The cost-effectiveness of physician assistants/associates: A systematic review of international evidence.

BACKGROUND: The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. METHODS AND FINDINGS: Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies-of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician's care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. CONCLUSIONS: Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity.

An activity analysis of Dutch hospital-based physician assistants and nurse practitioners.

BACKGROUND: The physician assistant (PA) and the nurse practitioner (NP) were introduced into The Netherlands in 2001 and 1997 respectively. By the second decade, national policies had accelerated the acceptance and development of these professions. Since 2015, the PA and NP have full practice authority as independent health professionals. The aim of this research was to gain a better understanding of the tasks and responsibilities that are being shifted from Medical Doctors (MD) to PAs and NPs in hospitals. More specifically in what context and visibility are these tasks undertaken by hospital-based PAs and NPs in patient care. This will enable them to communicate their worth to the hospital management. STUDY DESIGN: A descriptive, non-experimental research method design was used to collect and analyze both quantitative and qualitative data about the type of tasks performed by a PA or NP. Fifteen medical departments across four hospitals participated. METHODS: The patient scheduling system and hospital information system were probed to identify and characterize a wide variety of clinical tasks. The array of tasks was further verified by 108 interviews. All tasks were divided into direct and indirect patient care. Once the tasks were cataloged, then MDs and hospital managers graded the PA- or NP-performed tasks and assessed their contributions to the hospital management system. FINDINGS: In total, 2883 tasks were assessed. Overall, PAs and NPs performed a wide variety of clinical and administrative tasks, which differed across hospitals and medical specialties. Data from interviews and the hospital management systems revealed that over a third of the tasks were not properly registered or attributed to the PA or NP. After correction, it was found that the NP and PA spent more than two thirds of their working time on direct patient care. CONCLUSIONS: NPs and PAs performed a wide variety of clinical tasks, and the consistency of these tasks differed per medical specialty. Despite the fact that a large part of the tasks was not visible due to incorrect administration, the interviews with MDs and managers revealed that the use of an NP or PA was considered to have an added value at the quality of care as well to the production for hospital-based medical care in The Netherlands.

High rates of stopping or switching biological medications in veterans with rheumatoid arthritis.

OBJECTIVES: To define the characteristics of a population of veterans with rheumatoid arthritis (RA) who have stopped or switched their first biologic agent, and to assess if measures of disease activity are predictors in the decision to alter the regimen. METHODS: A retrospective analysis of the VA electronic medical record system identified RA patient demographic and disease activity parameters from 1999 to 2007. Demographic data included age, race/ethnicity, sex, and tobacco use. Disease-specific data included date of RA onset, past DMARD therapies, prednisone use, as well as the disease activity score (DAS-28) and the health assessment questionnaire (HAQ) at each clinic visit. The use of six biologicals (infliximab, etanercept, adalimumab, abatacept, rituximab, anakinra) was identified in order to compare those who continued with the medication to those discontinuing or switching to another biological. Descriptive and parametric statistics were applied to define differences between the two groups. RESULTS: Of 454 RA patients identified, 212 have been on a biologic agent at one point in time, and 100 patients (47%) had either stopped or switched their first biologic agent. Among these 100 patients, the most common reasons for stopping or switching a biologic agent were adverse events (in 48%) and inefficacy (43%) Adverse events included malignancies (23% of 48 patients), rash (23%), infections (18.8%), and cardiac complications (18.8%). When comparing the 100 patients versus the 112 that did not stop or switch their first agent, the DAS-28 correlated significantly with a change of regimen with an OR 2.1 (p<0.001). The HAQ score had an OR of 2.0 (p<0.04). CONCLUSION: RA patients who continue taking their initial biologic medication have similar age, RA disease duration, ethnicity, and smoking status to those requiring switching or discontinuation. The DAS28 and HAQ scores significantly correlated with stopping or switching of a first biologic agent. Adverse event rates were high and their distributions differed in this population compared to previous studies of younger Caucasian females.

Physician assistants in occupational medicine: how do they compare to occupational physicians?

BACKGROUND: Physician assistants (PAs) have been present in occupational and environmental medicine (OEM) in the USA since 1971, yet remarkably little is known about their activity. METHODS: An administrative study of PA activities was undertaken and compared with the activities of physicians in the same occupational medicine setting. Patients were not triaged to either provider and all resources of care were recorded for the visit. An episode of care approach was used for the analysis. RESULTS: The characteristics of patients seen by each provider were similar in age, gender ratio and severity of injury. Physicians saw a mean of 2.9 patients/h and PAs 2.5, but PAs worked more hours and saw more patients per year than physicians. The average charge per patient visit and total charge for an episode of care were similar. Differences between PAs and physicians were seen in the areas of 'limited duty' duration given to patients and on average PAs prescribed 15 days and physicians 17 days. PAs referred a patient 19.7% of the time, while physicians referred 17.4%. Most of the referrals were to physical therapy. The salary of a physician, based on an hourly rate, was approximately twice as much as a PA. CONCLUSION: The use of PAs in OEM may represent a cost-effective advantage from an administrative standpoint. Clearly, more research is necessary in determining the role and utilization of PAs in OEM and how they may improve the delivery of physician services.

Use of physician assistants and nurse practitioners in primary care, 1995-1999.

Federal policies and state legislation encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. In this paper we analyze primary care physician office encounter data from the 1995-1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office-based physicians used PAs and/or NPs for an average of 11 percent of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counseling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care.

Physician assistants in Texas.

Understanding the health requirements of a state begins with identifying the population at need and the workforce available to meet those needs. A descriptive study was undertaken to examine the physician assistant (PA) workforce in Texas as part of an ongoing effort to meet the health needs of Texas residents. In September 2000, Texas had 2237 licensed PAs practicing in 186 counties. Education for PAs in Texas began in 1970 and currently includes one private, one military, and six public programs. Most practicing PAs in Texas graduate from in-state programs and tend to locate within the state. Preparations are under way to shift the public undergraduate programs to graduate degree programs. Although barriers to health care access in Texas remain a substantial public health issue, PAs have helped reduce these barriers, especially in many rural communities. The supply of and demand for Texas PAs appear to be in equilibrium. Policy implications are discussed.

Use of physician assistants and nurse practitioners in primary care, 1995-1999.

Federal policies and state legislation in the United States encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. This article analyzes primary care physician office-encounter data from the 1995-1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office-based physicians used PAs and/or NPs for an average of 11% of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counselling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care.

"Elder" physician assistants and their practices.

UNLABELLED: Physician assistants (PAs) in American medicine are aging. After 30 years of having PAs enter the US health care system, it seems an appropriate time to examine where they are in their careers. This study describes the phenomenon of a rising number of elder PAs in the ranks of the nation's health providers and their patterns of practice. METHOD: A subpopulation cohort of practicing PAs 60 years and older was compared to all PAs. Age range, gender, practice setting, specialty, and other demographic variables were analyzed using established methods. Differences between elder PAs and all other PAs and services provided by the two groups were examined. RESULTS: Elder PAs constituted about 1.6% of full-time PAs in practice in 1998. Average age of elder PAs is 64 years (range, 60 years to 74 years) compared to 41 years (range, 21 years to 60 years) for all full-time practicing PAs. Analysis of several variables--gender, ethnicity, geographic distribution, number of patients seen in a week, and hours worked in a week--revealed few differences between the cohorts. On average, older PAs were in practice longer than all PAs (18.3 years and 9.2 years, respectively), had been with their current employer for 7.7 years, and worked one job. Elder PAs had an associate degree at twice the rate of all PAs, but three times as many of them had a doctorate. Elder PAs are more likely to be taking care of older patients, working in a rural area, and remaining in a rural area longer than PAs overall. INTERPRETATION: America's corps of PAs continues to work into and beyond the usual retirement age for most workers, and is caring for a greater percentage of older persons than all PAs are. Most elder PAs practice in family or general medicine and prefer to practice in a rural area. These practice preferences mirror results of previous studies of the practices of elder physicians in the United States and Canada. The aging of PAs has important implications for clinical practice and health workforce planning. If PAs were encouraged to take early retirement, more elderly patients would be shifted to younger providers--with the potential to affect delivery of primary care services in rural communities.

Physician assistants and the practice of neurology.

This is the first study of how physician assistants (PAs) function in neurology practice. Forty-six PAs who work full-time in a neurology practice were surveyed by telephone and by mail; 100% responded to all telephone survey questions on aspects of practice, and almost all responded to the mailed survey. Of these, 26 worked in a group practice; the average duration of neurology experience was 7 years. Diagnoses seen by these PAs were similar to those seen in most neurology practices. The scope of findings is limited but suggests that, in neurology settings where PAs are employed, they perform a broad range of functions. Furthermore, PAs in most neurology practices likely assist in off-loading patients whose requirements for care are considered "routine" by the PAs' supervising physician(s).

Implications for practice and education. Clinical activities of Iowa family practice PAs.

A survey of family practice physician assistants (PAs) in Iowa was undertaken to determine the frequency with which they utilized specific clinical skills. A response was received from 55 of 77 (74%) PAs surveyed. Average age of respondents was 42 years (range, 35 to 50). Respondents had, on average, been practicing for 13 years, mostly in family medicine; on average, they saw 25 patients a day. All reported providing patient education, prescribing and dispensing medication, interpreting radiographs, referring patients, and providing a wide range of services similar to their physician counterparts in Iowa. In regard to 62 activities identified, few differences emerged among respondents when population setting was considered--except that PAs who work in communities of fewer than 10,000 residents often perform a wider range of services than those who work in larger communities. Activities that have been ranked as important by Iowa family practice physicians in other surveys were also the clinical skills that PAs in this survey reported performing most often. This study supports mounting evidence that PAs are an important aspect of primary care delivery across society. Their activities in the delivery of care are similar to those that the physicians with whom they are most closely associated consider important.

Management of established osteoporosis.

Osteoporosis is established when certain types of fractures occur or a reliable form of bone densiometry detects low bone mass. The treatment of established osteoporosis is undertaken with a number of choices. The goals of therapy are to stabilize the patient's condition and to prevent fractures. Generally, this means preventing further osteoporosis and, if possible, increasing bone mineral density. Estrogen, calcitonin, alendronate, etidronate, exercise, and calcium with vitamin D are the most available therapies in the United States. Other therapies are discussed.

Physician assistants and nurse practitioners in hospital outpatient departments, 1993-1994.

OBJECTIVE: To describe the characteristics of visits to physician assistants (PAs) and nurse practitioners (NPs) in hospital outpatient departments in the United States. METHODS: Data from the 1993 and 1994 National Hospital Ambulatory Medical Care Surveys were used to compare hospital outpatient department visits in which the patient was seen by a PA or NP, or both, with outpatient visits to all practitioners. RESULTS: An average of 64 million annual outpatient visits were made in 1993-1994, and patients were seen by PAs, NPs, or both, at 8% of these visits. PA-NP visits were more likely than total visits to occur in the Midwest, in non-urban areas, and in obstetric-gynecology clinics, and a higher proportion involved patients younger than age 25. Smaller differences were found between PA-NP visits and total outpatient visits in "reason for visit," "principal diagnosis," and "medication prescribed." CONCLUSION: Beyond the care they provide in physicians' offices and other non-hospital settings, PAs and NPs make an important contribution to ambulatory health care delivery in hospital outpatient departments.

Analysis of the costs of NSAID-associated gastropathy. Experience in a US health maintenance organisation.

Clinicians recognise nonsteroidal anti-inflammatory drugs (NSAIDs) as valuable first-line agents in the treatment of rheumatic disorders and as dangerous irritants to the gastrointestinal tract. This has led to questions about the economic impact of NSAID-induced gastropathy in populations. This study estimated the 1992 costs of NSAID-associated gastropathy episodes, and calculated an iatrogenic cost factor for NSAID-associated gastropathy among elderly members of a health maintenance organisation (HMO), the Northwest Region of Kaiser Permanente. Using data retrieved from automated databases and from medical records, NSAID and antiulcer drug costs were calculated, and estimates were made of the incidence rates of inpatient and outpatient NSAID-associated gastropathies, the services provided to treat them, and the cost of those services. Kaiser Permanente Northwest spent $US0.35 for each $US1.00 spent on NSAID therapy for the elderly, an iatrogenic cost factor of 1.35. The estimated average treatment per NSAID-associated gastropathy episode was $US2172. The average outpatient pharmacy cost per elderly NSAID user was $US80 and estimated average NSAID-associated treatment cost per elderly NSAID user was $US43. Although the findings were specific to the HMO because of the databases used, the methodology employed and the drug formulary influence on NSAID selection, they show that a substantial amount of resources were used to treat NSAID-induced gastropathies in the elderly, underscoring the risk of prescribing NSAIDs and reinforcing the need for their prudent use in elderly patients.

Determinants of specialty choice of physician assistants.

PURPOSE: Although physician assistants (PAs) became part of the U.S. health scene in 1967 and have made important contributions to primary care, available information about the factors that may influence the career choices of this rapidly-growing group of health care providers is sparse. The intent of this analysis was to identify the main factors underlying the specialty-choice decisions of PAs in the first practice year after completing PA training and the reasons for their selections. METHOD: Data were collected from a 1994 survey of 4,416 PAs who had graduated in 1991-1993. Usable responses were obtained from 1,472 PAs (33%). Each PA was asked to state the specialty he or she had entered in the first practice year and also to rate each of 33 possible reasons for this decision. Primary care specialties were defined as family medicine, general internal medicine, and general pediatrics. The ratings were subjected to a factor analysis. RESULTS: The 33 original variables were reduced to nine basic factors influencing the specialty-choice decisions of the PAs, accounting for 47.3% of the variance. The two most important factors were intellectual content of the specialty and a technical orientation. Then factor scores were computed for each PA and subjected to further examination, in which the PAs were divided into two groups: 776 who had entered primary care specialties, and 646 who had entered non-primary-care specialties (50 did not specify their specialties). For the PAs in non-primary-care specialties, the most influential factors were technical orientation and income/employment. For the PAs in primary care, the most influential factors were prevention, academic environment, debt/scholarship, intellectual content, and peer influence. CONCLUSION: For this recently graduated group of PAs, factors representing the kinds of activities they would be engaged in as health care providers were among the most influential, but the relative importances of the factors varied according to whether the PAs were in primary care or non-primary-care specialties, with the latter group being more strongly influenced by marker forces such as income and employment opportunities.

Emergency department uses of physician assistants and nurse practitioners: a national survey.

A study was undertaken to determine the extent to which physician assistants (PAs) and/or nurse practitioners (NPs) are a source of health care delivery in emergency departments (EDs) in the United States. The National Hospital Ambulatory Medical Survey (NHAMCS) uses a multistage probability sample that examines patient visits within EDs. The sample included 437 hospitals with EDs. Visits were mostly from self-referred patients to EDs within nonfederal, short-stay hospitals, or general hospitals. Analysis of NHAMCS data found that a PA and/or NP was seen for 3.5 million ED visits in 1992. Remarkably little difference in gender, reason for visit, diagnosis, and medication prescribed was found between PA/NP visits and visits to all providers. This was the first study that systematically identified the extent of PA/NP-delivered ED services in the United States and compared it with physician services. Overall, PAs and NPs were found to be significant sources of health care service for hospital EDs. They are involved in care for almost 4% of all ED visits nationally and manage a wider range of conditions than has been previously reported. When types of visits are analyzed, including reasons for ED care, diagnosis, and treatment, it appears that visits associated with care by ED-based PA/NPs are similar to all ED visits, including those attended by emergency medicine physicians. More studies are needed to better understand the role of PAs and/or NPs in various ED settings. Recruitment and use of PAs and NPs may be a cost-effective strategy for improved delivery of emergency services.

Satisfaction of physician assistants and other nonphysician providers in a managed care setting.

Health maintenance organizations have employed physician assistants, nurse practitioners, and other nonphysician providers for decades, yet there is little information on how satisfied these providers are with this form of practice. This paper examines how physician assistants evaluate their experience practicing in a large group model health maintenance organization and compares their attitudes and satisfaction levels with those of other nonphysician providers-nurse practitioners, optometrists, mental health therapists, and chemical dependency counselors. The data source is a 1992 survey of 5,000 nonphysician employees of a health maintenance organization. The survey instrument was a self-administrated questionnaire that included both structured and open-ended questions. The response rate averaged 88 percent for physician assistants and the other non-physician providers. Physician assistants expressed the most satisfaction with the amount of responsibility, support from coworkers, job security, working hours, supervision, and task variety. They were less satisfied with workload, control over the pace of work, and opportunities for advancement. Most physician assistants were also satisfied with pay and fringe benefits. Compared with other nonphysician providers, chemical dependency counselors expressed the highest levels of satisfaction across the various dimensions of work and optometrists the lowest. Nurse practitioners, chemical dependency counselors, and mental health professionals also tended to be satisfied with most aspects of practice in this setting. In a number of instances, they were more satisfied than the physician assistants. The findings are consistent with other studies that found health maintenance organizations to be favorable practice settings for physician assistants. The limits of physician assistant involvement and their role satisfaction and efficient use in HMOs are more likely to relate to physician attitudes and acceptance than to lack of support by coworkers and other attributes of the work environment.

PAs and NPs in HMOs.

Recognition of NPP contributions to the delivery of care in HMOs has come slowly. Staffing continues to be a function of physician attitude instead of management rationale. Only a few enlightened HMOs seek management and staffing input from NPPs. Investigation of the role of NPPs in HMOs has seriously lagged behind that of physicians, nurses, pharmacists, and other health professionals. The status, reward systems, and job satisfaction of nonphysician clinicians, as well as efforts and problems in recruiting them, have been inadequately reported. Only a handful of HMOs have contributed to our understanding of NPP productivity and task delegation. If HMOs plan to continue using NPPs, much more information on optimizing their deployment must be shared. Member satisfaction surveys must be reported, prescribing practices must be compared, liability issues explored, and outcomes research pursued. We know little about the outcome of nonacute illness managed by NPPs. Do NPPs negate their cost-effectiveness by using more or different resources? Do differences between PAs and NPs exist with regard to each of these issues? Because so many study variables can be held constant by a large HMO which provides care in a given area under uniform market forces, HMOs can best explore how to maximize NPP effectiveness.