Healthcare workers in Africa
Africa's healthcare systems rely on services provided by midlevel healthcare workers. Investment in their training is worthwhile because they are more likely to be retained in underserved areas, require shorter training, and are less dependent on technology and investigations in their clinical practice than physicians. Their training programs and curricula need updating to be relevant to their practice and to reflect advances in healthcare professional education. This study was conducted to review the training and curricula of midlevel healthcare workers in Kenya, Nigeria, South Africa, and Uganda, to ascertain areas for improvement. Key informants from professional associations, regulatory bodies, training institutions, labor organizations, and government ministries were interviewed in each country. Policy documents and training curricula were reviewed for relevant content. Feedback was provided through stakeholder and participant meetings and comments recorded. District managers (n = 421) and midlevel healthcare workers (n = 975) from urban and rural government district health facilities completed self-administered questionnaires on midlevel healthcare worker training and performance. Qualitative data indicated commonalities in scope of practice and in training programs across the four countries, with a focus on basic diagnosis and medical treatment. Older programs tended to be more didactic in their training approach and were often lacking in resources. Significant concerns were raised about skills gaps and training quality. Nevertheless, quantitative data showed that most midlevel healthcare workers felt that their basic training was adequate for the work they do. Midlevel healthcare workers and district managers indicated that training methods needed updating with additional skills offered. Midlevel healthcare workers wanted their training to include more problem-solving approaches and practical procedures that could be lifesaving. They are essential frontline workers in health services, not just a stopgap. In Kenya, Nigeria, and Uganda, their important role is appreciated by healthcare service managers. At the same time, the countries have significant deficiencies in training program content and educational methodologies compared with programs in South Africa, which appear to have benefited from their more recent origin. Improvements to training and curricula, based on international educational developments as well as the local burden of disease, will enable these workers to function with greater effectiveness and contribute to better quality care and outcomes.
Commentary by Gerald Kayingo: Couper and colleagues investigated the curriculum and training needs of PA-like professions in four African countries.1 They found significant knowledge and skill gaps in these healthcare workers who are a major frontline component of Africa's healthcare systems. In line with previous studies, Couper and colleagues call for curricula reforms based on international educational developments as well as the local burden of disease.2 This study is relevant in an era where African healthcare systems are constrained with a double burden of communicable and noncommunicable diseases. Although African PA-like professions have been successful in managing traditional infectious diseases, they do not have the capacity to manage the rapidly growing epidemics of noncommunicable diseases.3 Curricula reforms should incorporate chronic disease models and competencies, interprofessional and team-based care, evidence-based practices, and quality and safety measures. Education and healthcare ministries should create opportunities for refresher courses, advanced training, and continuing medical education. Curricular reforms must be relevant to the societal needs and should be agile to cope with the new challenges in global healthcare. PA-like professions should not be regarded as technicians or mere medical assistants. These are professions that have been the backbone of African healthcare for the past 100 years.
1. Couper I, Ray S, Blaauw D, et al Curriculum and training needs of mid-level health workers in Africa: a situational review from Kenya, Nigeria, South Africa and Uganda. BMC Health Serv Res. 2018;18(1):553.
2. Frenk J, Chen L, Bhutta ZA, et al Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–1958.
3. Kayingo G. Task shifting and capacity building for non-communicable diseases in Uganda. Ann Global Health. 2016;82(3):370.
Buprenorphine treatment services for opioid use disorder in rural areas
The Comprehensive Addiction and Recovery Act lets NPs and PAs obtain a Drug Enforcement Administration waiver to prescribe medication-assisted treatment (MAT) for patients with opioid use disorder. This study projected the potential increase in MAT availability provided by NPs and PAs for rural patients. Using workforce and survey data, and state scope of practice regulations, the number of treatment slots that could be provided by NPs and PAs was estimated for rural areas. NPs and PAs are projected to increase the number of rural patients treated with buprenorphine by 10,777 (15.2%). Census divisions varied substantially in the number of projected new treatment slots per 10,000 population (0.8-10.6). The New England and East South Central Census divisions are projected to have the largest population-adjusted increase. NPs and PAs have considerable potential to reduce substantial MAT access disparities.1
Commentary by John E. Lopes, Jr.: According to data obtained from the 2015 National Surveys on Drug Use and Health, only 26% of patients with opioid use disorder accessed any sort of drug use treatment and only 19% used opioid-specific treatment.2 Access to MAT in rural areas is already difficult, with only 3.6% of waivered physicians practicing in rural counties.3 Of particular importance though, is the requirement included in the Comprehensive Addiction Recovery Act (CARA) that, in states where required by statute or regulation, PAs only prescribe buprenorphine under supervision or in collaboration with a qualified (waivered) physician.4 With hundreds of thousands of people with opioid use disorder lacking access to MAT, this problem continues to swell. Leaving aside the authors' assumptions, perhaps their most salient observation is that this may be an opportune time to address scope of practice laws that inhibit PAs from obtaining a waiver and prescribing buprenorphine. As Winston Churchill opined, “Never let a good crisis go to waste.”
Andrilla CHA, Patterson DG, Moore TE, et al Projected contributions of nurse practitioners and physicians assistants to buprenorphine treatment services for opioid use disorder in rural areas. Med Care Res Rev. 2018:1077558718793070.
2. Wu L, Zhu H, Swartz MS. Treatment utilization among persons with opioid use disorder in the United States. Drug Alcohol Depend. 2016;169:117–127.
3. Rosenblatt RA, Andrilla CH, Catlin M, Larson EH. Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med. 2015;13(1):23–26.
Comprehensive Addiction Recovery Act of 2016. Pub. L. 114-198. 130 Stat. 696-779. July 22, 2016. Government Printing Office.
PAs in hand surgery: The patient's perspective
The authors anonymously surveyed 939 consecutive new patients before their clinic visit. The questionnaire assessed patient perspectives toward PAs and NPs, including optimal scope of practice, choosing a hand surgeon, and pay equity for the same clinical services. Of 939 patients, 784 (84%) responded; 46% were female with a mean age of 44.1 years. Most (65%) patients consider the PA or NP training background when choosing a hand surgeon, with 31% of all patients considering PAs to have higher training than NPs and 17% the reverse. Patients responded that certain services should be physician-provided, including determining the need for MRI, follow-up for abnormal diagnostics, and new patient visits. Patients were amenable to services being PA- or NP-provided, including minor in-office procedures, preoperative teaching, and postoperative clinic visits. Patients lacked a consensus toward reimbursement equity for hand surgeons and PAs or NPs providing the same clinical services. These data suggest that patients presenting to a hand surgeon are comfortable receiving direct care from a PA or NP in many, but not all, circumstances. Hand surgeons can use these data when deciding how to use PAs and NPs to optimize patient satisfaction and practice efficiency as healthcare systems become increasingly consumer-focused and value-based.1
Commentary by Eric Barth: Meaningful attention has been paid to patients' perceptions of PAs and NPs.2-4 Despite the lack of literature specific to hand surgery, publications as recent as April 2018 can be extrapolated to this setting.2 Contrary to the authors' claims, studies investigating patient perceptions of care provided by PAs and NPs in specialty care have shown high satisfaction.2,4 Comparisons to hand surgery can be drawn from other surgical subspecialties in which PAs and NPs participate in high-volume, low-acuity practices. One study found that 89% of patients treated by PAs in urology reported either a preference to see the PA or no preference.2 Although most patient satisfaction studies are conducted after the patient has actually seen the provider, this study prospectively questioned patient perceptions and seemingly biased the participants. Hand surgeons should feel confident when integrating PAs and NPs into their practices as these professionals have a robust history of successfully complementing physicians in their practices and have earned high patient and physician satisfaction ratings across specialties.
Manning BT, Bohl DD, Luchetti TJ, et al Physician extenders in hand surgery: the patient's perspective. HAND (NY). 2018:1558944718795303.
2. Lindelow J, Birdsong H, Hepp C, et al Patient satisfaction and preferred choice of provider: advanced practice providers versus urologists. J Urol. 2018;199(4S):E299.
American Academy of PAs. Attitudes toward physician assistants: a 2014 survey by the American Academy of PAs. Methodology and partial data set, October 2014. http://www.aapa.org/wp-content/uploads/2017/01/AAPA-HarrisSurvey-Methodology-and-Tables.pdf. Accessed June 3, 2019.
4. Kurtzman ET, Barnow BS. A comparison of nurse practitioners, physician assistants, and primary care physicians' patterns of practice and quality of care in health centers. Med Care. 2017;55(6):615–622.
Comparing NPs, PAs, and physicians in the ED
This retrospective study compared NPs and PAs with physicians on their assignment of Emergency Severity Index (ESI) level 3 acute abdominal pain in ED patients. Data obtained from a large ED group staffing four hospitals yielded 12,440 deidentified adult patients diagnosed on ED admission with ESI level 3 acute abdominal pain. These data underwent descriptive analysis with logistic regression. Results revealed that the comparison of ESI level 3 acute abdominal pain diagnoses was consistent between admission and discharge: 95.3% for physicians, 92.9% for NPs and PAs, and 97.1% for NPs and PAs in collaboration with physicians (chi-square = 46.01, P < .001). Logistic regression suggested that NPs and PAs had significantly reduced odds (31%) of consistent admitting/discharge diagnoses but NPs and PAs in collaboration with physicians had significantly increased odds of consistent diagnosis (41%) compared with physicians alone. Two hospitals with similar distributions of NPs and PAs and physicians exhibited greater odds of consistent diagnoses over hospitals with disproportionate distributions, a secondary finding worth exploring. ESI level 3 acute for abdominal pain diagnoses by outcomes consisted of admissions (more than 99%), discharges (94%), and left against medical advice/transferred (98%; chi-square = 102.94, P < .001). The highest percentage of consistent ESI level 3 acute abdominal pain diagnoses made between ED admission and discharge occurred when NPs or PAs and physicians collaborated.1
Commentary by James C. Zedaker: Collaboration is an essential component of today's practice environment and is a crucial construct for optimal team practice. This is demonstrated by the statistically significant increase in diagnostic accuracy when a physician is paired with a PA or NP compared with any of these clinicians practicing alone. However, the authors appropriately identify the limitation that for the purpose of this study, PAs and NPs were considered collectively as advanced practice providers and not as separate and distinct professions. It is time to explore and compare the training, strengths, weaknesses, and limitations that each profession brings to the table to optimize the delivery of patient-centered care.
The implied effect of PAs and NPs on better patient adherence as the result of a positive patient satisfaction and experience cannot be overlooked. A retrospective analysis of patient experience research published in 2010 identified five common correlates to a positive patient experience: empathy/attitude, acceptable wait times, technical competence, pain management, and information dispensation.2 Patient adherence is positively correlated with patient satisfaction.3 PAs should bear in mind the concept of patience experience and include it as part of our training. It works and it is the right thing to do.
1. Hoyt KS, Ramirez E, Topp R, et al Comparing nurse practitioners/physician assistants and physicians in diagnosing adult abdominal pain in the emergency department. J Am Assoc Nurse Pract. 2018;30(11):655–661.
2. Welch SJ. Twenty years of patient satisfaction research applied to the emergency department: a qualitative review. Am J Med Qual. 2010;25(1):64–72.
3. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients' perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921–1931.