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Commentaries on health services research

Hooker, Roderick S. PhD, PA; Cawley, James F. MPH, PA-C; Everett, Christine M. PhD, MPH, PA-C; Brock, Douglas M. PhD

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Journal of the American Academy of Physician Assistants: August 2017 - Volume 30 - Issue 8 - p 1-3
doi: 10.1097/01.JAA.0000521150.63195.61
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What is the relationship between PA and APRN roles and patient outcomes?


Team-based care involving PAs and advanced practice registered nurses (APRNs) is one strategy for improving access and quality of care. This cross-sectional survey analysis examined multiple outcomes associated with primary care PA and APRN roles. Adult respondents to the 2010 Health Tracking Household Survey were studied. Outcomes included primary care and ED visits, hospitalizations, unmet need, and satisfaction. Three PA or APRN roles were categorized as physician only (no PA or APRN visits; reference), usual provider (PA or APRN provides majority of primary care visits), or supplemental provider (physician as usual provider, PA or APRN provides a subset of visits). Compared with patients with physician-only care, patients with PAs or APRNs as usual providers and supplemental providers had increased risk of having five or more primary care visits, increased risk of ED use, and lower satisfaction. No differences were seen for hospitalizations or unmet need. Healthcare use patterns and satisfaction varied between adults with PAs and APRNs in different roles, but reported unmet need did not. These findings suggest that a wide range of outcomes should be considered when identifying the best PA or APRN role on primary care teams.1

Commentary Roderick S. Hooker: A 5-decade quest to find how PAs, NPs, and certified nurse-midwives best fit in healthcare service delivery reveals (retrospectively) that they improve access, improve chronic disease management, improve hospital services, work in underserved communities, and are an economical labor innovation. Yet little research has focused on ambulatory care outcomes when PAs and APRNs are involved either as physician substitutes or complements. This is the second of two studies; the authors probed a 2010 national telephone survey and found when PAs and APRNs are in complementary roles, they are not as well-perceived by patients as when they are the principal providers.1,2 Such research gives one pause: are PAs and APRNs as useful as team members as thought? It appears not all patients are satisfied when these team members supplement the physician's care. But why and what about the high patient satisfaction studies on PAs across four countries when they are the substitutes of physicians?3 Not since the Mundinger and colleagues NP outcome study in the late 1990s have any significant well-designed, random controlled, prospective studies been done on NPs (and to date none on PAs).4 Until similar critical work is undertaken, PAs will remain a commodity whose value varies according to who is doing the talking.


    Implications of retiring physicians


    Physician retirement planning and timing have important implications for patients, hospitals, and healthcare systems. Unplanned early or late physician retirement can have significant consequences in terms of both patient safety and human resource allocations. This systematic review examined four questions: When do physicians retire? Why do some physicians retire early? Why do some physicians delay their retirement? What strategies facilitate physician retention and/or retirement planning?

    Physicians commonly reported retiring between ages 60 and 69 years. Excessive workload and burnout were frequently cited reasons for early retirement. Ongoing financial obligations delayed retirement and strategies to mitigate career dissatisfaction, workplace frustration, and workload pressure supported continuing practice. Knowing when physicians plan to retire and how they can transition out of practice helps succession planning. Healthcare organizations might consider promoting retirement mentorship programs, resource toolkits, education sessions, and guidance about financial planning for physicians throughout their careers, as well as creating postretirement opportunities that maintain institutional ties through teaching, mentoring, and peer support.1

    Commentary by James F. Cawley: Although medical workforce planning is essential to understand how supply will meet demand, it is also flawed and often wrong in its conclusions. One missing component is retirement patterns. This systematic review examined 65 studies of physician retirement, most of them cross-sectional. Most quantitative studies had adequate sample representativeness, had justified and satisfactory sample size, used appropriate statistical tests, and collected primary data by self-reported survey methods. This work holds implications for the 115,000 US PAs because little work has been done looking at retirement patterns. What is the career arc of a PA? Do PA retirement patterns differ from those of physicians? One small study suggested that a PA career was 29 years on average but that study targeted those already retired.2 What about sex, specialty, race, age at graduation, and part-time work? Little has been done thus far to house and analyze the emerging new and refined data nor to create such models. As the pioneer generation of the PA profession enters their retirement, the professions' organizations should encourage increased data gathering on PA retirement patterns and more clearly define the natural lifespan and its variants of the PA career.


      The value of integrated team-based care


      The value of integrated team delivery models is not firmly established. To evaluate the association of receiving primary care in integrated team-based care practices versus traditional practice management practices (usual care) with patient outcomes, healthcare use, and costs, a retrospective, longitudinal, cohort was assessed for integration of physical and mental health. Adults who received primary care in team-based care practices were compared with those treated in traditional internal medicine, family practice, and geriatrics practices. Outcomes included measures of quality, use, payments to the delivery system, and program investment costs. A total of 113,452 unique patients (mean age, 56 years; 59% women) accounted for 163,226 person-years of exposure in 27 team-based care practices and 171,915 person-years in 75 traditional practices. Patients treated in team-based care practices compared with those in traditional practices had higher rates of active depression screening, adherence to a diabetes care bundle, and self-care plans; lower proportion of patients with controlled hypertension; and no significant differences in documentation of advance directives. Per 100 person-years, rates of healthcare use were lower for patients in team-based care compared with those in traditional practices for ED visits, hospital admissions, ambulatory care sensitive visits (conditions for which appropriate ambulatory care prevents or reduces the need for hospital admission), admissions, and primary care physician encounters, with no significant difference in visits to urgent care facilities and visits to specialty care physicians. Per-patient payments to the delivery system were lower in the team-based care group ($3,400 compared with $3,515 for traditional practices) and were less than investment costs of the team-based care program. Among adults enrolled in an integrated healthcare system, receipt of primary care at team-based care practices was associated with higher rates of some measures of quality of care, lower rates for some measures of acute care use, and lower actual payments received by the delivery system.1

      Commentary by Christine M. Everett: In a time of reported primary care physician shortages, an increase in the demand for chronic illness and mental health services, and a mandate to reduce cost while improving access and quality, care delivery teams are offered as a key solution. As the authors point out, evidence supporting the value of team-based care is limited.1 Although some reductions in cost and use were found, as well as a few improvements in quality measures, only a few of the outcomes (mental health screening and documentation of shared care plans) showed impressive improvements. The potential explanations for this are numerous; however, two are particularly interesting. First, the technical challenges of studying teams will bias findings toward the null. The second might be the culture in which teams are designed. This study was conducted at Intermountain Healthcare Medical group's primary care practices, which list numerous PAs and NPs as primary care providers on their website. However, the study appears to exclusively study the patients of physicians working with nurse case managers and mental health professionals. Consensus is growing that the concept of teams will be better understood when the whole team is recognized.


        Does broadening NP scope of practice lower physician liability?


        Patients can hold physicians directly or vicariously liable for the malpractice of NPs under their supervision. Restrictive scope-of-practice laws governing NPs can ease patients' legal burdens in establishing physician liability. This study analyzed the effect of restrictive scope-of-practice laws on the number of malpractice payments made on behalf of physicians between 1999 and 2012. Enacting less restrictive scope-of-practice laws decreased the number of payments made by physicians by as much as 31%, suggesting that restrictive scope-of-practice laws have a salient extraregulatory effect on physician malpractice rates. The effect of enacting less restrictive laws varies depending on the medical malpractice reforms in place, with the largest decrease in physician malpractice rates occurring in states that have enacted fewer malpractice reforms. Relaxing scope-of-practice laws could mitigate the adverse extraregulatory effect on physicians identified in this study and could also lead to improvements in access to care.1

        Commentary by Douglas M. Brock: The authors report that less-restrictive NP scope-of-practice laws decrease physician malpractice rates and may increase access to care. Noteworthy, but confounding and data limitations do not adequately support the authors' conclusions. The reported relationships are affected by multiple factors. The National Practitioner Database does not allow examination of the effect of changing NP practice characteristics, changing dynamics of the physician-NP practice relationship, physician and NP specialty, and geographic shifts in the NP workforce. A causal association between less-restrictive scope-of-practice laws, reduced malpractice, and increased access to care is inferred, borrowing from Hellman and Showalter's findings (using Florida state data and aggregate survey data surveys conducted in the 1980s) that reducing malpractice rates increases access to care.2 However, profound changes have occurred in patient safety and litigation of error since the 2000 Institute of Medicine To Err is Human report was published, the effect of which may be seen partially in the decline in physician malpractice rates since 2005, a period during which NP malpractice rates have remained stable.3,4 The authors provide foundational support, using good available evidence, but the fact remains, the work raises but does not address the important questions. The nuanced relationship between clinician supervisory roles and malpractice risk remains poorly understood.


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