Christine M. Everett

Predictive modeling the physician assistant supply: 2010-2025.

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.

Physician Assistants and Nurse Practitioners as a Usual Source of Care

PURPOSE To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. METHODS Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). FINDINGS Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (beta=-0.22, 95% CI =-0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. CONCLUSIONS Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.

The contributions of physician assistants in primary care systems

Shortages of primary care doctors are occurring globally; one means of meeting this demand has been the use of physician assistants (PAs). Introduced in the United States in the late 1960s to address doctor shortages, the PA movement has grown to over 75,000 providers in 2011 and spread to Australia, Canada, Great Britain, the Netherlands, Germany, Ghana and South Africa. A purposeful literature review was undertaken to assess the contribution of PAs to primary care systems. Contemporary studies suggest that PAs can contribute to the successful attainment of primary care functions, particularly the provision of comprehensive care, accessibility and accountability. Employing PAs seems a reasonable strategy for providing primary care for diverse populations.

Low frequency of primary lipid screening among Medicare patients with rheumatoid arthritis

OBJECTIVE Although studies have demonstrated suboptimal preventive care in RA patients, performance of primary lipid screening (i.e., testing before cardiovascular disease [CVD], CVD risk equivalents, or hyperlipidemia is evident) has not been systematically examined. The purpose of this study was to examine associations between primary lipid screening and visits to primary care providers (PCPs) and rheumatologists among a national sample of older RA patients. METHODS This retrospective cohort study examined a 5% Medicare sample that included 3,298 RA patients without baseline CVD, diabetes mellitus, or hyperlipidemia, who were considered eligible for primary lipid screening during the years 2004-2006. The outcome was probability of lipid screening by the relative frequency of primary care and rheumatology visits, or seeing a PCP at least once each year. RESULTS Primary lipid screening was performed in only 45% of RA patients. Overall, 65% of patients received both primary and rheumatology care, and 50% saw a rheumatologist as often as a PCP. Any primary care predicted more lipid screening than lone rheumatology care (26% [95% confidence interval (95% CI) 21-32]). As long as a PCP was involved, performance of lipid screening was similar regardless of the balance between primary and rheumatology visits (44-48% [95% CI 41-51]). Not seeing a PCP at least annually decreased screening by 22% (adjusted risk ratio 0.78 [95% CI 0.71-0.84]). CONCLUSION Primary lipid screening was performed in fewer than half of eligible RA patients, highlighting a key target for CVD risk reduction efforts. Annual visits to a PCP improved lipid screening, although performance remained poor (51%). Half of RA patients saw their rheumatologist as often or more often than they saw a PCP, illustrating the need to study optimal partnerships between PCPs and rheumatologists for screening patients for CVD risks.

Receipt of Monitoring of Diabetes Mellitus in Older Adults with Comorbid Dementia

To examine the extent to which receipt of recommended monitoring of diabetes mellitus (DM) differed for participants with and without comorbid dementia, as well as the effect of other comorbidities on monitoring of DM in individuals with comorbid dementia.

Division of Primary Care Services Between Physicians, Physician Assistants, and Nurse Practitioners for Older Patients With Diabetes:

Team-based care involving physician assistants and/or nurse practitioners (PA/NPs) in the patient-centered medical home is one approach to improving care quality. However, little is known about how to incorporate PA/NPs into primary care teams. Using data from a large physician group, we describe the division of patients and services (e.g., acute, chronic, preventive, other) between primary care providers for older diabetes patients on panels with varying levels of PA/NP involvement (i.e., no role, supplemental provider, or usual provider of care). Panels with PA/NP usual providers had higher proportions of patients with Medicaid, disability, and depression. Patients with physician usual providers had similar probabilities of visits with supplemental PA/NPs and physicians for all service types. However, patients with PA/NP usual providers had higher probabilities of visits with a supplemental physician. Understanding how patients and services are divided between PA/NPs and physicians will assist in defining provider roles on primary care teams.

Effect of patient selection method on provider group performance estimates.

BackgroundPerformance measurement at the provider group level is increasingly advocated, but different methods for selecting patients when calculating provider group performance have received little evaluation. ObjectiveWe compared 2 currently used methods according to characteristics of the patients selected and impact on performance estimates. Research Design, Subjects, and MeasuresWe 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. ResultsFewer 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. ConclusionsThe 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.

Nurse practitioners, physician assistants, and physicians in community health centers, 2006-2010

PURPOSE Community health centers (CHCs) fill a vital role in providing health care to underserved populations. This project compares characteristics of patient visits to nurse practitioners (NPs), physician assistants (PAs), and physicians in CHCs. METHODS This study analyzes 2006-2010 annual survey data from the National Ambulatory Medical Care Survey CHC sample, a representative national sample of CHC providers and patient visits. We examine trends in provider mix in CHCs and compare NPs, PAs, and physicians with regard to patient and visit attributes. Survey weights are used to produce national estimates. RESULTS There were, on average, 36,469,000 patient visits per year to 150,100 providers at CHCs; 69% of visits were to physicians, 21% were to NPs, and 10% were to PAs. Compared to visits to NPs, visits made to physicians and PAs tended to be for chronic disease treatment and for patients whom they serve as primary care providers. Visits to NPs tended to be for preventive care. CONCLUSIONS This study found more similarities than differences in characteristics of patients and patient visits to physicians, NPs, and PAs in CHCs. When statistical differences were observed, NP patient and visit characteristics tended to be different from those of physicians. IMPLICATIONS Results provide detailed information about visits to NPs and PAs in a setting where they constitute a significant portion of providers and care for vulnerable populations. Results can inform future workforce approaches.

Time spent with patients by physicians, nurse practitioners, and physician assistants in community health centers, 2006-2010

BACKGROUND As health systems struggle to meet access, cost and quality goals in the setting of increased demand, nurse practitioners (NPs) and physician assistants (PAs) are expected to help meet the need for care. The amount of time spent with each patient can affect the clinical productivity, quality of care, and satisfaction of patients and clinicians. This paper compares time spent per patient in community health centers by whether the provider is a physician, NP, or PA. METHODS This paper uses National Ambulatory Medical Care Survey (NAMCS) Community Health Center (CHC) data from 2006-2010. The NAMCS CHC strata is a national sample of CHCs, providers within CHCs, and patient visits to CHCs. Provider characteristics and variables related to time spent with patients across provider types were compared using t tests and chi square tests of association. Multivariate linear regression analysis was used to compare time spent with patients, controlling for patient and visit characteristics. RESULTS There were no differences in the number of visits by provider type, but PAs saw patients for a slightly larger portion of the week (3.8 days) than did physicians (3.5 days, p<0.05) or NPs (3.4 days, p<0.05). There were no statistical differences in the mean time spent per patient in the crude and adjusted analyses. CONCLUSIONS Time spent per patient in CHCs is similar for physicians, NPs and PAs. This information may be useful to planners concerned with health system capacity and cost efficiency, and has implications for patient and provider satisfaction.

Physician Assistant Job Satisfaction: A Narrative Review of Empirical Research

Purpose To examine physician assistant (PA) job satisfaction and identify factors predicting job satisfaction and identify areas of needed research. With a global PA movement underway and a half-century in development, the empirical basis for informing employers of approaches to improve job satisfaction has not received a careful review. Methods A narrative review of empirical research was undertaken to inform stakeholders about PA employment with a goal of improved management. The a priori criteria included published studies that asked PAs about job satisfaction. Articles addressing PA job satisfaction, written in English, were reviewed and categorized according to the Job Characteristics Model. Results Of 68 publications reviewed, 29 met criteria and were categorized in a Job Characteristics Model. Most studies report a high degree of job satisfaction when autonomy, income, patient responsibility, physician support, and career advancement opportunities are surveyed. Age, sex, specialty, and occupational background are needed to understand the effect on job satisfaction. Quality of studies varies widely. Conclusions Employers may want to examine their relationships with PAs periodically. The factors of job satisfaction may assist policymakers and health administrators in creating welcoming professional employment environments. The main limitation: no study comprehensively evaluated all the antecedents of job satisfaction. PAs seem to experience job satisfaction supported by low attrition rates and competitive wages. Contributing factors are autonomy, experienced responsibility, pay, and supportive supervising physician. A number of intrinsic rewards derived from the performance of the job within the social environment, along with extrinsic rewards, may contribute to overall job satisfaction. PA job satisfaction research is underdeveloped; investigations should include longitudinal studies, cohort analyses, and economic determinants.