K., McCracken, R., Hedden, L., Lavergne, R., & Randhawa, G. K. (2024) · Healthcare Management Forum · doi:10.1177/08404704241229075 · Cited by 5 · see citing works
Contandriopoulos, D., Bertoni, K., Duhoux, A., & Randhawa, G. K. (2023) · BMJ Open · doi:10.1136/bmjopen-2023-072812 · Cited by 3 · see citing works
- Authors
- Liu, C., Hebert, P. L., Douglas, J. H., Neely, E. L., Sulc, C. A., Reddy, A., Sales, A. E., & Wong, E. S.
- Affiliations
- University of Washington (US)
- VA Puget Sound Health Care System (US)
- University of Michigan (US)
- Corresponding author
- Hebert, Paul L.
- Venue
- Health Services Research
- Publisher
- Wiley
- Published
- 2020-01-13
- Volume
- 55
- Issue
- 2
- Pages
- 178-189
- ISSN
- 0017-9124 (ISSN-L)
- 1475-6773
- PMC
- PMC7080399
- OpenAlex
- W3000032401
- Cited by
- 121
- References
- 54
- Citations by year
- 2026: 19 · 2025: 19 · 2024: 28 · 2023: 31 · 2022: 8 · 2021: 10 · 2020: 5
- FWCI
- 14.09
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- public-domain
- onlinelibrary.wiley.com/termsAndConditions#vor (vor)
- Locations
- Health Services Research (publishedVersion)
- PubMed Central (publishedVersion, public-domain)
- PubMed (publishedVersion)
- Deep Blue (University of Michigan) (submittedVersion)
- Funders
- Health Services Research and Development (CDA 13‐024, IIR14‐054)
- Topics
- Health Sciences › Health Professions › General Health Professions › Nursing Roles and Practices
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Keywords
- nurse practitioners, primary care, physician shortage, health care utilization, health care costs, quality of care, avoidable hospitalizations, glycemic control, blood pressure control, lipid control, veterans, Veterans Affairs health care, cost-effectiveness
- MeSH terms
- Adult, Delivery of Health Care, Female, Humans, Male, Middle Aged, Military Medicine, Nurse Practitioners, Patient Acceptance of Health Care, Primary Health Care, Quality of Health Care, United States, Physicians, Primary Care
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