The Case 

Community emergency departments have seen volumes increase over the years. Previously, departments responded to increases in patient volume by adding more physician coverage. Lately, hospital administrations have looked to advanced practice providers (APPs) such as physician assistants (PAs) or nurse practitioners (NPs) to meet volume demands. Your hospital is considering hiring some APPs. 

Clinical Question

What is the impact of APP staffing on ED productivity, flow, and safety?

Background

There has been an increased use of APPs in staffing U.S. emergency departments in recent years, justified in part on economic considerations. Advocates claim APPs can be just as productive as physicians and provide safe ED care while costing less money. This financial calculation could work if APP productivities are similar enough to that of physicians to offset differentials in billing rates and compensation. However, there are few data comparing productivity, safety, flow, or patient experiences in emergency medicine.

ACEP has published a number of documents discussing various issues around APPs in the emergency department. Recent concerns about postgraduate training of APPs in the emergency departments led to a joint statement issued in September 2020 by multiple organizations, including ACEP, that said the terms “resident,” “residency,” “fellow,” and “fellowship”​ in a medical setting must be limited to postgraduate clinical training of medical school physician graduates within GME training programs.1 

The debate is only heating up. 

Reference: Pines JM, Zocchi MS, Ritsema T, et al. The impact of advanced practice provider staffing on emergency department care: productivity, flow, safety, and experience. Acad Emerg Med. 2020;27(11):1089-1099.

• Population: 13 million ED visits from 94 hospitals in 19 states from one national emergency medicine group 
• Exposure: Proportion of total clinician hours staffed by APPs in a 24-hour period at a given emergency department
• Comparison: Emergency physician staffing
• Outcomes:
  • Primary Outcome: Productivity (patients/hour, relative value units [RVUs]/hour, RVUs/visit, RVUs/relative salary for an hour)
  • Secondary Outcomes: Proportion of 72-hour returns and proportion of 72-hour returns resulting in admission, length of stay (LOS), and left without completion of treatment (LWOT)

Authors’ Conclusions

“In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.” 

Key Results

There were more than 13 million ED visits over five years at 94 hospitals in 19 states. Of the ED visits, 75 percent were treated by a physician independently, 18.6 percent by a PA, 5.4 percent by an NP, and 1.4 percent by both a physician and an APP.

Physicians were more productive than APPs (PAs or NPs) (see Table 1).

Table 1: Productivity in the Emergency Department

• Effect of 10 percent increase in APP coverage:
  • Patients/hour: –0.12 (95 percent CI, –0.15 to –0.10)
  • RVUs/hour: –0.4 (95 percent CI, –0.5 to –0.3)
• Safety and Outcome: No significant effect on LOS, LWOT, and 72-hour returns

Evidence-Based Medicine Commentary

1. Surprise: These results were a surprise and do not reflect many of our own personal experiences working with APPs. Often APPs see lower-acuity patients in “fast-track” areas. 
2. Safety: It was reassuring to not see any signal of increased harm. However, LOS, LWOT, and 72-hour return rate is probably not granular enough to identify any potential safety concerns. 
3. External Validity: This was a large study with 19 states, 94 sites, and 13 million ED visits from one national organization. We need to be careful not to overinterpret these results to other practice locations like small community groups, democratic physician-led groups, or rural sites.

Bottom Line

We do not have good evidence that APPs will improve productivity or negatively impact safety. However, in regions with physician shortages, these data suggest that APPs might represent an important opportunity to reach underserved communities.

Case Resolution

You inform hospital administration that a large study has just been published showing physicians were more productive compared to APPs. Adding more APPs appears to have decreased patient flow and RVUs/hour. However, no safety issues were identified. It is unclear if the results can be applied to your community hospital. Successful implementation depends on how APPs are used in the emergency department. Departments should assess their own local data and think carefully about whether adding APPs to a department is warranted.

Thank you to Dr. Corey Heitz, an emerrgency physician in Roanoke, Virginia. 

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. 

Reference

1. Joint statement regarding post-graduate training of nurse practitioners and physician assistants. ACEP website. Accessed Dec. 7, 2020.