Researchers Study Imaging Use Rates Among Nonphysician Practitioners
By Dorothy Brooks
In a study focused solely on Medicare patient ED visits, investigators found nonphysician practitioners (NPP), including nurse practitioners (NPs) and physician assistants (PAs), ordered imaging tests 5.3% more often than physicians, potentially pointing to an opportunity to improve decision-making regarding judicious use of healthcare resources. (Learn more here.)
The study was led by Eric Christensen, PhD, director of economic and health services research at the Harvey L. Neiman Health Policy Institute, a Reston, VA-based organization that conducts research on the value and role of radiology and radiologists in healthcare delivery and payment systems.
“As the use of NPPs continues to expand in healthcare generally, we wanted to know if this expansion changes the utilization of healthcare resources,” he says. “If there is variation in care patterns between NPPs and physicians, it is an opportunity to improve care and make it more consistent.”
The research was based on a nationally representative sample of fee-for-service Medicare beneficiaries. The authors included more than 16 million visits made to the ED between 2005 and 2020. During this period, the share of ED visits managed by NPPs in the study sample increased markedly, from 6.1% in 2005 to 16.6% in 2020.
Christensen and colleagues found that when compared with EDs without NPPs, the presence of NPPs in the ED was associated with increases of 3.2% in radiography; 7.3% in CT scans; and 15% in other imaging modalities, including MRI and ultrasound. Also, in EDs with NPPs, there was a 3.4% greater likelihood of image ordering, as well as a 2.2% increase in the number of imaging studies performed per ED visit. Christensen notes that while he and colleagues observed a correlation between NPPs in the ED and more imaging, they made no determination regarding the efficacy of ordering more images.
Why might NPPs practicing in the ED use more imaging studies? Richard Duszak, MD, FACR, FSIR, FRBMA, a study co-author, says the study did not address that issue. However, he notes prior work by his team revealed NPPs in non-ED outpatient settings order more imaging than physicians, and that these findings align with the anecdotal observations of most radiologists and practice leaders.
“Our research does not allow [us] to assert a definitive explanation, but I, like many others, believe that this is related to the differential length and intensity of the clinical training of physicians vs. [NPPs],” says Duszak, chair of the department of radiology at the University of Mississippi Medical Center in Jackson. “The many additional years of both school and post-graduate residencies and fellowships result in greater clinical experience and confidence that likely reduces the need for marginally indicated diagnostic testing.”
How might EDs eliminate any variation in image ordering between NPPs and physicians? Duszak observes most physician organizations advocate for physician-led care teams rather than independent NPP care as the best practice for balancing patient access and quality.
“Care oversight, rigorous and critical case review, and scenario-based triage and care algorithms would all be components of such care models,” he says.
The authors concluded while using NPPs in the ED could lower costs, given that Medicare reimburses NPPs at 85% of what it pays physicians, more imaging use would cut into any cost-savings. However, considering researchers did not explore the specific cost implications of the observed imaging use variations between NPPs and physicians, they suggested this issue requires more research, as does the radiation exposure that is associated with more imaging.
Researchers recently discovered nonphysician practitioners, including nurse practitioners and physician assistants, ordered imaging tests 5.3% more often than physicians, potentially pointing to an opportunity to improve decision-making regarding judicious use of healthcare resources.
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