The proportion of visits to specialists in which nurse practitioners (NPs) and physician assistants (PAs) are involved has more than doubled in recent years, according to a research letter published online June 5 in JAMA Internal Medicine.

Kristin N. Ray, MD, MS, from the Department of Pediatrics at University of Pittsburgh School of Medicine in Pennsylvania, and colleagues used data from the National Center for Health Statistics’ National Ambulatory Medical Care Survey and found the following increased involvement for the midlevel practitioners:

Table. Growth of NP and PA Involvement in Visits to Specialists



The authors hypothesized that the involvement of PAs and NPs would have grown in the study period but thought the growth would primarily have been for routine follow-up.

However, the rise in involvement was similar for both new and return visits and for all reasons for visits, whether routine or flare in patients with chronic illnesses, preventive, or perioperative.

Recent years have seen almost twice the percentage of NP and PA visits (21.4% up from 12.3%) that happen without the patient seeing a physician as well (P = .004).

“These findings are particularly notable given that NPs and PAs in specialty care receive shorter formal training than specialist physicians, with specialty-specific training entirely on-the-job in some fields,” the authors write.

From 2010 to 2013, the participation of NPs and PAs has varied greatly by specialty. Otorhinolaryngology had the most participation, at 8.5%, followed by dermatology, at 8.3%. General surgery had the lowest participation percentage at 4%.

Participation also varied widely geographically. In the Northeast, participation was 9.6%, more than twice that in the Midwest (4%) and West (4.2%). The South had 6.8% participation. Rural and urban participation was similar (6.9% and 6.3%, respectively).

Most recently, the reason for the visit was also associated with participation. From 2010 to 2013, participation was 4.9% with routine chronic visits and 9.3% for presurgical and postsurgical visits (P = .004).

Still, growth in PA and NP participation overall has slowed in recent years, according to the report, and the involvement remains low among all specialty visits.

Although PA and NP participation in primary care visits has received increasing scrutiny, the authors say they believe this study is the first to analyze trends in their participation in specialty care and the findings hold information on issues of access and addressing the physician shortage.

A noted limitation of the study is that the information reflects only care reported by NPs and PAs who share rosters with physicians.

“As such, our results may underestimate total involvement of NPs and PAs in specialty care but should accurately reflect trends in NPs and PAs providing care in conjunction with specialist physicians,” the authors write.

Published by Medscape on June 6, 2017