Search

This study characterized adult primary care medical assistant (MA) staffing. National Survey of Healthcare Organizations and Systems (n = 1,252) data were analyzed to examine primary care practice characteristics associated with MA per primary care clinician (PCC) staffing ratios. In 2021, few practices (11.4%) had ratios of 2 or more MAs per PCCs. Compared with system-owned practices, independent (odds ratio [OR] = 1.76, P

BackgroundThere has been renewed focus on advancing inclusivity within organized medicine to reduce health disparities and achieve health equity by addressing the deleterious effects of implicit bias in healthcare and clinical outcomes. It is well documented that negative implicit attitudes and stereotypes perpetuate inequity in healthcare. The aim of this study is to investigate implicit bias training in postgraduate physician assistant (PA) and nurse practitioner (NP) education; describe delivery of content to trainees; and detail program directors' attitudes toward this type of training. Although there is research examining implicit bias training in physician residency education, there are no published studies on implicit bias training in postgraduate PA and NP postgraduate residency/fellowship programs.MethodA non-experimental, descriptive study was designed to obtain information via survey from members of the Association of Postgraduate Physician Assistant Programs (APPAP).ResultsThe response rate was 41%. The majority of respondents (76%) felt that PA and NP postgraduate programs should include implicit bias instruction. Educational strategies used by PA and joint PA/NP postgraduate programs or their sponsoring institution to deliver implicit bias content to trainees include: implicit bias training modules (50%), facilitated group discussions (36%), invited speaker on implicit bias (33%), case studies on implicit bias (16%), and implicit association test (10%); however, 30% of postgraduate programs do not provide implicit bias training to PA and/or NP trainees. Barriers to implementing implicit bias training expressed by some postgraduate programs include: uncertainty in how to incorporate implicit bias training (16%); lack of strategic alignment with training program or sponsoring institution (13%); time constraints (10%); financial constraints (6%); lack of access to content experts (6%); and unfamiliarity with evidence supporting implicit bias training (6%).ConclusionThe present study sheds some light on the current state of implicit bias training in PA and joint PA/NP postgraduate residency/fellowship programs. While the majority of programs offer some sort of implicit bias training, there is a need to standardize this training in PA and joint PA/NP postgraduate education curricula using an actionable framework.

The evolving COVID-19 pandemic has unevenly affected academic medical centers (AMCs), which are experiencing resource-constraints and liquidity challenges while at the same time facing high pressures to improve patient access and clinical outcomes. Technological advancements in the field of data analytics can enable AMCs to achieve operational efficiencies and improve bottom-line expectations. While there are vetted analytical tools available to track physician productivity, there is a significant paucity of analytical instruments described in the literature to adequately track clinical and financial productivity of physician assistants (PAs) and nurse practitioners (NPs) employed at AMCs. Moreover, there is no general guidance on the development of a dashboard to track PA/NP clinical and financial productivity at the individual, department, or enterprise level. At our institution, there was insufficient tracking of PA/NP productivity across many clinical areas within the enterprise. Thus, the aim of the project is to leverage our institution's existing visualization tools coupled with the right analytics to track PA/NP productivity trends using a dashboard report.MethodsWe created an intuitive and customizable highly visual clinical/financial analytical dashboard to track productivity of PAs/NPs employed at our AMC.ResultsThe APP financial and clinical dashboard is organized into two main components. The volume-based key performance indicators (KPIs) included work relative value units (wRVUs), gross charges, collections (payments), and payer-mix. The session utilization (KPIs) included (e.g., new versus return patient ratios, encounter type, visit volume, and visits per session by provider). After successful piloting, the dashboard was deployed across multiple specialty areas and results showed improved data transparency and reliable tracking of PAs/NPs productivity across the enterprise. The dashboard analytics were also helpful in assessing PA/NP recruitment requests, independent practice sessions, and performance expectations.ConclusionTo our knowledge, this is the first paper to highlight steps AMCs can take in developing, validating, and deploying a financial/clinical dashboard specific to PAs/NPs. However, empirical research is needed to assess the impact of qualitative and quantitative dashboards on provider engagement, revenue, and quality of care.

BackgroundBuprenorphine is a life-saving medication for people with opioid use disorder (OUD). U.S. federal law allows advanced practice clinicians (APCs), such as nurse practitioners (NPs) and physician assistants (PAs), to obtain a federal waiver to prescribe buprenorphine in office-based practices. However, states regulate APCs' scope of practice (SOP) variously, including requirements for physician supervision. States may also have laws entirely banning NP/PA buprenorphine prescribing or requiring that supervising physicians have a federal waiver to prescribe buprenorphine. We sought to identify prevalence of state laws other than SOP laws that either 1) prohibit NP/PA buprenorphine prescribing entirely, or 2) require supervision by a federally waivered physician.MethodsWe searched for state statutes and regulations in all 50 states and Washington D.C. regulating prescribing of buprenorphine for OUD by APCs during summer 2021. We excluded general scope of practice laws, laws only applicable to Medicaid-funded clinicians, laws not applicable to substance use disorder (SUD) treatment, and laws only applicable to NPs/PAs serving licensed SUD treatment facilities. We then conducted content analysis.ResultsOne state prohibits all APCs from prescribing buprenorphine for OUD, even though the state's general SOP laws permit APC buprenorphine prescribing. Five states require PA supervision by a federally waivered physician. Three states require NP supervision by a federally waivered physician.ConclusionsAside from general scope of practice laws, several states have created laws explicitly regulating buprenorphine prescribing by APCs outside of licensed state SUD facilities.

ObjectivesNurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians.Design, setting and participantsUsing nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination.ExposuresNPs/PAs.Main outcome measuresUse of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines.ResultsBefore propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p95% of NP/PA visits including the NP/PA-physician combination.Conclusions and relevanceWhile U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

IntroductionThe development of postgraduate programs for physician assistants (PAs) began in 1973 and by 2020 there were approximately 72 programs spread across a broad range of medical and surgical disciplines. PA Post-graduate education programs are voluntary and available to American licensed PAs. Therefore, an assessment of the characteristics of PA post-graduate fellowships and residencies programs was initiated.MethodA non-experimental, descriptive research study was designed to obtain information on the characteristics of PA postgraduate education programs in the US. The source of information was from surveyed members of the Association of Postgraduate Physician Assistant Programs (APPAP). Questions were drawn from consensus discussions. Directors of postgraduate programs that were operational in 2020 were eligible to participate.ResultsSeventy-two postgraduate program directors were invited to the survey and 34 program directors replied. These programs are geographically distributed across the US in 13 states. The respondents represent a wide range of medicine: surgery, emergency medicine, critical care, orthopaedics, hospitalist, psychiatry, oncology, primary care, pediatrics, and cardiology. Most programs are associated with an academic medical center and some institutions have more than one postgraduate specialty track. The curriculum includes bedside teaching, lectures, mentorship, assigned reading, procedures, simulation, and conferences. An average program length is 12 months and awards a certificate. Stipends for PA fellows are $50,000-80,000 (2020 dollars) and benefits include paid time off, health and liability insurance. About half of the programs bill for the services rendered by the PA. Over 90% of graduates are employed within 2 months of completing a PA postgraduate training program.ConclusionA trend is underway in American medicine to include PAs in postgraduate education. PA postgraduate training occurs across a broad spectrum of medical and surgical areas, as well as diverse institutions and organizations overseeing these programs. Most PA postgraduate programs are in teaching hospitals where the PA resident or PA fellow also serves as a house officer alongside a categorical resident. This study sets the stage for more granular economic and social research on this growing phenomenon in American medicine.

BackgroundThis study aims to investigate the admission criteria used by physician assistant postgraduate education programs in selecting licensed PA applicants for postgraduate training in the United States. To our knowledge, there have been no previously published reports on selection criteria and/or other factors influencing postgraduate PA admission decisions.MethodA non-experimental, descriptive research study was designed to obtain information from members of the Association of Postgraduate Physician Assistant Programs (APPAP).ResultsTwenty-three out of 73 postgraduate programs (35%) responded to the survey. The study reported that applicant PAs and NPs are largely selected on the basis of several factors. The most heavily weighted factor is the interview itself; other selection criteria perceived to be extremely/very important included board certification/eligibility, letters of recommendation, advanced degree, and personal essay. Survey data suggest that publications, undergraduate transcripts, and class rankings are not considered to be of high importance in applicant selection. The number of PA applicants applying to each postgraduate training program averages around 26 and total number of enrollees is about 3.6 per program. Additionally, some programs reported furloughing of trainees (temporary suspension of didactic and clinical training) during the pandemic, whereas the vast majority of postgraduate PA programs remained operational and some even experienced an increase in application volume. The total cost of training a PA resident or fellow in postgraduate programs is currently $93,000 whereas the average cost of training a categorical physician resident is estimated at $150,000 per year when considering both salary and benefits.ConclusionsThis novel study examined criteria and other factors used by postgraduate PA programs in selecting candidates for admission. Results can be used by postgraduate programs to improve or modify current selection criteria to enhance the quality of trainee selection. Further research is needed to examine correlations between applicant attributes, selection criteria, and trainee success in completing postgraduate training.

Postgraduate orthopaedic programs for physician assistants (PAs) and nurse practitioners (NPs) number 14 as of 2020. To better understand the characteristics of these programs a census was undertaken. The result is that most programs are 1 year in duration and in 2019 produced 40 graduates. The role of the orthopaedic PA and NP fellow is to gain an understanding of a wide range of musculoskeletal disorders, develop procedural skills, first assist in the operating room, and facilitate management of patients and discharge throughput. PA and NP fellows work alongside categorical orthopaedic physician residents. The number of graduates from PA orthopaedic training programs is estimated at 200, spanning 20 years. The other 11,145 + PAs (99%) are trained on-the-job. For hospital systems, the employment of orthopaedic postgraduate PA and NP fellows provides value through cost management and billable services.

PurposeAccording to the Williams Institute, 1.4 million U.S. adults identify as transgender. Many experience health care disparities. Professional organizations call for medical education to improve transgender care, but what curricula are being delivered is unknown. The goal of this study was to conduct the first comprehensive, national survey of transgender health care curricula in physician assistant (PA) education.MethodThe authors sent a questionnaire to program directors (PDs) at all 236 U.S. PA programs in June 2018. They categorized programs as those that currently deliver at least 1 hour of transgender health content and those who do not (Teaching/Not Teaching). They examined differences between Teaching and Not Teaching programs using chi-square tests, and they evaluated comments for themes.ResultsThe response rate was 100%. Of the 236 programs, 202 (85.6%) teach transgender content and 34 (14.4%) do not. According to PDs, most transgender content was delivered in medical interviewing (44.1%) or women's health (31.4%) and the most common transgender health topics included differentiating between sex and gender and between behavior and identity (78.8%), followed by health disparities (77.5%) and barriers to care (75.0%). PDs most commonly cited a lack of time (51.3%) and faculty knowledge (35.6%) as barriers for teaching transgender health topics. Half of the PDs (50.4%) ranked transgender health as very or extremely important. The authors detected statistically significant differences between Teaching and Not Teaching programs based on geographic region (P = .01), perceived importance (P ≤ .001), and presence of knowledgeable faculty (P = .01). Presence of knowledgeable faculty was significantly associated with perceived importance (P = .01).ConclusionsThis is the first comprehensive, nationwide survey of transgender health education in U.S. PA programs. A key finding is that the presence of expert faculty is significantly associated with delivery and perceived importance of transgender health curricula.

The novel coronavirus (SARS-CoV-2) represents a rapidly evolving pandemic. Health systems are scrambling to mobilize and redeploy their medical staff in the fight against COVID-19. Orthopaedic nurse practitioners/physician assistants should be part of any redeployment strategy to address unmet needs during these unprecedented times. This article discusses redeployment considerations and strategies that utilize these providers appropriately while mitigating risks.

ObjectivesWe examined advanced practice clinicians' (APCs: nurse practitioners [NPs], certified nurse midwives [CNMs], physician assistants) interest in training to provide medication and aspiration abortion in Colorado, where abortion provision by APCs is legal.MethodsWe surveyed a stratified random sample of APCs, oversampling women's health (CNMs/women's health nurse practitioners [WHNPs]) and rural APCs. We examined prevalence and predictors of interest in abortion training using weighted χ2 tests.ResultsOf 512 participants (21% response), the weighted sample is 50% NPs, 41% physician assistants, and 9% CNMs/WHNPs; 55% provide primary care. Only 12% are aware they can legally provide abortion. A minority of participants disagree that medication abortion (15%) or aspiration abortion (25%) should be in APC scope of practice. Almost one-third (29%) are interested in medication abortion training and 16% are possibly interested; interest is highest among CNMs/WHNPs (52%) (p

ObjectivesTo describe the composition of the US provider workforce for adults with cancer older than 65 years and to determine whether there were differences in patients who received care from different providers (eg, nurse practitioners [NPs], physician assistants [PAs], and specialty physicians).DesignObservational, cross-sectional study.SettingAdults within the 2013 Surveillance, Epidemiology, and End Results cancer registries linked to the Medicare claims database.ParticipantsMedicare beneficiaries who received ambulatory care for any solid or hematologic malignancies.MeasurementsInternational Classification of Diseases, Ninth Revision (ICD-9), diagnosis codes were used to identify Medicare patient claims for malignancies in older adults. Providers for those ambulatory claims were identified using taxonomy codes associated with their National Provider Identifier number.ResultsA total of 2.5 million malignancy claims were identified for 201, 237 patients, with 15, 227 providers linked to claims. NPs comprised the largest group (31.5%; n = 4,806), followed by hematology/oncology physicians (27.7%; n = 4,222), PAs (24.7%; n = 3767), medical oncologists (10.9%; n = 661), gynecological oncologists (2.6%; n = 403), and hematologists (2.4%; n = 368). Rural cancer patients were more likely to receive care from NPs (odds ratio [OR] = 1.84; 95% confidence interval [CI] = 1.65-2.05) or PAs (OR = 1.57; 95% CI = 1.40-1.77) than from physicians. Patients in the South were more likely to receive care from NPs (OR = 1.36; 95% CI = 1.24-1.49).ConclusionsA large proportion of older adults with cancer receive care from NPs and PAs, particularly those who reside in rural settings and in the southern United States. Workforce strategies need to integrate these provider groups to effectively respond to the rising need for cancer care within the older adult population.

BackgroundUS unintended pregnancy rates remain high, and contraceptive providers are not universally trained to offer intrauterine devices and implants to women who wish to use these methods.ObjectiveWe sought to measure the impact of a provider training intervention on integration of intrauterine devices and implants into contraceptive care.Study designWe measured the impact of a continuing medical education-accredited provider training intervention on provider attitudes, knowledge, and practices in a cluster randomized trial in 40 US health centers from 2011 through 2013. Twenty clinics were randomly assigned to the intervention arm; 20 offered routine care. Clinic staff participated in baseline and 1-year surveys assessing intrauterine device and implant knowledge, attitudes, and practices. We used a difference-in-differences approach to compare changes that occurred in the intervention sites to changes in the control sites 1 year later. Prespecified outcome measures included: knowledge of patient eligibility for intrauterine devices and implants; attitudes about method safety; and counseling practices. We used multivariable regression with generalized estimating equations to account for clustering by clinic to examine intervention effects on provider outcomes 1 year later.ResultsOverall, we surveyed 576 clinic staff (314 intervention, 262 control) at baseline and/or 1-year follow-up. The change in proportion of providers who believed that the intrauterine device was safe was greater in intervention (60% at baseline to 76% at follow-up) than control sites (66% at both times) (adjusted odds ratio, 2.48; 95% confidence interval, 1.13-5.4). Likewise, for the implant, the proportion increased from 57-77% in intervention, compared to 61-65% in control sites (adjusted odds ratio, 2.57; 95% confidence interval, 1.44-4.59). The proportion of providers who believed they were experienced to counsel on intrauterine devices also increased in intervention (53-67%) and remained the same in control sites (60%) (adjusted odds ratio, 1.89; 95% confidence interval, 1.04-3.44), and for the implant increased more in intervention (41-62%) compared to control sites (48-50%) (adjusted odds ratio, 2.30; 95% confidence interval, 1.28-4.12). Knowledge scores of patient eligibility for intrauterine devices increased at intervention sites (from 0.77-0.86) 6% more over time compared to control sites (from 0.78-0.80) (adjusted coefficient, 0.058; 95% confidence interval, 0.003-0.113). Knowledge scores of eligibility for intrauterine device and implant use with common medical conditions increased 15% more in intervention (0.65-0.79) compared to control sites (0.67-0.66) (adjusted coefficient, 0.15; 95% confidence interval, 0.09-0.21). Routine discussion of intrauterine devices and implants by providers in intervention sites increased significantly, 71-87%, compared to in control sites, 76-82% (adjusted odds ratio, 1.97; 95% confidence interval, 1.02-3.80).ConclusionProfessional guidelines encourage intrauterine device and implant competency for all contraceptive care providers. Integrating these methods into routine care is important for access. This replicable training intervention translating evidence into care had a sustained impact on provider attitudes, knowledge, and counseling practices, demonstrating significant changes in clinical care a full year after the training intervention.

Hepatic encephalopathy (HE) is a major cause of morbidity in cirrhosis. However, its severity assessment is often subjective, which needs to be studied systematically. The aim was to determine how accurately trainee and nontrainee practitioners grade and manage HE patients throughout its severity. We performed a survey study using standardized simulated patient videos at 4 US and 3 Canadian centers. Participants were trainees (gastroenterology/hepatology fellows) and nontrainees (faculty, nurse practitioners, physician assistants). We determined the accuracy of HE severity identification and management options between grades 2. Serum ammonia levels were ordered in almost a third of grade ≥2 patients. For trainees and nontrainees, HE grades were identified similarly between groups. Trainees were less likely to order serum ammonia and low-protein diets, more likely to order rifaximin, and more likely to perform a more thorough workup for precipitating factors compared with nontrainee respondents. There was excellent concordance in the classification of grade ≥2 HE between nontrainees versus trainees, but lower grades showed discordance. Important differences were seen regarding blood ammonia, specialized testing, and nutritional management between trainees and nontrainees. These results have important implications at the patient level, interpreting multicenter clinical trials, and in the education of practitioners. Liver Transplantation 24 587-594 2018 AASLD.

Background and objectivesThe transformation of primary care (PC) training sites into patient-centered medical homes (PCMH) has implications for the education of health professionals. This study investigates the extent to which physician assistant (PA) students report learning about the PCMH model and how clinical exposure to PCMH might impact their interest in a primary care career.MethodsAn electronic survey was distributed to second-year PA students who had recently completed their PC rotation from 12 PA programs. Descriptive statistics and ordered logistic regression analyses were used to characterize the results.ResultsA total of 202 second-year PA students completed the survey. When asked about their knowledge of the new health care delivery models, 30% of the students responded they had received instruction about the PCMH. Twenty- five percent of respondents stated they were oriented to new payment structures proposed in the Affordable Care Act and quality improvement principles. Based on their experiences in the primary care clerkship, 64% stated they were likely to pursue a career in primary care, 13% were not likely, and 23% were unsure. Predictors of interest in a primary care career included: (1) age greater than 35 years, (2) being a recipient of a NHSC scholarship, (3) clerkship site setting in an urban cluster of 2,500 to 50,000 people, (4) number of PCMH elements offered at site, and (4) positive impression of team-based care.ConclusionsPA students lack adequate instruction related to the new health care delivery models. Students whose clerkship sites offered greater number of PCMH elements were more interested in pursuing a career in primary care.

BACKGROUND: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. OBJECTIVE: To compare use of low-value services among U.S. APCs and physicians. DESIGN: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patients primary care provider (PCP). SETTING: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. PATIENTS: Patients presenting with upper respiratory infections (URIs), back pain, or headache. MEASUREMENTS: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). RESULTS: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. LIMITATION: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. CONCLUSION: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians perceptions that APCs provide lower-value care than physicians for these common conditions. PRIMARY FUNDING SOURCE: U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

PurposeThe goal of t his study was to describe the characteristics of primary care teams, activities, and ro les of physician assistant (PA) students as they encounter various primary care sites.MethodsAn electronic survey was distributed to second year PA students in 12 programs who had completed at least 4 weeks in a primary care rotation.ResultsOf the 179 students who responded (response rate 41 %), 88% had completed their primary care rotations in urban settings, mostly in private practices (53%). Physician assistant students reported encountering many types of health care providers on their teams, and the 2 most favored features of the rotations were the interactions with their supervising clinicians and clinical responsibilities. About 68% interacted with other health profession students during their rotation(interprofessional experiential learning). Almost all students completed histories, physical examinations, and treatment plans, but less than 30% reported involvement in billing or care coordination and less than 10% participated in quality improvement projects. More than 60% were satisfied with team-based and interprofessional practices encountered during their primary care rotations, and 39% were more than likely to pursue primary care careers.ConclusionsTeam-based prima ry ca re had a positive impact on students, but more exposure to underserved clinical settings, care coordination, quality improvement, and billing is needed to prepare PA students for the practice of the future. This study is t he first of its kind to explore the relationship between primary care sites and PA training in the era of health care reform.

In 2013 California passed legislation that expanded the pool of eligible aspiration abortion providers to include advanced practice nurses, nurse-midwives, and physician-assistants. This law, enacted in 2014, is based on evidence generated by the Health Workforce Pilot Project #171, which examined the safety and effectiveness of aspiration abortion care provided by these clinicians as well as patient acceptability and satisfaction. This evidence and the resulting policy change build on international research and established workforce strategies used to expand access to safe abortion services for women worldwide, representing a radical departure from the legislative trend of constricting access in the United States.

BackgroundA perception exists that residents are more costly than midlevel providers (MLPs). Since graduate medical education (GME) funding is a key issue for teaching programs, hospitals should conduct cost-benefit analyses when considering staffing models.ObjectiveOur aim was to compare direct patient care costs and length of stay (LOS) between resident and MLP inpatient teams.MethodsWe queried the University HealthSystems Consortium clinical database (UHC CDB) for 13 553 "inpatient" discharges at our institution from July 2010 to June 2013. Patient assignment was based on bed availability rather than "educational value." Using the UHC CDB data, discharges for resident and MLP inpatient teams were compared for observed and expected LOS, direct cost derived from hospital charges, relative expected mortality (REM), and readmissions. We also compared patient satisfaction for physician domain questions using Press Ganey data. Bivariate analysis was performed for factors associated with differences between the 2 services using χ(2) analysis and Student t test for categorical and continuous variables, respectively.ResultsDuring the 3-year period, while REM was higher on the hospitalist-resident services (P

BackgroundThe public preference for provider type in performing cutaneous surgery and cosmetic procedures is unknown in the United States.MethodsAn internet-based survey was administered to the lay public. Respondents were asked to select the health care provider (dermatologist, plastic surgeon, primary care physician, general surgeon, and nurse practitioner/physician's assistant) they mostly prefer to perform different cutaneous cosmetic and surgical procedures.ResultsThree hundred fifty-four respondents undertook the survey. Dermatologists were identified as the most preferable health care provider to evaluate and biopsy worrisome lesions on the face (69.8%), perform skin cancer surgery on the back (73.4%), perform skin cancer surgery on the face (62.7%), and perform laser procedures (56.3%) by most of the respondents. For filler injections, the responders similarly identified plastic surgeons and dermatologists (47.3% vs 44.6%, respectively) as the most preferred health care provider. For botulinum toxin injections, there was a slight preference for plastic surgeons followed by dermatologists (50.6% vs 38.4%). Plastic surgeons were the preferred health care provider for procedures such as liposuction (74.4%) and face-lift surgery (96.1%) by most of the respondents.ConclusionDermatologists are recognized as the preferred health care providers over plastic surgeons, primary care physicians, general surgeons, and nurse practitioners/physician's assistants to perform a variety of cutaneous cosmetic and surgical procedures including skin cancer surgery, on the face and body, and laser procedures. The general public expressed similar preferences for dermatologists and plastic surgeons regarding filler injections.

Background and study aimsDemand for endoscopic procedures worldwide has increased while the number of physicians trained to perform endoscopy has remained relatively constant. The objective of this study was to characterize non-physician performance of lower and upper endoscopic procedures.Patients and methodsBibliographical searches were conducted in Medline, EMBASE, and Cochrane Library databases. Studies were included where patients underwent flexible sigmoidoscopy, colonoscopy, or upper endoscopy done by a non-physician (nurse, nurse practitioner, physician assistant) and outcome measures were reported (detection of polyps, adenomas, cancer, and/or adverse events). Pooled rates were calculated for specific outcomes and rate ratios were determined for selected comparison groups.ResultsMost studies involved nurses performing flexible sigmoidoscopies for colorectal cancer screening. Nurses and nurse-practitioners/physician assistants performing flexible sigmoidoscopies showed pooled polyp detection rates of 9.9 % and 23.7 %, adenoma detection rates of 2.9 % and 7.2 %, colorectal cancer detection rates of 1.3 % and 1.2 %, and adverse event rates of 0.3 and 0 per 1000 sigmoidoscopies, respectively. There was no significant difference between polyp and adenoma detection rates in sigmoidoscopy performance studies comparing nurses or nurse-practitioners/physician assistants with physicians. For the 3 studies of non-physician performance of colonoscopy, pooled adenoma detection rate was 26.4 %, cecal intubation rate was 93.5 %, and adverse event rate was 2.2 /1000 colonoscopies. In the few studies examining upper endoscopies, 99.4 % of upper endoscopy procedures performed by nurses were successful with no reported adverse events.ConclusionAvailable studies suggest that when non-physicians perform endoscopic procedures, especially lower endoscopies, outcomes and adverse events are in line with those of physicians.

PurposeThe patient-centered medical home (PCMH) holds promise for improving primary health care delivery, but little is known about its impact on medical education. The purpose of this study was to examine the extent to which physician assistant (PA) students are exposed to elements of the PCMH during the didactic and clinical phases of their education.MethodsA survey was distributed to clinical coordinators at all accredited PA programs in the United States that met the study inclusion criteria. The survey inquired about curricula central to practice in the PCMH: team-based care, electronic medical record utilization, and principles of care coordination.ResultsOf the 211 clinical coordinators that were surveyed, we received responses from 87 (41%), of which 94% stated that they teach principles of interprofessional team-based practice during the didactic phase. Sixty percent or more teach concepts related to physician-directed teams, quality improvement, care coordination, and electronic medical records. Only 25% of respondents provide instruction in payment structures that reward care coordination and high quality care, and 22% stated that their students do not have exposure to the PCMH. Most importantly, less than 25% of respondents utilize designated PCMH clinical sites, and those that do have been doing so for less than two years.ConclusionMany PA programs teach some of the core concepts of PCMH during the didactic phase, but exposure to PCMH during clinical clerkships remains limited. Concerted effort is needed to better prepare PA students to function in these emerging team-based practices.

PurposeMindfulness (ie, purposeful and nonjudgmental attentiveness to one's own experience, thoughts, and feelings) is associated with physician well-being. We sought to assess whether clinician self-rated mindfulness is associated with the quality of patient care.MethodsWe conducted an observational study of 45 clinicians (34 physicians, 8 nurse practitioners, and 3 physician assistants) caring for patients infected with the human immunodeficiency virus (HIV) who completed the Mindful Attention Awareness Scale and 437 HIV-infected patients at 4 HIV specialty clinic sites across the United States. We measured patient-clinician communication quality with audio-recorded encounters coded using the Roter Interaction Analysis System (RIAS) and patient ratings of care.ResultsIn adjusted analyses comparing clinicians with highest and lowest tertile mindfulness scores, patient visits with high-mindfulness clinicians were more likely to be characterized by a patient-centered pattern of communication (adjusted odds ratio of a patient-centered visit was 4.14; 95% CI, 1.58-10.86), in which both patients and clinicians engaged in more rapport building and discussion of psychosocial issues. Clinicians with high-mindfulness scores also displayed more positive emotional tone with patients (adjusted β = 1.17; 95% CI, 0.46-1.9). Patients were more likely to give high ratings on clinician communication (adjusted prevalence ratio [APR] = 1.48; 95% CI, 1.17-1.86) and to report high overall satisfaction (APR = 1.45; 95 CI, 1.15-1.84) with high-mindfulness clinicians. There was no association between clinician mindfulness and the amount of conversation about biomedical issues.ConclusionsClinicians rating themselves as more mindful engage in more patient-centered communication and have more satisfied patients. Interventions should determine whether improving clinician mindfulness can also improve patient health outcomes.