Finally, some actual data on APP practice

[WilcoWorld]

Over a million encounters included, and the results are clear, APP's are better.

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[WilcoWorld]

Problem is, what they appear to be better at is spending healthcare dollars on non-beneficial care:

Despite the 2013 American Academy of Orthopaedic Surgeons clinical practice guideline recommending against the clinical utility of these injections, HA services continued to be widely implemented among Medicare beneficiaries. Although there were variations across specialties when evaluating overall utilization rates as well as rates per provider, APPs largely contributed to the increase seen in the U.S. over this study period. More data are needed to support continued implementation and spending on this low-value care.

 

[thegenius]

Over a million encounters included, and the results are clear, APP's are better.

The link goes to “
Hyaluronic Acid Injections for Knee Osteoarthritis
Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018?”

Wrong link?

 

[RustedFox]

So, PLPs can inject knees with a generally useless and innocuous item and there's no change in outcomes?

Astonishing.

 

[WilcoWorld]

The link goes to “
Hyaluronic Acid Injections for Knee Osteoarthritis
Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018?”

Wrong link?

That's the link I intended. A huge orthopedic study finding that, in the time since hyaluronic acid injections was shown to NOT help knee osteoarthritis it's use has nevertheless expanded by $35M...with the difference driven by APP's (p<0.01).

In other words, we still don't have good evidence to answer the question of whether MD/DO's provide better (or worse) outcomes than APPs. However the argument that APPs produce "cost savings" seems pretty well disproven.

 

[thegenius]

Ahhh....OK. right on.

APP's cost less...but they tend to test more as compared to physicians. That's what I see at my own hospital.

 

[turkeyjerky]

Ahhh....OK. right on.

APP's cost less...but they tend to test more as compared to physicians. That's what I see at my own hospital.

My anecdotal evidence is that they tend to test more, consult more, resuscitate less and admit the wrong patients. I swear to god, if I get signed out one more pt s/p major blunt trauma pending a non-con CT c/a/p I'm gonna scream.

 

[turkeyjerky]

Unfortunately, from our current healthcare systems' perspective this is a feature not a bug. NPPs cost less and charge more than physicians, from an administrators point of view.

 

[xaelia]

Judicious stewardship of health resources using the acquired training and experience of physicians fails to maximise profits.

When the cheaper option is a revenue machine, why pay more for less ...

 

[Rekt]

We're in the era of Burger King and McDonald's medicine. Severely exacerbated by PLPs and the internet. I'm discharging copious amount of viral syndromes per day right now waiting for the patient complaints to roll in because I tell them they don't need steroids and an antibiotic.

 

[Zebra Hunter]

We're in the era of Burger King and McDonald's medicine. Severely exacerbated by PLPs and the internet. I'm discharging copious amount of viral syndromes per day right now waiting for the patient complaints to roll in because I tell them they don't need steroids and an antibiotic.

Right there with ya. I've already had two patients threaten to sue me this week for not doing a COVID test or prescribing abx when they had normal VS and a chief complaint of "congestion". My response is always "good luck with that".

 

[RustedFox]

We're in the era of Burger King and McDonald's medicine. Severely exacerbated by PLPs and the internet. I'm discharging copious amount of viral syndromes per day right now waiting for the patient complaints to roll in because I tell them they don't need steroids and an antibiotic.

This is exactly, precisely what burned me out at my last gig and played a central role in my neurotic meltdown last year.

At my new shop (and there's no polite way to say this) the patient base is too poor, and too uneducated to argue. It's far, far better. I no longer spend a single second arguing with a patient about these things, or wether their medicines are low-cal and gluten-free.

 

[coffeebythelake]

Ahhh....OK. right on.

APP's cost less...but they tend to test more as compared to physicians. That's what I see at my own hospital.

Isnt that what the hospital wants? More billing.

 

[bravotwozero]

At my new shop (and there's no polite way to say this) the patient base is too poor, and too uneducated to argue. It's far, far better. I no longer spend a single second arguing with a patient about these things, or wether their medicines are low-cal and gluten-free.

+1 this.

Exactly why I find myself at my new gig. Inner city urban population with lots of psych, substance abuse and 'urban outdoorsman/woman' types. Don't really have the wherewithal to fill out a PG survey or demand to speak to the CNO, much less file a lawsuit. Not easy by any means, but also don't feel like I always have a target on my back.

 

[RustedFox]

+1 this.

Exactly why I find myself at my new gig. Inner city urban population with lots of psych, substance abuse and 'urban outdoorsman/woman' types. Don't really have the wherewithal to fill out a PG survey or demand to speak to the CNO, much less file a lawsuit. Not easy by any means, but also don't feel like I always have a target on my back.

Yep. I went from the country club medial center to quasi-rural and impoverished with lots of substance abuse. It is actual "emergency" medicine 90+% of the time. I never see triage level 4 or 5 on the tracker. It's a hard place to work; but the toll on my psyche is far, far less.

 

[RustedFox]

Isnt that what the hospital wants? More billing.

Yep. Exactly.
They don't care about the medicine at all.
They say things like:

"Patient care will always come first"

and

"Do the right thing for the patient"

- but they don't know what those things mean. At all.

The right thing for the patient is more often "less testing, less medicine" than they want to believe.

 

[thegenius]

+1 this.

Exactly why I find myself at my new gig. Inner city urban population with lots of psych, substance abuse and 'urban outdoorsman/woman' types. Don't really have the wherewithal to fill out a PG survey or demand to speak to the CNO, much less file a lawsuit. Not easy by any means, but also don't feel like I always have a target on my back.

Yea I hear ya. There are frustrations with all sorts of patient cohorts. The uneducated and poor tend not to understand your explanations, you test more because they don't have outpatient followup, or don't know how to get followup, and they are typically not as compliant. As a result it's harder to make a health difference with them.

I work at multiple hospitals, one is for poor folk and one is for rich folk. It's interesting how pathology (and treatment) is different at both places.

Poor Folk Hospital
- lots of chronic, self-induced medical problems
- much greater medical non-compliance
- low education, they just don't understand
- they don't care much, if at all, about cost of goods and services
- often can't reason with them - so I order more tests

Rich Folk Hospital
- less chronic, self-induced medical problems
- greater med compliance
- high education, I can reason with them about tests
- more sense of entitlement
- they care more about cost of services


Interesting how the demand to get stuff done NOW is about the same at both hospitals

 

[Lexdiamondz]

This is exactly, precisely what burned me out at my last gig and played a central role in my neurotic meltdown last year.

At my new shop (and there's no polite way to say this) the patient base is too poor, and too uneducated to argue. It's far, far better. I no longer spend a single second arguing with a patient about these things, or wether their medicines are low-cal and gluten-free.

I learnt the value of this early in training, and picked a job that pays almost 30k less than the fancy suburban hospitals annually to avoid dealing with the Karens and their Karen-spawn.

Half of my patient population doesn't speak English, most are working class and actually want to go back to work ASAP cuz they have families to feed and **** to do, and nearly all are at least grateful to be seeing a physician at all, since many (as do I) come from countries where the only medicines they had were tea, expired tylenol, prayer and (occasionally) witchcraft.

 

[xaelia]

100% working at public hospitals is a better Life Experience right now.

But, there's always something.

Kaiser NW had great integrated services, follow-up, and I felt like we generally did a great job doing good medicine for the members. But, we also had plenty of members who were always deeply suspicious we were ripping them off and skipping out on tests/treatments/referrals they otherwise deserved – and they disproportionately loaded the ED as their attempt to circumvent the system.

 

[coffeebythelake]

Yep. Exactly.
They don't care about the medicine at all.
They say things like:

"Patient care will always come first"

and

"Do the right thing for the patient"

- but they don't know what those things mean. At all.

The right thing for the patient is more often "less testing, less medicine" than they want to believe.

For hospital admin, "putting patients first" means giving patients what they WANT (as reflected in patient satisfaction surveys) rather than giving patients what they NEED (as reflected in actual outcomes)

 

[RustedFox]

For hospital admin, "putting patients first" means giving patients what they want (as reflected in patient satisfaction surveys) rather than giving patients what they need (as reflected in actual outcomes)

This is far better than I could have put it, despite all my (as another poster on here once put it) "Tolkien level of command of the written word".

 

[Apollyon]

"Tolkien level of command of the written word".

Is this supposed to be a brag, or self deprecating?

 

[RustedFox]

Is this supposed to be a brag, or self deprecating?

Totally a brag. I'm owning it.
Not my words; but they made me feel really good.

It was after I posted that diatribe on the overweight, smoky 40-something female sent emergently for US to rule out internal bleeding some 5-6 days after a low-speed MVC by a Jenny McJennyson because her amazingly adipose-laden abdomen had "some bruising".

Excerpt from my physical exam: "Nicotine stains are present on her toes. Somehow."