SGEM#316: What A Difference An A.P.P. Makes? Diagnostic Testing Differences Between A.P.P.s and Physicians

Date: January 20th, 2021 Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She is the cofounder of FOAMcast and a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and  research methodology editor for Annals of Emergency Medicine and as an Associate Editor for the NEJM Journal Watch Emergency Medicine. Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Case: A 50-year-old male presents to the Emergency Department (ED) with left lower quadrant abdominal pain. The patient is seen by an advanced practice provider (APP). He wants to know if being seen by an APP alters his chance of diagnostic testing or hospital admission. Background: We covered the use of advanced practice providers (APPs) on the SGEM#308. That SGEMHOP episode asked how the productivity of APPs compare to emergency physicians and what is its impact on ED operations? The key result from that study of 13 million ED visits across 94 states was that physicians were more productive than PAs and NPs. The SGEM bottom line was that increasing APP coverage has minimal effect on ED flow and safety outcomes based on the data. Over the past two decades, the use of APPs has increased. APPs have a significantly truncated medical training (about 2 years of training) and practice experience compared with the traditional 4 years of medical school and 3-4 years of residency for emergency physicians. There has been a concern about post-graduate training of NPs and PAs in the ED. A joint statement on the issue was published in 2020 by AAEM/RSA, ACEP, ACOEP/RSO, CORD, EMRA, and SAEM/RAMS. The American Academy of Emergency Medicine (AAEM) has a position statement on what they refer to as non-physician practitioners that was recently updated. The American College of Emergency Physicians (ACEP) also has a number of documents discussing APPs in the ED. The difference in training between and emergency medicine physician and APPs is well recognized. A concern is that some APPs may compensate for this training gap by increased testing. Clinical Question: Is ED evaluation by an APP associated with higher test utilization and hospitalization compared with evaluation by a physician? Reference: Pines et al. Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain. AEM January 2021 Population: All ED patients with a chief complaint of chest pain or abdominal pain triaged as an Emergency Severity Index (ESI) 2,3, or 4 who were seen independently by either an APP or emergency physician Excluded: Patients who left without treatment or against medical advice, those who were dead on arrival or died in the ED. They also excluded those with a triage level ESI 1 or 5, as these are less common, as well as those with a final diagnosis of injury or poisoning – as in those cases the diagnosis would generally be apparent. Intervention: Evaluated by an APP Comparison: Evaluated a physicial Outcome: Primary Outcomes: Laboratory tests, ECGs, imaging studies as well as hospital admissions (including transfer to other hospitals and observation admissions) Secondary Outcomes: Testing based on evidence-based practice Dr. Jesse Pines This is an SGEMHOP episode which means we have the lead author on the show. Jesse Pines MD is the National Director for Clinical Innovation at US Acute Care Solutions and a Professor of Emergency Medicine at Drexel University. In this role, he focuses on developing and implementing new care models including telemedicine, alternative payment models, and also leads the USACS opioid programs. Authors’ Conclusions: “We demonstrate that the care delivered in the ED b...