Commentaries on health services research

A Canadian research synthesis of nurse practitioners and physician assistants ABSTRACT A review was undertaken to provide information about nurse practitioners (NPs) and physician assistants (PAs) in the British Columbia health section, including organization, financing, funding, regulation, and service delivery. The review also sought to offer advice about the implementation and use of PAs and NPs. Numerous systematic reviews provide strong and consistent evidence that, within their scope of practice, NPs provide equivalent quality of care compared to their physician counterparts and that they are well-accepted by patients. Although considerably less research was found pertaining to PAs, their ability to safely conduct an increasingly wide range of clinical diagnostic and treatment procedures under physician supervision also is well documented. Despite this evidence, NPs face numerous barriers to and in practice, including lack of government leadership, attitudes of organized medicine and physicians, role confusion, and issues associated with payment models. Considerably fewer reports of barriers to PAs were identified and evidence indicates that physicians prefer to work with PAs. In British Columbia, considerable investment was made during the early 2000s to develop an NP workforce and expand primary healthcare capacity. However, as many as 30% of graduates report they are unable to find work as an NP. This failure to fully implement NPs is seen to be largely the consequence of inconsistency between two major health human resource initiatives that have been simultaneously under way in British Columbia since the early 2000s. On one hand, the government committed to a long-term agenda to develop and implement an NP workforce with the aim of strengthening interprofessional care as part of the national strategy. On the other hand, as part of a negotiated settlement with the British Columbia Medical Association, the government made a commitment to strengthen and sustain full-service family practice and not to undertake major structural changes to the primary healthcare sector. Wong S, Farrally V. The Utilization of Nurse Practitioners and Physician Assistants: A Research Synthesis. Prepared for the Michael Smith Foundation for Health Research. 2013. Vancouver, British Columbia, Canada. The focus on maintaining the traditional fee-for-service practice model in British Columbia, in part, shifted the province's primary healthcare agenda away from the national agenda that had promised major structural change. This decision eliminated the opportunity to establish new service models and multidisciplinary teams. With three provincial primary healthcare NP programs producing graduates each year, but few employers, the NP market is saturated. Without a strong strategy to expand or develop new interprofessional service capacities outside the primary healthcare practice environment, health authorities in British Columbia have few opportunities to establish new positions in the primary healthcare sector. Although several healthcare agencies have employed NPs in acute care or in specialty areas, this deployment requires considerable investment in orientation, so views on NPs have been mixed. The other key barrier to full NP implementation is lack of sufficient funding to establish positions and to develop needed infrastructure supports for the British Columbia NP workforce. British Columbia does not employ PAs, who are not designated as a health profession under the province's Health Professions Act. Despite the British Columbia medical association's expressed interest in using PAs, major considerations including role, funding, and training have not been publicly explored. The potential benefit of introducing PAs to the health system as a whole needs to be balanced against the potential costs of implementation, including establishing training and regulatory requirements. This 88-page report, while clearly biased toward NPs, does provide a measured review of the NP and PA literature up to 2012. Commentary by Roderick S. Hooker Social forces and an evolving physician assistant profession ABSTRACT Postgraduate physician assistant (PA) programs designed to train individuals for more specific roles in the workplace have existed since 1971. These residency programs continue to grow despite the lack of outcome data supporting improvements in PA learning, effects on career development, or improved patient care. Leadership bodies of the PA profession have been at odds over the meaning and ramification of postgraduate programs on specialty credentialing, accreditation standards, insurance reimbursement, and employment. Using Bourdieu's cultural conflict theory as a framework, we analyzed the issues confronting postgraduate PA training programs. We discuss implications related to shifts in power among the different stakeholders, concluding that although formal postgraduate PA training can be beneficial to both the PA and medicine, considerations related to underlying agendas need attention. Hlavin JA, Callahan JL. Specialization training programs for physician assistants: symbolic violence in the medical field?Health Sociol Rev. 2013;22(2):200–209. The work of sociologist Bourdieu is used to develop a social framework for understanding the complex struggle for power and financial gain in the medical field. Bourdieu's theory notes that capital comes not only in the form of economic gain, but also in cultural, social, and symbolic gain. Many forces are at play to determine the distribution of capital between the various players including doctors, nurses, and PAs; insurance companies; educational institutions; hospitals; and credentialing bodies. The PA field is young compared to medicine, and the distribution of power and status between PAs and physicians is evolving. Physicians maintain the dominant faction, and PAs are in competition for a share of the capital. This article highlights the importance of the thoughtful and informed approach that must be taken by the emerging PA profession in regard to specialty training. The authors remind us of the many other decisions the profession is facing at this time of social change in healthcare delivery. All want a share of the financial pie and tensions may be emerging as reimbursement becomes tighter. Commentary by Kristine A. Himmerick ED productivity of physician assistants and nurse practitioners ABSTRACT Mid-level providers (MLPs) are extensively used in staffing EDs. We sought to compare the productivity of MLPs staffing a low- and high-acuity area of a community ED. A retrospective review of MLP productivity at a 42,000-volume community ED was undertaken. MLPs staffed day shifts (8 a.m. to 6 p.m. or 10 a.m. to 10 p.m.) in high- and low-acuity sections of the ED. We compared patients/hour, relative value units (RVUs)/hour, and RVUs/patient between the two MLP groups. We included 49 low-acuity and 55 high-acuity shifts in this study. MLPs staffing low-acuity shifts treated a mean of 2.7 patients/hour; those staffing high-acuity shifts treated a mean of 1.6 patients/hour. MLPs staffing low-acuity shifts generated a mean of 4.5 RVUs/hour compared to 3.2 RVUs/hour for those staffing high-acuity shifts. MLPs staffing low-acuity shifts generated a mean of 1.7 RVUs/patient; those staffing high-acuity shifts generated a mean of 2.1 RVUs/patient, confirming that MLPs staffing a low-acuity area treated more patients/hour and generated more RVUs/hour than when staffing a high-acuity area. Silberman M, Jeanmonod D, Hamden K, et al. Mid-level providers working in a low-acuity area are more productive than when working in a high-acuity area. West J Emerg Med. 2013;14(6):598–601. Evaluating PA and NP production in a community ED setting by examining visits per hour and RVU generation is interesting. On the surface this is an admirable task, as labor division and task allocation is a difficult question that has plagued policy makers and healthcare administrators for some time. How can the workforce be deployed in the most-effective manner? This article is written in that spirit; however, it suffers from serious lack of methodological rigor and a flawed hypothesis. The study asks if PAs and NPs are more effective seeing low-acuity patients, but compared to what? The authors might have considered describing a comparison with physicians to draw contrast. Drawing many conclusions about PA and NP abilities and training, these physician authors do not reference or use any data to base this on, but instead speculate. The authors try to highlight a reduced RVU in high-acuity comparisons, but it is unsound, comparing all comers to PAs seeing high-acuity patients. This limited, small, weak study leaves one to ask, so what? Commentary by Michael P. Halasy

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.