Physician associates in England's hospitals: a survey of medical directors exploring current usage and factors affecting recruitment

The benefits and limitations of establishing the PA profession globally: A systematic review and mixed-methods study

OBJECTIVE

Physician associates/assistants (PAs) and their equivalents offer a solution to the supply and demand crisis to alleviate global healthcare needs. This study investigated how PA and PA equivalents address global healthcare needs across different healthcare systems, revealing recommendations for their use. The study also sought to catalog the global healthcare needs that PAs and equivalents are successfully alleviating, the roles in which they function, and the barriers facing implementation.

METHODS

A systematic review was conducted from October 2021 to April 2022 and rerun in June 2023 following PRISMA 2020 guidelines; additionally, supporting interviews were conducted with PAs and global health experts. Primary outcomes were geographic region, economy, healthcare needs, and healthcare systems. Secondary outcomes were PA use, license recognition, and successes or barriers when implementing PAs.

RESULTS

The literature and interviews focused on the global use of PAs and PA equivalents in six geographic regions, 63 countries, and five US territories where PAs or PA equivalents are employed, have been employed, are volunteering, or are being considered to support global healthcare needs. Most countries have a developing economy and an out-of-pocket healthcare system. PAs and PA equivalents hold 35 different practice titles, and most work in primary care. PAs alleviate healthcare shortages and economic disparities, specifically related to inequitable healthcare access. Globally, the profession is limited by a lack of legislation, regulation, and support.

CONCLUSIONS

PAs and PA equivalents worldwide belong to an adaptable profession that has well-documented success in alleviating the global healthcare shortage and addressing healthcare needs. Countries desiring PAs or PA equivalents should identify their specific needs, train their existing workforce, employ pilot programs, and focus on seeking early legislation and regulation. Broad support for existing PA and PA equivalent international organizations is recommended for global collaboration. This study serves as a guide for those advocating for the continued or future implementation of PAs and PA equivalents in their own country and provides a comprehensive resource to aid in the globalization of this profession. We offer recommendations to address the dire healthcare needs and workforce shortage faced across the globe.

Factors influencing the development, recruitment, integration, retention and career development of advanced practice providers in hospital health care teams: a scoping review

BACKGROUND

Advanced practice providers (APPs), including physician assistants/associates (PAs), nurse practitioners (NPs) and other non-physician roles, have been developed largely to meet changing healthcare demand and increasing workforce shortages. First introduced in primary care in the US, APPs are prevalent in secondary care across different specialty areas in different countries around the world. In this scoping review, we aimed to summarise the factors influencing the development, recruitment, integration, retention and career development of APP roles in hospital health care teams.

METHODS

We conducted a scoping review and searched Ovid MEDLINE, Ovid Embase, Ovid Global Health, Ovid PsycINFO and EBSCOhost CINAHL to obtain relevant articles published between Jan 2000 and Apr 2023 that focused on workforce management of APP roles in secondary care. Articles were screened by two reviewers independently. Data from included articles were charted and coded iteratively to summarise factors influencing APP development, recruitment, integration, retention and career development across different health system structural levels (macro-, meso- and micro-level).

RESULTS

We identified and analysed 273 articles that originated mostly from high-income countries, e.g. the US (n = 115) and the UK (n = 52), and primarily focused on NP (n = 183) and PA (n = 41). At the macro-level, broader workforce supply, national/regional workforce policies such as work-hour restrictions on physicians, APP scope of practice regulations, and views of external collaborators, stakeholders and public representation of APPs influenced organisations' decisions on developing and managing APP roles. At the meso-level, organisational and departmental characteristics, organisational planning, strategy and policy, availability of resources, local experiences and evidence as well as views and perceptions of local organisational leaders, champions and other departments influenced all stages of APP role management. Lastly at the micro-level, individual APPs' backgrounds and characteristics, clinical team members' perceptions, understanding and relationship with APP roles, and patient perceptions and preferences also influenced how APPs are developed, integrated and retained.

CONCLUSIONS

We summarised a wide range of factors influencing APP role development and management in secondary care teams. We highlighted the importance for organisations to develop context-specific workforce solutions and strategies with long-term investment, significant resource input and transparent processes to tackle evolving healthcare challenges.

A survey exploring factors affecting employment of physician associates in Ireland

BACKGROUND

In the Republic of Ireland, the employment of physician associates (PAs) is growing. Following a pilot project in a hospital setting, PAs are now employed across primary and secondary care in public and private sectors. Most of the Irish PA graduates are working in hospital settings.

AIMS

The aim of the study was to explore factors which supported or inhibited the employment of PAs in Irish hospital settings and the perceived supports or challenges for potential employers in recruiting PAs.

METHODS

An online survey gathered data via human resources departments of public and private hospitals, with a 25% response rate.

RESULTS

Similar to previous studies, the barriers included the lack of recognition and regulation of the role and the small number of PAs to fill available posts. Enablers, which influenced the employment of PAs, included improving workflow, continuity of care and helping to address junior doctors' working hours.

CONCLUSIONS

Our data suggests that there is a keen interest and willingness to employ PAs and there is great potential to expand the role in Irish healthcare. However, there are some key issues around funding and recognition to be addressed at government level for this profession to highlight its worth.

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.

Facilitators to the integration of the first UK-educated physician associates into secondary care services in the NHS

The physician associate (PA) profession is relatively new to the British NHS. Little research has been conducted on the facilitators to integrating these new health professionals into a secondary care service. Thus, a grounded theory qualitative study was conducted. PAs who were educated in the UK and were the first PA in their secondary care service were interviewed, as well as doctors who were on the team when the PA started. Ten facilitators were identified, comprising three facilitator themes: PA involvement in role and skill development is crucial; having a champion for the PAs promotes integration; and principled behaviour by the PA allows the role to develop safely and effectively. Having a clearly defined role for the PA is the primary facilitating factor. This research identified approaches that both PAs and hospital trusts can implement to facilitate the introduction of PAs to secondary care services in the NHS.

The roles of physician associates and advanced nurse practitioners in the National Health Service in the UK: a scoping review and narrative synthesis

BACKGROUND

Mid-level practitioners (MLPs), including physician associates (PAs) and advanced nurse practitioners (ANPs), have emerged to address workforce shortages in the UK and perform specific roles in relation to population needs. This has resulted in new ways of working and changes to established professional hierarchies. We conducted a study to investigate the career development, competencies, effectiveness, perceptions, and regulation of PAs and ANPs, with the aim of understanding ways to effectively integrate MLPs into the NHS workforce.

METHODS

We conducted a systematic scoping review following PRISMA guidelines. Embase, Medline, the Cochrane database, Pubmed, and CINAHL databases were searched, using terms relating to PAs and ANPs in the UK. A total of 128 studies (60 on PAs and 68 on ANPs) were included in the final analysis. A narrative synthesis, guided by the pre-defined themes and emerging themes, was conducted to bring together the findings.

RESULTS

PAs are educated on a medical model with basic medical skills but lack formal professional regulation and do not have prescribing rights. ANPs are educated on a nurse model with enhanced skills that depend on roles within specific specialities, and their governance is mostly employer-led. PAs are primarily employed in secondary care. ANPs are employed widely in both primary and secondary care. No defined career progression exists for PAs. In contrast, becoming an ANP is a form of career progression within nursing. Both roles were regarded as cost-effective in comparison to doctors performing simple tasks. PAs were less understood compared to ANPs and received a mixed reception from colleagues, which sometimes undermined their professional identity, whereas ANPs were mostly welcomed by colleagues.

CONCLUSIONS

Potential ways to better integrate PAs and ANPs into the NHS workforce include further initiatives by regulatory bodies and the NHS to create more awareness and clearer role definitions for MLPs, outline potential for career progression, offer transparency with regard to remuneration, and introduction of prescribing rights. Future research might include more cadres of MLPs and explore the international literature.

Clinical benefits of a combined physician associate and senior specialist-led emergency surgery ambulatory emergency care clinic introduced in response to the COVID-19 pandemic

Introduction

A well-designed ambulatory emergency care (AEC) can alleviate demand for inpatient beds by reducing admissions or supporting early discharges. Increasing service demands and workforce gaps present major challenges to surgical departments. Physician’s associates (PAs) have been suggested as one way to address this, but previous barriers include lack of job role clarity, and inability to prescribe or request ionising radiation. An AEC clinic using PAs supported by senior decision-makers could improve patient care and provide workforce stability alongside a new capacity for successful PA positions.

Methods

An emergency surgery AEC pathway was introduced to a single centre in anticipation of a second COVID-19 wave. All emergency surgical referrals were prospectively collected over 3 months (November 2020 to February 2021) with minimum 30-day follow-up. The primary aims were to evaluate clinical outcomes and success of a new AEC PA role.

Results

A total of 175 patients were entered into the study. The median time from request for senior review to treatment decision was 26 min (IQR 9–62 min). The primary discharge rate was 38.3% (n=67), while the overall discharge rate without needing admission was 84% (n=147). Of the total 28 (16.0%) patients requiring admission, 18 (10.3%) were clinically appropriate. Four patients represented with Clavien-Dindo Grade II complications and above: two grade II (1.1%) and two grade IIIb respectively (1.1%). The role of the PA was well defined with no team discord. No patient complaints were received.

Conclusion

During the COVID-19 pandemic, an emergency surgery AEC pathway was implemented by combining a PA with a senior decision-maker, enabling fewer emergency admissions and significantly reduced time-to-reach-treatment decisions. This in turn facilitates bed-flow and minimises delays in patient treatment. The use of a well-defined PA role in this setting shows initial success and should be considered as a long-term role.

The impact of hospital support function centralization on patient outcomes: A before-after study

Objectives

Study design

Methods

Results

Conclusions

•

Integrated health systems including multiple hospitals are increasingly frequent and can lead to economies of scale.

•

We found a decrease in readmissions and average length of stay associated with the centralization of support functions.

•

Additional studies are needed to evaluate the effect of health systems integration on patient outcomes.

Senior medical students as assistants in medicine in COVID-19 crisis: a realist evaluation protocol

INTRODUCTION

The assistant in medicine is a new and paid role for final-year medical students that has been established in New South Wales, Australia, as part of the surge workforce management response to the COVID-19 pandemic. Eligibility requires the applicant to be a final-year medical student in an Australian Medical Council-accredited university and registered with the Australian Health Practitioner Regulation Agency. While there are roles with some similarities to the assistant in medicine role, such as assistantships (the UK) and physician assistants adopted internationally, this is completely new in Australia. Little is known about the functionality and success factors of this role within the health practitioner landscape, particularly within the context of the COVID-19 pandemic. Given the complexity of this role, a realist approach to evaluation has been undertaken as described in this protocol, which sets out a study design spanning from August 2020 to June 2021.

METHODS AND ANALYSIS

The intention of conducting a realist review is to identify the circumstances and mechanisms that determine the outcomes of the assistant in medicine intervention. We will start by developing an initial programme theory to explore the potential function of the assistant in medicine role through realist syntheses of critically appraised summaries of existing literature using relevant databases and journals. Other data sources such as interviews and surveys with key stakeholders will contribute to the refinements of the programme theory. Using this method, we will develop a set of hypotheses on how and why the Australian assistants in medicine intervention might 'work' to achieve a variety of outcomes based on examples of related international interventions. These hypotheses will be tested against the qualitative and quantitative evidence gathered from all relevant stakeholders.

ETHICS AND DISSEMINATION

Ethics approval for the larger study was obtained from the Western Sydney Local Health District (2020/ETH01745). The findings of this review will provide useful information for hospital managers, academics and policymakers, who can apply the findings in their context when deciding how to implement and support the introduction of assistants in medicine into the health system. We will publish our findings in reports to policymakers, peer-reviewed journals and international conferences.

Building the evidence base-10 years of PA research in England

This article describes the 10-year journey of a research group helping to build the research evidence base for physician assistants (PAs), known as physician associates in the United Kingdom, in the National Health Service in England. It draws out some key issues that may be of interest to those developing PA research programs in different specialties and different countries. PA research also can help healthcare policy makers address growing demand, issues of quality, and cost.

Perceived impact on efficiency and safety of experienced American physician assistants/associates in acute hospital care in England: findings from a multi-site case organisational study

Objectives

To investigate the contribution, efficiency and safety of experienced physician associates included in the staffing of medical/surgical teams in acute hospitals in England, including facilitating and hindering factors.

Design

Mixed methods longitudinal, multi-site evaluation of a two-year programme employing 27 American physician associates: interviews and documentary analysis.

Setting

Eight acute hospitals, England.

Participants

36 medical directors, consultants, junior doctors, nurses and manager, 198 documents.

Results

Over time, the experienced physician associates became viewed as a positive asset to medical and surgical teams, even in services where high levels of scepticism were initially expressed. Their positive contribution was described as bringing continuity to the medical/surgical team which benefited patients, consultants, doctors-in-training, nurses and the overall efficiency of the service. This is the first report of the positive impact that, including physician associates in medical/surgical teams, had on achieving safe working hours for doctors in training. Many reported the lack of physician associates regulation with attendant legislated authority to prescribe medicines and order ionising radiation was a hindrance in their deployment and employment. However, by the end of the programme, seven hospitals had published plans to increase the numbers of physician associates employed and host clinical placements for student physician associates.

Conclusions

The programme demonstrated the types of contributions the experienced physician associates made to patient experience, junior doctor experience and acute care services with medical workforce shortages. The General Medical Council will regulate the profession in the future. Robust quantitative research is now required.

The early experiences of Physician Associate students in the UK: A regional cross-sectional study investigating factors associated with engagement

BACKGROUND

The number of physician associates (PAs) training and working in the UK has increased over the last few years following the proliferation of postgraduate courses. Understanding early experiences and what impacts on engagement is important if we are to appropriately support this relatively new professional group.

METHODS

This paper reports on a cross-sectional analysis of the first year of data from a prospective 10-year longitudinal cohort study. First year PA students (n = 89) were enrolled from five universities in one UK region where the training programmes were less than 2 years old. Data collected were: demographic information, wellbeing, burnout and engagement, expectations, placement experience, performance and caring responsibilities. Pearson's correlations were used to examine relationships between variables and to select variables for a hierarchical regression analysis to understand which factors were associated with engagement. Descriptive statistics were calculated for questions relating to experience.

RESULTS

The experiences of PA students during their first 3-6 months were mixed. For example, 78.7% of students felt that there were staff on placement they could go to for support, however, 44.8% reported that staff did not know about the role and 61.3% reported that staff did not know what clinical work they should undertake. Regression analysis found that their level of engagement was associated with their perceived career satisfaction, overall well-being, and caring responsibilities.

CONCLUSIONS

The support systems required for PAs may need to be examined as results showed that the PA student demographic is different to that of medical students and caring responsibilities are highly associated with engagement. A lack of understanding around the PA role in clinical settings may also need to be addressed in order to better support and develop this workforce.

Integrating physician associates into the health workforce: barriers and facilitators

Physician associates have been identified as a potential solution to the shortage of health-care workers in the UK, but the introduction of physician associates has not been universally welcomed and some uncertainty exists around their specific roles. This review enhances understanding of the barriers and facilitators for integrating physician associates into the workforce and identifies six key themes to inform future policy decisions at local and national levels.

The role of physician associates in secondary care: the PA-SCER mixed-methods study

Background

Increasing 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.

Methods

This 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.

Results

The 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.

Limitations

PAs work within medical and surgical teams, such that their specific impact cannot be distinguished from that of the whole team.

Conclusions

PAs 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 research

Comparative 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 registration

The systematic review component of this study is registered as PROSPERO CRD42016032895.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

WORKFORCE: The career aspirations and expectations of -student -physician associates in the UK

The NHS five year forward view 1 supports the development of a flexible workforce. Expanding the traditional medical workforce using physician associates (PAs) is increasing in popularity. This study explores the career aspirations and expectations of student PAs from a large PA school in England. Thematic analysis of qualitative data from an online survey examined the personal motivations and career aspirations of student PAs. Finally, we make nine recommendations to enhancing recruitment, retention and development of PAs post qualification. Lessons learnt from this data set are generalisable.

What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study

OBJECTIVES

To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services.

DESIGN

Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis.

SETTING

Six acute care hospitals in three regions of England in 2016-2017.

PARTICIPANTS

43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives.

RESULTS

A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors.

CONCLUSIONS

This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.

Risks and Rewards of Advanced Practice Providers in Cardiothoracic Surgery Training: National Survey

BACKGROUND

Changes in healthcare have led to increasing use of advanced practice providers (APPs), but their role in cardiothoracic surgery (CTS) education remains undefined. This study aimed to analyze the extent of APP use on the CTS team, their role within the hierarchy of clinical care, and the impact of physician extenders on CTS training from the resident perspective.

METHODS

CTS residents' responses to the 2017 Thoracic Surgery Residents Association/Thoracic Surgery Directors Association In-Service Training Examination survey regarding the role of APPs in specific clinical scenarios and perception of APP contribution to residents' educational environment were analyzed. Statistical analysis of categorical variables was performed in SPSS (version 22.0; IBM, Chicago, IL) using a Fisher's exact test and Pearson χ² test with statistical significance set at p < 0.05.

RESULTS

Response rate was 82.1% (280/341). The median number of employed APPs was 16 to 20, and 50.4% (n = 141) reported 11 to 25 physician extenders at their institution. The median numbers of APPs in the operating room, floor, and intensive care unit were three, three, and two, respectively. Overall impression of APPs was positive in 87.5% (n = 245) of respondents, with 47.7% (n = 133) "very positive" and 40.1% "positive" (n = 112). In general, residents reported greater resident involvement in postoperative issues and operative consults and greater APP involvement in floor issues; 72.5% of residents had not missed a surgical opportunity due to APPs, whereas 9.6% missed an opportunity due to APPs despite being at an appropriate level of training. Of those that reported missed opportunities 44% were integrated thoracic surgery residents. There were no significant differences in APPs' operative role based on resident seniority.

CONCLUSIONS

The overall impression of APPs among CTS residents was favorable, and they are more commonly involved in assisting on the floor or the operating room. Occasionally residents reported missing a surgical opportunity due to APPs. There is further opportunity to optimize and standardize their role within programs to improve clinical outcomes and enhance the CTS educational experience for residents.

Contribution of physician assistants/associates to secondary care: a systematic review

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.