A cardiology PA home care program
A PA home care program providing house calls was initiated to reduce hospital readmissions following cardiac surgery. The purpose was to compare 30-day PA home care and pre-PA home care readmission rate, length of stay, and cost. Patients who underwent adult cardiac surgery spanning 48 months were retrospectively reviewed using pre-PA home care patients as the control group. Readmission rate, length of stay, and healthcare cost, as measured by hospital billing, were compared between groups matched with propensity score. Of the 1,185 adults who were discharged directly home, 155 (13%) were readmitted. Total readmissions for the control group (N=648) were 101 patients (16%) compared with the PA home care group (N=537) total readmissions of 54 (10%), a 38% reduction in readmission. Propensity score matched groups showed a rate reduction of 41% with 17% (62 of 363) for the control compared with 10% (37 of 363) for the PA home care group. The average hospital bill per readmission was $39,100 for the control group and $56,600 for the PA home care group. The cost of providing home visits was $25,300 for 363 propensity score matched patients. This was a savings of $977,500 at a cost of $25,300 over 2 years, or $39 in healthcare saved for every $1 spent. Therefore, a home visit by a cardiac surgical PA is a cost-effective strategy to reduce readmissions after cardiac surgery.1
Commentary by Roderick S. Hooker: The quest to bring down hospital readmission within 30 days of discharge is tied to Medicare reimbursement. Embedded in this policy are finding strategies to decrease the cost burden and maximize hospital profits. Out of financial leverage comes an innovative strategy: discharge surgical patients as soon as possible and follow up at home shortly afterward with competent providers who can prescribe and modify treatment. The test is the labor rate of a PA and not that it works.2 Propensity scores were important to reduce selection bias by equating groups based on critical covariates. Although the study is not unique in using PAs, or even unique to the United States, what is welcomed is the financial analysis that accompanies such strategies.3 The cost-benefit analysis of PA labor in home health delivery services following discharge is far less than the incurred costs of readmission and sets the stage for more innovative uses of provider teams.
Nabagiez JP, Shariff MA, Molloy WJ, et al Cost analysis of physician assistant home visit program to reduce readmissions after cardiac surgery. Ann Thorac Surg. [e-pub May 24, 2016]
2. Iribarne A, Chang H, Alexander JH, et al Readmissions after cardiac surgery: experience of the National Institutes of Health/Canadian Institutes of Health Research Cardiothoracic Surgical Trials Network. Ann Thorac Surg. 2014;98(4):1274–1280.
3. Hall MH, Esposito RA, Pekmezaris R, et al Cardiac surgery nurse practitioner home visits prevent coronary artery bypass graft readmissions. Ann Thorac Surg. 2014;97(5):1488–1493.
Toward a more complete picture of office-based healthcare delivery
The healthcare system, particularly outpatient, office-based care, has been shifting toward service delivery by advanced practice providers, particularly NPs and PAs. The National Ambulatory Medical Care Survey (NAMCS) is a leading source of nationally representative data on care delivered by office-based physicians. This paper discusses key NAMCS expansion efforts, and presents major findings from exploratory studies that assess the feasibility of collecting data from NPs and PAs as sampled providers in NAMCS in 2013-2014. Modifications may be necessary for changing recruitment strategies, visit sampling procedures, and physician-centric survey items. Collectively, these initiatives are important for healthcare research, practice, and policy communities in their efforts toward providing a more complete picture of the changing outpatient, office-based workforce, team-based care approach, and service use in the United States.1
Commentary by James F. Cawley: Health services researchers have recognized the strengths and the weaknesses of the national surveys conducted by the National Center for Health Statistics. This has led to secondary data analyses to better describe the contributions of PAs and NPs to primary care delivery. This report describes efforts to improve the capability of both the NAMCS and the National Hospital Ambulatory Medical Care Survey to capture the extent of PA and NP practice activities in providing primary care in ambulatory settings. The result will be a more accurate means of reporting the content of PA care, a better sense of the degree to which the visit was performed on a physician-independent basis, and perhaps the features (such as combining preventive services with clinical services) that are unique to the PA and NP primary care patient visit.
Lau DT, McCaig LF, Hing E. Toward a more complete picture of outpatient, office-based health care in the U.S. Am J Prev Med. [e-pub April 5, 2016]
Organ recovery and transplant
This study assessed the effect of NPs and PAs on the deceased-donor liver transplant program. With the incorporation of NPs and PAs, the authors found that liver recipient length of stay was unaffected and the overall median warm ischemic time did not increase. Outcomes of liver transplantation for the patient and graft survival improved and remained at or above the expected values. Surgical and medical NPs and PAs are essential for optimal patient outcomes in a deceased-donor liver transplant program and facilitate a better learning experience for residents and fellows on their transplant rotations. Further investigations are recommended to assess PAs' and NPs' roles and their effect on the education of residents and fellows and transplant hepatology education programs and/or fellowships.1
Commentary by David Carpenter: This work joins other specialty outcome studies demonstrating equivalent or improved outcomes with the addition of PAs and NPs.2 Patient survival and length of stay are good measures of organ transplant service outcomes; warm ischemia time is not as good an index, as it appears to be determined more by surgeon proficiency than PA skill. The study is notable for what it lacks—specific role expectations, schedules, and workload. This research alludes to workload, lacks detail on how the PAs and NPs are employed, and lacks descriptions of the typical number of patient encounters per shift. For example, how do three surgical PAs cover a surgical transplant schedule, which tends to happen at odd hours? The addition of work description would enhance a very stimulating paper.
1. Chaney AJ, Harnois DM, Musto KR, Nguyen JH. Role development of nurse practitioners and physician assistants in liver transplantation. Prog Transplant. 2016;26(1):75–81.
2. Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual. 2011;26(6):452–460.
Can an NP in orthopedics improve trauma care outcomes?
The authors analyzed the effect of an NP in orthopedic trauma on length of stay and cost in a level I trauma center. A retrospective chart review of all patients discharged from the orthopedic surgery service 1 year before the addition of an NP and 1 year after the hiring of an NP was undertaken. Chart review included age, sex, length of stay, discharge destination, IV antibiotic use, negative-pressure wound therapy, admission location, and length of time to surgery. The hiring of an NP yielded a statistically significant decrease in length of stay across the following patient subgroups: patients transferred from the trauma service (13.56 compared with 7.02 days), patients age 60 years and older (7.34 compared with 5.04 days), patients discharged to a rehabilitation facility (10.84 compared with 8.31 days), and patients discharged on antibiotics/negative-pressure wound therapy (15.16 compared with 11.24 days). Length of time to surgery was also decreased (1.48 compared with 1.31 days). The addition of a dedicated NP in orthopedic trauma at a county level I trauma center resulted in a statistically significant decrease in length of stay and thus reduced indirect costs to the hospital.
Commentary by Robyn Chalupa: In academic hospitals, the lowest resident on the orthopedic trauma service usually is responsible for the majority of unit calls, coordination with ancillary services or outside facilities, and paperwork required for discharge. However, this poor intern would much rather be learning the surgical techniques of his or her chosen trade than managing paperwork; consequently, if paperwork can be put off, it likely will be. This institution added an NP to the orthopedic trauma team with the intent that she would help manage these tasks without the distraction of clinic or surgery. Not surprisingly, coordination and paperwork got done faster, especially when complicated or lengthy, leading to faster patient discharge. Additionally, the NP allowed the team to discharge patients and then bring them back for definitive surgery; previously, patients had been kept in-house until that time. This is just another of many examples that demonstrate the addition of a PA or NP to the health delivery team results in improved outcomes.
1. Hiza EA, Gottschalk MB, Umpierrez E, et al Effect of a dedicated orthopaedic advanced practice provider in a level I trauma center: analysis of length of stay and cost. J Orthop Trauma. 2015;29(7):e225–e230.
PA-managed pediatric emergency patients
This study examined the clinical care PAs provide to children older than 8 weeks through 6 years of age in a general community ED. The cohort was selected because it was considered to be representative of physiologic and pathologic conditions unique to children. The 72-hour recidivism rates were used as an objective outcome measure to compare the care provided by PAs with the care of attending emergency physicians. A total of 10,369 children age 6 years or younger were seen during a 24-month study period. The mean (SD) age of the patients was 2.2 years, with 2,909 (28%) age 1 year or younger. A total of 807 (7.8%) patients returned within 72 hours of their initial ED visit, with 57 (0.55%) subsequently admitted. Based on the outcome measure of 72-hour recidivism, PA management of children age 6 years or younger is similar to that of attending emergency physicians.1
Commentary by Brian T. Maurer: Although ED policy at this institution permitted PAs to evaluate, treat, and discharge patients of any age independent of the attending emergency physicians, well over half of this entire cohort of 10,000 children (those below age 2 years) were evaluated and treated by physicians alone. This was especially the case in sick children below age 8 weeks, who were almost exclusively triaged directly to physicians. Although patients treated only by PAs demonstrated significantly lower return rates at 72 hours after the initial ED encounter, many of these patients were older than age 2 years and less critically ill. The authors conclude that PA management of children age 6 years or younger in a general community ED is equivalent to that of attending emergency physicians. Up to a point, that may be true, but a closer look at the raw data suggests otherwise.
1. Pavlik D, Sacchetti A, Seymour A, Blass B. Physician assistant management of pediatric patients in a general community emergency department: a real world analysis. Pediatr Emerg Care. 2016;33(1):26–30.
Why a third wave of PA growth?
PA education began as an experiment in medical teaching and has proven to be highly successful in preparing capable, flexible, and productive clinicians. Three distinct phases of growth of US PA educational programs have emerged: the first stimulated by grants and public policy, the second by anticipated provider shortages, and the third growth began in the new century. American colleges and universities seeking to sponsor PA programs differ from past sponsoring institutions and tend to be mostly private, for-profit institutions seeking some investment value. The study describes the characteristics of new programs, makes projections of program growth, and examines the implications of the third expansion of PA education.1 The authors are senior PA educators and workforce scholars.
Commentary by Karen Hills: Clearly, with the US healthcare system undergoing another wave of major change, more research is needed into how to best educate PAs to meet fast-emerging needs. This paper raises a variety of important questions about the need for more PA-focused research on the ramifications of PA education expansion. Does evidence link educational effectiveness and graduate outcomes to institutional characteristics? What role does the student debt crisis play in steering PA graduates away from primary care positions in rural and medically underserved settings? Lastly, are our policy initiatives and discussions focused on whether the healthcare needs of the public are best served by current output patterns of PA education programs? As seasoned educators, the authors know that asking the right questions continues the drumbeat of pressure for more quality PA research, which is essential to advancing the PA profession.
1. Cawley JF, Eugene Jones P, Miller AA, Orcutt VL. Expansion of physician assistant education. J Physician Assist Educ. 2016;27(4):170–175.