Trends in Emergency Care Provided by Non-Physician Providers and Physicians: 2009-2021

We describe the types of emergency department (ED) visits managed by non-physician providers (NPPs), including physician assistants and nurse practitioners, and emergency medicine (EM) physicians, assessing shifts in care patterns over time.

We used data from the National Hospital Ambulatory Medical Care Survey collected from 2009 to 2021. We classified visits by provider type: physician only, physician with resident, physician with NPP, and NPP only. We described characteristics of visits by provider type, including patient demographics, triage urgency, imaging, length of stay, and disposition, and analyzed using Poisson regression. We described the change in type of provider seen over this study period and further analyzed by triage urgency and hospital location.

Of 1.684 billion estimated ED visits from 2009 to 2021, 1.171 billion were managed by physicians without residents or NPPs (physicians only), 136.3 million by physicians with residents, 209.1 million by physicians with NPPs, and 167.4 million by NPPs only. Patients seen by physicians only were older, were triaged as having more urgent needs, had a longer ED length of stay, and were more likely to be admitted compared to those seen by NPPs only. Physician-only visits decreased from 77% to 62%, while NPP-only visits increased from 6% to 11%. The physician with the NPP group similarly grew from 9% to 17%. For visits assigned a triage urgency level of 2 ("emergent"), physician-only visits decreased by 20%, physician with NPP visits increased by 13%, and NPP-only visits increased by 3%. In metropolitan areas, physician-only visits dropped 14%, with a 5% increase in NPP-only visits. In non-metropolitan areas, physician-only visits decreased 17%, with a 9% increase in NPP-only visits.

The EM workforce has shifted, with NPPs seeing a higher percentage of patients, including both lower- and higher-acuity patients. This shift is particularly prominent in rural areas but is evident across all regions.