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Perez R, Yarrington ME, Deri CR, Smith MJ, Hayes J, Wrenn RH, Moehring RW. Teams in Transition: Increasing Role of Advanced Practice Providers in Antimicrobial Use and Infectious Diseases Consultation. Open Forum Infect Dis 2024; 11:ofae141. [PMID: 38577030 PMCID: PMC10993059 DOI: 10.1093/ofid/ofae141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
Background Advanced practice providers (APPs) have taken on increasing responsibilities as primary team members in acute care hospitals, but the impact of this practice shift on antimicrobial prescribing and infectious diseases (ID) consultation requests is unknown. Here we describe longitudinal trends in antimicrobial days of therapy (DOT) and ID consultation by attributed provider type in 3 hospitals. Methods We performed a retrospective time series analysis of antimicrobial use and ID consultation from July 2015 to June 2022 at a major university hospital and 2 community hospitals. We evaluated antimicrobial DOT and ID consultation over time and assessed attribution to 3 groups of providers: attending physicians, trainees, and APPs. We used multinomial logistic regression to measure changes in percentage of DOT and ID consultation across the clinician groups over time using physicians as the referent. Results Baseline distribution of antimicrobial DOT and ID consultation varied by practice setting, but all subgroups showed increases in the proportion attributable to APPs. Large increases were seen in the rate of ID consultation, increasing by >30% during the study period. At our university hospital, by study end >40% of new ID consults and restricted antimicrobial days were attributed to APPs. Conclusions Hospitals had differing baseline patterns of DOT attributed to provider groups, but all experienced increases in DOT attributed to APPs. Similar increases were seen in changes to ID consultation. APPs have increasing involvement in antimicrobial use decisions in the inpatient setting and should be engaged in future antimicrobial stewardship initiatives.
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Affiliation(s)
- Reinaldo Perez
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
| | - Michael E Yarrington
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
| | - Connor R Deri
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Smith
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Jillian Hayes
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah H Wrenn
- Department of Pharmacy, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke Center for Antimicrobial Stewardship and Infection Prevention, Department of Medicine, Durham, North Carolina, USA
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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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Malone R. The role of the physician associate: an overview. Ir J Med Sci 2021; 191:1277-1283. [PMID: 34351601 DOI: 10.1007/s11845-021-02661-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/25/2021] [Indexed: 10/20/2022]
Abstract
The physician assistant role in healthcare delivery was first introduced during the 1960s in the USA as a solution to doctor shortages, greater population healthcare needs and increasing healthcare provision costs. Since then, many countries worldwide have utilized the successful USA physician assistant model as a benchmark to guide both physician assistant training and the incorporation of the role into their healthcare systems. While the USA retained the title physician assistant, Ireland and the UK use the title physician associate. Physician assistants/associates are trained in the generalist medical model and function under the supervision of a doctor. Tasks relating to the role include the following: taking patient's medical histories, performing examinations, making diagnosis, requesting tests, analysing results and the initiation of treatment. They practice across a broad range of specialities and settings. Physician assistants in the USA and the Netherlands have prescribing privileges. Statutory regulation for physician assistants/associates lays the groundwork for prescribing privileges and such regulation is under consideration by the government in the UK. Studies indicate that doctors and patients are largely satisfied with the contribution of this profession to healthcare services and physician assistants/associates report good job satisfaction.
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Affiliation(s)
- Rachel Malone
- Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
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EDITORIAL COMMENT. Urology 2021; 153:154. [PMID: 34311909 DOI: 10.1016/j.urology.2020.11.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/29/2020] [Indexed: 11/22/2022]
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Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008-2018. Crit Care Med 2020; 47:1442-1449. [PMID: 31414993 PMCID: PMC6750122 DOI: 10.1097/ccm.0000000000003925] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To provide a concise review of the literature and data pertaining to the use of nurse practitioners and physician assistants, collectively called advanced practice providers, in ICU and acute care settings. DATA SOURCES Detailed search strategy using the databases PubMed, Ovid MEDLINE, and the Cumulative Index of Nursing and Allied Health Literature for the time period from January 2008 to December 2018. STUDY SELECTION Studies addressing nurse practitioner, physician assistant, or advanced practice provider care in the ICU or acute care setting. DATA EXTRACTION Relevant studies were reviewed, and the following aspects of each study were identified, abstracted, and analyzed: study population, study design, study aims, methods, results, and relevant implications for critical care practice. DATA SYNTHESIS Five systematic reviews, four literature reviews, and 44 individual studies were identified, reviewed, and critiqued. Of the research studies, the majority were retrospective with others being observational, quasi-experimental, or quality improvement, along with two randomized control trials. Overall, the studies assessed a variety of effects of advanced practice provider care, including on length of stay, mortality, and quality-related metrics, with a majority demonstrating similar or improved patient care outcomes. CONCLUSIONS Over the past 10 years, the number of studies assessing the impact of advanced practice providers in acute and critical care settings continue to increase. Collectively, these studies identify the value of advanced practice providers in patient care management, continuity of care, improved quality and safety metrics, patient and staff satisfaction, and on new areas of focus including enhanced educational experience of residents and fellows.
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A chemotherapy privileging process for advanced practice providers at an academic medical center. J Oncol Pharm Pract 2020; 26:116-123. [DOI: 10.1177/1078155219846959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose Nurse practitioners, physician assistants, and pharmacists are advanced practice providers who are highly trained and qualified healthcare professionals that can help support traditional demands on oncologists' increased time in direct patient care. The purpose of this study was to detail and assess the creation of a privileging process for this group of medical professionals within an academic medical center. Obtaining the designation of limited oncology practice provider (LOPP) gives the right to modify chemotherapy orders and to order supportive care medications. Methods An interdisciplinary team developed a comprehensive training process inclusive of required educational domains, knowledge goals, and educational activities to become an LOPP. In 2018, five years after the implementation of the privileging process, a survey was distributed to assess perceptions of the training process and integration of LOPPs within oncology practice. Results Most oncologists noted that working with LOPPs is beneficial to oncology practice (94%) and that they make modifying chemotherapy orders more efficient (87%). Greater than 82% of LOPPs also reported that their privileges streamline the chemotherapy process and make them feel valuable. Conclusion The creation of the LOPP designation is an effective way to integrate nurse practitioners, physician assistants, and pharmacists within oncology practice. The inclusion of a focused privileging process ensures the safety of cancer care provided and has created a streamlined process for chemotherapy modifications and supportive care.
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Hylton HM, Smith GL. Collaborating With Advanced Practice Providers: Impact and Opportunity. Am Soc Clin Oncol Educ Book 2017; 37:e1-e7. [PMID: 28561713 DOI: 10.1200/edbk_175654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although significant progress has been made in cancer care, access to coordinated, high-quality care across the cancer care continuum remains a challenge for many patients. With significant workforce shortages in oncology anticipated, physician assistants (PAs) and nurse practitioners (NPs)-known collectively as advanced practice providers (APPs)-are considered to be a part of the solution to bridging the gap between the supply of and demand for oncology services. APPs are integral to the provision of team-based care in oncology, and optimizing the roles of all members of the patient's care team is vital to ensuring the teams are cost-effective and that each team member is performing at the functional level intended. Studies have shown significant patient, physician, and APP satisfaction with collaborative care models, and APPs are well positioned to enhance value for patients in the oncology setting. Understanding the full scope of APP impact can be challenging as it extends well beyond direct patient care. As rapid progress in cancer care continues, innovative approaches to care delivery will be necessary to ensure patients' access. Effective oncologist-APP partnerships will be key to providing optimal, value-centered care to patients.
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Affiliation(s)
- Heather M Hylton
- From Memorial Sloan Kettering Cancer Center, New York, NY; University of Michigan, Ann Arbor, MI
| | - G Lita Smith
- From Memorial Sloan Kettering Cancer Center, New York, NY; University of Michigan, Ann Arbor, MI
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Hylton HM, Scardino TG. Improving Access to Care: The Physician/Physician Assistant Team. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2016.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Povidone-Iodine Has a Profound Effect on In Vitro Osteoblast Proliferation and Metabolic Function and Inhibits Their Ability to Mineralize and Form Bone. Spine (Phila Pa 1976) 2016; 41:729-34. [PMID: 26641850 DOI: 10.1097/brs.0000000000001332] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A study examining the clinical protocol of scoliosis wound irrigation, demonstrating povidone-iodine's (PVI) effect on human osteoblast cells. Primary and immortal cell line osteoblasts were treated with 0.35% PVI for 3 minutes, and analyzed for proliferation rate, oxidative capacity, and mineralization. OBJECTIVE To model spinal wound irrigation with dilute PVI in vitro, in order to investigate the effect of PVI on osteoblast proliferation, metabolism, and bone mineralization. SUMMARY OF BACKGROUND DATA Previously PVI irrigation has been proposed as a safe and effective practice to avoid bacterial growth after spinal surgery. However, recent evidence in multiple cell types suggests that PVI has a deleterious effect on cellular viability and cellular function. METHODS Primary and immortal human osteoblast cells were exposed to either phosphate buffered saline control or with 0.35% PVI for 3 minutes. Cellular proliferation was measured over the duration of 7 days by MTS assay. Oxygen consumption rate, extracellular acidification rate, and proton production rate were analyzed using a Seahorse XF24 Bioanalyzer. Protein expression of the electron transport chain subunits CII-SDHB, CIII-UQRCR2, and CV-ATP5A was measured via Western blotting. Mineralized bone nodules were stained with alizarin red. RESULTS Expressed as a percentage of normal osteoblast proliferation, osteoblasts exposed to 0.35% PVI exhibited a significant 24% decrease in proliferation after 24 hours. This was a sustained response, resulting in a 72% decline in cellular proliferation at 1 week. There was a significant reduction in oxygen consumption rate, extracellular acidification rate, and proton production rate (P < 0.05), in osteoblasts that had been exposed to 0.35% PVI for 3 minutes, coupled with a marked reduction in the protein expression of CII-SDHB. Osteoblasts exposed to 0.35% PVI exhibited reduced bone nodule mineralization compared to control phosphate buffered saline exposed osteoblasts (P < 0.01). CONCLUSION PVI has a rapid and detrimental effect on human osteoblast cellular proliferation, metabolic function, and bone nodule mineralization. LEVEL OF EVIDENCE NA.
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Shah NN, Kucharczuk CR, Mitra N, Hirsh R, Svoboda J, Porter D, Loren A, Frey N, Schapira MM. Implementation of an Advanced Practice Provider Service on an Allogeneic Stem Cell Transplant Unit: Impact on Patient Outcomes. Biol Blood Marrow Transplant 2015; 21:1692-8. [DOI: 10.1016/j.bbmt.2015.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 05/22/2015] [Indexed: 12/22/2022]
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