APPs and Department Flow – More to the Story

Written by Clay Smith

Spoon Feed
A recent study found advanced practice providers (APPs) see fewer patients per hour and see lower complexity patients than physicians, but there is more to this story.

Why does this matter?
Recently, we summarized an article on the impact of APPs in the ED. This article in Academic Emergency Medicine generated quite a bit of social media buzz, and the Skeptic’s Guide to Emergency Medicine did a podcast and summarized the discussion in this AEM article.

APPs in the EDs
A quick recap: the study included 94 sites, staffed by the same national EM group, with 13 million visits. 75% of visits were seen by physicians. Physicians generated 3.7 RVUs/visit; NP visits 2.8; PA visits 2.7. Physicians saw 2.2 patients per hour; APPs 1.1 patients per hour. There didn’t seem to be any difference in quality or safety. A key issue raised in the social media discussion is that 1.1 patients per hour was only the measure of patients the APP saw completely alone, without the physician. However, many of the patients were required to be seen by the APP with the physician, for which the APP got half the RVUs and the physician got half. But did the physician do half the work? Likely they did not, especially in cases where they briefly popped in the room to say hello. APPs were required to see patients with abnormal vitals with a physician, which may have incentivized them to see less complex, lower RVU-generating patients. Sometimes less complex does not mean less time, such as a laceration repair. Also, almost all procedures were billed under the physician’s name, yet it is likely that some of these were done by the APP and supervised by the physician, making the APP contribution invisible. Finally, some of the APPs had other duties to promote ED flow but that did not contribute to RVU generation, such as working triage. The majority of Twitter users informally polled indicated that APPs increased productivity in the ED.

Source
SGEM#308: Taking Care of Patients Everyday with Physician Assistants and Nurse Practitioners. Acad Emerg Med. 2020 Dec 12. doi: 10.1111/acem.14193. Online ahead of print.

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