Commentaries on health services research

The effect of a PA on an infectious disease consult service ABSTRACT A retrospective case-control study of length of stay and mortality were examined in the infectious disease consult service compared with hospital-wide controls. The 2-year period before the introduction of a PA to the infectious disease consult service of a large urban hospital in Canada was compared with the 2 years after the service was introduced. Length of stay decreased among patients who used the infectious disease consult service by 3.6 days more than that seen in matched hospital-wide controls. Mortality did not significantly change after the PA introduction in either cases or controls. PAs can improve health efficiencies in the Canadian healthcare setting by reducing length of stay.1 Commentary by Sharona Kanofsky: Unsurprisingly, adding a PA to a busy urban hospital consult service decreased consultation times and lengths of stay. What is surprising is the sluggish use of PAs in Ontario. Decloe and many PAs like her found jobs thanks to an Ontario Career Start Grant for new graduates. The 2-year grant relies on the hope that hospitals like Toronto East General will continue the contracts based on positive results. But Ontario hospitals don't pay physicians directly (most physicians bill the province), so hospitals balk at the notion of paying medical staff out of pocket. Hospitals need to do some simple math. The average acute care hospital stay is $7,000/day in Canada ($5,273 in US dollars).2 By this measure, Decloe saved her hospital more than $25,000 ($18,831 US) per patient—a whopping $23 million ($17.3 million US) per year. And that's before you ask patients if they prefer waiting less and going home earlier. Ontario needs permanent PA funding and PA registration—it makes a lot of cents! REFERENCES 1. Decloe M, McCready J, Downey J, Powis J. Improving health care efficiency through the integration of a physician assistant into an infectious diseases consult service at a large urban community hospital. CanJ Infect Dis Med Microbiol. 2015;26(3):130–132. 2. Canadian Institute of Health Information. The Cost of Acute Care Hospital Stays By Medical Condition in Canada, 2004-2005. Ottawa, Ontario, 2008. The Papua New Guinea health extension officer: A PA analogue ABSTRACT Efforts to deliver healthcare take shape in different ways in different countries. The universal observation is that when physicians are scarce, nurse and physician assistant (PA) equivalents emerge to fill the vacuum. In Papua New Guinea, the health extension officer serves this function. The authors are PA educators who are observers of PA-like movements globally. Their observations in this report serve as a template for health and social researchers to do likewise. The article describes the education and deployment of health extension officers.1 At times Americans and others have amplified their training. The result has been an impressive health extension officer role in rural healthcare, where most of the Papua New Guinea population resides. Through the efforts of the Pedersens and others, human resources are being strategically strengthened. Promotion of rural health services is at the heart of this effort and is advanced in this article as worthwhile goals to improve the well-being of the global community.2 Commentary by Sandy Hoar: The adaptability of the PA concept is as alive in Papua New Guinea as elsewhere. Each country and different regions within a country modifies the base medical curriculum and experiential learning to make it specific to current needs. In low-resource countries, a PA may need to know not only how to interpret a radiograph, ultrasound, or complete blood cell count, but how to perform these diagnostic tests. Infectious diseases are decreasing but concurrently chronic diseases are increasing, so that clinicians may need to understand cholera, typhoid, and dengue, as well as diabetes and hypertension. Patients living longer may need an emphasis on geriatric conditions; communities may need help with methods to improve potable water, stop open defecation, and improve nutrition and childbirth—skills more often associated with public health. The village health patrols and the advanced training in eye care are great examples of locally needed skills. The health extension officer program is an interesting one and a role model that might be implemented in many different geographic settings. The danger becomes that as the amount of time needed for training increases and the curriculum becomes standardized, it risks becoming less flexible and less relevant. REFERENCES 1. Pedersen DM, Pedersen KJ, Barker DS. Rainforest physician assistants—the Papua New Guinea health extension officer: an international physician assistant analogue. J Physician Assist Educ. 2015;26(3):155–158. 2. Razee H, Whittaker M, Jayasuriya R, et al. Listening to the rural health workers in Papua New Guinea—the social factors that influence their motivation to work. Soc Sci Med. 2012;75(5):828–835. Cesarean section surgery in the context of a global shortage of human resources for health ABSTRACT Comprehensive emergency obstetric care including major surgery such as cesarean section is a major health system problem in rural areas of poor countries, where there are few physicians. Innovative workforce training models in African countries have demonstrated viable, scientifically valid solutions. Delegation of major surgery to duly trained “nonphysician clinicians” by “task shifting” should be seriously considered to address the human resources crisis in poor countries. The objective is to cope with current challenges to enhance maternal and neonatal survival. For example, nonphysician clinicians in Mozambique perform about 90% of cesarean sections at the district hospital level. A comparison between the outcomes of cesarean sections provided by these clinicians versus physicians demonstrates no clinically significant differences. These providers have remarkably high retention rates in rural areas (close to 90%) and their training and deployment is three times more cost-effective than that of physicians.1 Commentary by Ivy Lynn Bourgeault: Cesarean sections can be a lifesaving and necessary method of delivery of infants in emergency situations. Although consensus is lacking on an ideal cesarean section rate, experts agree that rates that are significantly higher than 20% (23% in the United Kingdom, 26% in Canada, and 32% in the United States) and those lower than 10% are of major concern and requires further investigation.2 The WHO states, “What matters most is that all women who need caesarean sections receive them.”3 This article outlines the training and deployment of associated clinicians to perform cesarean sections in areas of need, particularly in rural Mozambique and other sub-Saharan African countries. When this skill set is made available to “nonphysician clinicians” through task shifting, the results are promising. A particularly interesting caution, however, is that the most difficult aspect of emergency obstetrics is in optimal management before resorting to cesarean section. This suggests that this training might be more effective when combined with midwifery training in low-risk childbirth. REFERENCES 1. Bergström S. Training non-physician mid-level providers of care (associate clinicians) to perform caesarean sections in low-income countries. Best Practice & Research Clinical Obstetrics & Gynaecology. [e-pub Mar. 31, 2015]. www.bestpracticeobgyn.com/article/S1521-6934%2815%2900063-2/abstract. Accessed December 23, 2015. 2. Organisation for Economic Co-operation and Development. Health at a glance 2015: OECD indicators. www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm. Accessed December 23, 2015. 3. BBC News. Should there be a limit on caesareans? www.bbc.com/news/10448034. Accessed December 23, 2015.

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