The global PA
Physician assistant (PA) activity was cataloged to understand what determines their use in a country's healthcare system using a mixed-method study design that began with an online search of articles; personal communications with researchers, policy makers, government officials, and practitioners in each country; author visits to several countries; and a review of official reports. Domain analyses were based on stratification of differences among countries: global region, income, physician-to-population ratio, attitudes of medical professionals, and practice/regulatory authority. Countries were segmented into two categories: well-resourced and less well-resourced. Analysis revealed that determinants for the successful incorporation of PAs include prevailing medical needs; a shortage of physicians or an aging physician workforce; support and sponsorship of physician organizations and government agencies; the ability to mobilize and establish a legal and regulatory framework to accommodate PAs; and evidence that their introduction is acceptable to patients, physicians, and other healthcare professionals. The introduction of PAs into healthcare systems occurs because their training is less expensive and less time-intensive than for physicians. In addition, PAs are more likely to work in rural and underserved areas where physicians are scarce. In most instances, a physician-dependent role permits PAs to be introduced into healthcare systems in a manner that is not threatening to physicians. The use of PAs, particularly in primary healthcare roles, increases access to services, is cost-beneficial, and shows a physician-equivalent quality of care. PAs are a remarkable healthcare workforce policy development that have spread among countries' healthcare systems and are likely to continue.1
Commentary by Donald M. and Kathy Pedersen: The global PA report is timely, comprehensive, and represents a rigorous scholarly effort. Exporting the PA model from the United States to other countries is a phenomenon that needs to be closely observed, monitored, and evaluated. The authors have begun this process by looking at both well-resourced and less well-resourced countries. Their approach was to capture determinants of success or failure of the endeavor. Timing of the effort and support from those in power (including government, medical groups, and nursing groups) seems to be an important factor for success. Countries seeking counsel from honest brokers can put efforts far ahead in their pursuit to establish a new profession. The PA profession in the United States has a stake in this global game. The “four orgs” (the American Academy of PAs, Physician Assistant Education Association, National Commission on Certification of Physician Assistants, and Accreditation Review Commission on Education for the Physician Assistant) are challenged to develop a strategy to move forward and capture an opportunity that will soon pass and then be left to opportunists with personal agendas and less-than-altruistic motivations. Seize the day, as the saying goes, seems to be operational here. The PA profession is no longer solely a US enterprise. Research on the global expansion of the PA profession is of paramount importance if other countries are to benefit from this effort. We are indebted to the authors for initiating a process of investigation and analysis. This process will enhance the recognition of a profession that aims to make the world a better place.
1. Cawley JF, Hooker RS. Determinants of physician assistant/associate concept in global health systems. Int J Healthc. 2018;4(1):50–60.
Is prescribing by PAs and NPs comparable to physician prescribing?
PAs and NPs have broad prescribing authority in the United States, yet little is known about how the quality of their prescribing practices compares with that of physicians. The quality of prescribing practices of physicians, PAs, and NPs was investigated through a serial cross-sectional analysis of the 2006–2012 National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Ambulatory care services in physician offices, hospital EDs, and outpatient departments were evaluated using a nationally representative sample of patient visits to physicians, PAs, and NPs. Main outcome measures were 13 validated outpatient quality indicators focused on pharmacologic management of chronic diseases and appropriate medication use. The study sampled 701,499 patient visits during the study period, representing about 8.3 billion visits nationwide. Physicians were the primary provider for 96.8% of all outpatient visits examined; PAs and NPs each accounted for 1.6% of these visits. The proportion of eligible visits in which quality standards were met ranged from 34.1% (angiotensin-converting enzyme inhibitor use for patients with heart failure) to 89.5% (avoidance of inappropriate medications in older adults). The median overall performance across all indicators was 58.7%. On unadjusted analyses, differences in quality of care between PAs, NPs, and physicians for each indicator did not consistently favor one practitioner type over others. After adjustment for potentially confounding patient and provider characteristics, the quality of prescribing by PAs and NPs was similar to the care delivered by physicians for 10 of the 13 indicators evaluated, and no consistent directional association was found between provider type and indicator fulfillment for the remaining measures. Although significant shortfalls exist in the quality of ambulatory prescribing across all practitioner types, the quality of care delivered by PAs, NPs, and physicians was generally comparable.1
Commentary by Denys Lau: In the NHAMCS, patient visits were selected from a sample of outpatient/EDs regardless of the care provider seen; NAMCS visits were selected from the patient log of sampled office-based physicians.1 Therefore, medications documented in NAMCS office-based visits seen by PAs or NPs may be subject to the sampled physician's supervision or initiated before the sampled visit. Because of NAMCS/NHAMCS sampling designs, almost all ambulatory visits in the study seen by PAs or NPs were from NHAMCS. However, because 2012 NHAMCS outpatient data have not been publicly released, the total number of visits in 2012 was considerably lower than all other years in the study. Additionally, the study was limited to only eight medications documented per visit to determine prescribing quality. Since then, the maximum number of medications documented per visit has increased to 30. The percentage of NAMCS visits with more than eight medications documented ranged from 8.1% to 13% over the years.2–4 Provider sampling differences between NAMCS, which substantially undersamples PAs, and NHAMCS, which more accurately samples PAs, make mixing these two data sources problematic.
1. Jiao S, Murimi IB, Stafford RS, et al Quality of prescribing by physicians, nurse practitioners, and physician assistants in the United States. Pharmacotherapy. 2018;38(4):417–427.
Centers for Disease Control and Prevention. National Center for Health Statistics. Questionnaires, datasets, and related documentation. http://www.cdc.gov/nchs/ahcd/ahcd_questionnaires.htm. Accessed July 30, 2018.
Centers for Disease Control and Prevention. National Center for Health Statistics. National Ambulatory Medical Care Survey: 2012 state and national summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2012_namcs_web_tables.pdf. Accessed July 30, 2018.
Centers for Disease Control and Prevention. National Center for Health Statistics. National Ambulatory Medical Care Survey: 2015 state and national summary tables. http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2015_namcs_web_tables.pdf. Accessed July 30, 2018.
New workforce projections for physicians, NPs, and PAs
In this study, several nursing workforce experts take a fresh look at the status of the current medical workforce and set forth projections of the head count for the time frame between 2016 and 2030. The authors note the trends of: (1) a fairly constrained (less than 1% per year) growth of the physician workforce largely due to longer training times, limited expansion of undergraduate medical education, and ongoing restrictions on the number of positions in physician residency training (GME), and (2) a robust growth of the NP (6.8% annually) and PA (4.3% annually) professions in the coming years. These new estimates project that there will be over 1 million physicians, nearly 400,000 NPs, and about 185,000 PAs by 2030. The authors discuss the effect of the expansion of the NP and PA workforce on the physician segment, noting the increasing use of teams in practices of all types and the new team-oriented staffing patterns in primary care. They observe that patients may encounter more NPs and PAs when they seek care and note the potential of NPs and PAs to deliver primary care services at a level equivalent to physician care in terms of safety and quality at a reduced cost.1
Commentary by James F. Cawley: To the casual observer, the healthcare workforce is a changing and expanding segment of the US labor force, with the major trend being the expansion and practice of NPs and PAs. The observations and projection by Auerbach and colleagues appear to be on the mark in documenting this growth from the 2000 to 2016, and take the further step of offering projections of the numbers of physicians, NPs, and PAs in the healthcare workforce by 2030. Projecting the healthcare workforce of 12 years in the future is fraught with considerable uncertainty. The authors seem more confident in their estimates of the physician workforce, reflecting that it is unlikely that the key portions of the medical education pipeline for physicians will change appreciably. Projections for NPs and PAs may be less confident due in part to uncertainties in the job market. Yet the methods and assumptions used appear reasonable and no less accurate as estimates by other groups, such as the Association of American Medical Colleges and Health Resources and Services Administration. They also assert the opinion that “greater reliance on nonphysician clinicians is unlikely to threaten quality of care or increase costs,” a proposition that is supported by the health services research literature; however, the bulk of the research here pertains mostly to primary care. These observations include the likelihood that NP and PA demand will continue to be strong given the trends of team-based and interprofessional practice, clinician competency in a wide range of medical and surgical specialties, and service to rural and medically underserved populations.
1. Auerbach DI, Staiger DO, Buerhaus PI. Growing ranks of advanced practice clinicians—implications for the physician workforce. N Engl J Med. 2018;378(25):2358–2360.
PAs in ophthalmology
A PA was integrated into an ophthalmology consult service to enhance resident education. First-year resident annual surgical logs before and after the introduction of the PA were reviewed. Residents were anonymously surveyed for their perceptions about the effect of the PA integration on their residency experience. Consult wait time was compared for residents and the PA. Internal financial metrics for the PA were reviewed for a cost scenario analysis using 2016 national salary data for PAs. The PA provided about 28 days per year of inpatient consult coverage, freeing first-year residents for alternative clinical assignments, which resulted in a 75% increase in total first-year resident annual surgical volume. Most residents (93%) strongly agreed that having a PA improved their ophthalmic education by enabling them to spend time on other clinical assignments and improving their service to education balance on the consult rotation. Adjusted median consult wait time for residents was 28 minutes longer than for the PA. A PA would likely need to see an average of 8 to 12 patients per day to be cost-neutral to a consult service. Integrating a PA into an ophthalmology consult service can optimize the resident clinical service to balance education, reduce consult wait time, and be financially feasible. PAs trained in ophthalmology present a unique opportunity for all institutions that require clinical ophthalmology expertise.1
Commentary by Wietse Wieringa: In the western world, demand for eye care is increasing during a shortage of ophthalmologists.2,3 Alternative workforces such as integrating PAs in ophthalmology are being investigated.3,4 Lee and colleagues describe the successful integration of one PA in an academic setting.1 The PA in this study was a former ophthalmologist trained in India. The interpretation and generalization of this paper is difficult. The authors state that financial feasibility was reached with 8 to 12 patient visits a day, which is a low number in a busy ophthalmic practice. The other outcome parameters are subject to interpretation and do not give information about the quality of care delivered by the PA, although the quality of eye care delivered by this PA is supposedly high. This may confirm that in order to make PAs in ophthalmology a success, an educational background in ophthalmology must be present. In the Netherlands, almost all the PAs practicing in ophthalmology were previously educated as optometrists or orthoptists. At present in the Netherlands, 50 PAs are active in ophthalmology, of a population of about 1,300 PAs and 630 ophthalmologists. This development is perceived as a good partial solution for the shortage in eye care professionals in the Netherlands.
1. Lee B, D'Souza M, Singman EL, et al Integration of a physician assistant into an ophthalmology consult service in an academic setting. Am J Ophthalmol. 2018;190:125–133.
2. Keunen JE, Verezen CA, Imhof SM, et al Increase in the demand for eye-care services in the Netherlands 2010-2020. Ned Tijdschr Geneeskd. 2011;155(41):A3461.
3. Browning DJ. Physician assistants and nurse practitioners in ophthalmology—has the time come. Am J Ophthalmol. 2018;186:ix–xi.
4. Wilson WM, White GL Jr, Murdock RT. Physician assistants in ophthalmology: a national survey. Physician Assist. 1990;14(1):57–64.