Imaging ordering patterns between physicians and advanced practice clinicians

Advanced Practice Clinicians (APC) are civilian mid-level providers (ex. nurse practitioner, physician assistant) who have the ability to order imaging. Though, some proponents have suggested that mid-level providers may be inappropriately ordering unnecessary imaging for their patients. Hypothetically, this could lead to increased healthcare cost and spending. Hughes, Jiang, & Duszak (2015) used Medicare claims data and sought to find out whether there was a discrepancy between APCs and physicians (PCP). They wanted any potential differences between the two to be observable and quantitative; therefore, the primary outcome was whether an imaging event occurred after an evaluation and management visit (geographic variation, patient demographics, and the Charlson Comorbidity Index Score were all variables taken into consideration). The results were as follows:

-APCs ordered imaging 2.8% per episode of care whereas PCPs ordered 1.9% of the time. In adjusted estimates across all patient groups, APCs were associated with more imaging than PCPs (odds ratio, 1.34 [95% CI, 1.27-1.42]), ordering 0.3% more images per episode.

-For traditional radiographs, APCs ordered 0.3% and 0.2% more images for new and established patients. For advanced imaging, APCs ordered 0.1% more images than physicians.

It is interesting to note that the authors pointed out the potential broader implications of the findings. That is, increased healthcare cost and unnecessary radiation exposure may result on a national level if APCs ordered imaging to the same degree. Therefore, their growing role in primary care access should potentially be limited due to cost, safety, and quality implications. Does that make sense to you? It doesn’t to me. While I do believe more studies should be done on the subject matter, I do not think there is any merit in these statements given the aforementioned statistics. The differences were negligible within the sample study, and I hypothesize that the authors were expecting the differences to be much greater than they were.

The authors examined the imaging rates for two commonly seen conditions in the clinic: low back pain (LBP) and acute respiratory infection. They chose these two conditions because they are frequently seen and are usually managed conservatively without imaging. Interestingly enough, for reasons unknown, PCPs were associated with more images for patients who had acute respiratory infections. The authors hypothesized that APCs referred these patients to PCPs for further evaluation and imaging. If that is the case, why was the imaging rate the same for patients with LBP? It is a bit of a double standard–on one hand, APCs are associated with higher imaging rates. In the same breath, they are also sending patients with respiratory infections to PCPs for imaging? And this is supposed to explain why the rates are higher for PCPs compared to APCs?

The conclusion of the article was as follows: “Greater PCP and APC team coordination, as some have suggested, may produce better outcomes than merely expanding the scope of APC practice alone.” I do not believe any APCs are advocating for expanding their scope of practice without team collaboration (if they are, they shouldn’t be). However, the lack of primary care providers will force APCs scope of practice to increase. We have seen this in a number of states in the country. Rest assured, some studies have already shown that patient outcomes for many conditions are not inferior when APCs are caring for them rather than physicians (Newhouse, Stanik-Hutt, & White, 2011). With that said, patients will obtain the best outcomes when APCs collaborate with physicians. Managing patients is a group effort that requires teamwork from every single member. I believe PCPs should be at the helm, but improving the team’s autonomy will disperse the caseload and it will inevitably make life easier for physicians.

Similar opinions have been expressed about PTs gaining direct access and ordering imaging. Articles were written about how it would be unsafe for a PT to treat a patient without first being seen by a physician. PTs fought hard for their autonomy and proved their competence–now there are 18 states with unrestricted direct access and 26 states with provisional direct access. Rather than wasting a physician’s time to evaluate and write a prescription, patients are being seen sooner and treated quicker. I think that benefits all parties.

As for imaging, military PTs are providers who have been serving as physician extenders for quite some time. Compared to civilian PTs, they can order imaging for their patients and prescribe basic musculoskeletal medications. They have been doing this safely and appropriately since 1972. It has actually reduced the number of unnecessary images ordered without compromising military patient safety (Boyles et al., 2011). Unfortunately, civilian PTs do not have the same scope of practice. If APCs are allowed to order imaging for their patients, it makes sense that PTs should be able to as well.



Boyles, R.E., Gorman, I., Pinto, D., & Ross, M.D. (2011). Physical therapist practice and the role of diagnostic imaging. Journal of Orthopaedic & Sports Physical Therapy, 41(11), 829-837.

Hughes, D.R., Jiang, M., & Duszak, R. (2015). A comparison of diagnostic imaging order patterns between advanced practice clinicians and primary care physicians following office based evaluation and management visits. Journal of American Medical Association, 175(1), 101-107.

Newhouse, R.P., Stanik-Hutt, J., & White, K.M. (2011). Advanced practice outcomes 1990-2008: a systematic review. Nursing Economics, 29(5), 230-250.


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