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Commentaries on health services research

Ritsema, Tamera S. MPH, MMSc, PA-C; Jackson, George L. PhD; Kuilman, Luppo MPAS; Walker, Bryan MHS, PA-C; Rick, Tara J. MPAS, PA-C

Journal of the American Academy of PAs: December 2017 - Volume 30 - Issue 12 - p 52–54
doi: 10.1097/01.JAA.0000526788.49895.c8
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Tamera S. Ritsema is an assistant professor in the PA program at George Washington University School of Medicine and Health Sciences in Washington, D.C. George L. Jackson, PhD, is a research health scientist with the Center for Health Services Research in Primary Care at the Durham (N.C.) Veterans Affairs Health Care System and an associate professor in Division of General Internal Medicine at Duke University in Durham. Luppo Kuilman is program manager of the master of science PA program at Hanze University of Applied Sciences in Groningen, Netherlands, and an adjunct professor in the PA program at Northern Arizona University in Phoenix, Ariz. Bryan Walker is associate director of the advanced practice practitioner residency program in the Division of Multiple Sclerosis and Neuroimmunology at Duke University in Durham, N.C. Tara J. Rick is an adjunct professor in the PA program at St. Catherine University in St. Paul, Minn., practices oncology at University of Minnesota Health in St. Paul, and is a board member of the Foundation for Cancer Care in Tanzania, Africa.

Richard W. Dehn, MPA, PA, DFAAPA; Roderick S. Hooker, PhD, PA; and James F. Cawley, MPH, PA-C, department editors

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Patient expectations of UK PAs

ABSTRACT

Physician associates are new to the United Kingdom and set to expand in numbers. Little is known about the patient's perspective. A qualitative study, using semistructured interviews with thematic analysis, was undertaken with 30 volunteer patients of 430 who had consulted PAs in six general practices. Patients' conditions ranged from minor illnesses to those requiring immediate hospital admission. Understanding the PA role varied from certain and correct, to uncertain, to certain and incorrect (in which the patient believed the PA to be a physician). Most, but not all, reported positive experiences and outcomes of their consultation, with some choosing to consult the physician. Those with negative experiences described problems when the limits of the role were reached, delaying prescriptions or requiring additional physician consultations. Trust and confidence were derived from trust in the National Health Service (NHS), the general practice, and the PA. Willingness to consult a PA was contingent on the patient's assessment of the severity or complexity of the problem and the desire for provider continuity. Patients saw PAs as an appropriate general practitioner substitute. Patients' experience could inform delivery redesign.1

Commentary by Tamara S. Ritsema: The PA profession in the United Kingdom is young and most Britons are unaware of their role. Halter and colleagues sought to understand how this lack of public awareness affected the satisfaction of patients with urgent care visits to general practice PAs.1 As in other countries, patients in the UK were generally satisfied with the care provided with PAs and expressed willingness to see a PA again. Unsurprisingly, patients were less satisfied when they felt deceived about the training and status of the PA than when they had been educated about PAs before the visit. Although this study is interesting, it is not an accurate reflection of PA practice in the United Kingdom at this time. Four of the 7 (57%) PAs in the study were US-trained; only 10% of PAs practicing nationwide were US-trained in 2016.2 In addition, only urgent care appointments to general practice PAs were included in this study, ignoring the contribution these PAs make to chronic disease and preventive care. Further study should include a higher percentage of UK-trained PAs and an evaluation of the role PAs play in providing the full spectrum of primary care to patients.

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REFERENCES

1. Halter MF, Drennan VM, Joly LM, et al The patients' perspective of physician associates in primary care in England: a qualitative study. Health Expect. [e-pub Feb. 28, 2017]. http://epubs.surrey.ac.uk/813646. Accessed August 1, 2017.

2. Ritsema TS. Faculty of Physician Associates Sixth Annual Census. http://www.fparcp.co.uk/download-handler/?mid=22&lid=1. Accessed August 1, 2017.

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Which provider is likely to improve outcomes in diabetes and CVD?

ABSTRACT

The objective was to compare quality of diabetes and cardiovascular disease (CVD) care between PAs and NPs and physicians in a primary care setting. The authors identified patients with diabetes (N = 1,022,588) and those with CVD (N = 1,187,035) receiving primary care between 2013 and 2014 in 130 Veterans Affairs (VA) facilities. The study also compared glycemic control (defined as a hemoglobin A1C less than 7%) in patients with diabetes, BP of less than 140/90 mm Hg patients with diabetes or CVD, cholesterol control (low-density lipoprotein cholesterol less than 100 mg/dL, receiving a statin) in patients with diabetes or CVD, and those receiving a beta-blocker (with history of myocardial infarction in the last 2 years) among patients receiving care from physicians compared with PAs and NPs. Patients with diabetes receiving care from PAs or NPs were statistically more likely to have glycemic (50% versus 51.4%) and BP control (77.5% versus 78.4%); patients receiving care from physicians were more likely to have cholesterol control (receipt of statin 68% versus 66.5%) in adjusted models, although these differences were not clinically significant. Similar results were seen in patients with CVD. Quality of care for patients with diabetes or CVD was comparable between physicians and PAs and NPs with clinically insignificant differences. Regardless of provider type, improved performance on eligible measures is needed in patients with diabetes or CVD.1

Commentary by George L. Jackson: Like many organizations, the VA healthcare system is working to optimize the roles of PAs and NPs as primary care providers (PCPs). Virani and colleagues examined the intermediate outcomes and quality of diabetes and CVD care provided to patients with an assigned attending or staff PCP compared with a PA or NP PCP.1 Drawing on multivariable logistic regression models, the study used data on separate cohorts of more than 1 million veterans with diabetes or CVD. Intermediate outcomes were based on the last single measurement obtained before the patient's final primary care visit during the study period. As one might expect with cohorts of this size, a number of statistically significant differences were found in outcome control and quality measures between patients receiving care from physicians and those receiving care from PAs or NPs. As the authors correctly note, however, these differences were not clinically significant. None of the differences in odds of control or quality care were greater than 7%. This study adds to the literature indicating that chronic illness outcomes for patients treated by physicians or PAs and NPs are generally similar.2 The study examined NPs and PAs as one group, and did not take advantage of the large size of the sample to separately examine or compare care provided by NPs and PAs.

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REFERENCES

1. Virani SS, Akeroyd JM, Ramsey DJ, et al Comparative effectiveness of outpatient cardiovascular disease and diabetes care delivery between advanced practice providers and physician providers in primary care: implications for care under the Affordable Care Act. Am Heart J. 2016;181:74–82.

2. Jackson GL, Lee SY, Edelman D, et al Employment of mid-level providers in primary care and control of diabetes. Prim Care Diabetes. 2011;5(1):25–31.

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Urology management by PAs and NPs

ABSTRACT

As the US population ages and the urologic workforce struggles to meet patient access demands, the role of PAs and NPs in the provision of all aspects of urologic care is increasing. Commonly performed urologic procedures were linked to CPT codes from 1994 to 2012. National Medicare Part B beneficiary claims were identified using Physician Supplier Procedure Summary Master Files. Trends were studied for PA, NPs, urologists, and all other providers nationally across numerous procedures spanning complexity, acuity, and technical skill set requirements. During the 18 years of annual Medicare claims, urologic procedures by PAs and NPs increased dramatically. Cystoscopy increased from 24 to 1,820 (+7,483%) annual claims, transrectal prostate biopsy from 17 to 834 (+4,806%), complex indwelling urinary catheter placement from 471 to 2,929 (+522%), urodynamic testing from 41 to 9,358 (+22,727%), and renal ultrasound from 18 to 4,500 (+24,900%). These data reinforce the expansion of the PA and NP role in urology, and support the timeliness of ongoing collaborative and multidisciplinary efforts to address unmet needs in education, training, and guideline formation to maximize access to urologic procedural services.1

Commentary by Luppo Kuilman: Should training guidelines and educational opportunities for PAs in urology be standardized? In 2013, the American Urological Association (AUA) issued a consensus statement recognizing PAs in urology as members of the urologic team, and created a membership category for PAs and NPs. About 1,200 PAs practice in urology as of 2016, performing more than procedural tasks. New evidence identifies a significant increase of PAs acting as first assistants in urosurgical procedures, compared with a decline of second surgeon assisting.2 Because the role of these PAs is expanding, one suggested direction is to collaborate with the Accreditation Council for Graduate Medical Education and create a postgraduate residency that includes PAs. Another suggestion is to upgrade these specialty studies as a third cycle of professional attainment such as a clinical doctorate. Nor should these newly acquired qualifications be considered professional suicide.3 Instead, residencies should be an incentive to further progress in a PA career.

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REFERENCES

1. Langston JP, Duszak R Jr, Orcutt VL, et al The expanding role of advanced practice providers in urologic procedural care. Urology. 2017;106:70–75.

2. Swanton AR, Alzubaidi AN, Han Y, et al Trends in operating room assistance for major urologic surgical procedures: an increasing role for advanced practice providers. Urology. 2017;106:76–81.

3. Rahr RR. The physician assistant clinical doctorate: professional suicide in the making. J Physician Assist Educ. 2009;20(2):6–7.

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Projecting the multiple sclerosis neurologist workforce

ABSTRACT

Anecdotal reports suggest shortages among neurologists who care for patients with multiple sclerosis (MS). However, little information is available about the supply of and demand for this workforce. The authors used information from neurologist and neurology resident surveys, professional organizations, and previously reported studies to develop a model assessing the projected supply and demand (that is, the expected physician visits) of those providing care for patients with MS through 2035. The capacity for patient visits among the overall neurologist workforce is forecast to increase 1% by 2025 and by 12% for 2035. However, the number of patients with MS may increase at a greater rate, potentially resulting in reduced access to timely and high-quality specialty care. Shortages in the MS workforce may be particularly acute in small cities and rural areas. Based on sensitivity analyses of the model, potential strategies to substantially adjust to this demand include increasing the number of patients seen per neurologist, offering incentives to reduce neurologist retirement rates, and expanding the number of MS fellowship positions. To ensure access to needed care and support optimal outcomes among patients with MS, policies and strategies to enhance the neurologist workforce need to be explored now.1

Commentary by Bryan Walker: Predicting healthcare workforce need remains a moving target. Multiple variables include difficulty in adequately assessing optimal treatment needed for a particular disease, estimating workforce capacity, and projecting growth of patients, providers, and technology. Based on a neurologist shortage in general, and a perceived shortage in subspecialist MS neurologists, the authors ascertain what strategies would address the shortage.2 Their strategies include increasing the involvement of PAs and NPs in MS services. Expanding their role would permit more patients and annual visits, along with improved postgraduate medical training. This then begs the questions of how many PAs and NPs work in neurology and MS specialty care, and what are the recruitment and educational needs?3,4 Certainly, this is an area ripe for collaboration.

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REFERENCES

1. Halpern MT, Kane H, Teixeira-Poit S, et al Projecting the adequacy of the multiple sclerosis neurologist workforce. Int J MS Care. [e-pub March 7, 2017]

2. Dall TM, Storm MV, Chakrabarti R, et al Supply and demand analysis of the current and future US neurology workforce. Neurology. 2013;81(5):470–478.

3. Ross SC. An option for improving access to outpatient general neurology. Neurol Clin Pract. 2014;4(5):435–440.

4. Black SB, Pearlman SB, Khoury CK. Adding an advanced practice provider to a neurology practice Introduction to outpatient and inpatient models. Neurol Clin Pract. 2016;6(6):538–542.

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Task shifting and healthcare system efficiency

ABSTRACT

Task shifting has become an increasingly strategic way to increase access to healthcare services, especially in low-resource nations. Research has demonstrated that task shifting, including the use of community health workers to deliver care, can improve population health. This systematic review investigated whether task shifting in low-income and middle-income countries improved efficiency and reduced costs. The study found substantial evidence for cost savings and efficiency improvements from task shifting related to tuberculosis and HIV/AIDS, and additional evidence for potential cost savings related to malaria, childhood illness, and other diseases, especially at the primary healthcare and community levels. The conclusion is that task shifting presents a viable option for healthcare system cost savings, especially in low-income and middle-income countries. Planners should assess whether task shifting can improve population health and healthcare systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global healthcare priorities and healthcare systems strengthening activities such as supply chain management or monitoring and evaluation.1

Commentary by Tara J. Rick: This review provides a strong argument for task shifting (better known as task transfer). Most of the research cited shifted tasks to laypersons trained to perform specific tasks, rather than from physicians to PA-like healthcare providers, which have a strong presence in many low-resource and middle-resource countries, especially in sub-Saharan Africa. PAs, NPs, certified nurse-midwives, assistant medical officers, and other providers have lower training costs, reduced training duration, and generally work in rural underserved areas with critical shortages of healthcare personnel.2 Due to widespread physician shortages and the growing mortality from noncommunicable diseases such as heart disease and cancer in low-income and middle-income countries, PAs and similar providers have a growing opportunity to increase access to quality cost-effective healthcare. This in turn can free resources to be reinvested in community health. This review identifies that more rigorous research is needed in the cost-effectiveness of task shifting to PA-like providers in low-income and middle-income countries.

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REFERENCES

1. Seidman G, Atun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. Hum Resour Health. 2017;15(1):29.

2. Mullan F, Frehywot S. Non-physician clinicians in 47 sub-Saharan African countries. Lancet. 2007;370(9605):2158–2163.

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