Primary care physician assistant and advance practice nurses roles: Patient healthcare utilization, unmet need, and satisfaction $ Christine M. Everett a,n , Perri Morgan a , George L. Jackson b a Physician Assistant Program, Department of Community and Family Medicine, Duke University School of Medicine, 800 South Duke Street, Durham, NC 27701, United States b Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center and Division of General Internal Medicine, Duke University School of Medicine, United States article info Article history: Received 1 September 2015 Received in revised form 26 February 2016 Accepted 8 March 2016 Keywords: Physician assistant Advanced practice nurse Primary care Role abstract Purpose: Team-based care involving physician assistants (PAs) and advance practice nurses (APNs) is one strategy for improving access and quality of care. PA/APNs perform a variety of roles on primary care teams. However, limited research describes the relationship between PA/APN role and patient outcomes. We examined multiple outcomes associated with primary care PA/APN roles. Methods: In this cross-sectional survey analysis, we studied adult respondents to the 2010 Health Tracking Household Survey. Outcomes included primary care and emergency department visits, hospi- talizations, unmet need, and satisfaction. PA/APN role was categorized as physician only (no PA/APN visits; reference), usual provider (PA/APN provide majority of primary care visits) or supplemental provider (physician as usual provider, PA/APN provide a subset of visits). Multivariable logistic and multinomial logistic regressions were performed. Results: Compared to people with physician only care, patients with PA/APNs as usual providers [5–9 visits RRR ¼2.4 (CI 1.8–3.4), 10 þ visits RRR ¼3.0 (CI 2.0–4.5): reference 2–4 visits] and supplemental providers had increased risk of having 5 or more primary care visits [5–9 visits RRR ¼1.3 (CI 1.0–1.6)]. Patients reporting PA/APN as supplemental providers had increased risk of emergency department uti- lization [2 þ visits: RRR 1.8 (CI 1.3, 2.5)], and lower satisfaction [very dissatisfied: RRR 1.8 (CI 1.03–3.0)]. No differences were seen for hospitalizations or unmet need. Conclusions: Healthcare utilization patterns and satisfaction varied between adults with PA/APN in dif- ferent roles, but reported unmet need did not. These findings suggest a wide range of outcomes should be considered when identifying the best PA/APN role on primary care teams. & 2016 Elsevier Inc. All rights reserved. 1. Introduction The implementation of the Affordable Care Act (ACA) has heightened concerns over the capacity of the United States (U.S.) primary care workforce to meet patient needs. 1,2 An estimated 35 million people will gain insurance through the ACA by 2019, re- sulting in an anticipated increase of an additional 15–24 million primary care visits annually, 3–5 and potentially leading to a shortage of approximately 45,000 primary care providers. 6 Shortages of this magnitude could reduce access and quality of care. 7–9 Team-based care involving physician assistants (PAs) and advance practice nurses (APNs) is one strategy for improving ac- cess and quality of care despite the mismatch between primary care demand and physician supply. 10–12 The challenge for primary care practices is identifying the optimum patient-centered PA/APN role. PA and APN roles can vary within and between settings because roles are individually negotiated with collaborating physicians. 13– 15 The clinical role of primary care PAs/APNs can be defined by the division of responsibilities between the PA/APN and physician and historically has been classified into two categories reflecting the level of PA/APN involvement: usual provider and supplemental provider of care. 14,16–18 In the usual provider role, PA/APNs assume the responsibility for all functions of primary care. In supplemental roles, PA/APNs focus on a subset of primary care services, such as acute same day visits or chronic disease management. 14,16 Largely due to limitations in existing datasets, very little re- search describes the relationship between PA/APN roles and pa- tient outcomes. 19 Existing literature suggests that PAs and APNs improve access by disproportionately practicing in underserved areas and providing visits to underserved populations such as the uninsured, women, rural, and younger patients, while physicians Contents lists available at ScienceDirect journal homepage: www.elsevier.com/locate/hjdsi Healthcare http://dx.doi.org/10.1016/j.hjdsi.2016.03.005 2213-0764/& 2016 Elsevier Inc. All rights reserved. ☆ Prior Presentations: 10th Annual AAMC Health Workforce Research Conference; May 1, 2014; Washington, DC. n Corresponding author. E-mail addresses: christine.everett@duke.edu (C.M. Everett), perri.morgan@duke.edu (P. Morgan), george.l.jackson@duke.edu (G.L. Jackson). Please cite this article as: Everett CM, et al. Primary care physician assistant and advance practice nurses roles: Patient healthcare utilization, unmet need, and satisfaction. Healthcare (2016), http://dx.doi.org/10.1016/j.hjdsi.2016.03.005i Healthcare ∎ (∎∎∎∎) ∎∎∎–∎∎∎