Primary Care for Physician Assistants

Background. Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges.
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These studies use survey, observation and medical record review methods with small and large samples and provide widely varying levels of detail about the clinical activities, age groups and other clinical and non-clinical activities undertaken by PAs. When the patient presenting conditions are classified as acute, chronic or preventative, the majority of studies report on acute conditions [ 44 , 55 , 56 , 58 - 60 , 63 , 65 ], ranging from conditions of unknown severity on presentation [ 59 ] to minor conditions [ 44 , 55 , 58 - 60 , 63 , 65 ].

Preventative and well person or insurance checks are also reported to form a large proportion of the PA workload [ 44 , 51 , 61 , 62 , 64 - 66 ], while providing care to patients with chronic conditions is reported less frequently amongst these USA studies [ 56 , 59 , 61 ].

The first PA graduates in the s are reported to spend a large proportion of their patient contact time with paediatric patients [ 51 , 61 , 63 ] and young adults [ 63 ]. The activities of PAs vary by the size of the population served, with those in smaller communities carrying out a wider range of activities [ 66 ].

Comparative data with other groups present a picture of different consultation types between PAs and doctors: PAs see patients of all levels of complexity but patients are selected for consultations with PAs by presenting complaint [ 61 ]; doctors working in the same general practices as PAs attend more chronic, fewer acute conditions [ 58 , 67 ] and more serious problems [ 44 ], and PAs see patients with a younger age profile than that of those seen by doctors [ 67 ]. Similarity of the distributions of acute, chronic and preventative conditions seen by the PA with those seen by a nurse is suggested [ 56 ].

Doctors are reported to see more patients of higher socio economic status and white ethnicity than PAs [ 57 ]. Non clinical or indirect clinical activities are also reported in a small number of studies and include paperwork [ 51 ], documentation relating to the patient visit and consulting the doctor [ 58 ], administrative and data collection [ 61 ], and patient education, dispensing medication and specialist referrals [ 66 ].

The two non-USA studies present a similar picture in terms of providing detailed lists of condition groupings of patients seen by PAs [ 68 ], and, like the USA studies, lack any description of the severity of condition [ 53 , 68 ].

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Both the non-USA studies state that the PAs attend more patients with unspecified conditions [ 53 , 68 ] than doctors, but similarity with the role of the nurse is disputed [ 53 ]. The younger patient age profile is also replicated in the Netherlands [ 68 ]. In summary, the descriptive data without comparators suggest that a range of average numbers of patients is consulted per day by the PA 19 to 30 reporting from one of three decades each [ 51 , 63 , 66 ]. Those studies that use within-practice comparisons report that PAs have a patient load comparable with other unspecified clinic staff [ 60 ], or a slightly higher patient consultation rate than nurse practitioners [ 38 , 41 ].

It is also suggested that the numbers seen per week increase by one third from one year to the next with the introduction of the PA in the family medicine practice [ 56 ]. Finally, regarding patient throughput, modelling of the reasons for the variability concludes that the reason for the visit, the number of tasks performed in the consultation, patient age and payment source are predictive of time spent [ 69 ].

Comparison with the studies from outside of the USA is limited by different units of measurement used. The impact of the PA on the workload of others has been considered in two ways: Three studies published in the s consider physician productivity, two of which report positive impact on the workload of others in modelling of the potential productivity of a physician comparing PA and non-PA employing practices [ 55 ] and in a before and after study [ 58 ].

Outside of the USA and at least two decades later, a UK study suggests that eight of the nine general practices in the study had an increase in overall practice list size number of patients registered ranging from 2. Further, PAs are taking on tasks previously performed by GPs, although this is not quantified [ 53 ]. All studies from the USA report a low rate of immediate support or supervision required in patient care episodes. Two studies seek to describe this supervision contact — the first [ 61 ] suggests that for patient sequences involving a PA, the physician tasks were usually taking a partial history, performing a partial examination or writing a prescription.

One study attempts to measure the impact of PAs on the primary care system through their use of other healthcare services. Using patient encounter data and patient health survey data from six practices in one USA County at points in a three year period, PAs are reported to increase the tendency to hospitalise insured versus uninsured patients [ 56 ].

The sample size is not explicit in this paper, and the tendency is not quantified. A number of studies suggest that PAs are expensive to employ or reduce profits. One study notes that, while the average total cost per patient episode was not related to the type of provider, PAs accrue significantly higher medication and laboratory costs than other providers, and this was most noticeable in patients with poor outcomes of care [ 71 ]. Four studies report low revenue per patient encounter [ 60 , 62 , 67 , 72 ], although the reasons for this or its interpretation differ, for example undercharging [ 60 ] or the PA undertaking tasks that are time consuming yet simple and therefore less remunerative [ 71 ].

The deployment of PAs has largely been to address the acute patient workload usually undertaken by doctors in family practice in the USA and in early development in the UK and the Netherlands. The evidence on productivity is mixed, regardless of country of origin, with some authors suggesting lower productivity by PAs compared to physicians, some suggesting similar rates of consultation and others stating that PAs increase the capacity or productivity of a practice. These studies are mainly descriptive and do not control for any factors found likely to influence throughput, limiting reliance on the absolute figures they provide.

Studies which considered efficiency, examined through the impact of employing PAs on the workload and activities of the doctors in a practice, show that physician productivity may increase and indeed change focus with the introduction of a PA. However, this may be countered by the evidence that PAs work to a supervising doctor where supervision or advice is requested by the PA for up to one in six patients. The time spent in supervision of PAs by doctors was reported to be highest in recently qualified PAs or USA-trained PAs working in the UK related to the absence of prescribing rights and least for those with more experience working in their home country.

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In a more localised sense evidence is presented about the economic aspect of PAs in family practice. The evidence is mixed and USA-specific and challenging to transfer to other systems for funding family practice. The measures of outcome reported in the studies were in two main groups: Details of the studies are given in Additional file 3. Where the patient had been treated by a PA the level of satisfaction with the encounter was reported to be very high in a small interview study [ 45 ], high in medium sized survey studies [ 60 , 65 , 72 , 73 ] and in one large study of Medicare recipients [ 74 , 75 ] with very similar results for NPs and physicians.

The evidence is more mixed in one focus group study of community residents in an area where the PA had been the sole primary care provider for the previous two years, with the residents suggesting that they would sometimes prefer to see a doctor due to: Studies from the USA in which acceptability of the PA role was posed as a hypothetical question in interviews of general householders report positive findings [ 76 , 77 ].

These were tempered a little by decreasing willingness to see a PA over a physician for more complex conditions or those having greater severity [ 77 ]. The positive findings are however not universal, with poor documentation of history and physical examination reported at a remote clinic in the s [ 60 ], and with PAs being rated less favourably on all measures to monitor patients with diabetes and their patients less likely to achieve targets for disease control in [ 79 ].

There are some situations where they would prefer to see a doctor either for the complexity or severity of their condition, suggesting that patients who have experienced a PA or who envision such care feel they can determine which level of provider is appropriate for their need. The evidence on technically appropriate care provided by PAs, while mainly positive, is from often poorly reported studies, and there are also some less favourable comparisons with other providers. In addition, there is limited reported exploration of the appropriateness of care to patients who form the majority of the workload — the patients consulting with acute, undifferentiated conditions, or comparison with care provided by doctors for the same case mix of patients.

Retention of PAs is considered possible if the conditions of the local area, as well as their employment, fit their personal circumstance. Clinician support for the profession is reported to be high, particularly amongst those already employing PAs, though some consider it to be a low salaried position. PAs are also considered to be expensive, because their work involves low revenue-generating patients. The apparent support for PAs, coupled with increasing numbers, appears to fit with a picture of need in terms of workload demand in family practice.

The evidence for this comes in the studies that describe that the consultation type carried out by PAs is the acute, often undifferentiated caseload in family practice, with some suggestion however that the doctors see the older patients with more chronic or serious conditions. PAs are presented in several studies to potentially increase the workload of others through the need for supervision and in the UK in particular for prescribing support, though they may also enable an increase in physician or practice productivity.

Acceptability to patients appears to be very high in actual and hypothetical situations, although it was reported that there were conditions patients would prefer to see a doctor for. Other reports on the outcomes of care are positive in the main, though limited, with surprisingly little on the appropriateness of the care provided for the major reported workload group of acute conditions.

Why You Should See a Physician Assistant - One Medical - One Medical

When summarised against the contemporarily used three dimensions of quality — patient safety, effectiveness of care and patient experience - in the UK NHS [ 80 ], the review suggests that some supportive evidence for the PA in general practice has been found in each of these dimensions, albeit in limited form outside of patient experience.

However, there are a number of caveats to the support regarding patient safety and effectiveness of care as the findings do not provide robust evidence and there is a complete absence of studies in some areas. The second key message from the review is the issue of context and method. The majority of the studies included are from the USA, reflecting the development of this professional group since the s and its relatively recent introduction in a small number of other countries. Most of the studies are of weak to moderate quality as assessed against critical appraisal checklists.

Quantitative descriptive studies with no, or limited, comparative data dominate the literature. Where comparative data are presented, contextual factors, potentially confounding any analyses, are only controlled for in modelling studies. Qualitative studies rarely described their methods and analysis thoroughly. It might be assumed that the concentration of studies from the s reflected interest and potentially attempts to promote the role through local evaluation in what was then a new occupational group in the USA.

However, the apparent lack of change in research questions over time was more surprising, particularly in light of remaining gaps in the literature. This is exemplified in the limited reported exploration of the appropriateness of care to patients who form the majority of the workload — the patients consulting with acute, undifferentiated conditions - or comparison with care provided by doctors for the same case mix of patients.

It might be that the slowing down of evidence production alongside the growth in PA numbers can be seen as acceptance of the contribution of PAs as an occupational group. However, these issues of context and method limit the generalisability of the findings to PAs in family practice not only within the USA but also to the newly developing roles in the UK, Netherlands and Australia. Notwithstanding the low quality there is reasonable consistency of findings, particularly regarding conditions seen and acceptability of the role.

The implications of the findings of this review are twofold: If the findings from the USA are replicable it is also possible that PAs might fill any geographical gaps in the medical primary care workforce. This issue has not been addressed in previous reviews, but is acknowledged in a recently published review [ 25 ].

This lack of evidence does not appear to be unique to the PA role. A dearth of evidence is reported about changing workforce skill mix, especially for role changes out with doctors and nurses, and most particularly a lack of evaluation of cost effectiveness and impact on the wider health care system [ 81 ]. As changing workforce skill mix is a strategy in use to improve effectiveness and efficiency of healthcare, good research evidence is needed about the likely consequences of any skill mix change [ 81 ].

While our review of PAs in general practice settings provides some evidence of the consequence of the change from doctors to PAs, the review also makes it clear that a number of research questions remain, in general and in relation to primary care in the UK and similar clinical primary care elsewhere.

The questions we consider merit further investigation are:. What is the efficiency of the shift in work between professional groups? What is the economic cost and benefit of PAs in primary care? We suggest that these are questions that warrant further, country specific, investigation in good quality studies providing comparative data with other relevant professional groups.

In this way, health service planners, managers and commissioners might be provided with evidence to support their decision making as to the best deployment of their finite resources. This review has a number of limitations. Firstly, the review had a specific question, focusing on primary care as relevant to the UK and European definition of primary care, that is, care provided in general practice. This tightly defined focus together with the exclusion of studies where the primary care data could not be disaggregated from data in the secondary care setting [ 82 ] may have limited the available evidence.


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However, this approach has assisted in identifying the evidence as relevant to those countries with similar primary care systems to the UK in which PAs are starting to be employed and even trained, even though the setting for the majority of the studies was the USA. The approach can also aid those trying to transfer knowledge about workforce issues from one health care system to others. Secondly, the review included many studies that might be considered outdated being from the s and s and therefore being carried out when family practice in the USA and indeed elsewhere was more dominated by single handed physician practices prior to the move to the health managed organisations or other group practice configurations more prevalent today.

This historical contextual change potentially limits the generalisability of the findings. The age of the studies is also relevant in that standards of research reporting were less rigorous at that time and the several studies with limited descriptions of method, for example, limit the opportunities for synthesis of findings and the strength of conclusions that can be drawn. However, the rationale for the inclusion of such studies rested on the fact that the PA role is only recently introduced in many countries and findings from the early phases of role development in the USA may therefore be highly relevant.

The fact that the vast majority of the literature is from the USA might also be seen as an interesting finding of itself, particularly as other countries are appearing willing to at least trial the PA role without health system-specific evidence. There appears to be a progression in the reporting of new workforce roles which moves from the descriptive to single site evaluations to multi-site evaluations [ 83 , 84 ] and to ignore this would diminish the evidence for those considering introducing new roles.

In essence, PA education more closely resembles a condensed version of medical school than does any other health professions curriculum. Clinical education is required in a variety of settings, including outpatient and inpatient settings as well as emergency and long-term care facilities, typically in academic teaching settings. Inpatient clinical rotations are usually conducted in an experiential team format consisting of PA students, medical students, and residents, led by a staff attending physician.

The MGMA statistics reflect productivity at larger group practices, which are not necessarily representative of productivity in smaller group settings [7]. Each year, PAs in family practice have 42 percent of ambulatory encounters with patients physicians have the other 58 [7]. Use of average, annual patient encounters as the productivity measure may be leading to underestimation of the contribution of PAs because, though in some practices the PA might provide the majority of the care during a patient visit with the physician participating only at the end e.

These numbers suggest that hiring a PA in a large practice could be the equivalent of having 0. For general internal medicine and geriatrics, the percentages are somewhat lower ranging from 70 to 85 percent [7] —perhaps reflecting the complexity of adult cases. For NPs, average annual ambulatory visits and RVUs are lower, possibly reflecting greater use of NPs for administrative and other non-patient-care activities.

Although primary care practices differ in how they use certified nurse practitioners NP-Cs within a team, these numbers suggest that an NP-C offsets the work of 70 percent to 90 percent of an FTE primary care physician, on average. Additional research on the implications of greater use of NPs and PAs on demand for physicians would be useful.

PAs are likely to continue to be used increasingly in a wide variety of medical practice settings in American medicine, including primary care. They have been shown to be clinically versatile and cost-effective clinicians, extending the services of physician practices and improving delivery of care to underserved populations, and have thus become an important component of the U.

THE CONTRIBUTIONS OF PHYSICIAN ASSISTANTS IN PRIMARY CARE SYSTEMS

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Primary Care for Physician Assistants

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