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.