Musings: Blog of the JAAPA Editorial Board

Musings

Blog of the JAAPA editorial board.

Monday, July 2, 2018

Brian K. Yorkgitis, PA-C, DO

Throughout my career, I have committed to serving patients in a safety-net hospital. The ability to care for all who need care is a great reward. Last summer, I happened to be on call for every summer holiday: Memorial Day, Fourth of July, and Labor Day. I was receiving requests for transfer from hospitals that often do not send certain diagnoses to our facility. After several requests, I began asking; “Does your specialist not handle this type of case?” The answers were often similar: “We do not have anyone on call for the holiday,” “the OR is too busy for the holiday,” and other seemingly analogous answers. We have a policy to accept all in need and I accepted every patient. After all, these patients were falling through the cracks of the holiday and needed a safety net to catch them.

On any other day, these patients would receive their healthcare at their originating facility but for varying reasons required transfer to the safety-net hospital. I wondered if their reason for not choosing the safety-net hospital first was because they thought it provided lower-quality care compared with their first choice.

Working at safety-net hospitals over the past 16 years, I realized that often, complex patients are transferred to our facility once they have reached the limit of their initial facility’s capabilities. This always struck me as odd—wouldn’t you want to choose the facility that can care for any curveball thrown at it in case you have a rocky course? That is exactly what these hospitals do; hit those curveballs when the count is full. With increased scrutiny on quality of care, I have noticed that complex patients are being transferred to our facilities more often. Unfortunately, most quality measures can only risk-adjust for a few variables rather than the whole patient picture. This creates a selection bias when safety-net hospitals are sampled. The question I always have is whether a transferred patient should be included in the quality metrics. It’s like blaming a losing game on the relief pitcher who takes the mound in the 9th inning.

So, I began looking at the literature for quality measures for these hospitals. Examining esophagectomies, one of the most complex and high-risk surgical procedure performed, Gurien and colleagues found that compared with a national sample, patients treated at a safety-net hospital had fewer complications and reoperations along with a shorter hospital length of stay.1 Dhar and colleagues showed that treatment and survival after resection of pancreatic cancer (another complex and high-risk surgery) was equivalent at safety-net hospitals and non-safety-net hospitals.2

Won and colleagues examined the quality of two of the most common surgical procedures, appendectomy and cholecystectomy. Patients undergoing appendectomies at safety-net hospitals had similar morbidity and cost to those at non-safety-net hospitals. Not surprisingly, safety-net hospitals more often took care of patients with complicated cases of appendicitis, including rupture, while achieving the same morbidity as for patients with less complicated disease treated at non-safety-net hospitals.3 When looking at cholecystectomy, safety-net hospitals performed similarly in regards to morbidity but achieved the same quality with lower costs.4

The literature is also riddled with opposite results. The playing field is not often level. Social determinants of health are known to play a vital role in outcomes but most studies fail to include all aspects of this key factor. If we were able to capture all the aspects of social determinants, would the safety-net hospitals look even better?

If safety-net hospitals are good enough on a holiday, one might say they are better than their comparison, as they stand ready each day to catch any patient any time. Showing up for the game is the first step at winning. I know I would want my parachute to work every time, not just on non-holidays.

REFERENCES
1. Gurien LA, Tepas JJ, Lind DS, et al. How safe is the safety net? Comparison of Ivor-Lewis esophagectomy at a safety-net hospital using the NSQIP database. J Am Coll Surg. 2018;226(4):680-683.

2. Dhar VK, Hoehn RS, Young K, et al. Equivalent treatment and survival after resection of pancreatic cancer at safety-net hospitals. J Gastrointest Surg. 2018;22(1):98-106.

3. Won RP, Friedlander S, Lee SL. Outcomes and costs of managing appendicitis at safety-net hospitals. JAMA Surg. 2017;152(11):1001-1006.

4. Won RP, Friedlander S, de Virgillo C, Lee SL. Addressing the quality and cost of cholecystectomy at a safety net hospital. Am J Surg. 2017;214(6):1030-1033.

Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


 

Monday, June 18, 2018

Richard W. Dehn, MPA, PA-C, DFAAPA

Interest in becoming a PA appears to be higher than anytime in in the profession’s history. The applicant pool for PA program admissions continues to increase despite the development of an increasing number of new programs and an increasing number of enrollment slots in existing programs. The projected future demand for PAs in addition to the large and increasing number of good quality applicants vying to gain admission to PA programs further encourages educational institutions to develop new programs and for existing programs to further expand enrollment.  However, despite this substantial increase in the number of PA enrollment slots, the cost of becoming a PA continues to increase. The average cost of completing a PA program (tuition, fees, and required expenditures) in 2015-2016 was $49,317 for a resident at a public institution, $83,981 for a non-resident at a public institution, and $89,723 at a private institution.1 This an increase of 13%, 15%, and 14%, respectively, from only 2 years earlier, and roughly three times greater than the increase in the Consumer Price Index over the same time period.2

The phenomenal increase in the cost of PA education has an obvious consequence—most current PA graduates enter the profession with very high debt loads. The 2014 Physician Assistantn Education Association Matriculating Students Survey reported that 91% of matriculating students anticipated that they would hold some level of debt following their PA education, and that 48% held an average student debt of $35,717 incurred before enrolling in a PA program.3 The Class of 2016 reported an average PA education loan debt of $94,947.4 In many regions of the United States, the average cost of completing a PA program has surpassed the average new PA graduate salary, and the combined student load debt from undergraduate and PA education is likely much higher. The 2016 average PA education loan debt of $94,947 would require a $1,100 monthly payment for 10 years at the current interest rate. If the cost of PA education continues to rise at this rate, is there a point where those contemplating a career as a PA will question whether the profession will provide a reasonable return on investment?

A 2016 publication described a model comparing current net present value (NPV) of physician and PA training for women practicing in family medicine.5 The model was created using 2011-2012 data on salary, and took into account the cost and time involved in training as well as projected future income from the beginning of training at age 25 years to permanent retirement at age 67 years. Although the NPV for a female family physician was 15.1% higher than for a female PA in family medicine, the authors concluded that there was only a relatively small financial difference between the two choices. In contrast with today’s medical education environment, this study used the weighted average total tuition and fees for PA programs in 2011, or $31, 975, equal to about $35,000 in today’s dollars.

It would be interesting to repeat this study model using current data, and expand it to other subpopulations and specialties. Additionally, it would be interesting to apply similar NPV models to other providers such as NPs and separating physicians by MD and DO, because the cost and length of education of each of these professions differs. Will the substantial increase in PA and physician educational costs, and the resulting increase in student debt load, eventually result in a dampening effect on one’s interest in becoming a PA? We need more research on how educational costs affect career choices, the effect of rising costs on who decides to enter our profession, how these costs are passed on into the healthcare delivery system in the form or demands for higher salaries or choice of specialties, and the effect of student debt on the practice and employment choices of PA graduates. 

REFERENCES
1. Physician Assistant Education Association. By the Numbers: Program Report 32: Data from the 2016 Program Survey, Washington, DC: PAEA; 2017.

2. US Department of Labor. Bureau of Labor Statistics. CPI inflation calculator. 

3. Hamann RA, Jeffery C, Miller AA. Physician assistant educational debt: results from two surveys [abstract]. JAAPA. 2016, 29(10):1-2.

4. Physician Assistant Education Association. By the Numbers: Student Report 1. Washington, DC: PAEA, 2017.

5. Essary AC, Coplan BH, Cawley CF, et al. Women, family medicine, and career choice: an opportunity cost analysis. JAAPA. 2016;29(9):44-48.

Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus and a professor in the Department of Biomedical Informatics at the University of Arizona College of Medicine in Phoenix. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, June 4, 2018

Amy M. Klingler, MS, PA-C

To pay attention, this is our endless and proper work.Mary Oliver

How do you know what to pay attention to these days? When so much information is being spread across print and digital platforms, it is easy to miss important stories that affect our lives and the lives of our patients. To be honest, I think I swiped right past the article titled “Serena Williams on Motherhood, Marriage, and Making Her Comeback” when it first appeared in my newsfeed. Little did I know that that January 2018 Vogue article would bring my attention to something else I had missed–the appalling statistics on maternal mortality in the United States. This month’s issue of JAAPA includes a commentary by Tami Ritsema and myself that discusses maternal morbidity and mortality in the United States and offers suggestions for how PAs can have a positive effect on this public health crisis.

Since we wrote the article, I have been changing the way I talk to women who are pregnant or who are thinking of becoming pregnant. I take better advantage of opportunities to discuss the importance of preconception medical and dental care with them and try to ensure their chronic medical conditions are managed properly before they try to conceive. Rather than shy away from discussing potential complications of childbirth, I present them in greater detail to my pregnant patients and their partners. Just as importantly, I empower them to speak up when they have concerns. The POST-BIRTH acronym is a great tool that can be quickly taught to expectant mothers and their families to help them recognize and seek help for complications of childbirth.

 

Call 911 if you experience:

Pain in chest

Obstructed breathing or shortness of breath

Seizures

Thoughts of hurting yourself or your baby

 

Call your healthcare provider (or call 911 if your healthcare provider is unavailable) if you experience:

Bleeding, soaking through one pad/hour, or blood clots the size of an egg or bigger

Incision that is not healing

Red, swollen leg that is painful or warm to touch

Temperature of 100.4° F (38° C) or higher

Headache that does not get better, even after taking medicines, or a headache with vision changes.

 

I also make sure to take advantage of well-child checks to screen moms for postpartum depression (and check in with their partners, too) as recommended by the American Academy of Pediatrics. I have contacted my representatives in Congress about House Bill 1318 and Senate Bill 1112, which seek to establish maternal mortality review committees and eliminate disparities in maternal healthcare outcomes. They were introduced in 2017 and are gaining support in their respective houses of Congress, but have yet to pass. None of these acts take much effort on my part but they could mean the difference between life and death for one of my patients. Now, that is something worth paying attention to.

Amy M. Klingler practices at the Salmon River Clinic in Stanley, Idaho. The views expressed in this blog post are those of the author and may not reflect AAPA policies. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Wednesday, May 23, 2018

Thanks for joining us at AAPA 2018. We’ll be publishing a selection of poster abstracts online later this year--be sure to visit jaapa.com to read them.

Don’t miss these great sessions today:

• 8-9 a.m., Level 2 room 260--Expert panel on advanced sexual and gender minority health. Jonathan Baker, Diane Bruessow, and Danielle Varney discuss how the health concerns of sexual and gender minority patients can be complicated by a variety of psychosocial issues. Read more about primary care providers’ roles in caring for transgender patients.

• 2-4 p.m., Level 2 room 244--Promoting physical activity. Learn a three-step process to help patients incorporate more physical activity into their daily lives and improve their health. Read more about exercise as a prescription.

Be sure to mark your calendar for these upcoming conferences:
• AAPA 2019, May 18-22 in Denver
• AAPA 2020, May 16-20 in Nashville
• AAPA 2021, May 22-26 in Philadelphia
• AAPA 2022, May 21-25 in Indianapolis


 

Tuesday, May 22, 2018

Today is the last day for the exhibit hall (interactive map).  Brunch bites will be offered from 11 a.m.-1 p.m. today at various stations.

Come visit JAAPA at booth 1201. Podcast hosts Kristopher R. Maday, MS, PA-C, and Adrian S. Banning, MMS, PA-C, will be recording live at noon today. Post on Facebook or Twitter during the conference (using #jaapanola in your post or tweet) for a chance to win a $100 gift card.

Interested in serving our country? Already are serving? The Uniformed Services Symposium is today. Lt. Col. Amelia Duran-Stanton is one of the speakers, discussing musculoskeletal injuries and fractures from 1-2 p.m. today in Level 3, room 349. She wrote in the December 2017 issue of JAAPA about handling diseases and nonbattle injuries in austere environments.

Get the tl;dr on our author guidelines! Join JAAPA editors and editorial board members from 1-2:30 p.m. today in Level 2 room 242 for a workshop on writing for publication in medical journals.