Advanced-practice clinicians and primary care doctors provide similar amounts of wasteful tests and treatments

New UCLA-led research finds that contrary to physicians’ beliefs, advanced-practice clinicians such as nurse practitioners and physician assistants provide similar amounts of costly and unnecessary tests, treatments and referrals to specialists compared with physicians in the primary care setting.

The article, published June 21 in the peer-reviewed journal Annals of Internal Medicine, is one of the largest national studies to date on this issue and could inform the ongoing debate into expanding the role of advanced practice clinicians in doctors’ offices and hospitals. They could also dispel the commonly-held belief among physicians and physician groups that these clinicians provide more of such needless services, which are known as low-value health services.

Advocates say that expanding the role of advanced practice clinicians could improve access to necessary care for millions of Americans.

The U.S. currently faces a looming shortage of primary care physicians, especially with the Affordable Care Act (ACA) making health insurance available to millions of people who previously lacked coverage. While not calling for advanced practice clinicians to replace physicians, the findings suggest that they could pick up much of the slack in some services that general practitioners provide, particularly for relatively straightforward conditions with clearly-defined guidelines such as the ones the researchers studied, said Dr. John Mafi, assistant professor of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA, and the study’s lead author.

“Some estimate that we’re going to be short 20,000 doctors by 2020 and the causes relate to both supply and demand,” Mafi said. “There’s more demand for primary care providers due to the ACA, so millions of newly insured patients are looking for a provider—yet there are fewer trainees entering primary care because it’s lower paid and harder work.

Low-value health services are defined as services for which the risks typically exceed the benefits—for example, antibiotics for the common cold virus don’t help and can cause harmful side-effects.

“We’ve known for many years that low value health services are being given to patients, yet despite that we still provide large amounts of it, which not only is bad medicine, but it also raises costs” added Mafi, who is also an affiliated adjunct natural scientist in health policy at RAND Corporation. “Our main finding, that nurse practitioners and physician assistants are no worse than doctors in this way, is reassuring in light of recent efforts to expand advanced practice clinicians’ scope of practice and while the primary care physician workforce continues to shrink.”

The researchers used data from Jan. 1, 1997, through Dec. 31, 2011, from the National Ambulatory Medical Care Survey (12,170 physicians and 473 advanced practice clinicians) and the National Hospital Ambulatory Medical Care Survey (13,359 physician and 2,947 advanced practice clinicians). They examined three outcomes commonly considered to be low value health services: use of antibiotics for upper respiratory infections, X-rays for upper respiratory infections and back pain, and advanced imaging such as magnetic resonance imaging and computed tomography for back pain and headache. They also looked at physician referrals to specialists, which generally are not required for these routine and straightforward conditions.

They found no significant differences between physicians and advanced practice clinicians in either office-based or hospital-based primary care settings.

Here are the rates of low-value services ordered by physicians and advanced practice clinicians in primary care practice:



Advanced Practice Clinicians




Office based

48.7 percent

51.9 percent

Hospital based

46.0 percent

52.8 percent




Office based

5.7 percent

3.0 percent

Hospital based

7.1 percent

6.4 percent




Office based

10.0 percent

10.9 percent

Hospital based

10.5 percent

11.1 percent

Referrals to other physicians



Office based

7.6 percent

7.8 percent

Hospital based

8.3 percent

11.8 percent


The findings were roughly similar among patients with acute vs. chronic symptoms, though there was a suggestion that hospital-based advanced practice clinicians who were the patient’s own primary care provider ordered more services than physicians.

The study has some limitations. For instance, the National Ambulatory Medical Care Survey samples ambulatory visits to physician office practices and might underrepresent care that advanced practice clinicians provide. The researchers also could not precisely identify low-value health services because they lacked some types of clinical data, which might indicate the need for services that are otherwise considered low value. Also, the researchers could not fully account for variations in state-level laws regarding advanced practice clinicians across the U.S.

As debate continues over whether advanced practice clinicians’ scope of practice should expand, this analysis adds important data to the literature, suggesting that these caregivers seem to provide care equal to that of physicians in value and efficiency of delivery, said Dr. Bruce Landon, professor of health care policy and medicine at Harvard Medical School and the study’s senior author.

"As advanced practice clinicians rapidly expand their role in primary care, these findings have important implications for clinicians, practice leaders, and policymakers who have a stake in improving access to primary care services and ensuring the delivery of high-value care," Landon said. 

Study co-authors are Christina C. Wee, and Roger B. Davis of Beth Israel Deaconess Medical Center and Harvard Medical School.

A National Research Service Award training grant (T32HP12706) from the U.S. Health Services and Research Administration, the Ryoichi Sasakawa Fellowship Fund, a National Institutes of Health Midcareer Mentorship Award (K24DK087932), and a Harvard Catalyst National Institutes of Health Award (UL1 TR001102) funded this study.


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