Americans increasingly want to obtain healthcare services when it is convenient for them, a trend that has led to the development of new clinical specialties.1-4 Urgent care as a clinical specialty has emerged from this demand for convenience. Urgent care sits between emergency medicine and primary care. The American Academy of Urgent Care Medicine (AAUCM) defines urgent care medicine as the “provision of immediate medical service offering outpatient care for the treatment of acute and chronic illness and injury.”5 Providers who practice urgent care typically provide immediate outpatient care for urgent acute or subacute conditions such as minor injury, viral illness, rashes, sexually transmitted infections, and acute exacerbation of chronic diseases such as asthma.4 Urgent care providers generally do not provide longitudinal care for chronic illness, and do not conduct resuscitations or provide trauma care.5,6
Unlike EDs, urgent care centers typically do not have equipment and staff to perform complex serologic testing, CT scans, MRIs, or ultrasound. They also are not set up to perform interventions such as intubation, chest tubes, open fracture reduction, cardiac catheterization, or thrombolysis.5
Although freestanding urgent care centers are the most common setting, urgent care services also are provided in primary care clinics, EDs, retail clinics, and at student health centers.6,7 In urgent care centers in EDs, patients are triaged to urgent care or the main ED based on severity of illness and the number and type of resources required to evaluate the patient's symptoms.8,9
Urgent care services are provided by physicians, physician assistants (PAs), and NPs regardless of setting.4 A 2009 study found that 74.5% of all urgent care centers employed family physicians and 46.7% of urgent care centers employed emergency physicians.3 Grouped together, PAs and NPs were used by 52.9% of the centers.3
No research has been published on the contribution of PAs to the urgent care workforce. This article uses a national survey of PAs to describe the characteristics of these PAs and their practice compared with PAs in emergency medicine and PAs in all other specialties. This initial look at this professional subgroup may serve as a starting point for future research into the contributions of PAs to the urgent care workforce.
METHODS
A brief historical look at the trends for PAs in emergency medicine and primary care was developed using publically accessible AAPA census data.10 A national cross-sectional survey of the estimated 101,000 practicing PAs was conducted by AAPA in 2016. A total of 89,228 PAs and PA students in AAPA's database who had not opted out of communication from AAPA were based in the United States, and were not identified as retired were invited to participate in the survey. A total of 14,609 PAs across all specialties responded, yielding a response rate of 16.4% and a margin of error of ±0.72% at the 95% confidence level. Respondents were compared with the known population by comparing the sample characteristics of respondents with data collected on all certified PAs by the National Commission on the Certification of Physician Assistants.11 The percentages of respondents and the known PA population were within the overall survey margin of error on unchanging variables such as sex and calculated age and showed little variance on those that may change over time, including location and specialties. Because the two groups are similar, the low response rate may not impede the generalizability of the findings. Current data, as well as historic trend data from past AAPA census studies and national surveys on the PA workforce, are presented.
The data were analyzed based on the primary practice specialty indicated by respondents. Three groups were created from the data: PAs who primarily practice in urgent care, PAs who primarily practice in emergency medicine, and PAs who primarily practice in any other specialty. Finally, the practice characteristics included variables that the authors understood to be specialty-dependent and relevant to emergency medicine and urgent care.
Analyses included chi-square and tests of column proportions to determine between-group differences. When scale variables were used, t-tests were selected to determine between-group differences.
RESULTS
Although the percentage of PAs who practice emergency medicine is relatively unchanged since 1998, with fluctuations from 8.9% to 10.4% of all PAs, the percentage of PAs who chose urgent care as their practice setting has doubled in that time. Between 2.5% and 3.6% of all PAs chose urgent care as their practice setting throughout the 1990s and 2000s. However, in 2014 and 2015 these numbers increased to above 5% (Figure 1).
;)
FIGURE 1.: Percentage of PAs practicing in urgent care and ED settings from 1998 to 2015
PAs who practice emergency medicine are significantly more likely to be men (44%), compared with PAs in urgent care (35.5%) and PAs in all other specialties combined (29.4%). PAs in emergency medicine are also significantly more likely to be men than those who practice urgent care (P < .001).
About 40% of PAs who practice emergency medicine graduated from PA school less than 5 years ago compared with 32.6% of those who practice urgent care and 32.4% of those in all other specialties combined (P < .001). In terms of location, PAs in urgent care (21%) and PAs in emergency medicine (18%) were more likely to be working in a rural setting compared with PAs in all other specialties combined (14.2%) (P < .001) (Table 1).
TABLE 1.: Characteristics of PAs in urgent care and emergency medicine in 2015
PAs in urgent care work significantly longer shifts (mean = 10.6 hours) than PAs who do not practice urgent care or emergency medicine (mean = 9.3 hours; P < .001). PAs in urgent care see more patients per week (mean = 91.9) for their primary employer than those in emergency medicine (mean = 73.1) and those in all other specialties combined (mean = 65.7; P < .001). PAs in urgent care spend significantly less time consulting with physicians about the care that they provide (mean = 7.4% of their work week) than those in either emergency medicine (mean = 19.8%) or all other specialties combined (mean = 19.1%, P < .001). PAs in emergency medicine received higher compensation (mean = $106,877) than did PAs in urgent care (mean = $100,804) or all other specialties (mean = $99,194; P < .001) (Table 2).
TABLE 2.: Employment characteristics of PAs in 2015
PAs in urgent care perform more procedures (82.3%) than both PAs in emergency medicine (69.2%) and PAs in all other specialties (58.7%; P < .001). PAs in emergency medicine (17.6%) were more likely to supervise other PAs than PAs in urgent care (13.4%) and those in all other specialties (12.5%; P < .01). PAs in urgent care (19%) were more likely to supervise clinical staff other than PAs compared with PAs in emergency medicine (8.4%) but were as likely to supervise clinical staff other than PAs as those in other specialties (17.5%; P < .001). The same holds true for supervising nonclinical staff: PAs in urgent care (12.9%) differed from PAs in emergency medicine (3.9%) but not from all other PAs (12.3%; P < .001).
Finally, PAs in urgent care were less likely to precept PA students of any type, with only 34% acting as preceptors, compared with 62.1% in emergency medicine and 47.1% of all other specialties (P < .001). PAs in urgent care also were less likely to precept students in other healthcare professions: 28.7%, compared with 37.2% of PAs in emergency medicine, and 37.4% of all other PAs acting as preceptors for these students (P < .001) (Table 3).
TABLE 3.: Tasks completed by PAs in urgent care and emergency medicine in 2015
Eighty-eight percent of PAs in urgent care reported that their collaborating physician only saw their patients when the PA asked (as opposed to seeing all or a portion of the PA's patients), compared with 59.4% of PAs in emergency medicine and 50.8% of all other PAs (P < .001) (Table 4).
TABLE 4.: Proportion of patients seen by collaborating physician for PAs in 2015
DISCUSSION
Urgent care is a fast-growing setting for clinical practice for PAs and physicians. The Urgent Care Association of America reports a 13.6% increase in the number of urgent care centers in the United States from 2014 to 2016.7 In addition, the number of EDs is decreasing while the number of visits for emergency care is increasing.12 These factors, combined with powerful financial incentives from insurance companies for patients to go to urgent care centers rather than EDs, increase demand for urgent care services.13 Unsurprisingly, these new centers need staff. Our data reflect this increasing demand. The percentage of PAs who report their primary work setting was urgent care has increased from 2.5% in 2009 to 5.1% in 2015, consistent with the increase in the number of urgent care centers opening across the same time frame. PAs are a good fit for urgent care centers with their generalist medical background and the emphasis in PA programs on teaching procedural skills such as suturing, incision and drainage, and gynecologic procedures often in demand in urgent care centers. In addition, because PAs typically are paid less than half of what physicians are paid, and urgent care centers often are structured on a for-profit model, including PAs in the staffing of an urgent care center makes financial sense.14
The personal characteristics of PAs in urgent care deserve comment. PAs in urgent care are less likely to be men than PAs in emergency medicine, but more likely to be men than PAs in the “all other specialties” category. This finding seems consistent with the practice of urgent care, which often is considered a mix between the lower-acuity end of emergency medicine practice (which is more often undertaken by men) and primary care (which is more commonly practiced by women). This survey does not provide data regarding why women choose urgent care more often, so further research is needed.
Anecdotally, PA students perceive that it is difficult to get a job in emergency medicine either as a new graduate or as a second job early in their career. We found that new graduates (those with less than 1 year of experience) were more likely to be working in emergency medicine than in urgent care or in the “all other PA specialties” group. When comparing all levels of experience, early-career PAs (those with less than 5 years' experience) were more likely to be practicing emergency medicine than urgent care or other specialties. Part of the explanation may lie in the number of PAs in emergency medicine who have completed an emergency medicine postgraduate training program. PAs in emergency medicine are substantially more likely to have completed a PA residency. As most of these residencies have developed in the last 10 years, the availability of these training programs may be contributing to the number of early-career PAs who are successful in finding jobs in emergency medicine. However, the Association of Postgraduate PA programs lists only 21 PA residency programs in emergency medicine, and each of these programs only enroll between one and six residents per year.15
As has been reported in the past, PAs in emergency medicine are among the best-compensated nonsurgical PAs.16 This finding is consistent with those in the physician compensation literature for emergency medicine. With the high acuity of care provided in the ED, insurance companies reimburse emergency physicians well. The average physician in emergency medicine made $322,000 in 2016, about three times the $106,877 average salary for a PA in emergency medicine in 2015.17 PAs in urgent care make about the same amount as those in other specialties ($100,804 versus $99,194). Unsurprisingly, given the lower acuity of urgent care patients, PAs in urgent care see more patients per week than do PAs in emergency medicine. The lower acuity of urgent care patients also likely accounts, at least in part, for the lower salary of PAs in urgent care, as insurance reimbursement for care provided to lower-acuity patients is less than for high-acuity patients.
The scope of job responsibilities undertaken by PAs who practice urgent care in some respects is more like that of PAs in emergency medicine and in other respects is more like those who practice other specialties (Table 3). PAs in urgent care and in all other specialties are more likely to supervise non-PA clinical staff than those in emergency medicine, possibly reflecting the more clinic-like atmosphere of an urgent care center. PAs in urgent care are less likely to precept PA students than are PAs in emergency medicine. The most likely explanation for this is that the Accreditation Review Commission on Education for the Physician Assistant requires that all PA students complete training in emergency medicine. The standards, however, are clear that urgent care is not an acceptable substitute for an ED experience.18
PAs who practice urgent care are by far the most likely to be performing minor surgical procedures; 82.3% of PAs in urgent care conduct minor surgeries, compared with 69.2% of PAs in emergency medicine and 58.7% of all PAs. In this way, PAs in urgent care are more like those in emergency medicine than all other PAs combined. That PAs in urgent care perform the highest percentage of minor surgical procedures is unsurprising when the scope of practice of urgent care medicine is concerned.
Finally, PAs in urgent care are the least likely of all types of PAs to have their patients seen by a physician during the course of the visit (Table 4). This finding is unsurprising because high-acuity patients do not stay in urgent care but are transferred to the ED. The relatively low acuity and repetitive nature of urgent care complaints (for example, upper respiratory infections, sprains, fractures, lacerations, and urinary tract infections) means that PAs are well equipped to handle these patients without further input.19
LIMITATIONS
The low survey response rate is a significant limitation. Obtaining a high response rate is difficult when attempting to survey nearly 90,000 people. However, the 2017 survey yielded more than 14,000 responses, which provide statistical power to detect differences. Also, the consistency of the results with past AAPA surveys increases our confidence that for those who responded, the data are likely to be accurate. With the large sample and a corresponding low margin of error, we are confident that the data accurately represent the sample. Survey research has some inherent limitations. Respondents were free to answer or not answer questions at will. This variability may lead to nonresponse error across variables. In addition, although a few respondents may have intentionally provided false data, the large number of respondents means that an erroneous individual response will not influence the results in any meaningful way. Finally, we cannot detect subtle differences in practice in a survey like this. Some PAs in urgent care may primarily see insured patients. Some may serve high-need populations. Some may never see patients with psychiatric or ophthalmologic complaints. This survey is not granular enough to detect these differences.
CONCLUSION
Urgent care is growing as a specialty for PAs. Many characteristics of PA practice in urgent care appear to be a combination of emergency medicine and primary care practice. Further research is needed to understand why PAs choose urgent care as a specialty and to discover which factors influence PA satisfaction with urgent care practice.
REFERENCES
1. Advisory Board Company. Wait times and patient satisfaction: perception is reality.
www.advisory.com/research/medical-group-strategy-council/practice-notes/2014/october/wait-times. Accessed April 23, 2018.
2. Mehrotra A. The convenience revolution for treatment of low-acuity conditions.
JAMA. 2013;310(1):35–36.
3. Weinick RM, Bristol SJ, DesRoches CM. Urgent care centers in the U.S.: findings from a national survey.
BMC Health Serv Res. 2009;9(1):79.
4. Weinick RM, Burns RM, Mehrotra A. Many emergency department visits could be managed at urgent care centers and retail clinics.
Health Aff (Millwood). 2010;29(9):1630–1636.
5. American Academy of Urgent Care Medicine. What is urgent care medicine?
https://aaucm.org/what-is-urgent-care-medicine. Accessed April 23, 2018.
6. Yee T, Lechner AE, Boukus ER. The surge in urgent care centers: emergency department alternative or costly convenience? Center for Studying Health System Change. Research brief 26. July 2013.
www.researchgate.net/profile/Tracy_Yee/publication/257202014_The_surge_in_urgent_care_centers_emergency_department_alternative_or_costly_convenience/links/5750682008aed9fa2bd2d531.pdf. Accessed April 23, 2018.
7. Stoimenoff L, Newman N. The essential role of the urgent care center in population health.
https://ucaoa.site-ym.com/?whitepaper. Accessed May 8, 2018.
8. Sanchez M, Smally AJ, Grant RJ, Jacobs LM. Effects of a fast-track area on emergency department performance.
J Emerg Med. 2006;31(1):117–120.
9. Merritt B, Naamon E, Morris SA. The influence of an urgent care center on the frequency of ED visits in an urban hospital setting.
Am J Emerg Med. 2000;18(2):123–125.
10. American Academy of Physician Assistants. Research archives census reports.
www.aapa.org/research/research-archives. Accessed April 23, 2018.
11. National Commission on Certification of Physician Assistants. 2015 statistical profile of certified physician assistants.
https://prodcmsstoragesa.blob.core.windows.net/uploads/files/2015StatisticalProfileofCertifiedPhysicianAssistants.pdf. Accessed May 8, 2018.
12. Institute of Medicine. IOM report: the future of emergency care in the United States Health System.
Acad Emerg Med. 2006;13(10):1081–1085.
13. McNeeley S. Urgent care centers: an overview.
Am J Clin Med. 2012;9(2):80–81.
14. Hollander JE, Pines JM. Urgent care centers: an alternative to unscheduled primary care and emergency department care. In:
Value and Quality Innovations in Acute and Emergency Care. 1st ed. Cambridge, United Kingdom: Cambridge University Press; 2017:118–130.
15. Associate of Postgraduate PA Programs. Post Graduate PA Programs Listings by specialty or state.
http://appap.org/post-graduate-pa-programs/programs. Accessed April 23, 2018.
16. American Academy of PAs. AAPA 2016 salary report.
www.aapa.org/shop/salary-report. Accessed May 8, 2018.
17. Peckham C. Medscape physician compensation report 2016.
www.medscape.com/features/slideshow/compensation/2016/public/overview#page=2. Accessed April 23, 2018.
18. Accreditation Review Commission on Education for the Physician Assistant. Standards of accreditation.
www.arc-pa.org/accreditation/standards-of-accreditation. Accessed April 23, 2018.
19. Mehrotra A, Wang MC, Lave JR, et al. Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits.
Health Aff (Millwood). 2008;27(5):1272–1282.
