Commentaries on health services research

Are the Irish willing to be seen by a physician associate? ABSTRACT This study investigated the willingness of Irish citizens to be seen by a physician associate (PA) based on medical scenarios in a typical clinical setting. The PA role was piloted in Dublin, Ireland, between 2015 and 2017 but the concept of PAs and the acceptance of their role in Ireland had not been explored. A preference survey, with three medical scenarios, gave participants a choice to be treated by a PA or a physician, with two time trade-off options offered. Responses were supported with qualitative text. Four hundred people were invited to participate as surrogate patients and 270 (142 men and 128 women) accepted. The mean age was 60 years. In total, 95% of the respondents chose to see a PA over a physician based on the scenarios presented and a wait time of 30 minutes. Waiting time, trust, competency, and the severity or seriousness of the medical condition were categorized into three themes for choosing the PA over the physician. Knowing that PAs are supervised and can check decisions with their supervising physician influenced the “surrogate patient” decisions made by these respondents. These findings are consistent with studies in other countries where willingness to be seen by a PA is neither age- nor sex-specific. Patient preference seems to be based on the importance of trust and confidence in the medical provider.1 Commentary by Ian Jones: The introduction of a profession into any environment, be it a small-town clinic or internationally, often raises the question of If we provide it, will they come? This study explored the question of whether patients desired shorter wait times and were willing to risk trying something new and unknown or preferred to wait for the traditional physician. Seldom do studies of this type explore the terminology used to sell the new provider, focusing instead on how long people prefer to wait. If we used different phrases, would the quantified wait time vanish? Perhaps we need to explore using a variety of preferences. Around the globe and in our local communities, patients face the questions of convenience of something new, or trust and patience for the tried and true. I encourage readers to review this article and ask would these numbers be different if we marketed PAs better? REFERENCE A systematic review of PAs in nonprimary care ABSTRACT The authors appraised the research on PAs in secondary care by the effect on patients' experiences and outcomes, service organization, working practices, other professional groups, and costs. In emergency medicine, trauma, and orthopedics, when PAs are added to teams, researchers found reduced waiting and process times, lower charges, equivalent readmission rates, and good acceptability to staff and patients. Analgesia prescribing, operative complications, and mortality were variable. Internal medicine outcomes of care provided by PAs and physicians were equivalent. PAs have been deployed to increase the capacity of a team, enabling shorter waiting times and gains in throughput, continuity, and medical cover. When PAs were compared with medical staff, little or no negative effect was found on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organized in teams is highlighted. Further rigorous evaluation is needed to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting.1 Commentary by Gomathi Sundar: The United Kingdom trains PAs chiefly for primary care.2 However, as in the United States, the number of PAs in secondary care is increasing.3,4 The effect of PAs in secondary care is difficult to assess in the UK because of the small numbers employed. This review identified 12 studies from the United States and four from Canada, varying in scope, setting, outcomes, and healthcare providers. Some assessed PAs' role as part of a team; some, as a substitute for physicians. The authors found that PAs, as additions to serving on teams, improved coverage, reduced throughput times, and mortality. But, as physician substitutes, PAs provided very small or no difference in the outcomes measured. At the same time, employment in secondary care seems to have a positive effect on patient coverage and cost-effectiveness. The PA workforce in the UK in 2018 lacked statutory regulations, did not have prescribing rights, and could not order ionizing radiation, thus limiting an evolving workforce experience. Given these limitations, the moderate positive effect elicited from the review may not be able to be extrapolated to the UK. More studies with robust designs should be conducted to inform policy makers in the UK as to whether large-scale deployment of PAs in secondary care should be considered. REFERENCES Prescribing patterns of physicians, NPs, and PAs in the United States are of comparably poor quality ABSTRACT This study compared the quality of prescribing practices of physicians, NPs, and PAs. The authors used a serial cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006 to 2012. Ambulatory care services in physician offices, hospital EDs, and outpatient departments were evaluated, with the main outcome measures being 13 validated quality indicators focused on pharmacologic management of chronic diseases. The study covered 701,499 sampled patient visits. Physicians were the primary provider for 96.8% of all visits examined; NPs and PAs each accounted for 1.6% of these visits. The proportion of eligible visits in which quality standards were met ranged from 34.1% (angiotensin-converting enzyme inhibitor use for heart failure) to 89.5% (avoidance of inappropriate medications in older patients). The median performance across all indicators was 58.7%. After adjustment for potential confounding factors, the quality of prescribing by NPs and PAs was similar to that of physicians for 10 of the 13 indicators evaluated, and no consistent directional association was found between provider type and indicator fulfillment for the remaining measures. The authors conclude that significant shortfalls exist in the quality of prescribing across all practitioner types, and that the quality of care delivered by PAs, NPs, and physicians was generally comparable.1 Commentary by Theresa Hegmann: This article is another in a growing list of “data mining” studies that use large national databases to compare PA and NP practice patterns with those of physicians. Extracting meaningful information from the literally billions of visits represented in the NAMCS and NHAMCS databases requires enormous computing power—and an experienced statistician. These databases also contain many potential sources of error and bias. Most concerning here is a known sampling error problem with the NAMCS: the NAMCS randomly samples physicians (rather than all providers), so PAs and NPs who care for their own patient panels within group practices are not included.1 This leads to underestimation of the number of patients cared for by PAs and NPs in the office setting, as well as probable bias toward sampling of visits conducted by less-experienced PAs and NPs.2 This sampling quirk likely explains the strange pattern noted by Jiao and colleagues in their results section, where more than 85% of patient visits to physicians were in the office setting but less than half of patient visits included for PAs and NPs were in the office setting. This source of sampling error makes the exact numbers reported in this paper questionable; however, it is reassuring that the article's conclusions are similar to others that used different methodologies and databases. For example, Kurtzman and Barnow came to the same basic conclusions about both the comparability of the care and the overall questionable quality of care (based on national recommendations) across NPs, PAs, and physicians using the community health center subset of the NAMCS, which more accurately samples patient visits to PAs and NPs (email from Perri Morgan, PhD, PA-C, July 26, 2018).3 Physicians, PAs, and NPs seem to be equally poor at meeting national quality standards for prescribing. REFERENCES Geriatrics, PAs, NPs, RNs—the Dutch Model ABSTRACT More and more older adults desire and are able to grow old in their own homes. This change, together with the growing number of older adults, increases the demand for general practitioners (GPs). However, care for older adults lacks prestige among medical students and few are interested in geriatrics as a career. Innovative solutions are needed. The aim of this study was to describe the effects of introducing NPs, PAs, or RNs into primary healthcare for older adults. GPs, NPs, PAs, and RNs in the Netherlands were interviewed. In most cases, healthcare for older adults was only a small part of the tasks of the interviewees. The tasks they performed and their responsibilities in healthcare for older adults differed between, as well as within, professions. Interviewees considered NPs, PAs, and RNs an added value. The roles and responsibilities of NPs, PAs, and RNs for the care of older adults living at home are still not established but tremendous opportunities for these professionals are recognized and a clear vision is needed to maximize each professional's skill set.1 Commentary by Benjamin J Smith: As suggested by this study from the Netherlands, significant workforce challenges exist globally and require urgent attention to meet the healthcare needs of a growing and aging population. PAs are prepared, adaptable, and available to positively affect these workforce gaps. Patients desire one central primary care provider (PCP), a role in which PAs can serve. Common tasks required in this role of PCP may include a geriatric assessment, preventive home visits, and case management. As the authors suggest, this study provides a direction on which to build, and they call for additional observational studies to further investigate best practices when PAs are part of the team delivering care to older adults. Other medical specialties also would benefit from similar research. Although individual practices settings have varying and unique needs, more resources should be devoted to studying the most efficient models for incorporating PAs into practice and the value added when PAs are part of the medical team. The patient perspective is vital in these studies. As the volume of this literature increase, physicians, practice administrators, and policy makers will have a deepened appreciation for PAs and their key place in the healthcare environment. REFERENCE

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