Simulation of ICU patients—outcomes of PAs and medical residents
Because adequate staffing in ICUs is an increasing problem worldwide, the authors investigated whether PAs are able to substitute for medical residents in ICUs with at least the same quality of clinical skills. They compared PAs' level of clinical skills with those of medical residents with 6 to 24 months of work experience in the ICU. Two scenarios involving a human patient simulator and typical ICU cases were used to compare PAs and residents practicing in the Netherlands. The 11 PAs and 10 residents in the study were videotaped and their level of clinical skills scored with predefined checklists by two independent intensivists. Total scores were calculated as percentages and means were compared by student t-test. PAs and residents scored equally well (PAs, 66% ± 13%; residents, 68% ± 9%, P = .86) on their clinical performance in the simulated ICU setting.1
Commentary by David Carpenter: The authors attempted to answer the same question asked in the United States: How to deal with the shortage of intensivists?1 Tertiary medical centers in the United States have increasingly turned to PAs.2 The study results largely validate US studies comparing PAs and residents working in the ICU in terms of patient mortality and other outcomes.3-5 The methodology is unique in that it directly compared clinical skills using simulation. Virtually identical results imply similar skills between Dutch PAs and medical residents. Yet the study also highlights the difficulty comparing medical systems in different countries. One example is training: residents in the study had 6 to 24 months of ICU experience, compared with 3 to 6 months ICU experience for residents in the United States (although the two groups have significant differences in hours worked).6 In addition, Dutch PA students spend 9 months in the ICU, significantly above US requirements. Given the differences in training systems, extrapolating the clinical skill comparison is difficult. A comparison study under the same circumstances in the United States would be interesting.
1. van Vught AJAH, van den Brink GTWJ, Hilkens MGEC, van Oers JAH. Analysis of the level of clinical skills of physician assistants tested with simulated intensive care patients. J Eval Clin Pract. 2018;24(3):580–584.
2. Pastores SM, O'Connor MF, Kleinpell RM, et al The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units. Crit Care Med. 2011;39(11):2540–2549.
3. Kleinpell RM, Ely EW, Grabenkort R. Nurse practitioners and physician assistants in the intensive care unit: an evidence-based review. Crit Care Med. 2008;36(10):2888–2897.
4. Keller J, Reed H, Wang X, Guzman J. 49: ICU outcomes of physician assistants and acute care nurse practitioners compared to resident teams. Crit Care Med. 2014;42(12):A1380–A1381.
5. Gershengorn HB, Wunsch H, Wahab R, et al Impact of nonphysician staffing on outcomes in a medical ICU. Chest. 2011;139(6):1347–1353.
Accreditation Council for Graduate Medical Education. 2017. ACGME Program Requirements for Graduate Medical Education in Internal Medicine. http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/140_internal_medicine_2017-07-01.pdf. Accessed April 24, 2019.
Does the patient-centered medical home model change staffing and use in community health centers?
Has staffing changed with the adoption of the patient-centered medical home (PCMH)? The authors compared staffing and use outcomes in 450 community health centers that had adopted a PCMH model between 2007 and 2013 with a matched sample of 243 nonadopters in the 50 states and District of Columbia. They found that adopting a PCMH model was significantly associated with a growth in use of PAs and NPs (0.53 full-time equivalent [FTE], 8.77%); other medical staff (medical assistants, nurse aides, and quality assurance staff, 1.23 FTE, 7.46%); mental health/substance abuse staff (0.73 FTE, 17.63%; P = .005); and enabling service staff (case managers and health educators, 0.36 FTE, 6.14%); but not primary care physicians or nurses. No significant increase was found in the total number of visits per year. However, the visits marginally attributed to PA or NP staff (539 FTE, 0.89%) and mental health/substance abuse staff (353 FTE, 0.59%) significantly increased. These findings suggest that the implementation of PCMH actively reengineers staff composition and this, in turn, results in changes in marginal use by each staff type.1
Commentary by David Keahey: Community health centers are mandated to address the health of communities including social determinants of health. This has resulted in a primary care model predating the PCMH by 40 years and includes interprofessional care hallmarks: longitudinally coordinated primary, dental, and behavioral services. Given this heritage, it is unsurprising that community health centers responded to PCMH incentives and that their already robust use of PAs and NPs expanded. However, the authors may have missed the forest for the trees by focusing on PCMH adoption despite the association they found. PA and NP staffing ratios were expanding well before PCMH gained traction (0.54 in 2001; 0.72 in 2012).2 Medical student disinterest in family medicine, its ever-shrinking scope, and shortages have no doubt steadily contributed to PA and NP use.3 Controlling for these coexisting variables would have strengthened the study. The NP scope of practice variable is largely superfluous (outside an obvious benefit as a hiring advantage). The reality is that PAs and NPs fill exactly the same role in community health centers regardless of states' laws on full practice authority.
1. Park J, Wu X, Frogner BK, Pittman P. Does the patient-centered medical home model change staffing and utilization in the community health centers. Med Care. 2018;56(9):784–790.
National Association of Community Health Centers. Community health center chartbook, June 2018. http://www.nachc.org/wp-content/uploads/2018/06/Chartbook_FINAL_6.20.18.pdf. Accessed April 24, 2019.
3. Coutinho AJ, Cochrane A, Stelter K, et al Comparison of intended scope of practice for family medicine residents with reported scope of practice among practicing family physicians. JAMA. 2015;314(22):2364–2372.
Full practice authority for Dutch PAs and NPs
This survey evaluated the effects of granting legal full practice authority (FPA) to NPs and PAs in the Netherlands. The performance of specified reserved medical procedures and legal cross-compliance requirements was probed. Interviews focused on competence, knowledge, skills, responsibilities, routine behavior, NP or PA role, acceptance, organizational structure, collaboration, consultation, and adherence with protocols and resources. Data collection took place between 2011 and 2015. Quantitative data included 1,251 NPs, 798 PAs, and 504 physicians. Interviews were held with 33 healthcare providers and 28 key stakeholders, and 5 focus groups (31 healthcare providers). After obtaining FPA, the proportion of NPs and PAs performing reserved procedures increased from 77% to 85% and from 86% to 93%, respectively; the proportion of procedures performed on own authority increased from 63% to 76% for NPs and from 67% to 71% for PAs. The mean number of monthly contacts between NPs and PAs and physicians about procedures decreased (from 81 to 49 and from 107 to 54, respectively), as did the mean duration in minutes (from 9.9 to 8.6 and from 8.8 to 7.4, respectively). Use of FPA depended on the setting, as physician and medical board skepticism hampered full implementation. Legal cross-compliance requirements were mostly fulfilled. Informal practice was legalized. NPs and PAs had many opportunities to independently prescribe and to perform catheterizations, injections, punctures, and small surgical procedures. Care processes were organized more efficiently, and the most appropriate healthcare provider performed the required services. This led to the recommendation to continue FPA.1
Commentary by Tara J. Rick: The PA profession in the Netherlands is relatively new (initiated in 2001) and relatively small (fewer than 1,000 PAs in a country of more than 17 million) but growing and evolving rapidly. Dutch educational and professional structures, adapted from the US model for PAs, meet the needs of the country and are similar but not identical to the US system.2 Dutch PAs were granted FPA in 2017 after a 5-year trial period, and an amendment in July 2018 granted independent practice of eight approved procedures at least in part because of the findings of this research.3 NPs and PAs still collaborate with physicians in working agreements, multidisciplinary working groups, implementing practice protocols, and working together on administration and training. In this study, most Dutch PAs achieved FPA, which was shown to increase procedural efficiency. As the United States considers FPA for its PAs, it can learn from this study.
1. De Bruijn-Geraets DP, van Eijk-Hustings YJL, Bessems-Beks MCM, et al National mixed methods evaluation of the effects of removing legal barriers to full practice authority of Dutch nurse practitioners and physician assistants. BMJ Open. 2018;8(6):e019962.
2. van den Driesschen Q, de Roo F. Physician assistants in the Netherlands. JAAPA. 2014;27(9):10–11.
Nederlandse Associatie Physician Assistants. Annual overview: NAPA in 2017. https://www.napa.nl/2018/05/jaaroverzicht-napa-2017/ Accessed April 24, 2019.
Nonadherence to guidelines on medication prescribing—how do PAs compare?
This study determined the effect of substitution of inpatient care from physicians to physician assistants (PAs) on nonadherence to guidelines on medication prescribing. A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with physicians, with wards on which only physicians provide medical care. A set of 17 quality indicators to measure nonadherence to guidelines on medication prescribing by PAs and physicians was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) or preventing obstipation in patients taking opioids. These indicators were expressed in proportions by dividing the number of patients for whom the prescriber did not adhere to a guideline by the total number of applicable patients. Multivariable regression analysis was performed to adjust for potential confounders. The study consisted of 1,021 patients from 17 hospital units (PA/physician model) and 1,286 patients from 17 hospital units (physician model). Two of the 17 quality indicators showed significantly less nonadherence to guidelines for the PA/physician model: those concerning prescribing gastric protection for patients on NSAIDs and corticosteroids (OR 0.42, 95% CI 0.19 ± 0.9) and for patients older than age 70 years taking NSAIDs (OR 0.47, 95% CI 0.23 ± 0.95). No differences between patients in the two groups were found for the other quality indicators. This study suggests that the nonadherence to guidelines on medication prescribing in units with PA/physician staffing does not differ from units with traditional staffing by physicians only. Further research is needed to determine quality, efficiency, and safety of prescribing behavior of PAs.1
Commentary by Mary Lou Brubaker: This article adds to the limited body of research on the quality of prescribing in a hospital setting by PA/physician teams compared with physicians only. It also reflects on the continuity of care by PAs in settings with rotating physicians and residents. The study found little difference in prescribing behaviors for the 17 indicators developed by consensus.1 An older workforce study reviewed the prescribing habits of PAs and NPs compared with physicians.2 This study found similar numbers of prescriptions by all three groups but noted subtle differences in the type of prescriptions written by primary care providers in metropolitan areas compared with those in nonmetropolitan areas.2 A recent serial cross-sectional analysis of the 2006-2012 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey found numerous studies on the equivalent quality of care by PAs and NPs in ambulatory settings compared with physicians.3 However, the question of prescribing quality had not been directly studied in the United States. This study used indicators developed by the Institute of Medicine. Although these studies demonstrated little differences between the prescribing quantity and quality of physicians, PAs, and NPs, it did uncover a concern for quality of prescribing across all groups.1,3 An average of 25.9% (median 15.5%, SD 31.8%) of the time guidelines in the Bos and colleagues study were not followed.1 Prescribing practice indicators were not met 35.8% of the time in the Jiao and colleagues study.3 This highlights an area of concern involving patient care warranting further evaluation and collaboration.
1. Bos JM, Timmermans MJC, Kalkman GA, et al The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing. PLoS One. 2018;13(8):e0202626.
2. Hooker RS, Cipher DJ. Physician assistant and nurse practitioner prescribing: 1997-2002. J Rural Health. 2005;21(4):355–360.
3. 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.