Quality of Outpatient Cardiovascular Care: Does Provider Type Matter?

Study Questions:

Are there clinically meaningful differences in the quality of care delivered by advance practice providers (APPs; nurse practitioners [NPs] and physician assistants [PAs]) versus physicians in a national sample of cardiology practices?


This was an analysis of data from the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) PINNACLE (Practice Innovation and Clinical Excellence) Registry. The authors evaluated patients with coronary artery disease (CAD), heart failure (HF), or atrial fibrillation (AF) who had an outpatient cardiology clinic visit between January 1, 2012, and December 31, 2012. The outcome of interest was compliance with guideline-based CAD, HF, or AF performance measures.


A total of 416,138 patients were receiving care from 716 physicians, and 43,531 patients were receiving care from 167 advanced practice providers (141 NPs, 26 PAs). Compliance with most CAD, HF, and AF measures was comparable, except for a higher rate of smoking cessation screening and intervention (adjusted rate ratio [RR], 1.14; 95% confidence interval [CI], 1.03-1.26) and cardiac rehabilitation referral (RR, 1.40; 95% CI, 1.16-1.70) among CAD patients receiving care from APPs. Compliance with all eligible CAD measures was low for both provider categories (12.1% and 12.2% for advanced practice providers and physician providers, respectively).


Overall, the quality of outpatient care for CAD, HF, and AF measures by compliance with performance measures by APPs was equivalent to that of physician providers on most measures and better for smoking cessation and referral to cardiac rehabilitation.


This is an important contribution that demonstrates that APPs may deliver cardiovascular care that is comparable to that delivered by physicians. Such a finding has broad implications for the delivery of care and development of a collaborative care delivery model, as the number of Americans expected to secure health care coverage with the Affordable Care Act increases. Importantly, however, there may be meaningful differences in care delivery not captured by the current analysis, in which the sole outcome was compliance with performance measures.

Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Ambulatory Care, Atrial Fibrillation, Coronary Artery Disease, Heart Failure, National Cardiovascular Data Registries, Nurse Practitioners, Physician Assistants, Referral and Consultation, Rehabilitation, Smoking Cessation

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