RESUMO
ABSTRACT: Efforts to improve access to high-quality, efficient primary care have highlighted the need for team-based care. Most primary care teams are designed to maintain continuity of care between patients and primary care providers (PCPs), because continuity of care can improve some patient outcomes. However, PCPs are interdependent because they care for, or share, patients. PCP interdependence, and its association with continuity of care, is not well described. This study describes a measure of PCP interdependence. We also evaluate the association between patient and panel characteristics, including PCP interdependence. Our results found that the extent of interdependence between PCPs in the same clinic varies widely. A range of patient and panel characteristics affect continuity of care, including patient complexity and PCP interdependence. These results suggest that continuity of care for complex patients is sensitive to panel characteristics, including PCP interdependence and panel size. This information can be used by primary care organizations for evidence-based team design.
Assuntos
Continuidade da Assistência ao Paciente , Atenção Primária à Saúde , Humanos , Atenção Primária à Saúde/métodos , Qualidade da Assistência à Saúde , Instituições de Assistência AmbulatorialRESUMO
OBJECTIVE: Increased demand for quality primary care and value-based payment has prompted interest in implementing primary care teams. Evidence-based recommendations for implementing teams will be critical to successful PA participation. This study sought to describe how primary care providers (PCPs) define team membership boundaries and coordinate tasks. METHODS: This mixed-methods study included 28 PCPs from a primary care network. We analyzed survey data using descriptive statistics and interview data using content analysis. RESULTS: Ninety-six percent of PCPs reported team membership. Team models fell into one of five categories. The predominant coordination mechanism differed by whether coordination was required in a visit or between visits. CONCLUSIONS: Team-based primary care is a strategy for improving access to quality primary care. Most PCPs define team membership based on within-visit task interdependencies. Our findings suggest that team-based interventions can focus on clarifying team membership, increasing interaction between clinicians, and enhancing the electronic health record to facilitate between-visit coordination.
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Registros Eletrônicos de Saúde , Atenção Primária à Saúde , Pessoal de Saúde , Humanos , Equipe de Assistência ao Paciente , Qualidade da Assistência à Saúde , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: This is the final article in a series that examines the role of onboarding programs for new physician assistants (PAs) and NPs. On-the-job learning is highly relevant for this workforce. Here we examine the strategies organizations use to impart information and skills in onboarding programs. METHODS: In 2018, we interviewed 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Seven strategies were identified and are described in this article: Clinical mentoring, personal and professional mentoring, meeting with/shadowing other professionals, checking in by administrators, delivering didactic content, tailoring content or ramp-up, and assessing/ensuring competency. CONCLUSIONS: This article describes commonly used strategies in onboarding programs for PAs and NPs and can provide guidance to those designing their own onboarding programs. The programs we examined relied heavily on mentoring and other strategies appropriate for adult learners. Future work should evaluate the effectiveness of onboarding programs.
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Capacitação em Serviço/métodos , Tutoria/métodos , Profissionais de Enfermagem/educação , Assistentes Médicos/educação , Atenção Primária à Saúde , Competência Clínica , Humanos , Profissionais de Enfermagem/psicologia , Assistentes Médicos/psicologia , Avaliação de Programas e Projetos de Saúde , Qualidade da Assistência à Saúde , Recursos HumanosRESUMO
OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.
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Diabetes Mellitus/economia , Pessoal de Saúde/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Diabetes Mellitus/psicologia , Feminino , Pessoal de Saúde/normas , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Profissionais de Enfermagem/economia , Profissionais de Enfermagem/normas , Profissionais de Enfermagem/estatística & dados numéricos , Assistentes Médicos/economia , Assistentes Médicos/normas , Assistentes Médicos/estatística & dados numéricos , Médicos/economia , Médicos/normas , Médicos/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Estados Unidos , United States Department of Veterans Affairs/economia , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricosRESUMO
OBJECTIVES: The objective of this project was to evaluate demand for PAs by examination of job postings. We compared proportions of PAs in primary care with proportions of job postings in primary care in 2014 and 2016 and described job postings for PAs by specialty in 2014 and 2016. METHODS: Internet job postings for PAs supplied by Burning Glass Technologies were evaluated for practice specialty. Job postings were compared with existing filled positions by specialty as reported by the National Commission for the Certification of Physician Assistants. RESULTS: In both years, more than 25% of PAs in practice were in primary care and fewer than 20% of job openings were in primary care. More than half of postings were in medical and surgical subspecialties. CONCLUSIONS: Our findings provide insights into which specialties have emerging high demand for PAs. The demand for PAs appears to remain much stronger for specialty jobs than for primary care jobs.
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Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Assistentes Médicos/provisão & distribuição , Assistentes Médicos/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Especialização/estatística & dados numéricos , Humanos , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: To describe administrative factors that should be considered when designing an onboarding program for physician assistants (PAs) and NPs. METHODS: Interview study of 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Five administrative themes are summarized: goals of onboarding, critical organization factors, organizational fit, designing the program, and costs of onboarding. CONCLUSIONS: Careful planning and administration are essential to the success of onboarding programs. Although onboarding programs must be designed with unique institutional needs in mind, the considerations identified by our project might serve as a useful guide to PA and NP employers in the process of creating an onboarding program.
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Educação Continuada/métodos , Educação , Tutoria/métodos , Profissionais de Enfermagem/educação , Assistentes Médicos/educação , Avaliação de Programas e Projetos de Saúde , Feminino , Humanos , Masculino , Recursos HumanosRESUMO
OBJECTIVE: Healthcare organizations are interested in creating onboarding programs to assist new PA and NP employees as they transition to practice settings. There is a need for information on what the ideal content and topic areas are for clinics to include in their onboarding programs. METHODS: In 2018, we interviewed 13 administrators of onboarding programs. Interviews were transcribed and analyzed for themes by a team of researchers, with feedback from interviewees. RESULTS: Eight content areas were identified and described in this paper: culture and values; goals and strategies; task proficiency; rules and policies; structure; working relationships; wellness; and navigation and politics. CONCLUSIONS: These common content areas may provide a starting point for organizations designing onboarding programs for their unique organizations.
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Educação Continuada/métodos , Tutoria/métodos , Profissionais de Enfermagem/educação , Assistência ao Paciente , Assistentes Médicos/educação , Avaliação de Programas e Projetos de Saúde , Local de Trabalho , Competência Clínica , Feminino , Humanos , Masculino , Recursos HumanosRESUMO
Background: Primary care provided by nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a solution to expected workforce shortages. Objective: To examine potential differences in intermediate diabetes outcomes among patients of physician, NP, and PA primary care providers (PCPs). Design: Cohort study using data from the U.S. Department of Veterans Affairs (VA) electronic health record. Setting: 568 VA primary care facilities. Patients: 368 481 adult patients with diabetes treated pharmaceutically. Measurements: The relationship between the profession of the PCP (the provider the patient visited most often in 2012) and both continuous and dichotomous control of hemoglobin A1c (HbA1c), systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL-C) was examined on the basis of the mean of measurements in 2013. Inverse probability of PCP type was used to balance cohort characteristics. Hierarchical linear mixed models and logistic regression models were used to analyze continuous and dichotomous outcomes, respectively. Results: The PCPs were physicians (n = 3487), NPs (n = 1445), and PAs (n = 443) for 74.9%, 18.2%, and 6.9% of patients, respectively. The difference in HbA1c values compared with physicians was -0.05% (95% CI, -0.07% to -0.02%) for NPs and 0.01% (CI, -0.02% to 0.04%) for PAs. For SBP, the difference was -0.08 mm Hg (CI, -0.34 to 0.18 mm Hg) for NPs and 0.02 mm Hg (CI, -0.42 to 0.38 mm Hg) for PAs. For LDL-C, the difference was 0.01 mmol/L (CI, 0.00 to 0.03 mmol/L) (0.57 mg/dL [CI, 0.03 to 1.11 mg/dL]) for NPs and 0.03 mmol/L (CI, 0.01 to 0.05 mmol/L) (1.08 mg/dL [CI, 0.25 to 1.91 mg/dL]) for PAs. None of these differences were clinically significant. Limitation: Most VA patients are men who receive treatment in a staff-model health care system. Conclusion: No clinically significant variation was found among the 3 PCP types with regard to diabetes outcomes, suggesting that similar chronic illness outcomes may be achieved by physicians, NPs, and PAs. Primary Funding Source: VA Health Services Research and Development.
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Diabetes Mellitus Tipo 2/terapia , Profissionais de Enfermagem , Assistentes Médicos , Médicos de Atenção Primária , Atenção Primária à Saúde/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Sanguínea/fisiologia , LDL-Colesterol/sangue , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/fisiopatologia , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária/provisão & distribuição , Atenção Primária à Saúde/normas , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Growing demand for services is leading primary care organizations to explore new delivery models. One approach incorporates multiple primary care providers on a team. Effective incorporation of multiple clinicians into teams requires well-defined roles, including the usual provider (who provides the majority of primary care) and supplemental providers (who provide a minority of primary care visits). Using data from the Veterans Health Administration, we examined whether differences in diabetes outcomes exist among patients with different types of primary and supplemental providers (physicians, physician assistants (PAs), and NPs). No clinically meaningful differences were observed based on the profession of the usual provider or supplemental provider, or whether physicians provided supplemental care to patients with PAs or NPs as usual providers. These results suggest that physicians, PAs, and NPs can perform a variety of roles depending on the needs of the organization and patient population.
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Diabetes Mellitus/terapia , Profissionais de Enfermagem , Assistentes Médicos , Médicos de Atenção Primária , Atenção Primária à Saúde/organização & administração , Idoso , LDL-Colesterol/metabolismo , Diabetes Mellitus/metabolismo , Gerenciamento Clínico , Feminino , Hemoglobinas Glicadas , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente , Estados Unidos , United States Department of Veterans AffairsRESUMO
BACKGROUND: Continuity of care is a cornerstone of primary care and is important for patients with chronic diseases such as diabetes. The study objective was to examine patient, provider and contextual factors associated with interpersonal continuity of care (ICoC) among Veteran's Health Administration (VHA) primary care patients with diabetes. METHODS: This patient-level cohort study (N = 656,368) used electronic health record data of adult, pharmaceutically treated patients (96.5% male) with diabetes at national VHA primary care clinics in 2012 and 2013. Each patient was assigned a "home" VHA facility as the primary care clinic most frequently visited, and a primary care provider (PCP) within that home clinic who was most often seen. Patient demographic, medical and social complexity variables, provider type, and clinic contextual variables were utilized. We examined the association of ICoC, measured as maintaining the same PCP across both years, with all variables simultaneously using logistic regression fit with generalized estimating equations. RESULTS: Among VHA patients with diabetes, 22.3% switched providers between 2012 and 2013. Twelve patient, two provider and two contextual factors were associated with ICoC. Patient characteristics associated with disruptions in ICoC included demographic factors, medical complexity, and social challenges (example: homeless at any time during the year OR = 0.79, CI = 0.75-0.83). However, disruption in ICoC was most likely experienced by patients whose providers left the clinic (OR = 0.09, CI = 0.07-0.11). One contextual factor impacting ICoC included NP regulation (most restrictive NP regulation (OR = 0.79 CI = 0.69-0.97; reference least restrictive regulation). CONCLUSIONS: ICoC is an important mechanism for the delivery of quality primary care to patients with diabetes. By identifying patient, provider, and contextual factors that impact ICoC, this project can inform the development of interventions to improve continuity of chronic illness care.
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Continuidade da Assistência ao Paciente/estatística & dados numéricos , Diabetes Mellitus/tratamento farmacológico , Profissionais de Enfermagem , Médicos de Atenção Primária , Veteranos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Registros Eletrônicos de Saúde , Feminino , Humanos , Internato e Residência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Reorganização de Recursos Humanos , Assistentes Médicos , Estados Unidos , United States Department of Veterans AffairsRESUMO
The physician assistant (PA) profession is a health workforce innovation. This article discusses whether, after 50 years, the PA profession is still an innovation.
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Difusão de Inovações , Assistentes Médicos/provisão & distribuição , Atenção Primária à Saúde , Humanos , Estados Unidos , Recursos HumanosRESUMO
Physician assistant (PA)-focused research arose in response to the idea that an assistant to the busy physician could improve healthcare delivery. The process of answering questions about the profession has involved multiple approaches and various scholarly disciplines. In the course of this undertaking, what emerged were three stages of examination of PA behavior. The bibliographic span from this period contains about 2,400 studies that advance some notion of PA benefit to society. On the 50th anniversary of the PA profession, a question arises as to what research has shown. The answer is that PAs are providing care at significant levels of quality and quantity and their presence is enriching many challenges in healthcare delivery. In an era where demand for medical services is outstripping supply, the good idea born in the 1960s is emerging as a medical innovation domestically and globally.
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Pesquisa Biomédica , Atenção à Saúde/tendências , Assistentes Médicos/tendências , Atenção Primária à Saúde/tendências , Atenção à Saúde/métodos , Humanos , Estados UnidosRESUMO
OBJECTIVES: Physician assistants (PAs) and advanced practice registered nurses (APRNs) can perform multiple roles on primary care teams, but limited research describes the patients they serve. We sought to identify patient characteristics associated with roles of primary care PAs and APRNs. METHODS: We analyzed adult respondents to the 2010 Health Tracking Household Survey with a primary care usual provider (physician, PA, or APRN). The dependent variable is the PA or APRN role. Explanatory variables include sociodemographic characteristics, attitudes toward use, delayed care, and perceived health. RESULTS: Compared with respondents seen by physicians only, respondents seen by a PA or APRN in any role were more likely to be younger, female, living in rural areas, and put off needed medical care. Respondents seen by a PA or APRN as their usual provider were more likely to report better health. Patients seen by a PA or APRN in a supplemental role reported being sicker, more educated, and attitudinally less likely to use healthcare. CONCLUSIONS: PAs and APRNs perform different roles for different types of patients.
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Pacientes , Assistentes Médicos , Atenção Primária à Saúde , Adulto , Atenção à Saúde , Feminino , Humanos , MasculinoRESUMO
OBJECTIVES: To describe trends in physician assistant (PA) specialty distribution, compare these trends with physicians, and quantify the relationship of PA specialty prevalence with both PA and physician salary. METHODS: PA specialty and salary data were obtained from the 2013 American Academy of PAs' Annual Survey; physician specialty and salary data from the American Medical Association Physician Masterfile and the Medical Group Management Association. Analyses included descriptive statistics and linear regression. RESULTS: The proportion of PAs working in primary care decreased from 50% in 1997 to 30% in 2013. Substantial growth in PA proportions occurred in surgical and medical subspecialties. Regression models showed a higher prevalence of PAs in specialties with higher PA salary, higher physician salary, and higher physician-to-PA salary ratio (P<0.05). CONCLUSIONS: PAs are moving toward subspecialty practice. Our study suggests that demand for PAs may be an important factor driving the trend toward specialization.
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Assistentes Médicos/economia , Salários e Benefícios , Especialização , Humanos , Medicina , Médicos , Estados UnidosRESUMO
Electronic health record data linked with Medicare data from an academic physician group were used to propose a multidimensional characterization of PA and NP roles on panels of primary care patients with diabetes. Seven PA and NP roles were defined based on level of involvement, visits with complex patients, and delivery of chronic care. Findings suggest that PAs and NPs in primary care perform a variety of roles and frequently perform multiple roles within a clinic.
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Diabetes Mellitus/terapia , Profissionais de Enfermagem , Assistentes Médicos , Atenção Primária à Saúde , Papel Profissional , Idoso , HumanosRESUMO
BACKGROUND: Performance measurement at the provider group level is increasingly advocated, but different methods for selecting patients when calculating provider group performance have received little evaluation. OBJECTIVE: We compared 2 currently used methods according to characteristics of the patients selected and impact on performance estimates. RESEARCH DESIGN, SUBJECTS, AND MEASURES: We analyzed Medicare claims data for fee-for-service beneficiaries with diabetes ever seen at an academic multispeciality physician group in 2003 to 2004. We examined sample size, sociodemographics, clinical characteristics, and receipt of recommended diabetes monitoring in 2004 for the groups of patients selected using 2 methods implemented in large-scale performance initiatives: the Plurality Provider Algorithm and the Diabetes Care Home method. We examined differences among discordantly assigned patients to determine evidence for differential selection regarding these measures. RESULTS: Fewer patients were selected under the Diabetes Care Home method (n=3558) than the Plurality Provider Algorithm (n=4859). Compared with the Plurality Provider Algorithm, the Diabetes Care Home method preferentially selected patients who were female, not entitled because of disability, older, more likely to have hypertension, and less likely to have kidney disease and peripheral vascular disease, and had lower levels of predicted utilization. Diabetes performance was higher under Diabetes Care Home method, with 67% versus 58% receiving >1 A1c tests, 70% versus 65% receiving ≥1 low-density lipoprotein (LDL) test, and 38% versus 37% receiving an eye examination. CONCLUSIONS: The method used to select patients when calculating provider group performance may affect patient case mix and estimated performance levels, and warrants careful consideration when comparing performance estimates.
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Diabetes Mellitus/terapia , Prática de Grupo/normas , Serviços de Assistência Domiciliar/organização & administração , Seleção de Pacientes , Garantia da Qualidade dos Cuidados de Saúde , Algoritmos , Distribuição de Qui-Quadrado , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Masculino , Medicare , Reembolso de Incentivo , Estatísticas não Paramétricas , Estados UnidosRESUMO
OBJECTIVE: A component of health-care reform in 2010 identified physician assistants (PAs) as needed to help mitigate the expected doctor shortage. We modeled their number to predict rational estimates for workforce planners. METHODS: The number of PAs in active clinical practice in 2010 formed the baseline. We used graduation rates and program expansion to project annual growth; attrition estimates offset these amounts. A simulation model incorporated historical trends, current supply, and graduation amounts. Sensitivity analyses were conducted to systematically adjust parameters in the model to determine the effects of such changes. RESULTS: As of 2010, there were 74,476 PAs in the active workforce. The mean age was 42 years and 65% were female. There were 154 accredited educational programs; 99% had a graduating class and produced an average of 44 graduates annually (total n=6,776). With a 7% increase in graduate entry rate and a 5% annual attrition rate, the supply of clinically active PAs will grow to 93,099 in 2015, 111,004 in 2020, and 127,821 in 2025. This model holds clinically active PAs in primary care at 34%. CONCLUSIONS: The number of clinically active PAs is projected to increase by almost 72% in 15 years. Attrition rates, especially retirement patterns, are not well understood for PAs, and variation could affect future supply. While the majority of PAs are in the medical specialties and subspecialties fields, new policy steps funding PA education and promoting primary care may add more PAs in primary care than the model predicts.
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Assistentes Médicos/provisão & distribuição , Adulto , Feminino , Reforma dos Serviços de Saúde , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Modelos Teóricos , Assistentes Médicos/educação , Atenção Primária à Saúde , Estados Unidos , Recursos HumanosRESUMO
PURPOSE: The purpose of this study was to understand the association between physician assistant (PA) state scope of practice (SOP) laws and (1) PA program growth and (2) PA graduate demographics. METHODS: Scope of practice laws were categorized as ideal, average, and restrictive. Descriptive statistics by year and SOP categories were determined for the number of states, population density, PA programs, and PA graduate number, gender, race, and mean age. The Mann-Whitney U test was used to analyze demographic data by SOP categories. Adjusted risk ratios were generated for the number of PA programs and SOP categories. RESULTS: The number of PA programs is not associated with ideal SOP states. As of 2017, only 10 states have restrictive SOP laws. A minority of PA students now graduate from states with restrictive SOP laws. CONCLUSION: There is heterogeneity in PA SOP laws throughout the United States but only a minority of PA graduates now come from restrictive SOP states. This study provides foundational information prior to the implementation of optimal team practice.