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van den Brink GTWJ, Hooker RS, Van Vught AJ, Vermeulen H, Laurant MGH. The cost-effectiveness of physician assistants/associates: A systematic review of international evidence. PLoS One 2021; 16:e0259183. [PMID: 34723999 PMCID: PMC8559935 DOI: 10.1371/journal.pone.0259183] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. METHODS AND FINDINGS Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies-of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician's care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. CONCLUSIONS Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity.
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Affiliation(s)
- G. T. W. J. van den Brink
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - R. S. Hooker
- Adjunct Professor, Health Policy, Northern Arizona University, United States of America
| | - A. J. Van Vught
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - H. Vermeulen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - M. G. H. Laurant
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
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Hawkins CM. Rules and Regulations Relating to Roles of Nonphysician Providers in Radiology Practices. Radiographics 2018; 38:1609-1616. [DOI: 10.1148/rg.2018180031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- C. Matthew Hawkins
- From the Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-guided Medicine, Emory University School of Medicine, 1364 Clifton Rd NE, Suite D112, Atlanta, GA 30322; and Department of Radiology and Imaging Sciences, Division of Pediatric Radiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Ga
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Hawkins CM, Bowen MA, Gilliland CA, Walls DG, Duszak R. The Impact of Nonphysician Providers on Diagnostic and Interventional Radiology Practices: Operational and Educational Implications. J Am Coll Radiol 2015; 12:898-904. [DOI: 10.1016/j.jacr.2015.03.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 03/23/2015] [Indexed: 01/05/2023]
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Wang W, Zhang M, Zhang Y. Overall measurements of dose to patients in common interventional cardiology procedures. RADIATION PROTECTION DOSIMETRY 2013; 157:348-354. [PMID: 23770572 DOI: 10.1093/rpd/nct147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This study was designed to measure peak skin dose (PSD), dose-area product (DAP), cumulative dose (CD) and fluoroscopy time (FT) for interventional cardiology procedures and to evaluate whether patient doses were higher than that in other published data. Three cardiac procedure types, including coronary angiography (CAG), percutaneous transluminal coronary angioplasty (PTCA) and radio frequency (RF) ablation, were entered into the study. Data of four special metrics (PSD, DAP, CD and FT) for these procedures were collected and measured. A total of 238 patients who underwent interventional radiology procedures participated in this study. For every procedure, data about PSD were resulted from six TLD arrays and DAP, CD and FT were collected from the displayed monitor. The mean, standard deviation (SD), range and third quartile of the distribution of PSD, DAP, CD and FT recorded and measured on spot were calculated for all procedures. High-dose cases were specifically recorded. There was wide variation in the doses observed for different instances of the same procedure. PSD for PTCA and RF ablation ranged from 0.1 Gy to more than 3 Gy. Of 238 instances, there were 22 (9.2 %) with PSDs greater than 2 Gy and 4 (1.7 %) than 3 Gy. The third quartile of the distribution for PTCA had exceeded the DIMOND preliminary reference levels by 41.1 % in DAP and 25.0 % in FT. Mean DAP was in the range of reported values for CAG procedure, but higher than all data obtained in literatures for PTCA. Data from this study are in the range of most reported values for CAG and RF ablation procedure, while higher than that obtained in some literatures for PTCA. In case of a constant delivering of high doses to patient and physician himself, thorough training of interventionalists and staff is necessary, and the legislation has to be revised and set dose constrains especially for the interventional high-dose procedures.
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Affiliation(s)
- Weipeng Wang
- Shandong Medical Imaging Research Institute, Jingwu road No.324, Jinan 250021, P. R. China
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Bashore TM, Balter S, Barac A, Byrne JG, Cavendish JJ, Chambers CE, Hermiller JB, Kinlay S, Landzberg JS, Laskey WK, McKay CR, Miller JM, Moliterno DJ, Moore JWM, Oliver-McNeil SM, Popma JJ, Tommaso CL. 2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine. J Am Coll Cardiol 2012; 59:2221-305. [PMID: 22575325 DOI: 10.1016/j.jacc.2012.02.010] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Nelson KH, Willens HJ, Hendel RC. Utilization of radionuclide myocardial perfusion imaging in two health care systems: assessment with the 2009 ACCF/ASNC/AHA appropriateness use criteria. J Nucl Cardiol 2012; 19:37-42. [PMID: 22045393 DOI: 10.1007/s12350-011-9467-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 10/12/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although differences in the rate of utilization of invasive cardiac procedures between Veterans Affairs (VA) hospitals and other health care systems are present, noninvasive cardiac imaging use pattern has not been well studied. We evaluated the ability of the updated appropriateness use criteria (AUC) to determine utilization patterns of myocardial perfusion imaging (MPI) and compare use between an academic practice and a VA. METHODS One-hundred fifty stress/rest MPI studies in an academic practice and 150 at a VA hospital were retrospectively reviewed using the hierarchical approach published in the 2009 AUC. RESULTS Less than 1% of studies were unclassified. A higher percentage of MPI were requested for inappropriate reason at the VA, although this difference was not statistically significant (P = .248). In the VA, non-physicians requested significantly more inappropriate studies than physicians (26.8% vs 20.1%; P < .048). Within the academic practice non-cardiologists referred more patients for inappropriate indications than cardiologists (23.9% vs 10.1%; P = .001). Five most common inappropriate indications accounted for the vast majority of inappropriately requested MPI (77%). CONCLUSIONS The revised 2009 AUC allow for near complete categorization of appropriateness in testing. Differences between institutions and provider types were noted and areas for improved utilization were identified.
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Affiliation(s)
- Katarina H Nelson
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL 33133, USA
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Blue C, Phillips R, Born D, Lopez N. Beginning the Socialization to a New Workforce Model: Dental Students’ Preliminary Knowledge of and Attitudes About the Role of the Dental Therapist. J Dent Educ 2011. [DOI: 10.1002/j.0022-0337.2011.75.11.tb05204.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Christine Blue
- Division of Dental Hygiene; School of Dentistry, University of Minnesota
| | | | - David Born
- Division of Community Oral Health; School of Dentistry, University of Minnesota
| | - Naty Lopez
- School of Dentistry, University of Minnesota
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Complication rates and outcomes of 536 implanted subcutaneous chest ports: do rates differ based on the primary operator's level of training? Acad Radiol 2010; 17:464-7. [PMID: 20060749 DOI: 10.1016/j.acra.2009.10.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2009] [Revised: 10/22/2009] [Accepted: 10/24/2009] [Indexed: 11/21/2022]
Abstract
RATIONALE AND OBJECTIVES Totally implanted subcutaneous central venous access devices (chest ports) are an attractive option for patients in need of intermittent, recurrent venous access. In our department, these are placed by different operator types including interventional radiology (IR) attending physicians, dedicated IR nurse practitioners (NP), and IR fellows/radiology residents. The purpose of our study is to assess the rate of complications of subcutaneous chest port placement among the different operator types. MATERIALS AND METHODS A retrospective review of all subcutaneous central venous access devices implanted in our department between October 8, 2004, and October 19, 2007, was undertaken. Total numbers of port days, overall complication rates for all operators, as well as complication rates for the various operator types were calculated and were compared using the chi square test. RESULTS A total of 558 patients had totally implanted subcutaneous central venous access devices placed during the period of study. Of these, 536 had documented follow-up and comprise the study population. A total of 89 were placed by attending physician alone, 133 by an NP, and 314 by an IR fellow or resident, with supervision by an attending physician. Mean duration of port usage was 341 days with 182,522 total port days. A total of 39 complications occurred (7.28%), including 27 infections (5%). There was no statistically significant difference in overall complication rates, including infection rates, among operator groups (P = .925). CONCLUSIONS Our results confirm that well-trained physician extenders and trainees can safely perform chest port placement and that these providers, under appropriate supervision, can help provide improved access to chest port placement for patients and referring clinicians.
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Kadohira T, Kobayashi Y, Niitsuma Y, Imamaki M, Komuro I. Global ST-segment elevation associated with impending cardiac rupture during diagnostic cardiac catheterization. Int Heart J 2009; 50:539-42. [PMID: 19609057 DOI: 10.1536/ihj.50.539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cardiac rupture is a life-threatening complication during diagnostic cardiac catheterization, however, it rarely occurs nowadays. The present case report describes cardiac rupture during diagnostic cardiac catheterization using a 4F pigtail catheter and a 0.035" flexible guidewire, and global ST-segment elevation associated with impending cardiac rupture.
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Affiliation(s)
- Tadayuki Kadohira
- Department of Cardiovascular Science and Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
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Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Crit Care Med 2008; 36:2888-97. [DOI: 10.1097/ccm.0b013e318186ba8c] [Citation(s) in RCA: 202] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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O'Connor TM, Hooker RS. Extending rural and remote medicine with a new type of health worker: Physician assistants. Aust J Rural Health 2007; 15:346-51. [DOI: 10.1111/j.1440-1584.2007.00926.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Mathur M, Rampersad A, Howard K, Goldman GM. Physician assistants as physician extenders in the pediatric intensive care unit setting-A 5-year experience. Pediatr Crit Care Med 2005; 6:14-9. [PMID: 15636653 DOI: 10.1097/01.pcc.0000149133.50687.a1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the scope of practice and complementary role of physician assistants as physician extenders in the pediatric intensive care unit. DESIGN Descriptive report of a 5-yr experience using a physician assistant-resident staffing model in comparison to the traditional resident-only coverage. SETTING Six-bed pediatric intensive care unit at a tertiary care center subject to longstanding New York Hospital Code 405 restrictions on resident work hours. INTERVENTIONS Orientation, training, credentialing, and evaluation of physician assistants. MEASUREMENTS AND MAIN RESULTS New Accreditation Council for Graduate Medical Education regulations based on the longstanding New York Hospital Code 405 limit the number of resident hours worked per week. Our hospital employs physician assistants as physician extenders in the pediatric intensive care unit to enable regulatory compliance. Physician assistants were oriented for a period of 6 months to 1 yr to develop skill competencies, observe and learn pediatric intensive care unit practices and procedures, and complete credentialing to perform traditionally physician, nursing, and respiratory therapist functions. Physician assistants were then assigned to an independent but supervised patient care role similar to that of a resident physician. The impact of the physician assistant program was assessed by the attending physicians, and resident opinions were surveyed. CONCLUSIONS Physician assistants play a complementary role as physician extenders in the pediatric intensive care unit, enabling compliance with New York state and Accreditation Council for Graduate Medical Education resident work hour regulations. Physician assistants perform similar tasks and activities as the pediatric intensive care unit residents and integrate well with them in enhancing bedside patient care. Over time, physician assistants provide additional direction to the residents by virtue of their familiarity with unit-specific policies and procedures and repetitive pediatric intensive care unit practice patterns. As multifunctional members of the health care team, they support nursing and respiratory therapy functions and improve the day-to-day functioning of the unit. The physician assistant serves as a key member of the pediatric intensive care unit transport team. Limitations observed include high job turnover rates among the physician assistants and confusion between their role as shift workers or professional employees.
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Affiliation(s)
- Mudit Mathur
- Department of Pediatrics, The Children's Hospital at Downstate, and SUNY Downstate College of Medicine, Brooklyn, NY, USA
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Lambrew CT, Dove JT, Friday BA, Lloyd Doherty C, Nocero MA, Schott CR, Wann LS. Working group 5: Innovative care team models and processes that might enhance efficiency and productivity. J Am Coll Cardiol 2004; 44:251-5. [PMID: 15261914 DOI: 10.1016/j.jacc.2004.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Blackmore CC, Hoffer EK, Albrecht E, Mann FA. Physician assistants in academic radiology: the harborview experience. J Am Coll Radiol 2004; 1:410-4. [PMID: 17411618 DOI: 10.1016/j.jacr.2003.12.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We describe a model of how physician assistants can be used in an academic medical center to expand radiologist productivity, and to enhance the departmental academic and educational missions. At Harborview Medical Center, following a training program and graduated responsibility under supervision, physician assistants provide initial interpretation of radiology studies, consultation to referring physicians, and perform less complicated interventional procedures. Acceptance of physician assistants by the radiologists, radiology residents, and referring physicians has been high. Although the impact of physician assistants on departmental clinical productivity is difficult to measure, our data suggest that radiologists are more efficient when physician assistants are assigned to service, both in terms of numbers of studies interpreted, and timeliness of reporting and billing. As a result of the success of our program, we believe that physician assistants can have an important role in radiology practice.
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Affiliation(s)
- C Craig Blackmore
- Department of Radiology, Harborview Medical Center, University of Washington, Seattle, Washington 98104, USA.
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Gossman DE. Nonphysician cardiac catheterization: caveat emptor. Catheter Cardiovasc Interv 2004; 61:430. [PMID: 14988911 DOI: 10.1002/ccd.10788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Alex J, Rao VP, Cale ARJ, Griffin SC, Cowen ME, Guvendik L. Surgical nurse assistants in cardiac surgery: a UK trainee's perspective. Eur J Cardiothorac Surg 2004; 25:111-5. [PMID: 14690741 DOI: 10.1016/s1010-7940(03)00578-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE To assess the impact of surgical nurse assistants on surgical training based on a comparative audit of case-mix and outcome of coronary revascularizations assisted by surgical nurse assistants vs. surgical trainees. METHODS Relevant recent articles on Calman reform of specialist training and European working time directive (EWTD) on junior doctor working hours were reviewed for the discussion. For the audit prospectively entered data of elective and expedite first time coronary artery bypass grafting cases from 2000 to 2003 were analysed. Group A (n=233, Consultant+Surgical nurse assistant), group B (n=1067, Consultant+Junior surgical trainee). Chi-square test, t-test and Fisher's test were used as appropriate for statistical analysis. RESULTS Comparative preoperative variables were gender (P=0.8), body mass index (P=0.9), smoking (P=0.3), diabetes mellitus (P=0.2), hypertension (P=1), peripheral vascular disease (P=0.5), previous cerebrovascular accident (CVA)/transient ischemic attack (TIA) (P=0.3), renal dysfunction (P=0.4), preoperative rhythm disturbances (P=0.3), previous Q-wave myocardial infarction (MI) (P=0.4), Canadian Cardiovascular Society angina class (P=0.4), New York Heart Association heart failure class (P=0.4) and left ventricular function (P=0.4). Patients in group B were of higher risk due to age (P=0.01), coronary disease severity (P=0.05), left main stem disease (P=0.001), Parsonnet score (P=0.0001) and Euroscore (P=0.005. Regarding the myocardial protection technique, intermittent cross-clamp fibrillation was used more frequently in group A while antegrade-retrograde cold blood cardioplegia and off-pump coronary artery bypass were used more in group B (P=0.0001). The cross-clamp (P=0.0001) and operation time (P=0.0001) were significantly lower in group A despite a comparable mean number of grafts (P=0.2). There was no significant difference in the immediate postoperative outcome ventilation time (P=0.2), intensive care unit stay, postoperative stay (P=0.2), re-exploration for bleeding (P=0.5), inotrope+intra-aortic balloon pump (P=0.2), postoperative MI (P=0.9), postoperative rhythm disturbances (P=0.9), CVA/TIA (P=0.8), renal dysfunction (P=0.6), wound infection (P=0.7), sternal re-wiring (P=0.2), multi-organ failure (P=0.4) or mortality (P=0.1). CONCLUSIONS Surgical nurse assistants can be used effectively in low-risk cases without compromising postoperative results. However, initiatives to tackle the EWTD should be focused on areas that do not compromise the training needs of junior surgical trainees. An intermediate grade between the present senior house officer and registrar grades could be a way forward.
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