Physician Assistants: A Literature Review - Health Professions ...

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No. Description Reference13 The existing literature on the use of mid-level providers (MLPs) in inpatient venues is quite limited, and a recent review, while suggestingthat the existing literature does describe benefits of MLPs in the inpatient setting, also states that the overall quality of the evidence is quitepoor and that many studies suffer from significant limitations, including small populations, limited patient mixes, use of selected settings, andshort durations of outcome assessment. There have been other studies examining the use of MLPs in the inpatient setting in internalmedicine. Some of these studies have suggested that MLP-based models result in equivalent outcomes and efficiency to traditional teachingor nonteaching physician-only models. There are two important caveats, however, that must be considered. The total resources required forsuch models may be quite high, especially taking into account the costs of 24/7 coverage and physician backup of the MLPs, and mostimportantly there is almost no literature that robustly examines ultimate clinical outcomes in these models. Notably, while the evidence basein internal medicine is not robust, many studies have described successful use of MLPs in non-internal medicine inpatient settings. Thereasons for this success is debatable, but it may be that MLPs are more successful in settings where the care is either more protocol-drivenor where there is less diagnostic and therapeutic complexity. Given the paucity of data, it is clear that further research is needed on the roleof MLPs in hospital medicine. While waiting for such evidence to appear, it may be worthwhile to reflect on the recent experience of threemajor medical centers. A recent article (see entry XX, below) described five hospitalist models at major academic medical centers across thecountry. Two of the institutions described at the time (University of Michigan <strong>Health</strong> System, Ann Arbor, MI; and Brigham and Women’sHospital, Boston, MA) utilized MLPs as a major element of their staffing of nonresident hospitalist services while another had previouslyused MLPs as part of its model but phased them out about one year prior to publication of the article. Recently one of these institutions(Michigan) has chosen to phase out MLPs. At Michigan, a four-year experience with PAs on a general-medicine focused hospitalist serviceeventually led to the conclusion that continued use of PAs was not cost-effective. Significant barriers to success included a steep learningcurve and the significant time required before PAs developed sufficient autonomy and efficiency in caring for a highly complexheterogeneous patient population. A key point is that in each institution, MLPs continue to play an important role in some specialty inpatientareas such as Hematology/ Oncology and Bone Marrow Transplant, which is where MLPs have traditionally found their niche in inpatientInternal Medicine. These ‘‘focus shops’’ allow MLPs to develop a niche and expertise in a specialized area, where they may become moreautonomous and efficient than house staff. Thus these settings may be more appropriate for MLPs than a heterogeneous general medicineinpatient setting. The authors note they have some limited data from the Society of Hospital Medicine (SHM) annual survey that looks atMLPs in hospital medicine but the number of respondents for most data elements is less than 70, making generalizability difficult.Nonetheless, the data suggest that MLPs in hospital medicine average about 60% to 75% of the productivity of a physician when measuredby encounters, although there is wide variability depending on the employment model (academic vs. multispecialty group). Importantly, theexisting data do not provide any measure of how much physician input is provided to these MLPs but the authors suspect that in mostmodels there is some physician time and input. If one presumes that the MLPs bill independently and collect 85% of the physician feeschedule for a Medicare population, then collections would be about 50% to 65% of a typical physician. Given that median totalcompensation including benefits from the SHM survey was $120,000 for MLPs and $216,000 for physicians—about a 55% ratio—this wouldargue for potential financial neutrality when substituting MLPs for physicians in a 2:1 ratio but only if one presumes they require no physiciansupervision, which in the authors’ own experience is not likely in a general medicine population. The authors conclude that while someliterature exists that suggests that MLPs can successfully be used in the inpatient internal medicine setting, it is important to note that theevidence is quite limited and cannot be generalized across all care settings and patient populations. There is an urgent need to gather moredata and share our collective experiences to better inform our decision-making before we state that MLPs are the solution to workforceshortages in hospital medicine. In addition, existing data and experience suggest that MLPs may not be a cost-effective workforce solutionfor complex general medical patients who require significant physician input. The authors believe that redesigning the clinical training ofMLPs to focus on inpatient skills may hold promise and encourage interested parties to consider developing partnerships with MLP trainingprograms and hospital medicine groups, as a way to build a more robust and successful hospital medicine MLP workforce.Parekh, V. I. & Roy, C. L. (2010).Nonphysician providers inhospital medicine: Not so fast.Journal of Hospital Medicine,5(2), 103-106.Page 29 of 74
No. Description Reference14 Objective: The aim of this study was to evaluate the quality of care provided by physician assistants or nurse practitioners (i.e.,midlevel providers [MLPs]) in acute asthma, as compared with that provided by physicians. Methods: The authors performed asecondary analysis of the asthma component of the National Emergency Department Safety Study. They identified emergencydepartment (ED) visits for acute asthma in 63 urban EDs in 23 US states between 2003 and 2006. Quality of care was evaluatedbased on 12 guideline-recommended process-of-care measures, a composite guideline concordance score, and two outcome-of-caremeasures (admission and ED length of stay). Results: Of the 4,029 patients included in this analysis, 3,622 (90%) were seen byphysicians only, 319 (8%) by MLPs supervised by physicians, and 88 (2%) by MLPs not supervised by physicians. Performance ratesfor supervised MLPs were generally similar to physicians' rates; however, performance rates for unsupervised MLPs were generallylower than physicians' rates. After adjustment for patient mix, unsupervised MLPs were less likely to administer inhaled β-agonistswithin 15 minutes of ED arrival (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.7), less likely to prescribe systemiccorticosteroids in the ED (OR, 0.4; 95% CI, 0.2-0.9), and were 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 ofphysicians (−6 points; 95% CI, −9 to −3 points). Patients cared for by unsupervised MLPs had a shorter ED length of stay and wereless likely to be admitted, as compared with patients cared for by physicians or supervised MLPs. Supervised MLPs provided similarquality of care to that of physicians. Conclusions: The MLPs were involved in 10% of ED patients with acute asthma and providedindependent care for two percent of these patients. Compared with care provided by physicians or by supervised MLPs, there areopportunities for improvement in unsupervised MLP care.Tsai, C.-L., Sullivan, A. F.,Ginde, A. A., Camargo, C. A.(2010). Quality of emergencycare provided by physicianassistants and nursepractitioners in acute asthma.The American Journal ofEmergency Medicine, 28(4),485-491.Page 30 of 74
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