Association of State Share of Nonphysician Practitioners With Diagnostic Imaging Ordering Among Emergency Department Visits for Medicare Beneficiaries

IMPORTANCE: The use of nonphysician practitioners (NPPs) in the emergency department (ED) continues to expand, yet little is known about associations between NPPs and ED imaging use. OBJECTIVE: To investigate whether the state share of ED visits for which an NPP was the clinician of record is associated with imaging studies ordered, given that state NPP share is associated with state-level NPP scopes of practice. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study compared diagnostic imaging ordering patterns associated with ED visits based on 2005-2020 Medicare claims for a nationally representative 5% sample of fee-for-service beneficiaries. For all 50 states and the District of Columbia, the state NPP share of ED visits by year was used to represent state-specific practice patterns for NPPs and physicians and how those patterns have evolved over time. The analysis controlled for patient demographic characteristics, Charlson Comorbidity Index scores, ED visit severity, year, and principal diagnosis. EXPOSURES: The share of ED visits in each state in each year (state share) for which an NPP was the evaluation and management clinician. MAIN OUTCOMES AND MEASURES: The main outcomes were the number and modality of imaging studies associated with ED visits. Analyses were by logistic regression and generalized linear model with γ-distribution and log-link function. RESULTS: Among 16 922 274 ED visits, 60.0% involved women, and patients’ mean (SD) age was 70.3 (16.1) years. The share of all ED visits with an NPP as the clinician increased from 6.1% in 2005 to 16.6% in 2020. Compared with no NPPs, the presence of NPPs in the ED was associated with 5.3% (95% CI, 5.1%-5.5%) more imaging studies per ED visit, including a 3.4% (95% CI, 3.2%-3.5%) greater likelihood of any imaging order per ED visit and 2.2% (95% CI, 2.0%-2.3%) more imaging studies ordered per visit involving imaging. CONCLUSIONS AND RELEVANCE: In this study, use of NPPs in the ED was associated with higher imaging use compared with the use of only physicians in the ED. Although expanded use of NPPs in the ED may improve patient access, the costs and radiation exposure associated with more imaging warrants additional study.