PA applicant U.S. citizenship status and likelihood of program matriculation

BACKGROUND

Barriers to matriculation into Physician Assistant (PA) programs and entry into the PA profession have disproportionate impact on historically marginalized groups. This study evaluates if U.S. citizenship status is associated with likelihood of matriculation in PA Programs.

METHODS

Data from five Centralized Applicant Services for Physician Assistants (CASPA) admissions cycles (2012-2021) was evaluated cross-sectionally for the primary outcome of binary matriculation status (yes/no). Bivariate and multivariate logistic regression was utilized to investigate associations between self-identified U.S. citizenship status and likelihood of PA program matriculation. Models controlled for important potential confounders, including age, gender, race/ethnicity, non-native English speaker, patient care experience hours, total undergraduate grade point average (GPA), and number of applications submitted to various programs.

RESULTS

Non-U.S. citizen status was statistically associated with persistent lower likelihood of PA program matriculation compared to U.S. citizenship. Odds of matriculation were 41% [OR 0.59 (95% CI: 0.51, 0.68; p <.001)] to 51% [OR 0.49 (95% CI: 0.41, 0.58; p <.001)] lower in unadjusted models. Odds were 32% [OR 0.68 (95% CI: 0.56, 0.83; p <.001)] to 42% OR 0.58 (95% CI: 0.48, 0.71; p <.001) lower when adjusting for important covariates. The lowest likelihood occurred in 2012-2013 with 51% lower odds of matriculation and in 2016-2017 with 42% lower odds when accounting for important covariates.

DISCUSSION

PA programs are charged with improving diversity of clinically practicing PAs to improve health outcomes and better reflect patient populations. This analysis shows that non-U.S. citizenship may be a barrier to PA school acceptance. PA schools should raise awareness and create means and accessibility for admissions for this underrepresented group.

Feasibility of an automated interview grounded in multiple mini interview (MMI) methodology for selection into the health professions: an international multimethod evaluation

OBJECTIVES

Global, COVID-driven restrictions around face-to-face interviews for healthcare student selection have forced admission staff to rapidly adopt adapted online systems before supporting evidence is available. We have developed, what we believe is, the first automated interview grounded in multiple mini-interview (MMI) methodology. This study aimed to explore test-retest reliability, acceptability and usability of the system.

DESIGN, SETTING AND PARTICIPANTS

Multimethod feasibility study in Physician Associate programmes from two UK and one US university during 2019-2020.

PRIMARY, SECONDARY OUTCOMES

Feasibility measures (test-retest reliability, acceptability and usability) were assessed using intraclass correlation (ICC), descriptive statistics, thematic and content analysis.

METHODS

Volunteers took (T1), then repeated (T2), the automated MMI, with a 7-day interval (±2) then completed an evaluation questionnaire. Admission staff participated in focus group discussions.

RESULTS

Sixty-two students and seven admission staff participated; 34 students and 4 staff from UK and 28 students and 3 staff from US universities. Good-excellent test-retest reliability was observed at two sites (US and UK2) with T1 and T2 ICC between 0.65 and 0.81 (p<0.001) when assessed by individual total scores (range 80.6-119), station total scores 0.6-0.91, p<0.005 and individual site (≥0.79 p<0.001). Mean test re-test ICC across all three sites was 0.82 p<0.001 (95% CI 0.7 to 0.9). Admission staff reported potential to reduce resource costs and bias through a more objective screening tool for preselection or to replace some MMI stations in a 'hybrid model'. Maintaining human interaction through 'touch points' was considered essential. Users positively evaluated the system, stating it was intuitive with an accessible interface. Concepts chosen for dynamic probing needed to be appropriately tailored.

CONCLUSION

These preliminary findings suggest that the system is reliable, generating consistent scores for candidates and is acceptable to end users provided human touchpoints are maintained. Thus, there is evidence for the potential of such an automated system to augment healthcare student selection.

Associations between state scope of practice laws and US physician assistant wages from 1997 to 2017: a longitudinal analysis

OBJECTIVE

The purpose of this study is to determine whether, and to what degree, variations in physician assistant (PA) state scope of practice (SOP) laws across states are associated with (1) PA median wage over time and (2) if a specific SOP key element has greater impact on PA median wage than others. We hypothesise that expanded SOP laws will be associated with higher PA wage.

DESIGN

Longitudinal analysis from 1997 to 2017.

SETTING

Fifty states and the District of Columbia (US capital region).

PARTICIPANTS

Employed PAs from 1997 to 2017.

METHODS

Four national data sets were combined to allow for longitudinal analysis of state-level annual PA wage and state SOP laws. We used linear regression models to explore the associations of SOP elements with PA wage in 5-year intervals and individual growth models to assess the change in PA annual wage over the study period.

RESULTS

There was a 220% increase in weighted PA annual wage over two decades. There was a positive linear correlation between annual wage and age in 2012 and 2017 (r=0.52, p<0.01; r=0.29, p=0.04, respectively). The adjusted R² for individual SOP elements in the selected years were all small (range: 0.0-0.29), with no appreciable pattern across time for any SOP element. In 1997, several SOP laws show association with median wage but this impact disappears over time.

CONCLUSIONS

PA median wage has risen over twofold in the past two decades, with the rise in PA wage mainly explained by time and provider age. In 1997 some SOP elements were associated with increased average wage; however, the impact of this increase diminished over time in all such instances. As the PA profession moves towards Optimal Team Practice, future research should examine if this move towards greater autonomy impacts wage.

Cross-sectional analysis of US scope of practice laws and employed physician assistants

OBJECTIVE

This study examined if the variation in physician assistant (PA) state scope of practice (SOP) laws across states are associated with number of employed PAs, PA demographics and PA/population ratio per state. The hypothesis was that less restrictive SOP laws will increase the demand for PAs and the number of PAs in a state.

DESIGN

Retrospective cross-sectional analysis at three time points: 1998, 2008, 2017.

SETTING

Fifty states and the District of Columbia.

PARTICIPANTS

Employed PAs in 1998, 2008, 2017.

METHODS

SOP laws were categorised as permissive, average and restrictive. Three national datasets were combined to allow for descriptive analysis of employed PAs by year and SOP categories. We used linear predictive models to generate and compare PA/population ratio least square means by SOP categories for each year. Models were adjusted for percent female PA and PAs mean age.

RESULTS

There was a median PA/population ratio of 23 per 100 000 population in 1998 and 33 in 2017. A heterogeneous expansion of SOP laws was seen with 17 states defined as super expanders while 15 were never adopters. In 2017, comparing restrictive to permissive states showed that in adjusted models permissive SOP laws were associated with 11.7 (p .03) increase in ratio of employed PAs per 100 000 population, demonstrating that states with permissive SOP laws have an increased PA density.

CONCLUSIONS

There has been steady growth in the mean PA/population ratio since the turn of the century. At the same time, PA SOP laws in the USA have expanded, with just 10 states remaining in the restrictive category. Permissive SOP laws are associated with an increase in the ratio of employed PAs per state population. As states work to meet the projected physician need, SOP expansion may be an important policy consideration to increase the PA workforce.

Developing and Sustaining an Effective and Resilient Oncology Careforce: Opportunities for Action

Advances in cancer care have led to improved survival, which, coupled with demographic trends, have contributed to rapid growth in the number of patients needing cancer care services. However, with increasing caseload, care complexity, and administrative burden, the current workforce is ill equipped to meet these burgeoning new demands. These trends have contributed to clinician burnout, compounding a widening workforce shortage. Moreover, family caregivers, who have unique knowledge of patient preferences, symptoms, and goals of care, are infrequently appreciated and supported as integral members of the oncology "careforce." A crisis is looming, which will hinder access to timely, high-quality cancer care if left unchecked. Stemming from the proceedings of a 2019 workshop convened by the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine, this commentary characterizes the factors contributing to an increasingly strained oncology careforce and presents multilevel strategies to improve its efficiency, effectiveness, and resilience. Together, these will enable today's oncology careforce to provide high-quality care to more patients while improving the patient, caregiver, and clinician experience.

Maximizing Black applicant matriculation in U.S. PA programs: associations between the number of submitted applications and likelihood of matriculation

BACKGROUND

Physician Assistants (PA) are important members of the medical team, and increasing diversity in healthcare professionals has been consistently associated with improved health outcomes for underrepresented minority patients. In this study of a national cohort of PA program applicants, we investigated whether the number of programs a student applied to (Application Number, AN) was significantly associated with increased likelihood of matriculation into a PA program.

METHODS

We examined all applications (n = 27,282) to the 2017-2018 admissions cycle of the Central Application Service for Physician Assistants, which is utilized by over 90% of accredited PA programs in the US. As we a priori hypothesized that associations would be non-linear, we used natural cubic splines to estimate the associations between matriculation and AN, controlling for multiple metrics of academic achievement, experience, and applicant demographics. We subsequently used segmented regression analyses (modified poisson regression with robust error variance) to investigate log-linear associations above and below inflection points identified in the spline analyses. Additionally, we explored for effect modification by race/ethnicity.

RESULTS

The strongest associations were observed between application number 2-7, and a threshold effect was observed at > 16 applications, beyond which there was no significant, incremental benefit in matriculation likelihood. Associations differed by race, particularly for application number 2-7, wherein the incremental benefit from each additional application was highest for Black applicants (Likelihood Ratio [LR]: 1.243, 95% CI: 1.136 to 1.360) vs non-Latinx White (LR: 1.098, 95% CI: 1.072 to 1.125), with no additional, incremental benefit beyond 7 program applications. For all other races, significant increased likelihoods of matriculation were observed until 16 program applications.

CONCLUSIONS

These findings can help guide pre-PA advisors and PA programs, providing recommended thresholds to applicants on the most cost effective ways to increase their likelihood of admissions, and the PA profession as a whole by providing actionable information that can potentially increase Race/Ethnic diversity in the PA profession and, by extension, medical teams.

Physician Assistant Utilization in Inpatient Psychiatry: A Qualitative Study

Objective

There is a national shortage of psychiatric care providers, with approximately 1% of physician assistants (PAs) working in psychiatry. The study aimed to understand the utilization of PAs in inpatient psychiatry.

Methods

A qualitative study was performed utilizing semi-structured interviews focusing on PA autonomy, reimbursement, specialized certifications, training structure, and overall satisfaction with PAs in inpatient psychiatric care.

Results

Of the nine locations interviewed, four are currently using PAs, and five have never utilized PAs. All facilities utilizing PAs reported a decrease in physician workload with varying structures for training and billing, and required specialized certifications.

Conclusion

Most facilities surveyed do not utilize PAs and either preferred physicians or were unaware of the qualifications of PAs. Of the facilities utilizing PAs, there is wide variation in their utilization and reimbursement models; however, they reported a high level of satisfaction, reinforcing that PAs can provide high-quality care in inpatient psychiatric settings.

Opioid Misuse and Dependence Screening Practices Prior to Surgery

BACKGROUND

A majority of surgical patients are prescribed opioids for pain management. Many patients have pre-existing chronic pain managed with opioids and/or opioid use disorders (OUDs), which can complicate perioperative management. Patients who use opioids prior to surgery are at increased risk of developing OUD after surgery. To date, no studies have examined the prevalence of opioid screening and electronic medical record (EMR) documentation prior to surgery.

MATERIALS AND METHODS

A 40-item survey was administered to 268 patients at their first postoperative care visit at a single tertiary academic center from October 2017 to July 2018. A chart review of a random sample of 100 patients was performed to determine provider opioid screening prevalence in the presurgical setting. Log-binomial models were used to calculate prevalence ratios (PRs) to determine the provider role (surgeon, advanced practice clinicians [APC], surgical trainee) association with opioid screening documentation. Exploratory qualitative interviews were conducted with surgical providers to identify barriers to screening and screening documentation.

RESULTS

Only 7% of patients were screened preoperatively for opioid use. A total of 38% of patients self-reported that they had used opioids in the past year. Of that group, only 3% had screening by a surgical provider prior to surgery documented in their EMR. Provider role was not associated with likelihood of opioid screening (surgeon versus trainee, PR = 1.2, 95% CI 0.2-8.5) (surgeons versus APCs, PR = 1.05, 95% CI 0.17-8.53). EMRs were discordant with patient survey results for patients with no ICD-10 codes for opioid use. The most common perceived barriers to preoperative screening were insufficient clinic time; logistics of who should screen/not required as part of their clinical workflow; not perceiving screening as a priority; and lack of expertise in the area of chronic opioid use and OUD.

CONCLUSIONS

Preoperative screening for opioid use is uncommon, and EMRs are often discordant with patient self-reported use. Efforts to increase preoperative screening will need to address barriers screening practices and increasing health system support by incorporating screening into the clinical workflow and adding it to documentation templates.

Late-Stage Melanoma: Be Sure to Screen Uninsured, Unmarried Men

OBJECTIVE

The purpose of this study was to assess for any associations between individual and social factors and late-stage melanoma in Kentucky from 1995 to 2013.

METHODS

The study combines three datasets: individual-level data from the Kentucky Cancer Registry, census tract-level data from the US Census, and county-level physician licensure data from the Kentucky Department for Public Health. The study population is described by all cases, early stage, and late stage. Logistic regression was used to evaluate the unadjusted associations between each covariate and early-stage and late-stage disease groups. All of the significant variables were assessed for interaction effect, and the significant interaction terms were used in the final model. Multiple logistic regression provided the final model of late-stage disease.

RESULTS

In this study population, a dramatic increase in melanoma incidence is seen from 1995 to 2013 with a threefold increase in the number of cases per year. Of the 10,109 cases reported, 13.6% have late-stage disease, with a mean age for all cases at 56.9 years and the majority being men. Late-stage cases are more commonly uninsured or insured with Medicaid or Medicare compared with cases with early-stage lesions. Having a spouse or partner is clearly protective from being diagnosed as having late-stage melanoma, whereas being uninsured or having Medicaid increases the odds of late-stage melanoma.

CONCLUSIONS

The incidence of melanoma is increasing dramatically. With no screening recommendation for the general population from the US Preventive Task Force, clinicians should focus on those at increased risk of late-stage melanoma: unmarried men who are uninsured or receiving Medicaid.