The US Census Bureau estimates that by 2030, when all Baby Boomers (persons born between 1946 and 1964) will be over age 65 years, 20.3% of the US population will be over age 65 years, up from 13.7% in 2012.1 The shiftin the proportion of the US population over 65 creates an obvious concern about healthcare demand.2 Those interested in US healthcare systems, such as researchers, administrators, and clinicians, are acutely aware of the rapid growth in population of older adults; as early as 2002, researchers were examining the importance of meeting the challenges of the “2030 problem.”3
Seventy-five percent of patients with multiple chronic conditions are age 65 years or older.4 Stanton and Rutherford estimated in 2005 that the cost associated with treating patients with multiple chronic conditions was up to seven times as much as treating patients with only one chronic condition.5 In terms of Medicare spending per capita in 2015, for patients with zero or one chronic condition, spending was $1,867; for patients with six or more conditions, spending was $32,136.6 Increased frequency of medical appointments and hospital readmissions are in part driving the high cost of caring for patients with multiple chronic conditions. In 2014, of patients with zero to one chronic condition, only 4% had 13 or more physician visits per year. In contrast, 46% of patients with six or more chronic conditions visited their physician 13 or more times.7 Because multiple chronic conditions are more prevalent in adults age 65 years and older, this age group also is one of the costliest. Across age categories in 2014, adults age 65 years and older made up the smallest percentage of the total population (15.1%) yet accounted for 33.6% of the total healthcare spending in the United States.8 Research has shown that healthcare costs can be reduced through effective care-coordination strategies.9-11
PAs are uniquely trained to meet the needs of the aging population through their generalist medical training and focus on collaborative care. Very little is known about the overall characteristics of the patient populations cared for by PAs. Within the microcosm of the Veterans Administration (VA), patients with diabetes seen by PAs have been shown to have similar outcomes to patients seen by other types of providers.12 In a separate study of VA patients, PAs saw patients with similar complexity compared with physicians and NPs, and in fact saw more new patients with higher complexity.13 Patients in rural areas with cancer had 57% higher odds of receiving care from PAs than physicians.14 PAs are as or more effective as physicians when caring for older adults.15,16 Other researchers suggest that as the existing physician workforce ages, PAs can meet the growing demand for healthcare providers.17,18
This study sought to gain general insights into the patients PAs are working with to determine if PAs are experienced working with older adults or patients with complex medical needs.
Sampling and participants
Exactly 15,106 US-based, nonretired PAs as well as PA students who had not opted out of contact with the American Academy of PAs (AAPA) research department were contacted by email. Of these, 10,682 were a random sample of PA members and nonmembers of AAPA, representing every major specialty area and work setting. PAs and PA students were solicited to complete a survey on their practice or education; this study reports data from PA respondents. The sample size was established to ensure at least 600 responses would be obtained, for a 4% margin of error at the 95% confidence level. Half the sample was contacted via email in August 2017 and the other half in November 2017. In total, 676 responses were received from PAs, for a 6.3% response rate with an overall margin of error of 3.76% at the 95% confidence level. The study was exempt from institutional review board review.
To assess the representativeness of the sample, the respondents were compared with data from the National Commission on Certification of Physician Assistants (NCCPA), which has characteristics of more than 123,000 PAs in its 2018 report.19 Little variation was found across practice and professional demographics of the sample compared with the nationwide population of PAs, although women were slightly overrepresented (Table 1).
The survey included questions about personal and practice demographics, patients and prescribing, and measures of career satisfaction, questions that have been used by AAPA for many years. The present research focuses on the subset of data collected that included types of patients seen: the percentage of patients of different age groups, number of patient comorbidities, conditions PAs were treating, and what percentage of patients were medically complex, had socioeconomic challenges, have mental illness, or exhibit difficult behaviors or traits.
Although less than 2% of PAs reported geriatrics as their primary specialty, 92% reported that they see patients over age 65 years. When asked to report what percentage of their patients have characteristics related to patient complexity, results indicated that PAs frequently see complex patients: A mean of 54.8% of patients suffer three or more comorbidities, and 52.8% of patients were reported as medically complex (Tables 2 and 3).
Most PAs, though they may not specialize in geriatrics, reported that they treat patients for a variety of conditions that become more common as patients age.20 These conditions include hypertension (86.9%), osteoarthritis (82.1%), type 2 diabetes (86.9%), and chronic obstructive pulmonary disorder (COPD) (75.7%) (Table 3).
This study shows that PAs are caring for patients with multiple and complex medical conditions. Earlier research showed that a small portion (less than 1%) of PAs in the United States worked in geriatrics as their primary focus, and less than 2% of all PAs reported geriatrics as a secondary focus of their practice; 7% of PA students expressed interest in working in geriatrics.21 This study found that PAs are working directly with patients over age 65 years as well as patients with complex medical needs, and should be considered a part of the solution to prepare for the increased healthcare needs of older adults.
Efforts to increase the numbers of PAs in geriatrics would likely have a substantial effect on increased coordination of care for older adults with multiple chronic conditions. Continuing to prepare PA students during the formal training period of PA school to care for older adults and those with multiple comorbidities is essential. Lifelong learning efforts, including continuing medical education activities, should be supported to ensure that clinically practicing PAs remain prepared to care for older adults and those with complex medical histories. PAs should be recognized as one potential solution to meet the workforce needs of medically complex patients and older adults. Practice laws should provide an opportunity for PAs to contribute, unencumbered, to the care of older adults and patients who are considered medically complex.
Future research may focus on the different roles PAs serve in and outside of geriatrics. In addition, research on healthcare team composition may allow systems to formulate ideal teams for efficient and effective care for complex and aging patients.
This study has several limitations, beginning with the low response rate that may limit the data's generalizability. The sample in the current study was representative of specialty, experience, and work setting demographics of the PA profession, increasing our confidence in the representativeness and generalizability of the data, although women were slightly overrepresented.19
Another limitation is the self-reported and recall nature of the data, relying on the accuracy of PAs' memories. In addition, we do not have a measure of the frequency with which PAs are working with the different patient populations nor of the overlap between age, complexity, and conditions treated. Future research could potentially examine electronic health records data to verify these questions of interest. However, such studies pose logistic and ethical considerations, such as privacy concerns for patients.
This study was an initial examination of PA work with an aging population and with patients with complex medical conditions. As the population in the United States ages, strategies must be developed and implemented to increase the healthcare workforce prepared to care for older adults. PAs provide care to older adults and patients with multiple chronic conditions, although future research is needed to determine the scope of this work. In addition, opportunities should be provided through continuing medical education and other postgraduate educational opportunities, including education on the issues unique to older adults and the complexity that aging brings to patients' healthcare and care coordination needs.
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11. Berry LL, Rock BL, Smith Houskamp B, et al Care coordination for patients with complex health profiles in inpatient and outpatient settings. Mayo Clin Proc
12. Jackson GL, Smith VA, Edelman D, et al Intermediate diabetes outcomes in patients managed by physicians, nurse practitioners, or physician assistants
: a cohort study. Ann Intern Med
13. Morgan PA, Abbott DH, McNeil RB, Fisher DA. Characteristics of primary care office visits to nurse practitioners, physician assistants
and physicians in United States Veterans Health Administration facilities, 2005 to 2010: a retrospective cross-sectional analysis. Hum Resour Health
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: an underestimated workforce for older adults
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Keywords:Copyright © 2019 American Academy of Physician Assistants
geriatrics; older adults; chronic conditions; physician assistants; PAs; aging