Roderick S. Hooker

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.

Prescribing trends by nurse practitioners and physician assistants in the United States

Purpose: As an important step in analyzing the role of nurse practitioners (NPs) and physician assistants (PAs), we examined their prescribing behavior. The intent is to study the characteristics of providers and patients, and the type of prescriptions written by NPs and PAs in primary care and to compare these activities to physicians. Data sources: The National Ambulatory Medical Care Survey (NAMCS) database was examined for prescriptions written by primary care clinicians (family and general medicine, internal medicine, and general pediatrics). A representative sample of 88,346 primary care visits over a 6‐year period (1997–2002) was analyzed in which a prescription was written by an NP, a PA, or a physician in an urban or rural setting. Conclusions: The characteristics of all the patients seen were similar for geographical region of visit, age, and gender, but differed by ethnicity and race. An NP or a PA was the provider of record for 5% of the primary care visits in the NAMCS database. The three clinician types were likely to write at least one prescription for 70% of all visits, and the mean number of prescriptions was 1.3–1.5 per visit (range 0–5) depending on the provider. PAs were more likely to prescribe a controlled substance for a visit than a physician or an NP (19.5%, 12.4%, 10.9%, respectively). Only in nonmetropolitan settings did differences emerge. In rural areas, NPs wrote significantly more prescriptions than physicians and PAs. Implications for practice: We suggest that NPs and PAs may provide a role that is similar to that of physicians in primary care based on prescribing behavior. The prescribing behavior of PAs and NPs parallels that of physicians by the number of medications per visit, the types of therapeutic classes, and the type of patient. However, in nonmetropolitan areas, prescribing differences emerge between the three types of providers that bear further exploration.

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.

Anti-CCP antibody and rheumatoid factor concentrations predict greater disease activity in men with rheumatoid arthritis

Objective To examine associations of anti-cyclic citrullinated peptide (aCCP) antibody and rheumatoid factor (RF) concentrations with future disease activity in men with rheumatoid arthritis (RA). Methods Outcome measures were examined in male US veterans with RA and included (1) proportion of observations in remission (disease activity score (DAS28) ≤2.6); (2) remission for ≥3 consecutive months; and (3) area under the curve (AUC) for DAS28. The associations of autoantibody concentration (per 100 unit increments) with outcomes were examined using multivariate regression. Results 826 men with RA were included in the analysis; the mean (SD) age was 65 (10.5) years and follow-up was for 2.6 (1.3) years. Most were aCCP (75%) and RF (80%) positive. After multivariate adjustment, aCCP (OR 0.93; 95% CI 0.89 to 0.96) and RF concentrations (OR 0.92; 95% CI 0.90 to 0.94) were associated with a lower odds of remission, a lower proportion of observation in remission (p=0.017 and p=0.002, respectively) and greater AUC DAS28 (p=0.092 and p=0.007, respectively). Among patients with discordant autoantibody status, higher concentrations of both aCCP and RF trended towards an inverse association with remission (OR 0.93; 95% CI 0.83 to 1.05 and OR 0.80; 95% CI 0.59 to 1.10, respectively). Conclusions Higher aCCP concentrations (particularly in RF-positive patients) are associated with increased disease activity in US veterans with RA, indicating that aCCP concentration is predictive of future disease outcomes in men.

Veterans' perceptions of care by nurse practitioners, physician assistants, and physicians: A comparison from satisfaction surveys

Purpose: To examine the differences in patient satisfaction with care provided by nurse practitioners (NPs), physician assistants (PAs), and physicians in the Veterans Health Administration (VHA) system. Data source: Secondary data was obtained from the VHAs Survey of Healthcare Experience of Patients (SHEP), a monthly survey designed to measure patient satisfaction. Descriptive statistics were calculated and categorical variables were summarized with frequency counts. Conclusions: Of the 2,164,559 surveys mailed to the veterans, 1,601,828 (response rate 64%) were returned. The study found that satisfaction scores increased by 5% when the number of NPs was increased compared to 1.8% when the number of physicians was increased and slightly increased or remained the same when the number of PAs was increased. Physician to PA/NP ratio was 7:3. Implications for practice: The VHA is the largest healthcare system and the single largest employer of NPs and PAs in the country. This study shows that a majority of the primary care clinic patients prefer to see NPs as compared with PAs and physicians. Besides clinical care, NPs focus on health promotion, disease prevention, health education, attentiveness, and counseling. Physicians and PAs should be educated on these characteristics to promote patient satisfaction and expected outcomes.

Cardiovascular Outcomes in Male Veterans With Rheumatoid Arthritis

In men with rheumatoid arthritis (RA), the confounding effect of adverse cardiovascular risk profile on the independent association of RA disease activity score (DAS) and major adverse cardiovascular events (MACEs) continues to be debated. The aim was to analyze the association of RA DAS with MACEs in a prospective cohort of men with RA enrolled in the VARA Registry at the Dallas site from January 2003 to October 2006. All subjects met American College of Rheumatology criteria for RA. All events were obtained by reviewing patient clinical data. DAS was categorized as low, 0 to 3.2; moderate, 3.2 to 5.09; and high, > or =5.1. Of 282 men (mean age 66 +/- 11.1 years), 231 had valid DASs (150, low; 60, moderate; and 21, high DAS) and were followed up for 4.4 +/- 2 years. Ninety-two subjects (32.6%; 95% confidence interval 27 to 38) experienced an MACE, a composite end point of death (9 patients; 10%), acute coronary syndrome (38 patients; 42%), coronary revascularization (47 patients; 49%), new-onset heart failure (37 patients; 40%), and stroke (15 patients; 16%). DAS was a significant predictor of MACEs (hazard ratio 1.31, 95% confidence interval 1.1 to 1.6, p = 0.01) independent of traditional risk factors. Compared with patients with low or moderate DASs, patients with high DASs had a lower mean event-free period (35 and 30 vs 19 years, respectively; p = 0.03). In conclusion, in a population of male US veterans aged >50 years, (1) patients with RA were at high risk of MACEs, and (2) RA DAS was a significant predictor of MACEs independent of traditional cardiovascular risk factors.

Physician Assistant Education: Five Countries

Background: Physician assistant (PA) education has undergone substantial change since the late 1960s. After four decades of development, other countries have taken a page from the American experience and launched their own instructional initiatives. The diversity in how different countries approach education and produce a PA for their nations needs provides an opportunity to make comparisons. The intent of this study was to document and describe PA programs in Australia, Canada, the United Kingdom, The Netherlands, and the United States. Methods: We reviewed the literature and contacted a network of academics in various institutions to obtain primary information. Each contact was asked a set of basic questions about the country, the PA program, and the deployment of graduates. Information on US PA programs was obtained from the Physician Assistant Education Association. Results: At years end 2010, the following was known about PA development: Australia, one program; Canada, four programs; United Kingdom, four programs; The Netherlands, five programs; the United States, 154 programs. Trends in program per capita growth remain the largest in the United States, followed by The Netherlands and Canada. The shortest program length was 24 months and the longest, 36 months. Outside the United States, almost all programs are situated in an academic health center ([AHC] defined as a medical university, a teaching hospital, and a nursing or allied health school), whereas only one‐third of US PA programs are in AHCs. All non‐US programs receive public/ government funding whereas American programs are predominately private and depend on tuition to fund their programs. Conclusion: The PA movement is a global phenomenon. How PAs are being educated, trained, and deployed is known only on the basic level. We identify common characteristics, unique aspects, and trends in PA education across five nations, and set the stage for collaboration and analysis of optimal educational strategies. Additional information is needed on lesser‐known PA programs outside these five countries.

The Role of Physician Assistants in Rural Health Care: A Systematic Review of the Literature.

PURPOSE A literature review was performed to assess the role of physician assistants (PAs) in rural health care. Four categories were examined: scope of practice, physician perceptions, community perceptions, and retention/recruitment. METHODS A search of the literature from 1974 to 2008 was undertaken by probing the electronic bibliographic databases of English language literature. Criterion for inclusion was original data published on rural PAs. Each paper was assessed and assigned to the four categories. FINDINGS A total of 51 papers were identified; 28 papers had a primary focus on research and specified PAs in a rural setting. Generally, the literature suggests that PAs provide cost-efficient and supplemental medical services to underserved rural populations and that these services are valued. It also appears that rural PAs possess a larger scope of practice than urban PAs. This broad range of skills and procedures may be necessary to match the extensive health care needs of underserved rural populations. Over a 35-year period of examination, the literature improved in numbers of PAs studied and the quality of research. However, the lack of longitudinal studies was considered a shortcoming of rural health PA observational research. CONCLUSIONS Through this review, some insights about the role of PAs emerged. Overall, they seem well adapted to rural health. Important issues regarding the recruitment and retention of PAs to rural populations also emerged. Improvement in enabling legislation contributes to the utilization of PAs in America.

The Globalization of the Physician Assistant Profession

The global spread of the physician assistant (PA) profession is a medical workforce phenomenon largely born at the turn of the century. Because this observation comes with little analysis, we used investigative journalism techniques to collect information about the use of PAs outside of the United States. As of 2007, at least seven countries — Australia, Canada, England, the Netherlands, Scotland, South Africa, and Taiwan — are in various stages of expansion of PA-like medical workers that function under the supervision of a doctor. With the exception of Taiwan and South Africa, these countries have American-trained PAs working as expatriates, and most are developing educational programs that produce a health care provider functioning as an addition to the doctor. Each country has made its PA a distinct entity, with cultural and educational influences shaping their roles. Common denominators of these PAs are: they function as semiautonomous clinicians under the direct supervision of a doctor and have roles that tend to complement those of the doctor. Historical observations suggest the development of the PA profession in different countries tends to follow a similar path and that lessons learned from these nations may be useful in further expansion of the profession.

Career Flexibility Of Physician Assistants And The Potential For More Primary Care

In part because of their core generalist education, physician assistants can change clinical specialties over the course of their work life. This is known as career flexibility. Using medical care providers who can adapt quickly to new opportunities could help alleviate medical workforce shortages in primary care. We studied annual surveys undertaken by the American Academy of Physician Assistants to determine how many physician assistants changed specialties and how frequently. Over four decades, 49 percent of all clinically active physician assistants changed specialties sometime in their careers. This suggests that incentives, such as educational grants, could draw more physician assistants to work in primary care. These findings suggest that an array of new incentives under health reform could draw and retain more physician assistants into primary care medicine.