Commentaries on health services research

Do patient-centered medical homes reduce clinician burnout? ABSTRACT A high proportion of the US primary care workforce reports burnout, which is associated with negative consequences for clinicians and patients. The literature on patient-centered medical home (PCMH) and burnout is limited, with most findings based on small-scale demonstration projects among physicians. A study determined if components of PCMH related to team-based care were associated with lower burnout among primary care team members participating in the US Department of Veterans Affairs (VA) Patient Aligned Care Team (PACT). The study design included a web-based, cross-sectional survey of 4,539 VA primary care personnel. The dependent variable was burnout, and the independent variables were measures of team-based care: team functioning, time spent in huddles, team staffing, delegation of clinical responsibilities, working to top of competency, and collective self-efficacy. Overall, 39% of respondents reported burnout. Participatory decisionmaking and having a fully staffed PACT were associated with lower burnout; higher burnout was associated with being assigned to a PACT, spending time on work that someone with less training could do, and having a stressful, fast-moving work environment. Lower burnout may be achieved by PCMHs that are appropriately staffed, emphasize anticipatory decisionmaking, and increase the proportion of time team members spend working to the top of their competency level.1 Commentary by Perri Morgan, PhD, PA: This study of healthcare worker perception of burnout associated with the work environment illustrates two factors central to PAs: team practice and health system transformation. PAs work in the vortex of change in both of these dynamics. As team models of care evolve beyond happy-talk and reach implementation, PAs will clearly be affected. Based on the concept of negotiated autonomy, PAs have collective experience in inventing and negotiating roles on teams. They work in the midst of systems transitioning to emerging models of care based on new financing models, scrutiny of outcomes, and patient-centeredness, to name just a few prominent current healthcare transformations. Although this study presents findings relevant to PAs and notes that working at the top of one's competency range is associated with less burnout, perhaps the greatest contribution to PAs is in the study's appendix. The authors have assembled and validated a measurement tool well-suited for future PA workforce research projects assessing topics such as PA team roles, burnout, and response to system change, as well as research that takes the next step of correlating these factors with crucial access, cost, and quality outcomes. REFERENCE 1. Helfrich CD1, Dolan ED, Simonetti J, et al. Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. J Gen Intern Med. 2014;29(Suppl 2):S659–S666. Do PAs and NPs influence quality of ICU outcomes? ABSTRACT Cohort data from the 2009-2010 Acute Physiology and Chronic Health Evaluation clinical information system and an ICU-level survey included patients admitted to 29 adult medical and mixed medical-surgical ICUs in 22 US hospitals. The primary exposure was admission to an ICU where NPs and PAs participated in patient care; the outcome was patient level in-hospital mortality. We used multivariable relative risk regression to examine the effect of NPs and PAs on in-hospital mortality, accounting for differences in case mix, ICU characteristics, and patient clustering within ICUs. We also examined this relationship in subgroups: patients on mechanical ventilation, patients with the highest quartile of Acute Physiology Score (>55), ICUs with low-intensity physician staffing, and ICUs with physician trainees. Patients in ICUs with NPs and PAs had lower mean Acute Physiology Scores and mechanical ventilation rates than patients in ICUs without NPs and PAs. Unadjusted and risk-adjusted mortality were similar between groups [adjusted relative risk: 1.10, (95% CI: 0.92, 1.31)]. This result was consistent in all examined subgroups. NPs and PAs appear to be a safe adjunct to the ICU team, supporting NP and PA management of the critically ill.1 Commentary by Harrison Reed, MMSc, PA-C: With no shortage of ambition, this workforce study tackles mortality, the holy grail of medical outcomes and one that is notoriously hard to budge in critical care. The authors sought to examine the effect of PA and NP practice in 21 different ICUs across the country. Because the individual patients treated by PAs and NPs proved too difficult to tease out, the authors defined PA and NP care by a simple question: do PAs and NPs routinely practice in your ICU? This essentially scrutinized whether the mere exposure of a patient to a PA- and NP-staffed ICU affected mortality. Fortunately for the authors, contact with a PA and NP workplace proved neither prophylactic nor lethal and endorsed a previous finding.2 If any difference had existed, the authors would have faced the expansive task of listing the confounders that could account for discrepancy in such a heterogeneous sample. REFERENCES 1. Costa DK, Wallace DJ, Barnato AE, Kahn JM. Nurse practitioner/physician assistant staffing and critical care mortality. CHEST. Epub ahead of print, August 28, 2014. 2. Kleinpell R, Hohmann S. Outcomes of nurse practitioners and physician assistant patient encounters. Chest. 2013; 144(4_MeetingAbstracts):532A. Disclosing PA medical errors ABSTRACT Evolving state law, professional societies, and national guidelines, including those of the American Medical Association and the Joint Commission, recommend that patients receive transparent communication when a medical error occurs. Although error disclosure is widely endorsed in the medical and nursing literature, there is little discussion of the unique role that the physician assistant (PA) might play in these interactions. How PAs should collaborate with physicians in sensitive error disclosure conversations with patients is unclear. With the number of practicing PAs growing rapidly in nearly all domains of medicine, PAs' role in the error disclosure process warrants exploration. The authors call for educational societies and accrediting agencies to support policy to establish guidelines for PA disclosure of error. They encourage medical and PA researchers to explore and report best-practice disclosure roles for PAs. Finally, they recommend that PA educational programs implement trainings in disclosure skills, and hospitals and supervising physicians provide and support training for practicing PAs.1 Commentary by Jeffrey G. Nicholson, PhD, PA-C: Although the incidence of medical errors reported in the National Practitioner Databank is proportionately less for PAs than physicians, the authors imply that the growing number of PAs in clinical practice will result in more PA involvement in medical errors.2 Professional organizations including the AMA have adopted policies recommending full disclosure of medical errors by physicians to their patients, yet no such policy or training in how to disclose errors exists for the PA profession. Despite organizational recommendations for error transparency and disclosure, providers are challenged by the fear of malpractice claims, damaged reputations, or disciplinary action. To this end, many states have adopted laws that prevent disclosure from being admissible evidence in malpractice claims. Disclosure guidelines for physicians may not apply to PAs and their unique role as both an autonomous yet supervised provider. The standard of care for PAs is circumstantial and not always the same as for the supervising physician. Thus PA-specific guidelines for disclosure are needed. Although the authors recommend that PA educational associations and accrediting agencies establish guidelines for PA training in error disclosure, an equally important recommendation would be to adopt guidelines or requirements for training PAs to prevent medical errors in the first place. REFERENCES 1. Brock D, Quella A, et al. Physician assistants and the disclosure of medical error. Academic Med. 2014;89(6):1–5. 2. Hooker R, Nicholson J, et al. Does the employment of physician assistants and nurse practitioners increase liability. J Medical Licensure Discipline. 2009;95(2):6–16.

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