The cost-effectiveness of physician assistants/associates: A systematic review of international evidence

Characterizing malpractice cases involving emergency department advanced practice providers, physicians in training, and attending physicians

OBJECTIVE

The objective was to evaluate available characteristics and financial costs of malpractice cases among advanced practice providers (APPs; nurse practitioners [NPs] and physician assistants [PAs]), trainees (medical students, residents, fellows), and attending physicians.

METHODS

This study was a retrospective analysis of claims occurring in the emergency department (ED) from January 1, 2010, to December 31, 2019, contained in the Candello database. Cases were classified according to the provider type(s) involved: NP, PA, trainee, or cases that did not identify an extender as being substantially involved in the adverse event that resulted in the case ("no extender").

RESULTS

There were 5854 cases identified with a total gross indemnity paid of $1,007,879,346. Of these cases, 193 (3.3%) involved an NP, 513 (8.8%) involved a PA, 535 (9.1%) involved a trainee, and 4568 (78.0%) were no extender. Cases where a trainee was involved account for the highest average gross indemnity paid whereas no-extender cases are the lowest. NP and PA cases differed by contributing factors compared to no-extender cases: clinical judgment (NP 89.1% vs. no extender 76.8%, p < 0.0001; PA 84.6% vs. no extender, p < 0.0001), documentation (NP 23.3% vs. no extender 17.8%, p = 0.0489; PA 25.9% vs. no extender, p < 0.0001), and supervision (NP 22.3% vs. no extender 1.8%, p < 0.0001; PA 25.7% vs. no extender p < 0.0001). Cases involving NPs and PAs had a lower percentage of high-severity cases such as loss of limb or death (NP 45.6% vs. no extender 50.2%, p = 0.0004; PA 48.3% vs. no extender, p < 0.0001).

CONCLUSIONS

APPs and trainees comprise approximately 21% of malpractice cases and 33% of total gross indemnity paid in this large national ED data set. Understanding differences in characteristics of malpractice claims that occur in emergency care settings can be used to help to mitigate provider risk.

PA and NP general practice employment in the Netherlands

ABSTRACT

General practitioners (GPs) are the cornerstone of primary healthcare in the Netherlands. As a national strategy, physician associates/assistants (PAs) and NPs were introduced to address growing healthcare demand. In this study, four representative practices were analyzed quantitatively and qualitatively-two solo practices with a PA or NP and two group practices with a PA or NP. A reference group of GPs served as experts. The annual encounters per full-time GP averaged 6,839; for the NPs, 2,636; and the PAs, 4,926. Billable services were 70% to 100%, averaging 71% for NPs and 85% for PAs, and in three of the four practices, the employment of the NP or PA was cost-efficient. The qualitative data show that PAs and NPs contribute to general practice, easing the workload so that the GP has more time for complex patients. PA and NP employment was financially beneficial in 75% of cases.

[Physician assistants as a future model in primary care: Experiences, needs, potentials and barriers]

INTRODUCTION

In the coming decades, demographic change will dramatically increase health care needs, especially for general practitioners (GPs). However, there is a shortage of young primary care physicians, with signs of (impending) underuse already becoming apparent in rural and structurally weak areas. Innovative care concepts are needed to counteract this development and ensure the future of primary care. In addition to medical assistants (MFA), academically trained physician assistants (PAs) could be considered for more demanding delegation tasks and be involved in direct patient care under the responsibility of a physician in the practice team. In England, the Netherlands and the USA, PAs have been a part of the health care systems for many years.

RESEARCH QUESTIONS

1) What are the potentials for delegation/possibilities for PAs working in primary care practices in contrast to medical assistants? 2) What structural requirements are necessary to regularly integrate PAs in primary care practices?

METHODS

After preliminary interviews with PA experts and primary care researchers and practitioners (n=29), four expert interviews (n=4) with GPs and PAs were performed in a case analysis in order to elicit experiences with PAs in family practice. Based on this, three focus groups were conducted with GPs and practice staff (n=15) to discuss the extent, the need and the willingness to delegate physician services to PAs, as well as existing barriers. After transcription, analyses were performed using qualitative content analysis according to Mayring.

RESULTS

The participants acknowledged the potential to reduce physician workloads and showed a high willingness to delegate tasks. Practical examples suggest that a clearly defined delegation of medical tasks to PAs, e.g. participation in infection consultations, is possible after only a few weeks working in family practices. Thus, the cooperation between GPs, PAs and medical assistants can be successful. Uncertainties exist regarding the legal possibilities and limits of delegation as well as the current and future financial reimbursement of PAs.

DISCUSSION

The legal and financial framework for the utilization of PAs in ambulatory care should be reliably clarified as well as transparently communicated so that the considerable potentials of delegating tasks to academically trained staff, e.g. PAs, especially in the GP sector, can be exploited in the future.

CONCLUSION

Participation of PAs in the GP team could be key to overcoming the often threatening or already existing under-provision of medical care in structurally weak regions.

Professionalism in Physician Assistant Education as a Predictor of Future Licensing Board Disciplinary Actions

PURPOSE

The purpose of this study was to evaluate associations between postgraduate disciplinary actions (PGDA) by state licensing boards and physician assistant (PA) school documented professionalism violations (DPV) and academic probation.

METHODS

This was a retrospective cohort study comprising PA graduates from 2001 to 2011 at 3 institutions (n = 1364) who were evaluated for the main outcome of PGDA and independent variable of DPV and academic probation. Random-effects multiple logistic regression and accelerated failure time parametric survival analysis were used to investigate the association of PGDA with DPV and academic probation.

RESULTS

Postgraduate disciplinary action was statistically significant and positively associated with DPV when unadjusted (odds ratio [OR] = 5.15; 95% CI: 1.62-16.31; P = .01) and when adjusting for age, sex, overall PA program GPA (GPA), and Physician Assistant National Certifying Exam Score (OR = 5.39; 95% CI: 1.54-18.85; P = .01) (fully adjusted). Academic probation increased odds to 8.43 times (95% CI: 2.85-24.92; P < .001) and 9.52 times (95% CI: 2.38-38.01; P < .001) when fully adjusted.

CONCLUSION

Students with professionalism violation or academic probation while in the PA school had significant higher odds of receiving licensing board disciplinary action compared with those who did not. Academic probation had a greater magnitude of effect and could represent an intersection of professionalism and academic performance.

A comparison of the practice patterns of emergency department teams that include physicians, nurse practitioners, or physician assistants

BACKGROUND

Physicians see most emergency department (ED) patients, but, recently, nurse practitioners (NPs) and physician assistants (PAs) have provided an increasing amount of ED care.

PURPOSE

Compare NP and PA teams' practice patterns to physician teams in EDs.

METHODS

Using 12 years of data from the National Hospital Ambulatory Medical Care Survey (2009-2020), we used multivariate regression analysis to separately examine the associations between the ED practice patterns (i.e., number of diagnostic services, number of procedures, waiting time, boarding time, length of visit, and hospital admission) of patients seen by NP or PA teams compared with physician teams.

DISCUSSION

Patient visits to NP and PA teams received fewer diagnostic services and procedures, had shorter visits, and were less likely to be hospitalized.

CONCLUSION

If the additional diagnostic services, procedures, and hospital admission provided by physician teams were unnecessary for the patients studied, NP and PA team care could be more efficient.

The changing employment of physicians, nurse practitioners, and physician associates/assistants

ABSTRACT

Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 nurse practitioners (NPs), and 139,100 physician associates/assistants (PAs). These three health care professionals accounted for approximately 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

Flexner has fallen: Transitions in medical education system across time, a gradual return to pre-Flexnerian state (de-Flexnerization)

The modern medical education system has gradually evolved starting from 1910 incorporating the suggestions by Abraham Flexner, his public disclosure of the poor conditions at many medical schools provided a means to galvanize all the constituencies needed for reform to occur. He could say what other reformers could not, due to their links to the medical education community. But now we are again going back to a pre-Flexnerian state due to multiple reasons such as gradually diminishing importance of basic science subjects for the students, the decline in the number and quality of investigator initiated research among clinical researchers, lesser emphasis to bedside training by means of detailed clinical examination and making appropriate observation of signs to reach to a diagnosis rather than over reliance on the laboratory tests and radiological modalities for the diagnosis, poor exposure to basic clinical skills starting from college throughout residency and the trend of disrespect and absenteeism from both theoretical and clinical/practical classes. The attitude of students is just to complete their required attendance so that they are not barred from appearing in examinations. This de-Flexnerization trend and regression to pre-Flexnerian era standards, ideologies, structures, processes, and attitudes, are bound to beget pre-Flexnerian outcomes, for you get what you designed for.

The changing employment of physicians, NPs, and PAs

ABSTRACT

Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics (BLS) employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 NPs, and 139,100 physician associates/assistants (PAs). These three healthcare professionals accounted for about 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than that of physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

The influence of government policies on the nurse practitioner and physician assistant workforce in the Netherlands, 2000-2022: a multimethod approach study

BACKGROUND

Many countries are looking for ways to increase nurse practitioner (NP) and physician assistant/associate (PA) deployment. Countries are seeking to tackle the pressing issues of increasing healthcare demand, healthcare costs, and medical doctor shortages. This article provides insights into the potential impact of various policy measures on NP/PA workforce development in the Netherlands.

METHODS

We applied a multimethod approach study using three methods: 1) a review of government policies, 2) surveys on NP/PA workforce characteristics, and 3) surveys on intake in NP/PA training programs.

RESULTS

Until 2012, the annual intake into NP and PA training programs was comparable to the number of subsidized training places. In 2012, a 131% increase in intake coincided with extending the legal scope of practice of NPs and PAs and substantially increasing subsidized NP/PA training places. However, in 2013, the intake of NP and PA trainees decreased by 23% and 24%, respectively. The intake decreased in hospitals, (nursing) home care, and mental healthcare, coinciding with fiscal austerity in these sectors. We found that other policies, such as legal acknowledgment, reimbursement, and funding platforms and research, do not consistently coincide with NP/PA training and employment trends. The ratios of NPs and PAs to medical doctors increased substantially in all healthcare sectors from 3.5 and 1.0 per 100 full-time equivalents in medical doctors in 2012 to 11.0 and 3.9 in 2022, respectively. For NPs, the ratios vary between 2.5 per 100 full-time equivalents in medical doctors in primary care and 41.9 in mental healthcare. PA-medical doctor ratios range from 1.6 per 100 full-time equivalents in medical doctors in primary care to 5.8 in hospital care.

CONCLUSIONS

This study reveals that specific policies coincided with NP and PA workforce growth. Sudden and severe fiscal austerity coincided with declining NP/PA training intake. Furthermore, governmental training subsidies coincided and were likely associated with NP/PA workforce growth. Other policy measures did not consistently coincide with trends in intake in NP/PA training or employment. The role of extending the scope of practice remains to be determined. The skill mix is shifting toward an increasing share of medical care provided by NPs and PAs in all healthcare sectors.

Evaluation of the impact of technical physicians on improving individual patient care with technology

BACKGROUND

The rapid introduction of technical innovations in healthcare requires that professionals are adequately prepared for correct clinical use of medical technology. In response to the technological transformation of healthcare, a new type of professional, the Technical Physician (TP), was created and is trained to improve individual patient care using technology tailored to the needs of individual patients. This study investigates the TPs' impact on patient care in terms of innovation, effectiveness, efficiency, and patient safety.

METHOD

Semi-structured, in-depth interviews were conducted with 30 TPs and 17 medical specialists (MSs) working in academic or teaching hospitals in the Netherlands. The pre-structured and open-ended interview questions focused on: 1) the perceived impact on innovation, effectiveness, efficiency, and safety, and 2) opportunities and challenges in daily work.

RESULTS

TPs and MSs unanimously experienced that TPs contributed to innovation. A majority indicated that effectiveness (TP 57%; MS 71%) and efficiency (TP 67%; MS 65%) of clinical practice had increased. For safety, 87% of TPs but only 47% of MSs reported an increase. The main explanation given for TPs positive impact was combining medical and technical knowledge. Mainly organizational barriers were mentioned as a potential cause for a less visible contribution of TPs.

CONCLUSION AND DISCUSSION

TPs and MSs unanimously agreed that TPs contributed to innovating patient care through their integrative medical and technical competencies. Most TPs and MSs also reported increased effectiveness, efficiency, and safety of patient care due to the TPs' work. TPs and MSs expected that the TPs' impact on direct and indirect patient care will be enhanced once organizational barriers are removed.

How does government policy influence the employment and training of nurse practitioners and physician assistants? A realist analysis using qualitative interviews

AIMS

The aim of this study was to develop insights into how and why Dutch government policies on deployment and training of nurse practitioners and physician assistants have effect and under what circumstances.

DESIGN

A realist analysis using qualitative interviews.

METHODS

Data analysis of 50 semi-structured interviews conducted in 2019 with healthcare providers, sectoral and professional associations, and training coordinators. Stratified purposive and snowball sampling were used.

RESULTS

Policies stimulated employment and training of nurse practitioners and physician assistants by: (1) contributing to the familiarity of participants in the decision-making process in healthcare providers with and medical doctors' trust in these professions; (2) contributing to participants' motivation in employment and training; and (3) eliminating barriers perceived by medical doctors, managers and directors. The extent to which policies affected employment and training was largely determined by sectoral and organizational circumstances, such as healthcare demand and complexity, and decision-makers in healthcare providers (medical doctors or managers/directors).

CONCLUSION

Effectuating familiarity and trust among participants in the decision-making process is a crucial first step. Next, policymakers can motivate participants and lower their perceived barriers by extending the scope of practice, creating reimbursement opportunities and contributing to training costs. Theoretical insights into nurse practitioner and physician assistant employment and training have been refined.

IMPACT

The findings highlight how governments, health insurers, sectoral and professional associations, departments, councils, healthcare providers and professionals can facilitate and support nurse practitioner and physician assistant employment and training by contributing to familiarity, trust and motivation, and by clearing perceived barriers.

The main features of physician assistants/associates and insights for the development of similar professions in China

The physician assistant/associate (PA) profession originated in the United States; PAs play an active role in alleviating the shortage of health and medical resources and improving the quality of medical care. This position has been introduced in and developed by many countries. Based on extensive literature research, this article summarizes the three main features of PAs, namely, that there is professional education for training PAs, the PA is an independent and exclusive professional type and PAs assist doctors in completing medical work. With reference to the innovative concept of the PA profession, this article summarized the existing "assistant" position in China that is similar to the PA position, compared it with the three features of PAs, revealed the shortcomings of the existing "assistant" position in China, provided a reference for the development of relevant careers in China, and provided solutions for solving the problems of medical and health resources in China.

Physician Associates/Assistants in Primary Care: Policy and Value

Since the new century, primary care physician supply has worsened. Analysts predict that health service demand in the United States will grow faster than physician supply. One strategy is the utilization of physician assistants/associates (PAs). Most PAs work full-time, and approximately one quarter are employed in family medicine/general medicine. PAs deliver primary care services in a team-oriented fashion in a wide variety of settings, including private health systems and community health centers. One fifth work in rural and medically underserved areas. Together PAs and nurse practitioners provide approximately one third of the medical services in family medicine, urgent care, and emergency medicine.

Adaptation and factor structure of three psychometric instruments measuring behavioral aspects of medication prescribing in physician assistants

OBJECTIVES

(1) Present the factor structure of two psychometric instruments for self-efficacy and one for outcome expectations of medication prescribing; (2) evaluate the reliability of the scales, and (3) present preliminary evidence of validity.

METHODS

Physician assistants (PA) and PA students completed a survey evaluating three psychometric instruments: (1) Self-Efficacy in Prescribing (SEP), (2) Self-Efficacy in Prescribing-Geriatric (SEPG), and (3) Outcomes Expectations of Prescribing Errors (OEP). Students also evaluated 3 hypothetical prescriptions, two of which contained a prescribing error. Students were instructed to identify (1) if an error occurred and (2) what type of error. The data were analyzed using parallel analysis with a varimax rotation, Cronbach's α, Pearson and Spearman correlations.

RESULTS

One hundred eighty five (n = 185) respondents completed the survey (response rate = 63.8%). The parallel analysis found that the SEP had one 7-item factor with α = 0.94 (M = 5.7 (SD = 1.9) out of 10). The SEPG also had one 7-item factor with α = 0.95 (M = 5.5 (1.9). The OEP had one 6-item factor with α = 0.89 (M = 3.5 (SD = 0.8) out of 5). The SEP and SEPG, were correlated to the OEP each other (both p < 0.01). Actively practicing PAs had the highest composite mean SEP and SEPG scores. First-year PA students had the highest mean scores for the OEP. There was a weak association between the mean SEPG score and the number of correctly identified prescriptions (r_s = 0.18, p = 0.04).

CONCLUSION

The SEP, SEPG, and OEP show preliminary evidence of reliability and structural, construct, and known-group validities using simulated prescriptions. These tools may be able to be used by educators and implementation scientists as one method to show the effectiveness of future interventions to reduce incidence of prescribing errors.

American health workforce policy and PAs: A brief history

ABSTRACT

Health workforce policy in the United States from the mid-1970s has been strongly influenced by perceptions of the adequacy of the physician supply and its relationship to physician assistants/associates (PAs) and NPs. During the 1980s, a series of inaccurate reports by the federal government mistakenly warned of an impending physician surplus and shaped policy decisions for decades. In spite of perceptions of a physician surplus, the PA profession expanded rapidly in the 1990s. Projections of the adequacy of the physician supply changed to a shortage in the first decade of this century and the PA component of the healthcare workforce continued to expand. During the past decade, the Association of American Medical Colleges has employed microsimulation modeling expertise to project the extent of physician shortages, an effort that initially failed to incorporate the contributions of PAs and NPs in the workforce. Although current projection models include the contributions of PAs and NPs, the substitution ratios used are notably low. Specifically, PA and NP productivity effort was set roughly at one-quarter to one-half that of the physician. PAs and NPs make up a substantial contingent within the US healthcare workforce and should be included fully in future workforce projection estimates. This article provides policy recommendations for the advancement of PA contributions to the delivery of medical care.

Optimizing the productivity and placement of nurse practitioners and physician assistants in outpatient primary care sites

BACKGROUND

It is increasingly imperative that organizational leaders continually assess nurse practitioners' (NPs) and physician assistants' (PAs) productivity, turnover, and vacancies. Optimizing the feasibility, impact, strategic placement, and monitoring increases patient access, improves wait times and affordability, and increases revenue.

LOCAL PROBLEM

A healthcare system needed a systematic, data-driven approach aimed at optimizing productivity and placement of NPs and PAs in outpatient primary care sites.

METHOD

Results from this project are reported using the Revised Standards for Quality Improvement Reporting Excellence framework. After formation of a QI team, a gap analysis, and action plans were developed and implemented.

INTERVENTION/RESULTS

Priority areas requiring action included the development of an integrated position justification algorithm and tracking form addressing NPs' and PAs' placement, establishing consistent patient contact hours, setting workload expectations, and consistently communicating these via an organization-specific situation background, assessment, and recommendation communication tool.

CONCLUSION

Health care leaders should leverage the talents of NPs and PAs meeting organizational benchmarks and goals as well as the needs of patients. Nurse practitioner and PA leaders should focus on benchmarking performance and analyzing barriers to optimization. These efforts are most beneficial when multidisciplinary in nature.

Optimizing the productivity and placement of NPs and PAs in outpatient primary care sites

OBJECTIVE

Organizational leaders must continually assess the productivity, turnover, and vacancies of physician assistants (PAs) and NPs. Optimizing the feasibility, effect, strategic placement, and monitoring increases patient access, improves wait times and affordability, and increases revenue. This quality improvement project sought to develop a systematic, data-driven approach to optimize productivity and placement of NPs and PAs in outpatient primary care sites.

METHODS

Results from this project are reported using the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE) framework. Postformation of a quality improvement team, a gap analysis, and action plans were developed and implemented.

RESULTS

Priority areas requiring action included the development of an integrated position justification algorithm and tracking form addressing NP and PA placement, establishing consistent patient contact hours, setting workload expectations, and consistently communicating these via an organization-specific situation, background, assessment, and recommendation communication tool.

CONCLUSIONS

Healthcare leaders should leverage the talents of NPs and PAs meeting organizational benchmarks and goals as well as the needs of patients. NP and PA leaders should focus on benchmarking performance and analyzing barriers to optimization. These efforts are most beneficial when multidisciplinary in nature.