As PA practice appears in an increasing number of
settings and specialties, many of these emerging environments are then described by researchers. This installment of Research Corner reviews two articles describing PAs in oncology, one reviewing the utilization of PAs as advocates for greater PA utilization in gastroenterology, and one analyzing the efficiency and patient outcomes of a PA hospitalist service in an academic medical center.
Ross AC, Polansky MN, Parker PA, Palmer JL. Understanding the role of physician assistants
in oncology. J Oncol Pract. 2010;6(1):26-30.
http://www.jop.ascopubs.org
ABSTRACT: Purpose: To understand the deployment of physician assistants (PAs) in oncology. A recent analysis of the oncology workforce in the United States commissioned by ASCO predicted a significant shortage of providers by 2020. Methods: A descriptive study was undertaken using a Web-based questionnaire survey. Invited participants, including all PAs listed in the national PA database (n = 855) and all PAs at The University of Texas M. D. Anderson Cancer Center (Houston, TX; n = 159), were mailed letters directing them to the Web-based survey. Results: The study produced a 30% response rate. A total of 186 PAs worked in medical oncology (the population of interest). Of the respondents, 80% were women, mean age was 36 years, average time employed as a PA was 9.5 years (6.5 years in oncology), 55% had obtained a master's degree, four had completed a postgraduate oncology program, 91% reported that direct mentorship by a supervising physician was very important in obtaining oncology-based knowledge, and 61% reported that becoming fully competent in the practice of oncology required 1 to 2 years. The majority of PAs (78.5%) worked 33 to 50 hours per week, and 56% of those reported working 41 to 50 hours per week. Three fourths (77%) wrote chemotherapy orders, most requiring physician co-signature, and 69% prescribed schedule III to V controlled substances. Additional data were gathered regarding clinical duties, research, and teaching. Conclusion: Oncology PAs are used in multiple medical settings, and many assume high-level responsibilities. Future research addressing function and factors that limit use of PAs may allow for improved organizational efficiency and enhancement in the delivery of health care.
Polansky M, Ross AC, Coniglio D. Physician assistant perspective on the ASCO workforce study regarding the use of physician assistants and nurse practitioners. J Oncol Pract. 2010;6(1):31-33.
http://www.jop.ascopubs.org.
ABSTRACT: Purpose: A workforce study by the Association of American Medical Colleges (AAMC) predicted a shortage of 2,350 to 3,800 oncologists, or 9.5 to 15 million visits, by 2020. Proposed solutions included use of physician assistants (PAs) and nurse practitioners (NPs). Although 56% of the oncologists reported working with PAs/NPs, the AAMC did not survey PAs or NPs. This article uses additional data to examine the role of PAs/NPs in the oncology workforce. Materials and methods: American Academy of Physician Assistant (AAPA) census data and a study of PAs in oncology were used to examine these workforce issues. Results: The AAMC reported oncologists working with PAs/NPs had increased productivity compared with physicians who did not, primarily when the PAs/NPs performed advanced roles or worked in private practice. Visits handled by PAs/NPs themselves were not reported. According to the AAPA, PAs in the outpatient setting saw an average of 62.4 patients per week (inpatient PAs saw 62.2 patients per week), supporting the AAMC report that 70% to 92% of oncologists experienced increased efficiency with PAs/NPs. Whereas the AAMC reported that 46.4% of oncologists used PAs/NPs in advanced roles, Ross et al reported that more than 70% of PAs wrote chemotherapy orders (most requiring physician co-signature); more than 80% wrote prescriptions, including for controlled substances; and more than half performed invasive procedures. The AAMC reported that 13% of PAs/NPs performed research activities, and the AAPA reported that 60.5% of medical oncology PAs participated in clinical trials. Conclusion: The AAMC workforce study inadequately examined the role of PAs/NPs in oncology. Given the available data in PA literature, the contribution of PAs/NPs to the workforce was substantially underestimated. In examining workforce issues, understanding opportunities for increasing collaborative practice requires the input of PAs/NPs.
Dorn SD. Mid-level providers in gastroenterology. Am J Gastroenterol. 2010;105(2):246-251.
ABSTRACT: One response to the challenges of modern day clinical practice has been to employ "mid-level providers" (MLPs), such as physician assistants and nurse practitioners. MLPs may complement physicians by supporting patient self-management and performing routine, protocol-guided management. In turn, MLPs may improve health outcomes and simultaneously lower costs. Within gastroenterology, the prevalence of MLPs remains unknown, though it appears to be significant and increasing. Additionally, professional organizations predict that in the future, MLPs will play a central role in digestive disease care. Although incorporating MLPs into gastroenterology has great potential, numerous challenges exist, and their specific roles must first be defined and evaluated.
Roy CL, Liang CL, Lund M, et al. Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes. J Hosp Med. 2008;3(5):361-368.
ABSTRACT: Background: Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions have led to the widespread implementation of non-house staff services in academic medical centers, yet little is known about the quality and efficiency of patient care on such services. Objective: To evaluate the quality and efficiency of patient care on a physician assistant/hospitalist service compared with that of traditional house staff services. Design: Retrospective cohort study. Setting: Inpatient general medicine service of a 747-bed academic medical center. Patients: A total of 5,194 consecutive patients admitted to the general medical service from July 2005 to June 2006, including 992 patients on the physician assistant/hospitalist service and 4,202 patients on a traditional house staff service. Intervention: A geographically localized service staffed with physician assistants and supervised by hospitalists. Measurements: Length of stay (LOS), cost of care, inpatient mortality, intensive care unit (ICU) transfers, readmissions, and patient satisfaction. Results: Patients admitted to the study service were younger, had lower comorbidity scores, and were more likely to be admitted at night. After adjustment for these and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95% confidence interval [CI] 27.5% to 20.3%), but LOS was not significantly different (adjusted LOS 5.0% higher; 95% CI, 20.4% to 110%) as compared with house staff services. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction. Conclusions: For general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency.
DISCUSSION
The article by Ross and colleagues reports the result of a descriptive Web-based survey conducted in 2007 on all PAs in the AAPA national database who were likely to practice in medical oncology (N = 1,004). The response rate was 30%, of whom 61.8% reported working in medical oncology, 80% were women, 60% were younger than 40 years, and 63% had practiced in the specialty for fewer than 5 years. Practice barriers were reported as 26.9% indicating that their state and 14.1% that their employer did not allow them to order chemotherapy. Only 39.8% had state-delegated authority to prescribe schedule II controlled substances.
The article by Polansky and colleagues questions the accuracy of data collected by a recent Association of American Medical Colleges (AAMC) workforce report on oncology. This report estimated that the demand for oncology services will increase by 48%, producing a shortage of 2,350 to 3,800 oncologists. The AAMC study did not survey oncology PAs or NPs, even though 56% of physician responders reported working with one. The author examines AAPA census data, noting that in 2008, 2.4% of PAs reported practicing in oncology, compared to 1.9% of PAs and 1% of NPs in 2005. The author concludes that the AAMC report significantly underestimated the contribution of PAs in oncology.
The article by Dorn references 94 sources to describe and suggest that midlevel providers (MLPs) play an increasingly important role in many medical specialties. The author concludes that incorporating MLPs into gastroenterology practices has great potential for improving physician and patient satisfaction.
The article by Roy and colleagues compares length of stay, cost of care, inpatient mortality, ICU transfers, readmissions, and patient satisfaction in patients admitted to either a PA hospitalist service or a traditional house staff service in an academic medical center (N = 5,194) in 2005-2006. The cost of care of the PA service was 3.9% lower; otherwise no difference was seen in the other measured outcomes.
These four articles document an increasing utilization of PAs in medical specialty settings, recommend that PA utilization be increased, and suggest that a PA hospitalist service produces good outcomes with cost savings. More similar studies are needed to further understand the changing role of PAs. JAAPA
Rick Dehn is a clinical professor in the Department of Family and Community Medicine and program director of the FNP/PA program at the University of California at Davis School of Medicine, Sacramento. He is a member of the JAAPA editorial advisory board. The author has indicated no relationships to disclose relating to the content of this article.