2017 HSC Section 2 - Practice Management

reporting period. During this period, data for a systematic ran-

dom sample of visits are recorded by the physician on an

encounter form provided for that purpose. It is estimated that

84% of all ambulatory visits in the United States fall within the

NAMCS sampling frame, and the survey has been previously

validated in comparison to direct observation with very good ac-

curacy with respect to the provision of health services.

We and

others have previously used this data set to examine care pro-

vided for a number of otolaryngologic conditions including

chronic rhinosinusitis, otitis media, and otologic diagnoses in

the elderly.

5–8

The study was reviewed and received an institutional

review board exemption. From the combined years data set,

office visits to ambulatory ear, nose, and throat (ENT) practices

were extracted including diagnosis codes, patient demographic

data, and provider data. Each visit contains provider data

related to type of providers seen: physician, physician assistant

(PA), nurse practitioner (NP), and registered nurse (RN)/li-

censed practical nurse (LPN). For purposes of evaluation,

physician assistants and nurse practitioners were grouped to-

gether as APCs.

From the ENT office visits, the types of providers seen

were tabulated. Next, for patients seen by a PA, NP, or RN, the

fraction of patients seen by the auxiliary personnel alone (visit

independent of physician) and auxiliary personnel with physi-

cian (collaborative visit) were determined. Furthermore, the top

10 visit diagnoses were determined and tabulated for each of

the auxiliary personnel: physician, NP, and RN. Last, the rela-

tionship between auxiliary personnel and type of office visit

(office new patient vs. established patient) was determined and

tabulated. Because the NAMCS design uses clustering, stratifi-

cation, random sampling, and weighting, appropriate statistical

methods that incorporate these study design elements into sta-

tistical calculations for complex samples were used. Statistical

significance was set at

.05.

RESULTS

For combined calendar years 2008 and 2009, an

estimated 38.6

3.73 million outpatient office visits to

an ENT provider/practice (raw sample, 2714 visits) were

identified for analysis. The distribution of providers seen

at these office visits are presented in Table I. In Table I,

the providers seen are not mutually exclusive (i.e., at a

given outpatient visit, the patient may have seen both a

physician and an NP). In 6.3

2.0% of office visits, an

APC (PA or NP) was seen. A nurse (RN/LPN) was

involved in 25.1

7.6% of ENT office visits. Figure 1

demonstrates the joint versus independent visit rate for

APCs and RNs with respect to collaborating physicians.

NPs were more likely to see patients independent of a

physician when compared to PAs (47.7% independent

visit rate vs. 23.3%). Less than 0.5% of ambulatory otola-

ryngologic visits involved care provided by a RN alone

(i.e., without concurrent physician-level care).

Tables II and III present the top 10 diagnoses asso-

ciated with an APC- or RN-related ENT visit, as well as

physician-alone visits. Disorders associated with the

external and middle ear (i.e., otitis externa, cerumen

impaction, acute otitis media) were the most common

diseases with and APC and/or an RN component to the

encounters. With respect to patient visit type, for 7.2

2.3% of established patient visits, an APC was involved

in the outpatient visit. In contrast, for new patient visit

types, an APC was involved in the outpatient visit less

frequently, 4.3

1.8% of the time (

.080)

DISCUSSION

There is little question that APCs are increasingly

becoming part of the core healthcare providership in the

United States. As the US population ages and with pre-

dicted increases in chronic conditions such as obesity,

diabetes, and allergic diseases, it is further likely that

care provided by physician extenders will increase across

multiple medical specialties. Given that recent work sug-

gests a increasing volume of patients who will require

otolaryngologic care in the upcoming decades, coupled

with a relatively aging otolaryngologic physician work-

force, a significant penetration of APCs into ambulatory

otolaryngologic care is likely.

2,9

As a specialty, otolaryn-

gology–head and neck surgery will need to recruit, train,

and supervise these nonphysician providers. For

TABLE I.

Distribution of Medical Providers Seen for Otolaryngologic Office Visits, 2008 and 2009.

Medical Provider Seen

No.

% of Visits*

Physician

37,647,017

3,742,272

97.5

1.1

Physician assistant

1,770,980

702,253

4.6

1.9

Nurse practitioner

659,674

359,556

1.7

0.9

RN/LPN

9,669,216

3,500,089

25.1

7.6

No. represents number of visits.

*Provider seen is not mutually exclusive (i.e., patient may have seen both physician and nurse practitioner) thereby sum totals

100%.

standard error; RN

registered nurse; LPN

licensed practical nurse.

Fig. 1. Distribution of joint versus independent office visits in oto-

laryngology for physician assistants, nurse practitioners, and

nurses. [Color figure can be viewed in the online issue, which is

available at

wileyonlinelibrary.com.

]

Laryngoscope 122: May 2012

Bhattacharyya: Physician Extenders in Otolaryngology

136