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Abstract: Physician associate/assistant (PA) leaders are essential to healthcare and critical to a healthcare organization's success. In this article, the second of a two-part series on PA leadership, we summarize methods for implementing and sustaining PA leadership opportunities and organizational structures., (Copyright © 2024 American Academy of Physician Associates.)

Current trends demonstrate that the proportion and complexity of emergency care provided by advanced practice providers (APPs) is increasing, which underscores the importance of emergency physician supervision and support. Laws governing supervision vary between physician assistants and nurse practitioners, with the latter legally able to practice independently in some states. Regardless of the supervision model, emergency medicine professional organizations advocate for physician-led teams. Communication lapses and contradictory documentation with errors and omission are potential sources of medical error and risk. Ensuring appropriate oversight with consideration of the APPs experience and documenting appropriately may minimize legal risk., Competing Interests: Disclosure The authors have no financial disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction New Zealand's health care system faces significant shortages in health care workers. To address workforce challenges and meet the population's health needs, health care systems around the world have introduced new clinical roles, such as physician associates/assistants (PAs) into existing health care teams. Aim This article aims to examine the benefits, challenges, and broader implications of regulating PAs in the context of New Zealand's primary care sector, with a specific emphasis on how it may impact general practice. Methods A range of literature surrounding the role, impact, and perception of PAs were selected and included in this article. Results The PA profession can significantly strengthen New Zealand's primary care workforce, improving patient access and continuity of care. However, the global deployment of PAs has faced scrutiny due to concerns about its potential risks to patient safety and the overall viability of such a role. Discussion If regulated, the PA profession can reshape New Zealand's primary care, offering a partial solution to current medical staff shortages. Trained under a generalised medical model similar to doctors, PAs possess the necessary skills to perform both routine and non-routine medical tasks. This dual capability can significantly improve primary care service provision, reduce existing workloads, and allow for a more efficient deployment of doctor expertise. However, medico-legal issues and the supervisory burden can impede widespread integration into general practice. Despite challenges, the success of the PA role relies on mutual trust, respect, and support from other clinical team members within primary health care.

The aging US population requires an increasing volume of otolaryngology-head and neck surgery services, yet the otolaryngologist physician workforce remains static. Advanced practice providers (APPs), including physician assistants and nurse practitioners, improve access across the continuum of primary and subspecialty health care. The rapid growth of APP service is evidenced by a 51% increase in APP Medicare billing for otolaryngology procedures over 5 years. APPs increasingly participate in delivering otolaryngology care; however, reaping the benefits of enhanced patient access and modernizing care delivery is predicated on successful integration of APPs into practices. Few data are available on how best to incorporate APPs into team-based models or how to restructure practices to allow graduated responsibility that supports autonomy and effective teamwork. We compare national APP and physician workforce trends in otolaryngology, consider approaches to optimizing efficiency by integrating APPs, and identify opportunities for improving data collection and practice.

Purpose: To evaluate the impact of a collaborative intervention by pharmacists and primary care clinicians on total cost of care, including costs of inpatient readmissions, emergency department visits, and outpatient care, at 30, 60, and 180 days after hospital discharge in a population of patients at high risk for readmission due to polypharmacy., Methods: A retrospective study of cost outcomes in a cohort of adult patients discharged from a single institution from July 1, 2013 to March 25, 2016, was conducted. All patients had at least 10 medications listed on their discharge list, including at least 1 drug frequently associated with adverse events leading to hospital readmission. About half of the cohort (n = 496) attended a postdischarge visit involving both a pharmacist and a primary care clinician (a physician, physician assistant, or licensed nurse practitioner); this was designated the pharmacist/clinician collaborative (PCC) group. The remainder of the cohort (n = 500) attended a visit without pharmacist involvement; this was designated as the usual care (UC) group. Costs were compared using a quantile regression to assess the potential heterogeneous impacts of the PCC intervention across different parts of the cost distribution. All outcomes were adjusted for differences in baseline characteristics., Results: At 30 days post index discharge, there was a significant decrease in total costs in the 10th and 90th cost quantiles in the PCC cohort vs the UC cohort, without a statistically significant decrease in the 25th, 50th or 75th quantiles. The difference was significant in the 75th and 90th quantiles at 60 days and in the 25th, 50th, and 75th quantiles at 180 days. There was a nonsignificant cost reduction in all other quantiles., Conclusion: Medically complex patients had a significantly lower total cost of care in approximately half of the adjusted cost quantiles at 30, 60, and 180 days after hospital discharge when they had a PCC visit. PCC visits can improve patient clinical outcomes while improving cost metrics., (© American Society of Health-System Pharmacists 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This article describes the 10-year journey of a research group helping to build the research evidence base for physician assistants (PAs), known as physician associates in the United Kingdom, in the National Health Service in England. It draws out some key issues that may be of interest to those developing PA research programs in different specialties and different countries. PA research also can help healthcare policy makers address growing demand, issues of quality, and cost.

Background/Significance of problem: Atopic Dermatitis (AD) is a common, chronic, inflammatory dermatosis and skin disease that follows a relapsing pattern and requires a dynamic stepwise approach to management. Providers feel comfortable treating chronic disease states with a guided tool or care plan in many chronic diseases. Care plans used in many chronic diseases such as asthma, diabetes, and COPD have demonstrated effectiveness in disease and healthcare provider management. There is an unmet need for a universal AD care plan for providers. Clinical question/project purpose: A universal AD care plan was developed to improve AD disease management and patient outcomes. Post-implementation of providers & perceptions was assessed for how the AD universal care plan affected their ability to provide patient education. Search of literature/best evidence: Review of literature includes: CINAHL, ProQuest Health, PubMed, Fusion, and UpToDate databases from 2008-2018.Search terms included: Atopic Dermatitis, Eczema, care plans, care plan use in chronic disease. Clinical appraisal of literature/best evidence: Analysis of the evidence supported the need for AD education, which then supported the need for a universal AD care plan for providers. Integration into practice: "Your Eczema Care Plan" was used by thirty-five healthcare providers to improve patient outcomes in a similar manner as other evidence-based care plans.Evaluation of evidenced-based practice: Post-implementation of providers & perceptions were evaluated on how the AD care plan tool affected their ability to provide patient education. Results suggest patient education, disease management, and QOL are all improved when utilizing "Your Eczema Action Plan." J Drugs Dermatol. 2020;19(10): 950-955. doi:10.36849/JDD.2020.5090.

Objectives: Mental Health First Aid (MHFA) is designed to help the general public acquire the knowledge and skills needed to respond to a person in a mental health emergency and offer support to someone in emotional distress. Through the PA Foundation's Mental Health Outreach Fellowship, 16 physician assistants (PAs) were selected to become MHFA instructors and teach the course to members of their local communities over 1 year., Methods: MHFA course evaluations, completed by course participants, were reviewed to determine the effectiveness of the PA fellows as instructors., Results: The fellows' mean evaluation instructor presentation score was 4.82 and the mean course content score was 4.75. The national mean for instructor presentation was 4.72 for presentation and 4.66 for course content. The maximum possible score in each category was a 5., Conclusions: The PAs selected for the Mental Health Outreach Fellowship were effective MHFA instructors. Benefits to having a PA serve as the instructor include positively affecting communities by increasing the public's mental health literacy, reducing the stigma associated with mental illness, increasing visibility and promotion of the PA profession, and enhancement of a PA's individual career through education and service.

Background: The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital., Methods: To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017., Results: The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period., Conclusion: Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

Purpose: To evaluate patient access, provider productivity, and patient satisfaction during a 24-month redesign process of an academic medical center, which requires balance between clinical and educational missions., Methods: A series of activities were conducted to optimize primary care across 17 attending physicians, 6 Advanced Practice Providers (APPs), and 39 residents. Patient access was defined as the next available appointment for either existing/established patients or new patients. Productivity was measured using panel sizes for each provider. Patient satisfaction was based on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CGCAHPS)., Results: Despite decreasing clinical effort to allow faculty and APPs to participate in education and research, there was an overall increase in access for both new and established patients, and an increase the percent of each providers' panel that was full from 78.89% in 2017 to 115.29% in 2019. When comparing panel sizes for the 11 faculty present before and after strategic changes, we found significant increase in both overall panel size, and actual to expected ratios between 2017 and 2019. In addition, throughout the time period, patient satisfaction remained high with no significant changes., Conclusions: While this project was limited to one site, the inclusion of a set of well-planned metrics, and tracking of processes over time can provide insight for ongoing primary care redesign efforts at similar sites seeking to balance the academic mission with clinical productivity and high patient satisfaction.

As the number of advanced practice providers has grown in emergency medicine, establishment of guidelines and policies governing their practice has become increasingly important. This article addresses the scope of practice of physician assistants and nurse practitioners working in the emergency department, including the various forms of supervision and the effect on billing, credentialing, and medicolegal considerations in patients' care., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The effective redesign of primary care delivery systems to improve diabetes care requires an understanding of which particular components of delivery consistently lead to better clinical outcomes. We identified associations between common systems of care management (SysCMs) and the frequency of meeting standardized performance targets for Optimal Diabetes Care (NQF#0729) in primary care practices., Research Design and Methods: A validated survey of 585 eligible family or general internal medicine practices seeing ≥30 adult patients with diabetes in or near Minnesota during 2017 evaluated the presence of 62 SysCMs. From 419 (72%) practices completing the survey, NQF#0729 was determined in 396 (95%) from electronic health records, including 215,842 patients with type 1 or type 2 diabetes., Results: Three SysCMs were associated with higher rates of meeting performance targets across all practices: 1 ) a systematic process for shared decision making with patients ( P = 0.001), 2 ) checklists of tests or interventions needed for prevention or monitoring of diabetes ( P = 0.002), and 3 ) physician reminders of guideline-based age-appropriate risk assessments due at the patient visit ( P = 0.002). When all three were in place, an additional 10.8% of the population achieved recommended performance measures. In subgroup analysis, 15 additional SysCMs were associated with better care in particular types of practices., Conclusions: Diabetes care outcomes are better in primary care settings that use a patient-centered approach to systematically engage patients in decision making, remind physicians of age-appropriate risk assessments, and provide checklists for recommended diabetes interventions. Practice size and location are important considerations when redesigning delivery systems to improve performance., (© 2019 by the American Diabetes Association.)

Background: The role of Surgical Care Practitioner (SCP) was first introduced by the NHS in the field of cardiothoracic surgery more than two decades ago to overcome the chronic shortage of junior doctors, and subsequently evolved into other surgical specialties. This review aims to provide evidence on the current situation of SCPs' clinical outcomes within their surgical extended role, with an emphasis on the cardiothoracic surgical field., Method: A systematic search of PubMed, Scopus, Embase via Ovid, Web of Science and TRIP was conducted with no time restriction to explore the evidence on SCPs. All included articles were reviewed by three researchers using the selection criteria, and a narrative synthesis was undertaken., Findings: Ten out of the 38 studies identified were selected for inclusion. Only one study specifically investigated cardiothoracic SCPs. Three themes were identified: (1) clinical outcomes (six studies), (2) workforce impact (two studies) and (3) colleagues' opinions (two studies). All studies demonstrated that SCPs provided safe practice, added value and were of benefit to workforce environments and surgical teams., Conclusion: Although the current literature provides assurances that the presence of SCPs within surgical teams is beneficial in terms of their clinical outcomes, their impact on the workforce and colleagues' opinions, a significant gap was identified around the SCPs' role within their surgical extended role, specifically in cardiac surgery. Thus, prospective clinical research is required to evaluate SCPs' clinical impact.

Introduction: Advanced practice providers (APPs), including nurse practitioners and physician assistants, have been deployed in children's hospital-based academic pediatric otolaryngology practices for many years. However, this relationship in terms of prevalence, roles, financial consequences and satisfaction has not been examined. The objective of this study is to explore how APPs impact healthcare delivery in this setting., Methods: Pediatric otolaryngology chiefs of all academic children's hospitals in the US were electronically surveyed about the ways APPs intersected clinically and financially in their respective practice., Results: A total of 29 of 36 children's hospital-based pediatric otolaryngology practices completed the survey, of which 26 practices (90%) utilized APP. There were large variances within the APP practice cohort in faculty size (mean/median/range = 9.4/8.5/3-29); annual patient visits (mean/median = 18,373/17,600); number of practice site (mean/median/range = 4.3/4/2-9) and number of outpatient APP (mean/median/range = 6.3/5/1-30). No factors (faculty size, annual visits and number of practice sites) differentiated between the APP and non-APP practices. Among APP practices, significant correlation (p<.00001) was observed between size of APP cohort to faculty size and annual visits. 69% of the practices did not differentiate job functions of nurse practitioners and physician assistants. 85% of the practices utilized APPs in all practice sites and 19% utilized APPs in the operating room. 77% of APPs billed independently and 46% had on-site supervision. The most prevalent APP salary bracket based on 0-5, 6-10 and > 11 years of tenure were $76-100K (65%), $100-150K (77%) and $100-150K (86%), respectively. In 46% of the practices, APPs were able to generate enough revenue to cover more than 75% of their salary and 23% of practices generated a profit. 81% of the chiefs ranked the effectiveness of APPs as high (4 and 5) on a 5-point Likert scale., Discussion: The majority of academic pediatric otolaryngology practices employed APPs. Despite the diversity seen in practice complexity, APP functionality and financial impact, most found the APP model to be beneficial in improving patient care, patient access and faculty productivity., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Purpose: Community medicine curriculum prepares physician assistant (PA) students to provide services to vulnerable and underserved populations. This article describes a service-learning model that uses a mobile health clinic (MHC) experience as part of the community medicine rotation. It provides an overview of the clinic's operation, patient documentation and characteristics, and student learning experiences., Methods: Students collected demographic information on patients who visited the MHC during January through December 2017. The students summarized patient demographics and reflected on their experiences in a report., Results: Two main outcomes are discussed: characteristics of the MHC patients and student observations about their experiences. In 2017, 113 students rotated through the MHC and recorded 813 patient encounters. The largest proportions of patients reported living on the street or in a shelter (71%) and were older than 56 years (40%), males (74%), Caucasian (43%), single (65%), nonveterans (77%), and high school graduates (41%). The top 5 reasons for visits were preventive care, cognitive/functional impairment, cardiometabolic disorders, skin issues, and respiratory illness. The MHC experience and process of recording and analyzing demographic data contributed to students' data management and analytical skills. The students identified problems of recordkeeping and their implications for patient care, gained a greater understanding of medical needs and complexities of treating the homeless, and provided suggestions for improving quality and efficiency of care., Conclusions: The MHC service-learning model provides diverse, meaningful experiences for students. Our findings benefit PA programs aiming to expand and strengthen their community medicine curriculum.

Purpose: The capacity available to deliver outpatient surgical services is outweighed by the demand. Although additional investment is sometimes needed, better aligning resources, increasing operational efficiency and considering new processes all have a role in improving delivering these services. The purpose of this paper is to evaluate the safety of a physician associate (PA) delivered virtual outpatient department (VOPD) consultation service that was established in a General and Colorectal Surgery Department at an Irish teaching hospital., Design/methodology/approach: A series of low-risk surgical patients were referred by senior surgeons to a PA delivered virtual clinic (VOPD). Medical records belonging to half the included patients were randomly selected for review by two doctors three months following discharge back to primary care to confirm appropriate standards of care and documentation and to audit any recorded adverse incidents or outcomes., Findings: In total, 191 patients had been reviewed by the PA in the VOPD with 159 discharged directly back to primary care. Among the 95 medical records that were reviewed by the NCHDs, there were no recorded adverse incidents after discharge. Medical record keeping was deficient in 1 out of 95 reviewed cases., Practical Implications: Using a PA delivered VOPD consultation appears to have a role in following up patients who have undergone low-risk procedures irrespective of age or co-morbidity when selected appropriately. This may assist in reducing the demand on outpatient services by reducing unnecessary return visits, thereby increasing the capacity for new referrals., Originality/value: While there are reported examples to date of virtual clinics, these relate to services delivered by registered medical practitioners. Here, the authors demonstrate the acceptability of this model of care in an Irish population as delivered by a PA.

Importance: Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs)., Objectives: To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem., Design, Setting, and Participants: This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019., Main Outcomes and Measures: Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions., Results: Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout., Conclusions and Relevance: Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.

The evolving role of nurse practitioners (NPs) and physician assistants (PAs) in the United States continues to progress. NP and PA responsibilities have expanded from primary care practices to medical and surgical specialties. They provide acute care in hospitals and intensive care units, and they serve as educators, lobbyists, and researchers. Questions have arisen from NP/PA leaders, physician leaders, and administrators on how to best implement a successful NP/PA model within their practice. This article reviews some common themes in the literature by looking at the current state of NP/PA practice, outlines some practice models established therein, and provides recommendations for implementing a successful NP/PA model in a liver transplant practice., (Copyright © 2019 by the American Association for the Study of Liver Diseases.)

Background: We examined and compared APP versus surgical resident perceptions of the role of APPs in surgical subspecialty teams., Methods: Residents/first year surgical critical care fellows and inpatient service-specific APPs responded to a survey that examined perceptions about the APP-resident/fellow relationship. Statistical analysis compared responses using a Pearson chi-square test., Results: Thirty-two resident/fellows (48%) and 10 APPs (42%) responded. There was consensus that having an APP on service decreases workload, contributes to continuity of care and enhances resident-patient coordination education and agreement that there was clear communication and adequate collaboration. Both groups differed with respect to APPs contribution to resident/fellow clinical education, role definition and chain of command. The majority of trainees felt that APPs function at a PGY2 level (51.7%) compared to APPs, who felt that they functioned at a PGY4/5 (22%) or Fellow (44%) level., Conclusion: APPs and resident/fellows agree that APPs impact resident workload, continuity of care and patient-coordination education., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Healthcare providers can benefit from adding less costly capacity to their existing resources in order to satisfy demand while maintaining the quality of patient care. The addition of mid-level service providers (MLSPs) such as physician assistants or nurse practitioners that carry out portions of patient care provides a viable alternative for adding physician capacity. This research considers the circumstances under which adding an MLSP to a single-physician outpatient office becomes the best strategy for the clinic, and determines how scheduling policies from the widely-researched single-stage environment should be adjusted for a multi-stage environment. Compared to a single-stage system where a physician completes all portions of the service, we show that adding an MLSP can reduce patient waiting time, patient flow time, and physician service time with patients. This, in turn, can enable the clinic to see more patients and/or free up physician time for other tasks. Appointment scheduling rules are developed for a multi-stage outpatient service system using a simulation optimization approach. Performance measures focus on the patient experience and clinic operation before and during each stage of service.

Objectives: Hospitals are employing more nurse practitioners and physician assistants on inpatient pediatric units. With this study, we compared patient outcomes in high-volume inpatient diagnoses on pediatric hospital medicine services staffed by attending physician hospitalists and residents (hospitalist and resident service [HRS]) with 1 staffed by attending physician hospitalists and advanced practice providers (HAPPS)., Methods: A historical cohort study was implemented by using administrative data for patients admitted to HRS and HAPPS from 2007 to 2011 with asthma, bronchiolitis, cellulitis, and pneumonia with severity levels 1 and 2 for all-patient refined diagnosis-related groups. Length of stay, readmission, ICU transfer, and hospital charges were compared., Results: After controlling for clinical, demographic, and socioeconomic differences, the average probability of discharge was 10% greater each day (event ratio [ER] = 1.1 [1.06-1.14]) on HAPPS compared with HRS. By diagnosis, this trend persisted with asthma (ER = 1.07 [1.02-1.12]), cellulitis (ER = 1.2 [1.1-1.3]), and pneumonia (ER = 1.17 [1.08-1.28]) but not for bronchiolitis (ER = 0.99 [0.92-1.06]). Both 3- and 30-day readmissions were higher for HRS discharges with bronchiolitis (odds ratio = 5.9 [1.3-28.6] and 2.0 [1.3-3.3], respectively) but not for the other diagnoses. Hospital charges were 13% higher for patients on HRS than HAPPS. ICU transfers did not differ statistically., Conclusions: Within the limitations of the design, HAPPS performed at least as well as HRS with respect to length of stay, readmissions, ICU transfers, and charges for 4 of the most common inpatient diagnoses with severity levels 1 to 2. Indicated in these results is that in this configuration, advanced practice providers on pediatric hospitalist services represent a viable model for other institutions to consider and test., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objectives: To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services., Design: Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis., Setting: Six acute care hospitals in three regions of England in 2016-2017., Participants: 43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives., Results: A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors., Conclusions: This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice., Competing Interests: Competing interests: SdL is head of the Department of Clinical and Experimental Medicine at the University of Surrey, which launched a physician associate course in 2016. JP chairs the UK and Ireland Board for Physician Associate Education and was director of the physician associate course at the University of Birmingham. PB is honorary faculty at the University of Birmingham and has taught on the physician associate programme since 2008. JE teaches part time on the University of Birmingham physician associate course., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Nursing leaders at the University of South Alabama (USA) Health collaborated to explore the need for a structured practice model for advanced practice providers (APP). The goal of this collaboration was to create an organizational structure where APPs could thrive clinically and professionally.

Objective: To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients' experiences of chronic care., Data Sources: Clinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation., Study Design: A three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects., Principal Findings: Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (β=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs., Conclusions: Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.

Background: The effectiveness of cardiovascular disease (CVD) and diabetes care delivered by NPs and physician assistants (PAs), and resource use by these providers has not been studied., Methods: We performed regression analyses of patients with diabetes or CVD with a primary care visit in 130 Veterans Affairs (VA) facilities to assess the association between provider type and effectiveness or resource use., Results: The diabetes cohort consisted of 156,034 patients assigned to NPs and 54,590 assigned to PAs. Glycemic and BP control, statin use, number of primary or specialty care visits, lipid panels, and A1C results were comparable between groups. The CVD cohort consisted of 185,694 patients assigned to NPs and 66,217 assigned to PAs. BP control; use of beta-blockers, statins, or antiplatelets; primary or specialty care visits; lipid panels; and number of stress tests ordered were comparable between groups., Conclusion: Effectiveness of care and resource use among patients in both groups were comparable.

Objective: To appraise and synthesise research on the impact of physician assistants/associates (PA) in secondary care, specifically acute internal medicine, care of the elderly, emergency medicine, trauma and orthopaedics, and mental health., Design: Systematic review., Setting: Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles., Included Articles: Peer-reviewed articles of any study design, published in English, 1995-2017., Interventions: Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken., Outcome Measures: Impact on: patients' experiences and outcomes, service organisation, working practices, other professional groups and costs., Results: 5472 references were identified and 161 read in full; 16 were included-emergency medicine (7), trauma and orthopaedics (6), acute internal medicine (2), mental health (1) and care of the elderly (0). All studies were observational, with variable methodological quality. In emergency medicine and in trauma and orthopaedics, when PAs are added to teams, reduced waiting and process times, lower charges, equivalent readmission rate and good acceptability to staff and patients are reported. Analgesia prescribing, operative complications and mortality outcomes were variable. In internal medicine outcomes of care provided by PAs and doctors were equivalent., Conclusions: PAs have been deployed to increase the capacity of a team, enabling gains in waiting time, throughput, continuity and medical cover. When PAs were compared with medical staff, reassuringly there was little or no negative effect on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organised in teams is highlighted. Further rigorous evaluation is required to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting., Prospero Registration Number: CRD42016032895., Competing Interests: Competing interests: SL: University of Surrey runs a Physician Associate course. JP: chairs the UK and Ireland Board for Physician Associate Education and is the director of the Physician Associate programme at the University of Birmingham., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: We conducted a prospective validation study to develop a physician assistant (PA) clinical rotation evaluation (PACRE) instrument. The specific aims of this study were to 1) develop a tool to evaluate PA clinical rotations, and 2) explore associations between validated rotation evaluation scores and characteristics of the students and rotations., Methods: The PACRE was administered to rotating PA students at our institution in 2016. Factor analysis, internal consistency reliability, and associations between PACRE scores and student or rotation characteristics were determined., Results: Of 206 PACRE instruments sent, 124 were returned (60.2% response). Factor analysis supported a unidimensional model with a mean (SD) score of 4.31 (0.57) on a 5-point scale. Internal consistency reliability was excellent (Cronbach α=0.95). PACRE scores were associated with students' gender (P = .01) and rotation specialty (P = .006) and correlated with students' perception of being prepared (r = 0.32; P < .001) and value of the rotation (r = 0.57; P < .001)., Conclusions: This is the first validated instrument to evaluate PA rotation experiences. Application of the PACRE questionnaire could inform rotation directors about ways to improve clinical experiences. The findings of this study suggest that PA students must be adequately prepared to have a successful experience on their rotations. PA programs should consider offering transition courses like those offered in many medical schools to prepare their students for clinical experiences. Future research should explore whether additional rotation characteristics and educational outcomes are associated with PACRE scores.

Purpose: To describe the impact of a physician assistant (PA) in an academic ophthalmology consult service., Design: Evaluation research., Methods: A PA was integrated into our ophthalmology consult service to enhance resident education. First-year resident annual surgical logs before and after the introduction of the PA were reviewed. Residents were anonymously surveyed for their perceptions regarding the impact of the PA integration on their residency experience. Consult wait time was compared for residents and the PA. Internal financial metrics for the PA were reviewed for a cost scenario analysis using 2016 national salary data for PAs., Results: The PA made approximately 28 days per year for each first-year resident available for alternative clinical assignments, which resulted in a 75% increase in total first-year resident annual surgical volume. The majority of residents (93%) strongly agreed that having a PA improved both their ophthalmic education (by enabling them to spend time on other clinical assignments) and their service-to-education balance on the consult rotation. Adjusted median consult wait time for residents was 28 minutes longer (P < .001) than for the PA. A PA would likely need to see an average of 8-12 patients per day to be cost neutral to a consult service., Conclusions: Integrating a PA into an ophthalmology consult service can optimize the resident clinical service-to-education balance, reduce consult wait time, and be financially feasible. PAs trained in ophthalmology present a unique opportunity for all institutions that require clinical ophthalmology expertise., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Literature in Europe regarding implementation of nurse practitioners or physician assistants in the intensive care unit (ICU) is lacking, while some available studies indicate that this concept can improve the quality of care and overcome physician shortages on ICUs. The aim of this study is to provide insight on how a Dutch ICU implemented non-physician providers (NPP), besides residents, and what this staffing model adds to the care on the ICU., Methods: This paper defines the training course and job description of NPPs on a Dutch ICU. It describes the number and quality of invasive interventions performed by NPPs, residents, and intensivists during the years 2015 and 2016. Salary scales of NPPs and residents are provided to describe potential cost-effectiveness., Results: The tasks of NPPs on the ICU are equal to those of the residents. Analysis of the invasive interventions performed by NPPs showed an incidence of central venous catheter insertion for NPPs of 20 per fulltime equivalent (FTE) and for residents 4.3 per FTE in one year. For arterial catheters the NPP inserted 61.7 per FTE and the residents inserted 11.8 per FTE. The complication rate of both groups was in line with recent literature. Regarding their salary: after five years in service an NPP earns more than a starting resident., Conclusion: This is the first European study which describes the role of NPPs on the ICU and shows that practical interventions normally performed by physicians can be performed with equal safety and quality by NPPs.

Background: Medical scribes are frequently incorporated into the patient care model to improve provider efficiency and enable providers to refocus their attention to the patient rather than the electronic health record (EHR). The medical scribe program was based on four pillars (objectives): (1) provider satisfaction, (2) standardized documentation, (3) documentation components for risk adjustment, and (4) revenue enhancement., Methods: The medical scribe program was deployed in nine non-resident-supported clinics (internal medicine, ophthalmology, orthopedics, hematology/oncology, urology), with the medical scribes (who have no clinical duties) supporting both physicians and advanced practice providers (nurse practitioners and physician assistants). This paper describes a prospective quasi-experimental study conducted at an academic, inner-city, hospital-based clinic system, RESULTS: A pre-post analysis showed positive results; of the 51 providers, 44 responded to the survey pre and 41 responded post. Respondents in the post-scribe group felt that a scribe was valuable (90.2%), that documentation time at the office improved (75.0% poor or marginal pre-scribe, vs. 24% post; p <0.0001), and that time spent on the EHR at home declined (63.6% with excessive or moderately high home EHR time pre vs. 31.7% post; p = 0.003). More providers felt satisfied with their role in clinic with the use of scribes, and more providers felt that with scribes they could listen sufficiently to patients (p <0.05)., Conclusion: Scribe support was well received across the institution in multiple clinical settings. Benefits for providers were seen in documentation time and ability to listen to patients. Scribes appear to be an effective intervention for improving clinician work life., (Copyright © 2018 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Nurse Practitioners and Physician Assistants - called non-physician practitioners or NPPs - are common, but little is known about their educational promise and problems., Methods: General surgery faculty in 13 residency programs were surveyed (N = 279 with a 71% response rate) and interviewed (N = 43) about experiences with NPPs. The survey documents overall patterns and differences by program type and primary service; interviews point to deeper rationales and concerns., Results: NPPs reduce faculty and resident workloads and teach residents. NPPs also reduce resident exposure to educationally valuable activities, and faculty sometimes round, make decisions, and operate with NPPs instead of residents. Interviews indicate that NPPs can overly reduce resident involvement in patient care, diminish resident responsibility and decision making, disrupt team dynamics, and compete for procedures., Conclusions: NPPs both enhance and hinder surgical education and highlight the need to more clearly articulate learning outcomes for residents and activities necessary to achieve those outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To design and implement a formal otolaryngology inpatient consultation service that improves satisfaction of consulting services, increases educational opportunities, improves the quality of patient care, and ensures sustainability after implementation., Methods: This was a retrospective cohort study in a large academic medical center encompassing all inpatient otolaryngology service consultations from July 2005 to June 2014. Staged interventions included adding fellow coverage (July 2007 onward), intermittent hospitalist coverage (July 2010 onward), and a physician assistant (October 2011 onward). Billing data were collected for incidences of new patient and subsequent consultation charges. The 2-year preimplementation period (July 2005-June 2007) was compared with the postimplementation periods, divided into 2-year blocks (July 2007-June 2013). Outcome measures of patient encounters and work relative value units were compared between pre- and postimplementation blocks., Results: Total encounters increased from 321 preimplementation to 1211, 1347, and 1073 in postimplementation groups ( P < 0.001). Total work relative value units increased from 515 preimplementation to 2090, 1934, and 1273 in postimplementation groups ( P < 0.001)., Conclusions: A formal inpatient consultation service was designed with supervisory oversight by non-Accreditation Council for Graduate Medical Education fellows and then expanded to include intermittent hospitalist management, followed by the addition of a dedicated physician assistant. These additions have led to the formation of a sustainable consultation service that supports the mission of high-quality care and service to consulting teams.