Does Including NPs and PAs in Rheumatology Practice Lead to Better Outcomes?


The ACA has several provisions that promote greater reliance on nurse practitioners (NPs) and physician assistants (PAs) in an effort to increase the efficiency and lower the cost of health care. To date, however, there hve been few studies that have assessed the impact of NPs and PAs in the specialist care setting.

The recent Supreme Court decision to uphold health insurance subsidies for individuals in all 50 states as part of the Affordable Care Act (ACA) has far-reaching implications for healthcare, as covered here and here. The Court’s ruling was mostly about subsidies for insurance care, and there remain significant state challenges to the ACA that will still be heard in courts across the country. But the decision does mean it’s more likely than not that, as President Obama stated after the ruling, the ACA is “here to stay.”

One aspect of the ACA is that it supports greater reliance on nurse practitioners (NPs) and physician assistants (PAs) in an effort to increase the efficiency and lower the cost of health care. Clinicians and policymakers are deeply divided over whether including NPs and PAs has a significant impact on clinical care, and there is little research to back up the views on either side of the debate. A 2008 study in Critical Care Medicine revealed that, at that time, only two randomized controlled trials assessing the impact of nurse practitioner care in intensive care settings; neither of those trials showed definitive evidence of improvements or declines in care. Seven years later, the same is still true in most specialist care settings.

A recent study in Arthritis Care & Research took a fresh look at NP and PA care in rheumatology. While that study isn’t necessarily any more conclusive on the impact of including these health care professionals in specialist care, it does provide a hint of the positive impacts non-physician providers can have.

The small study enrolled seven rheumatology practices in the United States; four practices with NPs or PAs (or both), and three with rheumatologists only. The researchers then measured the disease activity of rheumatoid arthritis, categorized as remission, low, moderate, or high, using standardized measures abstracted from medical records from the most recent 2 years. They then performed a repeated measures analysis using generalized linear regression to compare disease activity for visits to practices with NPs or PAs versus rheumatologist only, adjusting for disease duration, serologic status, RA treatments and disease activity measures.

The results show that patients seen in practices with NPs or PAs were less likely to have higher disease activity than those seen in practices with rheumatologists only. “However,” the authors note, “there were no differences in the change in disease activity between visits either within or between type of provider practice.”

With the ACA expected to be a going concern, more research on the effectiveness of NPs and PAs as part of the care team is needed.

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