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van Doorn – Klomberg A, Ruiterkamp B, van den Brink G. The first 2 decades of the physician assistant movement in the Netherlands. Future Healthc J 2022; 9:301-304. [PMID: 36561813 PMCID: PMC9761471 DOI: 10.7861/fhj.2022-0033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the Netherlands, the physician associate/assistant (PA) was introduced in 2001. We aim to describe the characteristics of PAs in the Netherlands. Information from public resources, mainly a report on capacity needs and a survey of PAs, was aggregated to provide an overview of the Dutch PA population. Results show that 73% were women; ages between 30 and 59 years were all evenly represented; and there was a wide variety in the background, specialty and location. Overall, the demographic characteristics of the Dutch PA profession are comparable with those of other PA workforces in the world. Presently, the PA movement in the Netherlands has a solid base of central support and national policy. PAs have full practice authority, and their numbers are steadily growing. While demand will eventually level out, the ideal number or PA ratio in the healthcare workforce remains unknown.
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Affiliation(s)
- Arna van Doorn – Klomberg
- AHAN University of Applied Sciences, Nijmegen, The Netherlands,Address for correspondence: Arna L van Doorn – Klomberg, HAN University of Applied Sciences, PO Box 6960, 6503 GL Nijmegen, The Netherlands.
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Martín-Fernández J, López-Nicolás Á, Oliva-Moreno J, Medina-Palomino H, Polentinos-Castro E, Ariza-Cardiel G. Risk aversion, trust in institutions and contingent valuation of healthcare services: trying to explain the WTA-WTP gap in the Dutch population. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:27. [PMID: 33952285 PMCID: PMC8097777 DOI: 10.1186/s12962-021-00281-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background The preferences of citizens are a basic element to incorporate into the decision-making process when planning health policies. Contingent valuation (CV) is a common method for calculating the value for citizens that new technologies, interventions, and the provision of services or policies have. However, choosing the correct CV tool may not be a neutral decision. This work aims to assess the substitution of a healthcare service by comparing valuation differences between the willingness to pay (WTP) for the maintenance of the service versus the willingness to accept compensation (WTA) for its substitution, both of which are related to subject characteristics, with a particular focus on trust in institutions and risk aversion. Methods A CV study was designed to study Dutch population preferences when physician assistants replace anaesthesiologists. Differences between the distributions of WTA and WTP were compared through full decomposition methods, and conditional quantile regression was performed. Results Nearly two-thirds of surveyed citizens expressed null values for WTA and WTP. The other third systematically reported a value of WTA higher than that of WTP, which increased further with lower income and the possible presence of a strategic bias. In contrast, being more than 65 years old, having trust in government, and preferring anaesthesiologists decreased the WTA-WTP difference. Risk aversion had no clear association with the WTA-WTP gap. Conclusions Known differences between the perceived value of health services from the perspective of gains and losses could be related to people’s characteristics. Trust in government but not aversion to risk was related to the WTA-WTP differences. Identifying a profile of citizens who are averse to losing health services should be considered when designing and implementing health services or interventions or making disinvestment decisions. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00281-9.
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Affiliation(s)
- Jesús Martín-Fernández
- Family and Community Medicine Teaching Unit Oeste, Primary Care Management, Madrid Health Service, Móstoles, Madrid, Spain. .,Faculty of Health Sciences, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. .,Research Network in Health Services and Chronic Diseases (REDISSEC), Madrid, Spain.
| | - Ángel López-Nicolás
- Economics Department, Faculty of Business Science, Universidad Politécnica de Cartagena (UPCT), Cartagena, Murcia, Spain
| | - Juan Oliva-Moreno
- Department of Economic Analysis and Finance, Faculty of Law and Social Sciences in Toledo, University of Castilla La-Mancha, Toledo, Spain
| | | | - Elena Polentinos-Castro
- Research Network in Health Services and Chronic Diseases (REDISSEC), Madrid, Spain.,Primary Care Research Unit, Primary Care Management, Madrid Health Service, Madrid, Spain
| | - Gloria Ariza-Cardiel
- Family and Community Medicine Teaching Unit Oeste, Primary Care Management, Madrid Health Service, Móstoles, Madrid, Spain.,Research Network in Health Services and Chronic Diseases (REDISSEC), Madrid, Spain
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Drennan VM, Halter M, Wheeler C, Nice L, Brearley S, Ennis J, Gabe J, Gage H, Levenson R, de Lusignan S, Begg P, Parle J. The role of physician associates in secondary care: the PA-SCER mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIncreasing demand for hospital services and staff shortages has led NHS organisations to review workforce configurations. One solution has been to employ physician associates (PAs). PAs are trained over 2 years at postgraduate level to work to a supervising doctor. Little is currently known about the roles and impact of PAs working in hospitals in England.Objectives(1) To investigate the factors influencing the adoption and deployment of PAs within medical and surgical teams in secondary care and (2) to explore the contribution of PAs, including their impact on patient experiences, organisation of services, working practices, professional relationships and service costs, in acute hospital care.MethodsThis was a mixed-methods, multiphase study. It comprised a systematic review, a policy review, national surveys of medical directors and PAs, case studies within six hospitals utilising PAs in England and a pragmatic retrospective record review of patients in emergency departments (EDs) attended by PAs and Foundation Year 2 (FY2) doctors.ResultsThe surveys found that a small but growing number of hospitals employed PAs. From the case study element, it was found that medical and surgical teams mainly used PAs to provide continuity to the inpatient wards. Their continuous presence contributed to smoothing patient flow, accessibility for patients and nurses in communicating with doctors and releasing doctors’ (of all grades) time for more complex patients and for attending to patients in clinic and theatre settings. PAs undertook significant amounts of ward-based clinical administration related to patients’ care. The lack of authority to prescribe or order ionising radiation restricted the extent to which PAs assisted with the doctors’ workloads, although the extent of limitation varied between teams. A few consultants in high-dependency specialties considered that junior doctors fitted their team better. PAs were reported to be safe, as was also identified from the review of ED patient records. A comparison of a random sample of patient records in the ED found no difference in the rate of unplanned return for the same problem between those seen by PAs and those seen by FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57;p = 0.40). In the ED, PAs were also valued for the continuity they brought and, as elsewhere, their input in inducting doctors in training into local clinical and hospital processes. Patients were positive about the care PAs provided, although they were not able to identify what or who a PA was; they simply saw them as part of the medical or surgical team looking after them. Although the inclusion of PAs was thought to reduce the need for more expensive locum junior doctors, the use of PAs was primarily discussed in terms of their contribution to patient safety and patient experience in contrast to utilising temporary staff.LimitationsPAs work within medical and surgical teams, such that their specific impact cannot be distinguished from that of the whole team.ConclusionsPAs can provide a flexible advanced clinical practitioner addition to the secondary care workforce without drawing from existing professions. However, their utility in the hospital setting is unlikely to be fully realised without the appropriate level of regulation and attendant authority to prescribe medicines and order ionising radiation within their scope of practice.Future researchComparative investigation is required of patient experience, outcomes and service costs in single, secondary care specialties with and without PAs and in comparison with other types of advanced clinical practitioners.Study registrationThe systematic review component of this study is registered as PROSPERO CRD42016032895.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Vari M Drennan
- Centre for Health and Social Care Research, Joint Faculty of Kingston University and St George’s, University of London, London, UK
| | - Mary Halter
- Centre for Health and Social Care Research, Joint Faculty of Kingston University and St George’s, University of London, London, UK
| | - Carly Wheeler
- Centre for Health and Social Care Research, Joint Faculty of Kingston University and St George’s, University of London, London, UK
| | - Laura Nice
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Sally Brearley
- Centre for Public Engagement, Joint Faculty of Kingston University and St George’s, University of London, London, UK
| | - James Ennis
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Jon Gabe
- Royal Holloway, University of London, Egham, UK
| | - Heather Gage
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | | | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Phil Begg
- The Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Jim Parle
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
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Bos JM, Timmermans MJC, Kalkman GA, van den Bemt PMLA, De Smet PAGM, Wensing M, Kramers C, Laurant MGH. The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing. PLoS One 2018; 13:e0202626. [PMID: 30138432 PMCID: PMC6107206 DOI: 10.1371/journal.pone.0202626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
Abstract
AIM This study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing. METHODS A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders. RESULTS 1021 patients from 17 hospital wards in the 'PA/MD model' group and 1286 patients from 17 hospital wards in the 'MD model' group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19-0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23-0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found. CONCLUSION This study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.
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Affiliation(s)
- Jacqueline M. Bos
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- * E-mail:
| | - Marijke J. C. Timmermans
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Gerard A. Kalkman
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Peter A. G. M. De Smet
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- Department of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Miranda G. H. Laurant
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
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Halter M, Wheeler C, Pelone F, Gage H, de Lusignan S, Parle J, Grant R, Gabe J, Nice L, Drennan VM. Contribution of physician assistants/associates to secondary care: a systematic review. BMJ Open 2018; 8:e019573. [PMID: 29921680 PMCID: PMC6020983 DOI: 10.1136/bmjopen-2017-019573] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To appraise and synthesise research on the impact of physician assistants/associates (PA) in secondary care, specifically acute internal medicine, care of the elderly, emergency medicine, trauma and orthopaedics, and mental health. DESIGN Systematic review. SETTING Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles. INCLUDED ARTICLES Peer-reviewed articles of any study design, published in English, 1995-2017. INTERVENTIONS Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken. OUTCOME MEASURES Impact on: patients' experiences and outcomes, service organisation, working practices, other professional groups and costs. RESULTS 5472 references were identified and 161 read in full; 16 were included-emergency medicine (7), trauma and orthopaedics (6), acute internal medicine (2), mental health (1) and care of the elderly (0). All studies were observational, with variable methodological quality. In emergency medicine and in trauma and orthopaedics, when PAs are added to teams, reduced waiting and process times, lower charges, equivalent readmission rate and good acceptability to staff and patients are reported. Analgesia prescribing, operative complications and mortality outcomes were variable. In internal medicine outcomes of care provided by PAs and doctors were equivalent. CONCLUSIONS PAs have been deployed to increase the capacity of a team, enabling gains in waiting time, throughput, continuity and medical cover. When PAs were compared with medical staff, reassuringly there was little or no negative effect on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organised in teams is highlighted. Further rigorous evaluation is required to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting. PROSPERO REGISTRATION NUMBER CRD42016032895.
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Affiliation(s)
- Mary Halter
- Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - Carly Wheeler
- Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - Ferruccio Pelone
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, Surrey, UK
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, UK
| | - Jim Parle
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Robert Grant
- Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
| | - Jonathan Gabe
- Centre for Criminology and Sociology, School of Law, Royal Holloway, University of London, London, UK
| | - Laura Nice
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Vari M Drennan
- Faculty of Health, Social Care and Education, Kingston University and St George's, University of London, London, UK
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Timmermans MJC, van Vught AJAH, Peters YAS, Meermans G, Peute JGM, Postma CT, Smit PC, Verdaasdonk E, de Vries Reilingh TS, Wensing M, Laurant MGH. The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study. PLoS One 2017; 12:e0178212. [PMID: 28793317 PMCID: PMC5549960 DOI: 10.1371/journal.pone.0178212] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/09/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Medical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients' length of stay (LOS), quality and safety of care, and patient experiences with the provided care. METHODS In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients' LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients' experiences with the provided care. RESULTS Data on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (β 1.20, 95%CI 0.99-1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (β 0.49, 95% CI 0.22-0.76, p = .001). CONCLUSIONS This study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01835444.
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Affiliation(s)
- Marijke J. C. Timmermans
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- * E-mail:
| | | | - Yvonne A. S. Peters
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
| | - Geert Meermans
- Department of Orthopaedics, Bravis Hospital, Bergen op Zoom and Roosendaal, The Netherlands
| | - Joseph G. M. Peute
- Department of Cardiology, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
| | - Cornelis. T. Postma
- Department of Internal Medicine, Radboud university Nijmegen medical center, Nijmegen, The Netherlands
| | - P. Casper Smit
- Department of Surgery, Reinier Haga Groep, Delft, The Netherlands
| | - Emiel Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands
| | | | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Miranda G. H. Laurant
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
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One PA's experiences in the Netherlands, South Africa, and Australia. JAAPA 2017; 30:39-43. [PMID: 28742744 DOI: 10.1097/01.jaa.0000521140.69033.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As the PA profession develops internationally, few mechanisms let PAs move from country to country for clinical practice opportunities. The first author of this paper has worked in the civilian health sectors in two countries, the Netherlands and South Africa, and taught PA students in South Africa and Australia. He reports on PA development in each country and reflects on and compares his professional and clinical experiences.
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Timmermans MJC, van den Brink GT, van Vught AJAH, Adang E, van Berlo CLH, van Boxtel K, Braunius WW, Janssen L, Venema A, van den Wildenberg FJ, Wensing M, Laurant MGH. The involvement of physician assistants in inpatient care in hospitals in the Netherlands: a cost-effectiveness analysis. BMJ Open 2017; 7:e016405. [PMID: 28698344 PMCID: PMC5541617 DOI: 10.1136/bmjopen-2017-016405] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To investigate the cost-effectiveness of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs). DESIGN Cost-effectiveness analysis embedded within a multicentre, matched-controlled study. The traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which, besides MDs, PAs are also employed (PA/MD model). SETTING 34 hospital wards across the Netherlands. PARTICIPANTS 2292 patients were followed from admission until 1 month after discharge. Patients receiving daycare, terminally ill patients and children were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES All direct healthcare costs from day of admission until 1 month after discharge. Health outcome concerned quality-adjusted life years (QALYs), which was measured with the EuroQol five dimensions questionnaire (EQ-5D). RESULTS We found no significant difference for QALY gain (+0.02, 95% CI -0.01 to 0.05) when comparing the PA/MD model with the MD model. Total costs per patient did not significantly differ between the groups (+€568, 95% CI -€254 to €1391, p=0.175). Regarding the costs per item, a difference of €309 per patient (95% CI €29 to €588, p=0.030) was found in favour of the MD model regarding length of stay. Personnel costs per patient for the provider who is primarily responsible for medical care on the ward were lower on the wards in the PA/MD model (-€11, 95% CI -€16 to -€6, p<0.01). CONCLUSIONS This study suggests that the cost-effectiveness on wards managed by PAs, in collaboration with MDs, is similar to the care on wards with traditional house staffing. The involvement of PAs may reduce personnel costs, but not overall healthcare costs. TRIAL REGISTRATION NUMBER NCT01835444.
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Affiliation(s)
- Marijke J C Timmermans
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen
| | | | | | - Eddy Adang
- Department of Health Evidence, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Charles L H van Berlo
- Department of Surgery Venlo, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
| | - Kim van Boxtel
- Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Weibel W Braunius
- Department of Head and Neck Surgical Oncology, UMC Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Loes Janssen
- Department of Orthopaedics, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
| | - Alyssa Venema
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Michel Wensing
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Miranda G H Laurant
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen
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Lovink MH, Persoon A, van Vught AJAH, Schoonhoven L, Koopmans RTCM, Laurant MGH. Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: protocol for a realist evaluation case study. BMJ Open 2017; 7:e015134. [PMID: 28600370 PMCID: PMC5734255 DOI: 10.1136/bmjopen-2016-015134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/13/2017] [Accepted: 03/13/2017] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION In developed countries, substituting physicians with nurse practitioners, physician assistants and nurses (physician substitution) occurs in nursing homes as an answer to the challenges related to the ageing population and the shortage of staff, as well as to guarantee the quality of nursing home care. However, there is great diversity in how physician substitution in nursing homes is modelled and it is unknown how it can best contribute to the quality of healthcare. This study aims to gain insight into how physician substitution is modelled and whether it contributes to perceived quality of healthcare. Second, this study aims to provide insight into the elements of physician substitution that contribute to quality of healthcare. METHODS AND ANALYSIS This study will use a multiple-case study design that draws upon realist evaluation principles. The realist evaluation is based on four concepts for explaining and understanding interventions: context, mechanism, outcome and context-mechanism-outcome configuration. The following steps will be taken: (1) developing a theory, (2) conducting seven case studies, (3) analysing outcome patterns after each case and a cross-case analysis at the end and (4) revising the initial theory. ETHICS AND DISSEMINATION The research ethics committee of the region Arnhem Nijmegen in the Netherlands concluded that this study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (WMO) (registration number 2015/1914). Before the start of the study, the Board of Directors of the nursing home organisations will be informed verbally and by letter and will also be asked for informed consent. In addition, all participants will be informed verbally and by letter and will be asked for informed consent. Findings will be disseminated by publication in a peer-reviewed journal, international and national conferences, national professional associations and policy partners in national government.
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Affiliation(s)
- Marleen Hermien Lovink
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, the Netherlands
| | - Anke Persoon
- Department of Primary and Community Care, Radboud university Medical Center, Radboud Institute for Health Sciences, the Netherlands
| | - Anneke JAH van Vught
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, the Netherlands
| | - Lisette Schoonhoven
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, the Netherlands
- University of Southampton, Faculty of Health Sciences, Southampton, UK
| | - Raymond TCM Koopmans
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, the Netherlands
- Joachim & Anna, Center for Specialized Geriatric Care, Nijmegen, the Netherlands
| | - Miranda GH Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, the Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, the Netherlands
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van der Biezen M, Derckx E, Wensing M, Laurant M. Factors influencing decision of general practitioners and managers to train and employ a nurse practitioner or physician assistant in primary care: a qualitative study. BMC FAMILY PRACTICE 2017; 18:16. [PMID: 28173766 PMCID: PMC5297134 DOI: 10.1186/s12875-017-0587-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Due to the increasing demand on primary care, it is not only debated whether there are enough general practitioners (GPs) to comply with these demands but also whether specific tasks can be performed by other care providers. Although changing the workforce skill mix care by employing Physician Assistants (PAs) and Nurse Practitioners (NPs) has proven to be both effective and safe, the implementation of those professionals differs widely between and within countries. To support policy making regarding PAs/NPs in primary care, the aim of this study is to provide insight into factors influencing the decision of GPs and managers to train and employ a PA/NP within their organisation. METHODS A qualitative study was conducted in 2014 in which 7 managers of out-of-hours primary care services and 32 GPs who owned a general practice were interviewed. Three main topic areas were covered in the interviews: the decision-making process in the organisation, considerations and arguments to train and employ a PA/NP, and the tasks and responsibilities of a PA/NP. RESULTS Employment of PAs/NPs in out-of-hours services was intended to substitute care for minor ailments in order to decrease GPs' caseload or to increase service capacity. Mangers formulated long-term planning and role definitions when changing workforce skill mix. Lastly, out-of-hours services experienced difficulties with creating team support among their members regarding the employment of PAs/NPs. In general practices during office hours, GPs indented both substitution and supplementation for minor ailments and/or target populations through changing the skill mix. Supplementation was aimed at improving quality of care and extending the range of services to patients. The decision-making in general practices was accompanied with little planning and role definition. The willingness to employ PAs/NPs was highly influenced by an employees' motivation to start the master's programme and GPs' prior experience with PAs/NPs. Knowledge about the PA/NP profession and legislations was often lacking. CONCLUSIONS Role standardisations, long-term political planning and support from professional associations are needed to support policy makers in implementing skill mix in primary care.
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Affiliation(s)
- Mieke van der Biezen
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.
| | - Emmy Derckx
- Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, Eindhoven, 5652 NP, The Netherlands
| | - Michel Wensing
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.,Department of General Practice and Health Services Research, Heidelberg University, INF- Marsilius Arkaden, Im Neuenheimer Feld 130.3, Heidelberg, 69120, Germany
| | - Miranda Laurant
- Radboud university medical center, Radboud Institute for Health Sciences, IQ healthcare, Scientific Center for Quality of Healthcare, P.O. Box 910, Nijmegen, 6500 HB, The Netherlands.,HAN University of Applied Sciences, Faculty of Health and Social Studies, P.O. Box 6960, Nijmegen, 6503 GL, The Netherlands
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Timmermans MJC, van Vught AJAH, Maassen ITHM, Draaijer L, Hoofwijk AGM, Spanier M, van Unen W, Wensing M, Laurant MGH. Determinants of the sustained employment of physician assistants in hospitals: a qualitative study. BMJ Open 2016; 6:e011949. [PMID: 27864243 PMCID: PMC5128943 DOI: 10.1136/bmjopen-2016-011949] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment. DESIGN We conducted a qualitative study with semistructured interviews with care providers. Interviews continued until data saturation was achieved. All interviews were transcribed verbatim. A framework approach was used for data analysis. Codes were sorted by the themes, bringing similar concepts together. SETTING This study was conducted between June 2014 and May 2015 within 11 different hospital wards in the Netherlands. The wards varied in medical speciality, as well as in hospital type and the organisational model for inpatient care. PARTICIPANTS Participant included staff physicians, residents, PAs and nurses. RESULTS The following themes emerged to be important for the initial employment of PAs and the sustainability of their employment: the innovation, individual factors, professional interactions, incentives and resources, capacity for organisational change and social, political and legal factors. CONCLUSIONS 10 years after the introduction of PAs, there was little discussion among the adopters about the added value of PAs, but organisational and financial uncertainties played an important role in the decision to employ and continue employment of PAs. Barriers to employ and continue PA employment were mostly a consequence of locally arranged restrictions by hospital management and staff physicians, as barriers regarding national laws, PA education and competencies seemed absent.
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Affiliation(s)
- Marijke J C Timmermans
- Radboud university medical centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, Physician Assistant Program, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Anneke J A H van Vught
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Irma T H M Maassen
- Radboud university medical centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Lisette Draaijer
- Department of ENT, Head and Neck Oncology Surgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Anton G M Hoofwijk
- Department of Surgery, Zuyderland Medical Centre, Sittard, The Netherlands
| | - Marcel Spanier
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Wijnand van Unen
- Netherlands Association of Physician Assistants and Physician Assistant, Utrecht, The Netherlands
- Department of Cardiology, VieCuri Medical Centre Noord-Limburg, Venlo, The Netherlands
| | - Michel Wensing
- Radboud university medical centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Miranda G H Laurant
- Radboud university medical centre, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
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12
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Timmermans MJC, van Vught AJAH, Van den Berg M, Ponfoort ED, Riemens F, van Unen J, Wobbes T, Wensing M, Laurant MGH. Physician assistants in medical ward care: a descriptive study of the situation in the Netherlands. J Eval Clin Pract 2016; 22:395-402. [PMID: 26695837 DOI: 10.1111/jep.12499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Medical ward care has been increasingly reallocated from medical doctors (MDs) to physician assistants (PAs). Insight into their roles and tasks is limited. This study aims to provide insight into different organizational models of medical ward care, focusing on the position, tasks and responsibilities of the involved PAs and MDs. METHODS In this cross-sectional descriptive study 34 hospital wards were included. Characteristics of the organizational models were collected from the heads of departments. We documented provider continuity by examination of work schedules. MDs and PAs in charge for medical ward care (n = 179) were asked to complete a questionnaire to measure workload, supervision and tasks performed. RESULTS We distinguished four different organizational models for ward care: medical specialists in charge of admitted patients (100% MS), medical residents in charge (100% MR), PAs in charge (100% PA), both MRs and PAs in charge (mixed PA/MR). The wards with PAs had the highest provider continuity. PAs spend relatively more time on direct patient care; MDs spend relatively more time on indirect patient care. PAs spend more hours on quality projects (P = 0.000), while MDs spend more time on scientific research (P = 0.030). CONCLUSION Across different organizational models for medical ward care, we found variations in time per task, time per bed and provider continuity. Further research should focus on the impact of these differences on outcomes and efficiency of medical ward care.
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Affiliation(s)
- Marijke J C Timmermans
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Anneke J A H van Vught
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | | | - Erik D Ponfoort
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Frank Riemens
- Department of Surgery, Van Weel Bethesda Hospital, Dirksland, The Netherlands
| | - Jacco van Unen
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - Theo Wobbes
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Miranda G H Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
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Timmermans MJC, van Vught AJAH, Wensing M, Laurant MGH. Erratum to: The effectiveness of substitution of hospital ward care from medical doctors to physician assistants: a study protocol. BMC Health Serv Res 2016; 16:115. [PMID: 27044303 PMCID: PMC4820881 DOI: 10.1186/s12913-016-1330-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 03/03/2016] [Indexed: 12/04/2022] Open
Affiliation(s)
- Marijke J C Timmermans
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare, Nijmegen, The Netherlands.
| | - Anneke J A H van Vught
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare, Nijmegen, The Netherlands
| | - Miranda G H Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare, Nijmegen, The Netherlands.,HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen, The Netherlands
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Pannick S, Beveridge I, Ashrafian H, Long SJ, Athanasiou T, Sevdalis N. A stepped wedge, cluster controlled trial of an intervention to improve safety and quality on medical wards: the HEADS-UP study protocol. BMJ Open 2015; 5:e007510. [PMID: 26100026 PMCID: PMC4479997 DOI: 10.1136/bmjopen-2014-007510] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION The majority of preventable deaths in healthcare are due to errors on general wards. Staff perceptions of safety correlate with patient survival, but effectively translating ward teams' concerns into tangibly improved care remains problematic. The Hospital Event Analysis Describing Significant Unanticipated Problems (HEADS-UP) trial evaluates a structured, multidisciplinary team briefing, capturing safety threats and adverse events, with rapid feedback to clinicians and service managers. This is the first study to rigorously assess a simpler intervention for general medical units, alongside an implementation model applicable to routine clinical practice. METHODS/ANALYSIS 7 wards from 2 hospitals will progressively incorporate the intervention into daily practice over 14 months. Wards will adopt HEADS-UP in a pragmatic sequence, guided by local clinical enthusiasm. Initial implementation will be facilitated by a research lead, but rapidly delegated to clinical teams. The primary outcome is excess length of stay (a surplus stay of 24 h or more, compared to peer institutions' Healthcare Resource Groups-predicted length of stay). Secondary outcomes are 30-day readmission or excess length of stay; in-hospital death or death/readmission within 30 days; healthcare-acquired infections; processes of escalation of care; use of traditional incident-reporting systems; and patient safety and teamwork climates. HEADS-UP will be analysed as a stepped wedge cluster controlled trial. With 7840 patients, using best and worst case predictions, the study would achieve between 75% and 100% power to detect a 2-14% absolute risk reduction in excess length of stay (two-sided p<0.05). Regression analysis will use generalised linear mixed models or generalised estimating equations, and a time-to-event regression model. A qualitative analysis will evaluate facilitators and barriers to HEADS-UP implementation and impact. ETHICS AND DISSEMINATION Participating institutions' Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations. TRIAL REGISTRATION NUMBER ISRCTN34806867.
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Affiliation(s)
- Samuel Pannick
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK West Middlesex University Hospital NHS Trust, London, UK
| | - Iain Beveridge
- West Middlesex University Hospital NHS Trust, London, UK
| | - Hutan Ashrafian
- Department of Surgery & Cancer, Imperial College London, London, UK
| | - Susannah J Long
- NIHR Imperial Patient Safety Translational Research Centre, Imperial College London, London, UK St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Nick Sevdalis
- Centre for Implementation Science, Health Service & Population Research Department, King's College London, London, UK
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