Substitution of PAs and NPs for doctors in ED settings

Richard Dehn, MPA, PA-C, DFAAPA

January 27, 2011

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Abstract 

Objective: The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (ie, midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians. 

Methods: We performed a secondary analysis of the asthma component of the National Emergency Department Safety Study. We identified emergency department (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluated based on 12 guideline-recommended process-of-care  measures, a composite guideline concordance score,  and two outcome-of-care measures (admission and ED length of stay). 

Results: Of the 4,029 patients included in this analysis, 3,622 (90%) were seen by physicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled beta-agonists within 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemic corticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and more likely to prescribe inappropriate antibiotics at discharge (OR, 2.1; 95% CI, 1.1-4.1), as compared with physicians. Overall, their composite guideline concordance score was lower than that of physicians (-6 points; 95% CI, -9 to -3 points). Supervised MLPs provided quality of care similar to that of physicians. 

Conclusions: The MLPs were involved in 10% of ED patients with acute asthma and provided independent care for 2% of these patients. Compared with care provided by physicians or by supervised MLPs, there are opportunities for improvement in unsupervised MLP care.  

Larkin GL, Hooker RS. Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis? Am J Bioethics. 2010;10(8):1-10.  

Abstract 

Physician assistants (PAs), nurse practitioners (NPs), and medical residents constitute an increasingly significant part of the American health care workforce, yet patient assent to be seen by nonphysicians is only presumed and seldom sought. In order to assess the willingness of patients to receive medical care provided by nonphysicians, we administered provider preference surveys to a random sample of patients attending three emergency departments (EDs). Concurrently, a survey was sent to a random selection of ED residents and PAs. All respondents were to assume the role of patient when presented with hypothetical clinical scenarios and standardized provider definitions. Despite presumptions to the contrary, ED patients are generally unwilling to be seen by PAs, NPs, and residents. While seldom asked in practice, 79.5% of patients fully expect to see a physician regardless of acuity or potential for cost savings by seeing another provider. Patients are more willing to see residents than nonphysicians. 

Jecker NS. The ethics of substituting physician assistants, nurse practitioners, and residents for attending physicians. Am J Bioethics. 2010;10(8):11-18.  

Abstract

In "Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does presumption of assent have an empirical basis," Larkin and Hooker note the expanding role of alternative providers and assess the willingness of patients to be seen by physician assistants (PAs), nurse practitioners (NPs), and medical residents in emergency department (ED) settings in the United States. Although their primary purpose is to fill a gap in the empirical literature on patient preferences and willingness to receive care from alternative providers, the study also sets forth the following ethical claims: (1) choice of provider is "basic to respecting an autonomous patient's legitimate quest to control what happens to his or her own body;" and (2) "physician substitution has often been covert in the emergency department." This paper addresses these ethical claims. I argue that patients do not always have a right to choose the type of provider they see, although they do have a right to receive full disclosure.

DISCUSSION 

Data describing how PAs function in the medical workforce have been reported since the profession's inception. The questions of whether PAs can safely perform activities traditionally done by physicians and whether patients are satisfied by the care they receive from PAs have been addressed by various data collection modalities. Early research on these questions consists primarily of survey data.¹ Recently, research has concentrated on comparing the provision of specific medical services by different medical providers. Such studies typically compare one type of provider to another as defined by adherence to recommended treatment standards or patient outcomes. The article by Tsai and colleagues investigates the treatment of asthma in the ED setting, comparing treatment by physicians, PAs or NPs directly staffed by a physician, and PAs or NPs not directly staffed by a physician. They utilized data from the National Emergency Department Safety Study (NEDSS), which included data from 63 mostly urban EDs in 23 US states. Acute asthma cases (4,029) were abstracted from randomly selected ED visits utilizing ICD-9 codes, consisting of 3,622 seen by a physician only, 319 seen by both a PA/NP and a physician, and 88 seen by a PA/NP only. Visits with PAs or NPs were combined because of small sample sizes. Outcomes were determined by a compliance score. Patients were divided into two levels of acute asthma severity, each containing 12 treatment components based on expected treatment guidelines. Each patient encounter was scored by the number of processes performed during the visit. Results showed that the supervised PA/NP group scored similar to physicians, but the PA/NP-only group scored lower than the other two groups. However, this study has several limitations, primarily that the patients seen by the PA/NP-only group comprised just 2% of the study sample and were less sick than the patients seen by the other two provider groups. These factors complicate any comparison to the other two groups.  

Data on patient acceptance of treatment by PAs rely for the most part on patient satisfaction surveys administered after the patient was seen by a PA. The article by Larkin and Hooker investigates a new issue: whether patients are willing to by seen by a PA or NP as determined prior to the encounter by the presentation of standardized theoretical scenarios. As PA utilization has increased in the medical workforce, the assumption that patients consent to see PAs rather than physicians is typically taken for granted. The authors assembled two groups: one consisting of a random sample of 507 ED patients from three urban hospitals that utilize resident physicians, PAs, and NPs in the ED, and a randomly selected group of 251 resident physicians and 212 PAs to represent a "medically knowledgeable" sample for comparison. A survey was constructed that asked, given a minor injury or illness, more serious injury or illness, or major injury or illness, would one be willing to have a PA, NP, or physician in training alone handle the medical care. ED patients were willing to see a PA or NP more than 50% of the time involving minor injuries or illnesses, but this fell to 35% and 15% as the severity moved to moderate and severe respectively. Patients were more willing to see resident physicians than a PA or NP in the moderate and severe scenarios. PAs were more willing than patients to be treated by PAs or NPs, but resident physicians were generally unwilling to be treated by PAs or NPs. The authors conclude that if patients have an expectation to be treated in the ED by a physician, having them treated by a PA, NP, or resident physician may be an ethical violation of their right to informed consent. The article by Jecker takes issue with this conclusion by making the case that patients do not always have a right to choose the type of provider they see if the quality of care meets acceptable standards, although patients do have the right to receive prior full disclosure of who is treating them.  

The article by Tsai and colleagues illustrates that provider comparisons in the clinical setting can be difficult and complicated, as providers representing different professions tend to attract different patient populations. One must be cautious in drawing conclusions when making such comparisons, as many confounding factors may be involved. Larkin and Hooker ask an important new question, and the data presented explore an important ethical foundation of informed consent—the question of whether ED patients encouraged or required to see PAs, NPs, and resident physicians are being treated unethically if they would prefer to see physicians. This dilemma is discussed in detail from an ethical perspective by Jecker, who questions the premise that society has an obligation to fulfill patients' ideal expectations and argues that society's obligation is instead to provide competent care as long as patients know in advance who they are seeing. JAAPA 

Rick Dehn is a professor in the School of Health and Human Services and chair of the PA program at Northern Arizona University, Flagstaff. 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.

REFERENCE 

1. Dehn RW. Physician assistant educational research. J Physician Assistant Education. 2007;18(3):94-99. 

From the January 2011 Issue of JAAPA