Circumcision by clinical associates
Voluntary medical male circumcision reduces the acquisition of HIV in heterosexual men by up to 60%. One HIV infection is averted for every 5 to 15 circumcisions. Large numbers of trained healthcare professionals are needed to perform this procedure. To bridge this gap, South Africa has clinical associates. This retrospective study assessed the ability of clinical associates to perform circumcisions of adequate quality and to meet the demands of circumcision in a population with a high HIV burden. Patient files (N = 4,850) of surgical circumcisions conducted over 16 months were reviewed; 88.66% of the procedures were performed by clinical associates and the remaining 11.34% by physicians. The number of adverse reactions did not differ between the two groups. Data on intraoperative adverse reactions were available for 4,738 patients. Of these, 7.2% experienced intraoperative adverse reactions. Clinical associates performed circumcisions in shorter times (14.63 minutes) compared with physicians (15.25 minutes). Recorded pain, bleeding, swelling, infection, and wound destruction did not differ between patients circumcised by clinical associates and those circumcised by physicians. Clinical associates can help address the demand for circumcisions and have results comparable to circumcisions performed by physicians.1
Commentary by Todd Doran: Circumcision has been lauded as a public health solution to reduce HIV transmission by as much as 60%. The challenge in scaling up this intervention in sub-Saharan Africa has been to develop the appropriate medical infrastructure to perform the necessary procedures.1,2 Ngo is the first to report on a 3-month history (2008) of mainly nurses performing a forceps technique circumcision with a 3% moderate to severe complication rate signifying the need for medical or surgical intervention. The Ngcobo article expands on work demonstrating that clinical associates in South Africa performed 88.7% of the circumcisions compared with physicians in a rural region with 12.3% fewer adverse reactions and 11% faster average time in a population including patients with HIV and diabetes. Physicians performed more procedures in patients with phimosis or paraphimosis but the number accounted for fewer than 1.6% of the total cases. The type of technique is omitted from the study and may have affected the complication rate.3
1. Ngcobo S, Wolvaardt JE, Bac M, Webb E. The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: A retrospective analysis. PLoS One. 2018;13(1):e0190795.
2. Ngo TD, Obhai G. Male circumcision uptake, postoperative complications, and satisfaction associated with mid-level providers in rural Kenya. HIV AIDS (Auckl). 2012;4:37–43.
3. Feldblum P, Martinson N, Bvulani B, et al Safety and efficacy of the PrePex male circumcision device: results from pilot implementation studies in Mozambique, South Africa, and Zambia. J Acquir Immune Defic Syndr. 2016;72(suppl 1):S43–S48.
PAs in hospital medicine: An expanded role or just more PAs?
The authors wanted to determine whether a higher than conventional PA-to-physician hospitalist staffing ratio could achieve similar clinical outcomes for inpatients at a community hospital. A retrospective cohort study compared hospitalist groups at a 384-bed community hospital. One group (“expanded PA”) had a high PA-to-physician ratio model, with three physicians and three PAs; the PAs rounded on 14 patients a day (35.7% of all visits). The other group (“conventional”) had a low PA-to-physician ratio model, with nine physicians and two PAs; the PAs rounded on nine patients a day (5.9% of all visits). For 16,964 adult patients discharged by the hospitalist groups with a medical principal APR-DRG code between 2012 and 2013, in-hospital mortality, cost of care, readmissions, length of stay (LOS), and consultant use were analyzed using logistic regression and adjusted for age, insurance status, severity of illness, and mortality risk. No statistically significant differences were found between the two groups for in-hospital mortality, readmissions, LOS (effect size 0.99 days shorter LOS in expanded PA group), or consultant use. Cost of care was less in the expanded PA group (effect size 3.52% less; estimated cost $2,644 versus $2,724). An expanded PA hospitalist-staffing model at a community hospital provided similar outcomes at a lower cost of care.
Commentary by Richard Rohrs: As a practicing PA and an administrator with more than 4 decades of hospital medicine experience, I was excited to read this article comparing outcomes when using a broader scope for inpatient PAs. Over my administrative career, I witnessed PAs become more autonomous providers who evolved from a task-oriented role to that of true patient management. Unfortunately, we have had very little research to support this evolution, so what the authors proposed heightened my anticipation. Although I am quite pleased with the outcomes presented, I have to question if indeed there was true differentiation between the two models compared. The number of PAs in each group was clearly distinct but the very explicit collaboration protocol outline in Table 2 of the study tempered my enthusiasm. I fully support PAs having physician support always available but the model, at least on paper, suggests a much more limited approach to true PA autonomy, with key decisions remaining under the purview of the physician.
1. Capstack TM, Segujja C, Vollono L, et al A comparison of conventional and expanded physician assistant staffing models at a community hospital. JCOM. 2016;23:455–461.
Hospital credentialing of PAs and NPs in the United States
As US hospitals' interest in PAs and NPs grows, their leadership is eager to know how their medical staffing privileging policies for these professionals compare with peer hospitals. The authors assessed the variation of these policies in four clinical areas and examined whether the differences are associated with state scope of practice laws for PAs and NPs. They also examined the relationship of PA and NP privileging policies to each other and found no evidence that hospital privileging is associated with state scope of practice; indeed, variation within a state is more significant than cross-state variation. A strong correlation was found between PA and NP privileging in all four clinical areas. These results suggest the need for additional research to understand the institutional-level variables and human dynamics at the level of medical staffing committees that may explain the dramatic variation in privileging policies. Ultimately, the effects of different privileging levels on costs and quality need to be assessed.1
Commentary by Roderick S. Hooker: The United States has nearly 4,000 civilian hospitals, as well as 153 VA and 42 military medical centers amounting to 2.8 beds per 1,000 people. The United States ranks 37th in number of beds per capita, with Japan at the top with 13.2/1,000.2 Although the United States has a low bed ratio compared with 36 other well-resourced nations, it still suffers from medical staffing shortages. Medical postgraduate programs are the labor source for house staff and their salaries are funded through Medicare. Although Medicare covers most of the cost that teaching hospitals spend on training medical residents, the Balanced Budget Act of 1997 capped the number of residency slots the federal government would fund. The shortfall (what is not covered by the federal government) is paid by the hospitals where residents train. Although hospitals can increase the number of residents, they must fund the entire cost of those additional training positions.
Not surprising, hospitals are interested in learning how their PA and NP privileging policies compare with those of peer hospitals. The Pittman group found wide variation in privileging policies for PAs and NPs at the hospital level and no evidence that scope of practice laws are associated with privileging policies.1 If hospitals are to understand this rising cadre of new house staff, a modern approach is needed to understand how they are employed and what they do.
Pittman P, Leach B, Everett C, et al NP and PA privileging in acute care settings: do scope of practice laws matter. Med Care Res Rev. [e-pub Feb. 1, 2018].
Organisation for Economic Co-operation and Development. OECD stat. stats.oecd.org. Accessed April 16, 2018.
What the data can't tell us: Comparing apples and oranges
Clinical practice guidelines do not recommend systemic corticosteroids for treating acute respiratory tract infections. Although some studies have shown earlier symptom resolution in patients given corticosteroids for pharyngitis, clinical trials show no efficacy of systemic corticosteroids for sinusitis and bronchitis. This study examined the frequency of corticosteroid use for acute respiratory tract infections in Louisiana and nationally and examined factors associated with this clinical practice. The authors conducted a retrospective observational study of adults who had outpatient ambulatory care encounters that included a diagnosis of acute respiratory tract infection through Ochsner Health System primary care clinics in 2014 and also as reported in the National Ambulatory Medical Care Survey (NAMCS) in 2012 to 2013. The main outcome for the Ochsner Health System analysis was corticosteroid injection and for the NAMCS analysis was a steroid prescription. They chose corticosteroid injection usage because they anecdotally observed that this was common practice in the southeast United States. The NAMCS database does not query for IM injections used in outpatient encounters; for this reason, the authors chose systemic oral corticosteroid prescriptions. The NAMCS data results showed that almost 11% of adult outpatient encounters for acute respiratory tract infections included a corticosteroid prescription. Multivariate analysis found significantly higher odds for corticosteroid prescriptions among patients with a medical history of chronic obstructive pulmonary disease (COPD) or asthma, visit diagnosis of bronchitis, and an encounter with an NP or PA. The Ochsner data results showed that 23% of adult primary care encounters for acute respiratory tract infection included corticosteroid injections. In multivariate analysis, odds for steroid injection were significantly higher among patients with a medical history of COPD; visit diagnoses of sinusitis or otitis, allergic rhinitis, upper respiratory infection, or bronchitis; and encounters with an NP. Odds for corticosteroid injection were lower among encounters with patients who were nonwhite or Medicaid or Medicare insured, had medical history of diabetes and/or osteoporosis, had been seen by a PA, and had a visit diagnosis of pneumonia. This study revealed high rates of systemic corticosteroid use among patients with acute respiratory tract infections in Louisiana and nationally.1
Commentary by Richard W. Dehn: Few articles directly compare differences in treatment and/or outcomes between PAs, NPs, and physicians. Two publications have demonstrated comparable outcomes in the treatment of patients with type 2 diabetes whether the provider is a physician, PA, or NP.2,3 Useful studies would be those that compare patient outcomes between providers. This study, however, compares provider treatments rather than outcomes, and includes the analysis and comparison of two independent data sets, the NAMCS data and the data from the Ochsner Health System. The NAMCS data appear to only include oral corticosteroid treatment, and the Ochsner data only included injected corticosteroid treatment. Thus, the investigators were apparently trying to determine the overall rate of corticosteroid treatment for acute respiratory tract infections by measuring and comparing the rate of two different corticosteroid treatments calculated from two different independent sets of data in different years. This unorthodox research method, although possibly useful in determining an estimated frequency of the treatments, is unlikely to provide valid additional detailed insight into the use of overall corticosteroid use in treating these infections. Additionally, NAMCS data likely underreport PA and NP visits and overreport physician visits.4 Unfortunately, methodologic shortcomings such as these limit this study's usefulness in describing provider differences in the treatment of acute respiratory tract infection. More and better quality studies are needed to help understand the differences between physicians, PAs, and NPs and their most effective use in today's complicated healthcare delivery system.
1. Dvorin EL, Lamb MC, Monlezun DJ, et al High frequency of systemic corticosteroid use for acute respiratory tract illnesses in ambulatory settings. JAMA Intern Med. 2018;178(6):852–854.
2. Morgan P, Everett CM, Smith VA, et al Factors associated with having a physician, nurse practitioner, or physician assistant as primary care provider for veterans with diabetes mellitus. Inquiry. 2017;54:46958017712762.
3. 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.
4. Morgan PA, Strand J, Østbye T, Albanese MA. Missing in action: care by physician assistants and nurse practitioners in national health surveys. Health Serv Res. 2007;42(5):2022–2037.