The effect of primary care clinician type and care team characteristics on health care costs.

OBJECTIVE: To evaluate health care costs as a function of assigned primary care clinician type and care team characteristics. METHODS: Administrative data were collected for 68 family medicine clinicians (40 physicians and 28 nurse practitioners [NPs]/physician assistant [PAs]), on 11 care teams (variable MD, NP and PA on teams), caring for 77,141 patients. We performed a generalized linear mixed multivariable regression model of standardized per member per month (PMPM) median cost as the outcome, with four practice sites included as random effects. RESULTS: In bivariate analysis, cost was higher in physicians than NP/PAs, in more complex patients, and associated with emergency department (ED) visit rate. On multivariate analysis, patient complexity, ED visit rate and higher patient experience ratings were independently associated with greater PMPM cost. More time in practice was associated with lower PMPM cost. In the adjusted multivariate model, physicians had 8.3% lower median PMPM costs than NP/PAs (p = 0.046). CONCLUSIONS: The primary drivers of greater PMPM cost were patient complexity, ED visits and patient satisfaction.

PA job satisfaction and career plans.

OBJECTIVE: To understand the relationships between burnout, job satisfaction, and career plans among physician assistants in the United States. METHODS: The authors surveyed PAs in 2016. The survey included the Maslach Burnout Inventory and items on job satisfaction and career plans. RESULTS: Overall 82.7% of PAs were satisfied with their job, 32.2% indicated intent to leave their current position, and 19.5% reported intent to reduce work hours. On multivariate analysis, burnout increased the odds of job dissatisfaction, intent to reduce work hours within the next year, and intent to leave the current practice in the next 2 years. CONCLUSIONS: About a third of PAs indicated intent to leave their current practice and one in five indicated intent to reduce their clinical hours. Burnout was an independent predictor of job satisfaction and career plans.

Clinician Care Team Composition and Health Care Utilization.

OBJECTIVE: To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization. PATIENTS AND METHODS: We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions. RESULTS: The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = -0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians. CONCLUSION: Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits.

Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes.

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels (P < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team (P = .78). Physicians had a 1.082 (95% confidence interval 1.007-1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.

Efficacy of the Well-Being Index to identify distress and stratify well-being in nurse practitioners and physician assistants.

BACKGROUND AND PURPOSE: To evaluate the ability of the Well-Being Index (WBI) to stratify distress and well-being (high quality of life [QOL]) in nurse practitioners and physician assistants (NPs and PAs) and identify those whose degree of distress place them at an increased risk for medical error or turnover. METHODS: A national sample of NPs and PAs completed a survey that included the WBI and instruments to measure QOL, fatigue, burnout, recent suicidal ideation, medical error, and intent to leave the current job. CONCLUSIONS: Overall, 1,576 of 4,106 (38.4%) NPs and PAs completed the survey. Those NPs and PAs with low mental QOL, extreme fatigue, recent suicidal ideation, or burnout had less favorable WBI scores (all p < .0001). Using a prevalence of low overall QOL among APPs of 14.4% as the pretest probability, the WBI score can reduce the posttest probability of low QOL to 2% or increase it to 64.7%. As the WBI score worsened, the posttest probability of high overall QOL decreased from 73% to 8.2%. Also, WBI score stratified the NPs and PAs likelihood of reporting recent medical errors and intent to leave his or her current job. IMPLICATIONS FOR PRACTICE: The WBI is a useful screening tool to stratify distress and well-being in APPs across a variety of domains and identify those NPs and PAs whose degree of distress may increase the risk of medical error or turnover.

Patient throughput benefits of triage liaison providers are lost in a resource-neutral model: a prospective trial.

OBJECTIVES: Patient throughput is an increasingly important cause of emergency department (ED) crowding. The authors previously reported shorter patient length of stay (LOS) when adding a triage liaison provider, which required additional personnel. Here, the objective was to evaluate the effect of moving a fast-track provider to the triage liaison role. METHODS: This was a prospective observational before-and-after study design with predefined outcomes measures. A "standard staffing" situation (where an advanced practice provider staffed treatment rooms in the fast track) was compared with an advanced practice provider performing the triage liaison staffing role, with no additional staff. Eleven intervention ("triage liaison staffing") days were compared with 11 matched control ("standard staffing") days immediately preceding the intervention. Total LOS was measured for all adult Emergency Severity Index (ESI) 3, 4, and 5 patients (excluding behavioral health patients), and results were compared using Wilcoxon rank-sum and chi-square tests. RESULTS: A total of 681 patients registered on control days and 599 on intervention days. There was no significant difference in total patient LOS: median = 273 minutes, interquartile range (IQR) 176 to 384 minutes on intervention days versus median = 253 minutes, IQR = 175 to 365 minutes on control days (p = 0.20). There was no difference in left-without-being-seen (LWBS) rates (n = 48, 7% on control days vs. n = 35, 6% on intervention days; p=0.38). Secondary analysis of only ESI 3 patients showed no difference in total LOS between periods (median = 284 minutes, IQR = 194 to 396 minutes on intervention days vs. median = 290 minutes, IQR = 217 to 397 minutes on control days; p = 0.22). There was, however, significantly greater total LOS for ESI 4 and 5 patients during the intervention period (median = 238 minutes, IQR = 124 to 350 minutes on intervention days vs. median = 192 minutes, IQR = 124 to 256 minutes on control days; p = 0.011). CONCLUSIONS: The previously reported benefits on patient LOS and LWBS rates after adding a triage liaison (resource additive) were lost when that provider was moved from fast track to the triage role (resource neutral). While the triage liaison provider role may be a way to improve ED throughput when additional resources are available, as evidenced by our prior study, the triage liaison model itself does not appear to replace the staffing of treatment rooms, as evidenced by this study.

A case of persistent dizziness after travel.

Although vertigo is a common complaint with patients presenting to an ED, some uncommon causes also must be considered. This report focuses on a woman who developed sudden-onset vertigo with associated mental status changes after a long-distance flight. Her symptoms were consistent with mal de debarquement syndrome, an uncommon cause of vestibular dysfunction.

Effect of a physician assistant as triage liaison provider on patient throughput in an academic emergency department.

OBJECTIVES: Overcapacity issues plague emergency departments (EDs). Studies suggest that triage liaison providers (TLPs) may shorten patient length of stay (LOS) and reduce the proportion of patients who leave without being seen (LWBS), but these results are not universal. Previous studies used physicians as TLPs. We evaluated whether a physician assistant (PA), acting as a TLP, would shorten LOS and decrease LWBS rates. METHODS: The authors used an observational cohort controlled before-and-after study design with predefined outcome measures, comparing 8 pilot days to 8 control days. The TLP evaluated all Emergency Severity Index (ESI) level 3, 4, and 5 patients, excluding pediatric and behavioral health patients. RESULTS: A total of 353 patients were included on pilot days and 371 on control days. LOS was shorter on pilot days than control days (median [interquartile range {IQR}] = 229 [168 to 303] minutes vs. 270 [187 to 372] minutes, p < 0.001). Waiting room times were similar between pilot and control days (median [IQR] = 69 [20 to 119] minutes vs. 70 [19 to 137] minutes, p = 0.408), but treatment room times were shorter (median [IQR] = 151 [92 to 223] minutes vs. 187 [110 to 254] minutes, p < 0.001). Finally, a lower proportion of patients LWBS on pilot days (1.4% vs. 9.7%, p < 0.001). CONCLUSIONS: The addition of a PA as a TLP was associated with a 41-minute decrease in median total LOS and a lower proportion of patients who LWBS. The decrease in total LOS is likely attributable to the addition of the TLP, with patients having shorter duration in treatment rooms on pilot days compared to control days.

A descriptive analysis of factors influencing physician assistant specialty selection.

This study assessed factors impacting practice selection among primary care and specialty physician assistants (PAs). Certified PAs randomized by the National Commission on Certification of Physician Assistants (NCCPA) (30,000) were surveyed, with 2,020 responses (RR = 6.7%). Results showed that factors influencing primary care and specialty selection differ. Increasing reimbursements may not increase selection of primary care by PAs.