Background
With approval of the Affordable Care Act, millions of Americans who were without access to health insurance in 2010 will have affordable health insurance options by 2014 [
1]. Furthermore, under the Affordable Care Act, Medicare and new health insurance plans and policies must cover selected evidence based preventive services without co-insurance, cost sharing, a copayment or contributions towards a deductible. These services include cervical, breast, and colorectal cancer screening. They also include human papillomavirus (HPV) vaccination for age eligible adults and tobacco use screening and cessation interventions [
2,
3].
Coverage of cancer-related screening and preventive services will increase the demand for the services of primary care physicians (PCP). However, the act of fulfilling all of the US Preventive Services Task Force recommendations at the appropriate frequency to an average size patient panel in the United States would consume an estimated 7.4 hours of an average US PCP’s workday, exclusive of treatment of illness and ongoing administrative activities [
4]. In team-based practice settings, advanced practice registered nurses and physician assistants (APRN/PA) may help meet this demand for primary care. This approach has been suggested for improved organization of practice systems for chronic disease management since the 1980’s [
5,
6]. Additionally, a recent Institute of Medicine report (2011) called upon nurses to serve as full partners with physicians to help realize the goals of the Affordable Care Act [
7]. APRNs are nurses with post-graduate education in nursing with an advanced scope of practice in nursing. The Affordable Care Act also provides for the Expansion of Physician Assistant (PA) Training Program as outlined by the US Department of Health and Human Services [
8]. Physician assistants practice medicine alongside a physician supervisor with a similar scope of practice.
However, there are very few existing data sources to investigate these relationships between APRN/PA, other provider types, and receipt of care in relation to evidence-based guidelines at a national level. In this study, we used a theoretical framework to guide our evaluation of the relationship between type of medical provider seen in the past 12 months and receipt of cancer screening and prevention recommendations in a nationally representative sample. We hypothesized that individuals who have had a visit with an APRN/PA would be more likely to have received cancer screening and prevention recommendations than participants who have not seen a primary care provider or than participants who have not seen any healthcare provider.
Discussion
For more than two decades, team-based healthcare has been known to play a key role in improving primary care [
5,
6,
21,
22], yet this is one of the first studies to use nationally-representative data to investigate the relationship between provider type, including PCP, APRN and/or PA, and other providers and receipt of cancer screening and cancer risk reduction recommendations. Overall, type of provider seen in the past 12 months, if any, was associated with receipt of guideline-consistent cancer risk reduction recommendations and cancer screening. These findings suggest that seeing a PCP alone, or in addition to an APRN/PA is associated with greater receipt of a wide range of cancer prevention services and recommendations compared to not seeing any provider or another provider type even when controlling for number of provider visits in the past year. The importance of a visit with a primary care provider was underscored by the findings of this study. These findings are supported by previous literature that suggests the availability of primary care physicians is one of the most influential factors related to self-rated health, public health, and population health outcomes [
23‐
25].
Our study adds to the limited literature assessing the effects of an APRN/PA visit on cancer risk factor reduction and screening recommendations. Only a small number of studies have evaluated cancer screening and risk reduction recommendations by provider type or by APRN/PA. These studies generally report high levels of Pap test, mammography or colorectal cancer screening ordered or performed by nurse practitioners (NP) [
26‐
30] and in some situations NP had better performance than their physician counterparts [
30]. Other studies have shown that patients interacting with NP, certified nurse midwives (CNM), or PA in both primary care facilities and hospitals are likely to receive smoking cessation counseling [
26,
27,
31‐
35]. In addition, a few studies have shown that NP are more likely to counsel on diet and physical activity than their physician counterparts [
27,
31,
32] while some noted that APRN/PA provide counseling on physical activity to less than a quarter of their patients [
27,
32]. These studies generally had small samples and rarely had comparison groups or evaluated multiple cancer control interventions in the same populations. Further, none of these studies reported cancer screening or risk reduction recommendations in relation to evidence-based guidelines.
More work is needed to identify the optimal structure of primary care provider teams for improving delivery of cancer screening and prevention recommendations. Findings will aid in the further development and design of US healthcare systems to meet the expected demands for primary care as a result of the Affordable Care Act.
This study’s findings highlight the importance of identifying provider type when evaluating delivery of primary care services. In several instances, associations between receipt of cancer screening and seeing a non-primary care provider in the past 12 months was similar to not seeing any provider at all. More work is needed to understand the roles of PCP and APRN/PA separately and as a part of primary care teams as related to increasing compliance with cancer screening and prevention recommendations. A combination of in-depth qualitative interviews and quantitative surveys with patients and providers within and between healthcare systems could inform the development and evaluation of interventions integrating APRN/PA in primary care teams. Because vulnerable populations in the United States, including the uninsured, low-income, and minorities, are less likely to be compliant with cancer screening and prevention recommendations [
36] they may be a particularly important target for intervention activities, particularly in safety net clinics.
Unlike breast and cervical cancer screening guidelines, which are based on intervals for mammography and Pap testing, there are a number of test options with different recommended intervals for meeting colorectal cancer screening guidelines (i.e., FOBT, sigmoidoscopy, and colonoscopy). Thus, patients may need more provider time to guide their decision-making processes. Further, on a national level, compliance with colorectal cancer screening guidelines is low at 59%, compared to compliance with breast (72%) and cervical cancer (83%) screening guidelines among age eligible adults [
37]. In addition to having more room for improvement, colorectal cancer screening assessments are less vulnerable to a ceiling effect. Thus, learning how to optimally integrate APRN/PA into primary care teams may lead to greater improvements in colorectal cancer screening rates than would be feasible for breast and cervical cancer screening rates. Furthermore, there is also large room for improvement to increase advice to quit smoking and to offer physical activity recommendations where integration of APRN/PA in primary care may help improve these low rates (less than 60% of participants received advice to quit smoking and less than 40% of participants received a recommendation to begin or continue physical activity).
Few studies have investigated the role of APRN/PA in HPV vaccination, although NP working with adolescents are more likely to recommend STI vaccines [
38] and CNM are active in the assessment of the need for vaccinations among their patients [
26]. Future work in this area should investigate the relationship between a visit with an APRN/PA and receipt of the HPV vaccine within pediatrics clinics to better capture the patient populations (girls and boys aged 11 and 12 years) who would receive the most benefit from the vaccine.
This study exhibits several limitations. First, the data do not allow for a separate analysis of the services specifically provided by APRN/PA in relation to those that are provided by PCP. Secondly, it is unknown if participants saw an APRN/PA at the same visit and in the same practice as their PCP. Athough it is impossible to assess the impact of a provider team on receipt of cancer screening and prevention recommendations, most states do require that APRN/PA practice with a PCP. Furthermore, the dates of cancer screening test, HPV vaccination, and provider recommendations for cancer prevention and specific date of each provider visit are not available. For colorectal cancer screening, this study assessed receipt of screening tests within a recommended time interval for type of test received (i.e., home FOBT in the past year, sigmoidoscopy within 5 years, colonoscopy within 10 years) yet participants were asked about visits with primary care providers and other healthcare providers in the past 12 months. However, this analysis is likely to underestimate receipt of colorectal cancer screening received five or more years ago. Lastly, these data were gathered from self-report survey items. Participant recall of the specific type of medical provider(s) seen in the past 12 months and participant accuracy in reporting of the timing of type of medical recommendation, procedure, and/or service received is an additional limitation. Self-report of cancer screening may overestimate receipt of screening [
39‐
41], although some studies demonstrate reliable agreement of self-report screening [
42,
43] as compared to physician reports and medical records.
Conclusions
Opportunities exist to increase the role of APRN/PA in cancer prevention and control to respond to a growing demand for affordable preventive services in primary care settings in the United States. APRN/PA may be a strong leverage point to heighten cancer-prevention among vulnerable populations. More intervention research efforts are needed to explore how APRN/PA will be best able to increase cancer screening, HPV vaccination, and receipt of behavioral counseling, especially during this era of healthcare reform, as both individual practitioners and as members of healthcare delivery teams. Lastly, increasing overall access to primary care providers will likely improve the delivery of cancer-prevention services in the United States.
Acknowledgements
Dr. Kepka has received some support from the Huntsman Cancer Foundation, the University of Utah College of Nursing, and the University of Utah Center for Clinical and Translational Science for this study. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number 1ULTR001067. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Alexandria Smith volunteered her time on this study. Christopher Zeruto is employed by a contractor to the National Cancer Institute and did not receive specific funding for this work. Dr. Yabroff is a federal employee with no external source of support for the work. Dr. Kepka would also like to acknowledge the assistance of Echo Warner, Research Analyst, and Djin Lai, Graduate Research Assistant, at the Huntsman Cancer Institute, on the text and revisions of this manuscript.
Competing interests
We do not have any competing interests to Report.
Authors’ contributions
DK conceived of the research question, led the data analysis activities and wrote the manuscript. LS completed the literature review, and wrote and edited the manuscript. CZ completed the data analysis activities and reviewed the manuscript. RY helped DK oversee the study, wrote sections of the manuscript, and reviewed, and edited the manuscript. All authors read and approved the final manuscript.