Commentaries on health services research

The UK physician associate role: What do the physicians think? ABSTRACT Physician associates are a new profession in the United Kingdom, introduced in 2000. Doctors who supervise physician associates were surveyed in 2012 and were generally satisfied with their role. Most believed that a physician associate on the team benefited doctors and patients. Positive feedback from patients reinforced this feeling. Furthermore, respondents reported that an unregulated status of the profession impairs their ability to use their physician associate staff to their fullest.1 United Kingdom (UK) PAs have recently declared themselves to be physician associates as a strategy for obtaining much-needed regulation. While UK efforts were first directed at the creation of a demonstration project and then to the development of PA programs, regulation was lower on the list of priorities. The lack of regulation—which also means the absence of prescriptive privileges or the ability to order radiograph—is now recognized as a significant barrier for UK PA expansion.2 This study reviews the support of supervising physicians for PAs and also describes positive feedback from patients about their care.3 An interesting feature of the UK PA population is that it includes PAs educated in the UK as well as PAs educated in the United States. Some employers have worked with PAs from both backgrounds. This study has value for countries considering the development of PAs as a health workforce solution.4 Commentary by Ruth Ballweg, MPA, PA REFERENCES 1. Williams LE, Ritsema TS. Satisfaction of doctors with the role of physician associates. Clin Med. 2014;14(2):113–116. 2. Parle JV, Ross NM, Doe WF. The medical care practitioner: developing a physician assistant equivalent for the United Kingdom. Med J Aust. 2006;185(1):13–17. 3. Ostler J, Vassilas C, Parle J. Physician assistants: friends or foes to doctors. Br Med J. 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20008022. Accessed March 21, 2014. 4. Dini L, Sarganas G, Boostrom E, et al. German GP's willingness to expand roles of physician assistants: a regional survey of perceptions and informal practices influencing uptake of health reforms in primary health care. Fam Pract. 2012;29(4):448–454. Are female primary care physicians contributing to a workforce shortage? ABSTRACT Are female physicians in developed countries contributing to a primary care shortage because they work fewer hours and see fewer patients in the time frame they are working than male physicians? To establish an evidence base, a systematic literature review for relevant studies published from 1991-2013 led to 1,271 unique abstracts; full text of 74 studies was reviewed. Inclusion criteria yielded 34 studies. Systematic review showed that female primary care physicians (PCPs) had fewer patient encounters, worked fewer hours, spent more time with patients dealing with more problems, and wrote fewer prescriptions but ordered more diagnostics and referred more to specialists. The studies suggest small negative effect of the feminization of the workforce. Differences between female and male PCPs are complicated and nuanced.1 A health services research team investigated workforce implications of female PCPs by conducting a literature review to address the question of whether female family physicians are less productive than male counterparts. What the reviewers concluded was that female PCPs saw more female patients (and proportionally more patients with urogenital and psychosocial issues). Childbearing years as a nested population were not specified in the studies. One speculation was that female practice patterns, with proportionally more diagnostics and referrals, could boost demand for specialists and laboratory technicians. Of the 34 studies, 15 were done in Canada, five in the United Kingdom, and four in the United States. From this angle, US research on female PCP productivity is wanting. An output study on female family medicine PAs would likely be no more conclusive, because PA labor data often are hidden in healthcare reporting and billing records.2,3 Workforce studies are needed to investigate work-life balance, leave of absence reasons (such as childbearing), as well as understanding practice patterns of female providers including referrals or prolonged visits. Commentary by Dawn LaBarbera, PhD, PA-C REFERENCES 1. Hedden L, Barer ML, Cardiff K, et al. The implications of the feminization of the primary care physician workforce on service supply: a systematic review. Human Resources for Health. 2014;12(1):32. 2. Ogunfiditimi F, Takis L, Paige VJ, et al. Assessing the productivity of advanced practice providers using a time and motion study. J Healthcare Manage. 2012;58(3):173–185. 3. Marriott T. PA Productivity: pitfalls and pearls. PA Professional. 2011;3(5):7. Scope of PA and NP ambulatory procedures ABSTRACT “Mid-level providers” were originally envisioned to provide primary care services in underserved areas. This study details the scope of independent procedural billing to Medicare of difficult, invasive, and surgical procedures by medical mid-level providers. In 2012, NPs and PAs billed independently for more than 4 million procedures at our cutoff of 5,000 paid claims per procedure. Most (54.8%) were performed in dermatology. The findings are relevant to safety and quality of care. Recently, the shortage of primary care clinicians has prompted discussion of widening the scope of practice for PAs and NPs. It would be prudent to temper widening the scope of practice of PAs and NPs by recognizing that their practice is not solely limited to primary care, and may involve procedures for which they may not have formal training.1 As the US health system moves to a model of care delivered in teams, clinicians must understand who is doing what in ambulatory care. In 2012 PAs and NPs independently billed for more than 4 million procedures with Medicare patients; nearly half were dermatologic procedures. Two dermatologist authors conclude (without evidence) that patients are at risk because PAs and NPs performing procedures are not trained in the same depth as dermatologists. This conclusion is based on data that include no measures of quality of care or procedure outcomes. The unsubstantiated conclusion may be partially explained by a 2013 editorial by the lead author, in which he equates PAs and NPs to inexperienced teenage drivers recklessly piloting jet airplanes.2 Rather than cast stones, these authors would do well to review the safety literature and then invite an ambulatory care PA or NP into the copilot seat to navigate the context of these data and results.3 Commentary by Kristine A. Himmerick, MPAS, PA-C REFERENCES 1. Coldiron B, Ratnarathorn M. Scope of physician procedures independently billed by mid-level providers in the office setting. JAMA Dermatol. Epub ahead of print, August 11, 2014. 2. Coldiron BM, Brod BA. Who needs medical school to practice medicine? Ask an electrician. JAMA Dermatol. 2013;149(2):140–142. 3. 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. Physician assistant location theory ABSTRACT Analysis of the geographic distribution of PAs across the United States explores their practice patterns as well as how and why they changed between 2001 and 2008. Cartographic results suggest that PAs are more clustered across the United States than MDs and that their clusters are larger. In addition, the largest low-PA cluster grew noticeably between 2001 and 2008. Statistical results suggest that PAs did not continue to practice in underserved places in 2008 as they had in 2001. An economic explanation is the most plausible for the latter result, but further analyses with disaggregate data are necessary to generalize such results.1 This data-mining exercise compared MD and PA provider densities in the United States at two points in time. Provider densities by county were scaled relative to the nationwide average provider density. The Moran I test statistic was applied to this metric and, unsurprisingly, indicated that provider coverage is spatially clustered. Multivariate regression of demographic variables was used to explain differences in provider coverage, apparently without adjusting for the demonstrated spatial dependence.2 Besides this apparent methodological violation, the study had some fundamental omissions: DO physicians and NPs, stratifying the analysis by primary and specialist providers, and addressing other limitations of the data. Many geographic articles are published that lead readers down the path of ecological fallacy; a common seduction when granular data of high quality are unavailable.3 Commentary by Joseph A. Tabor, PhD REFERENCES 1. Shaffer R, Zolnik E. The geographic distribution of physician assistants in the US: Clustering analysis and changes from 2001 to 2008. Applied Geography. 2014;53:323–331. 2. Anselin L, Bera AK. Spatial dependence in linear regression models with an introduction to spatial econometrics. In Ullah A, Giles DEA (eds.), Handbook of Applied Economic Statistics. Marcel Dekker, Inc., 1998:237–289. 3. Lozier JD, Aniello P, Hickerson MJ.Predicting the distribution of Sasquatch in western North America: anything goes with ecological niche modelling. J Biogeogr. 2009;36(9):1623–1627.

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