The contribution of nurse practitioners and physician assistants to generalist care in Washington State

OBJECTIVE: To quantify the total contribution to generalist care made by nurse practitioners (NPs) and physician assistants (PAs) in Washington State. DATA SOURCES: State professional licensure renewal survey data from 1998-1999. STUDY DESIGN: Cross-sectional. Data on medical specialty, place of practice, and outpatient visits performed were used to estimate productivity of generalist physicians, NPs, and PAs. Provider head counts were adjusted for missing specialty and productivity data and converted into family physician full-time equivalents (FTEs) to facilitate estimation of total contribution to generalist care made by each provider type. PRINCIPAL FINDINGS: Nurse practitioners and physician assistants make up 23.4 percent of the generalist provider population and provide 21.0 percent of the generalist outpatient visits in Washington State. The NP/PA contribution to generalist care is higher in rural areas (24.7 percent of total visits compared to 20.1 percent in urban areas). The PAs and NPs provide 50.3 percent of generalist visits provided by women in rural areas, 36.5 percent in urban areas. When productivity data were converted into family physician FTEs, the productivity adjustments were large. A total of 4,189 generalist physicians produced only 2,760 family physician FTEs (1 FTE = 105 outpatient visits per week). The NP and PA productivity adjustments were also quite large. CONCLUSIONS: Accurate estimates of available generalist care must take into account the contributions of NPs and PAs. Additionally, simple head counts of licensed providers are likely to result in substantial overestimates of available care. Actual productivity data or empirically derived adjustment factors must be used for accurate estimation of provider shortages.     

Autonomous ambulatory care by nurse practitioners and physician assistants in office-based settings

Data from the 1997 National Ambulatory Medical Care Survey were used to examine the autonomous provision of ambulatory medical care by nurse practitioners (NPs) and physician assistants (PAs) in physician-managed office-based settings. An estimated 6.81 million office visits involved autonomous care by NPs and PAs, for an overall rate of 2.55 visits per 100 persons. The visit rates were greatest for patients over 64 years of age, females, blacks, and patients from the Northeast. The visits encompassed a broad range of acute and chronic problems, with a greater proportion of non-illness care visits when compared with visits to physicians. While NPs and PAs provided diagnostic services and pharmacotherapy, there was more emphasis on therapeutic or preventive services in their practices than among physicians' practices. Predisposing, enabling, and need factors were differentially associated with visits to NPs and PAs. Utilization of NPs and PAs as autonomous providers in office-based settings appears limited. Public policy and educational initiatives can focus on predisposing, enabling, and need factors to increase access to autonomous practice of NPs and PAs in ambulatory care.     

Primary Health Care in Community Health Centers and Comparison with Office-Based Practice

We examine the roles of nurse practitioners (NPs), physician assistants (PAs), and nurse midwives (CNMs) in community health centers (CHCs). We also compare primary care physicians in CHCs with office-based physicians. Estimates are from the National Ambulatory Medical Care Survey, a nationally representative annual survey of nonfederal, office-based patient care physicians and their visits. Analysis of primary care delivery in CHCs and office-based practices are based on 1,434 providers and their visits (n = 32,300). During 2006–2007, on average, physicians comprised 70% of CHC clinicians, with NPs (20%), PAs (9%), and CNMs (1%) making up the remainder. PAs, NPs, and CNMs provided care in almost a third of CHC primary care visits; 87% of visits to these CHC providers were independent of physicians. Types of patients seen by clinicians suggest a division of labor in caring for CHC patients. NPs and PAs were more likely than physicians to report providing health education services. There were no other differences among services examined. Office-based physicians were less likely to work alongside PAs/NPs/CNMs than CHC physicians. CHC staffing is contingent on a variety of providers. CHC staffing patterns may serve as models of primary care staffing for office practices as demand for primary care services nationwide increases.     

How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants

Nurse practitioners (NPs) and physician assistants (PAs) now outnumber family practice doctors in the United States and are the principal providers of primary care to many communities. Recent growth of these professions has occurred amidst considerable cross-state variation in their regulation, with some states permitting autonomous practice and others mandating extensive physician oversight. I find that expanded NP and PA supply has had minimal impact on the office-based healthcare market overall, but utilization has been modestly more responsive to supply increases in states permitting greater autonomy. Results suggest the importance of laws impacting the division of labor, not just its quantity.     

Quality of diabetes care in family medicine practices: influence of nurse-practitioners and physician's assistants

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician’s assistants (PAs), or neither, and which practice attributes contribute to any differences in care.METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs.RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A_1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤ .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A_1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P <.001) than physician-only practices.CONCLUSIONS Family practices employing NPs performed better than those with physicians only and those employing PAs, especially with regard to diabetes process measures. The reasons for these differences are not clear.     

Trends in the supply of physician assistants and nurse practitioners in the United States

In 2001 an estimated 103,612 nurse practitioners (NPs) and physician assistants (PAs) were in clinical employment in the United States. The roles of PAs and NPs in providing comparable physician services are similar; they differ in that NPs are predominantly in primary care, while PAs are divided between primary and specialty care. PA and NP education processes also differ in the student pool and trends in the output. The combined number of graduates totaled 11,585 in 2001. However, the annual number of NP graduates is declining, while the number of PA graduates is increasing. These observations have implications for the future in the types of patients they see and the degree of health care services they provide.     

Satisfaction and well-being of primary care providers in managed care

We compared perceptions about the practice environment and the job satisfaction of physician assistants (PAs), nurse practitioners (NPs), and primary care physicians in a large group-model HMO. The data source was a self-administered mail survey (average response rate = 79%). PA/NPs and primary care physicians reported that professional autonomy was not a problem and were satisfied with most aspects of practice in this setting. Common areas of dissatisfaction included patient load and amount of time with patients. PA/NPs were more likely than the physicians to experience stress on a daily basis, however, and were less likely to report that they would choose the practice setting again. They also were significantly less satisfied than the physicians with their incomes and fringe benefits. Our findings suggest that more attention should be given to practice conditions and compensation of PAs and NPs in managed care.     

Physician assistants in occupational medicine: how do they compare to occupational physicians?

BACKGROUND: Physician assistants (PAs) have been present in occupational and environmental medicine (OEM) in the USA since 1971, yet remarkably little is known about their activity. METHODS: An administrative study of PA activities was undertaken and compared with the activities of physicians in the same occupational medicine setting. Patients were not triaged to either provider and all resources of care were recorded for the visit. An episode of care approach was used for the analysis. RESULTS: The characteristics of patients seen by each provider were similar in age, gender ratio and severity of injury. Physicians saw a mean of 2.9 patients/h and PAs 2.5, but PAs worked more hours and saw more patients per year than physicians. The average charge per patient visit and total charge for an episode of care were similar. Differences between PAs and physicians were seen in the areas of 'limited duty' duration given to patients and on average PAs prescribed 15 days and physicians 17 days. PAs referred a patient 19.7% of the time, while physicians referred 17.4%. Most of the referrals were to physical therapy. The salary of a physician, based on an hourly rate, was approximately twice as much as a PA. CONCLUSION: The use of PAs in OEM may represent a cost-effective advantage from an administrative standpoint. Clearly, more research is necessary in determining the role and utilization of PAs in OEM and how they may improve the delivery of physician services.     

Use of physician assistants and nurse practitioners in primary care, 1995-1999.

Federal policies and state legislation encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. In this paper we analyze primary care physician office encounter data from the 1995-1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office-based physicians used PAs and/or NPs for an average of 11 percent of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counseling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care.     

Growth of Physicians and Nurse Practitioners Practicing Full Time in Nursing Homes

ObjectivesThe objective was to describe the growth of physicians, nurse practitioners (NPs), and physician assistants (PAs) who practice full time in nursing homes, to assess resident and nursing home characteristics associated with receiving care from full-time providers, and describe variation among nursing homes in use of full-time providers.DesignRetrospective cohort study.Setting and ParticipantsA 20% national sample Medicare data on long-term care residents in 2008 to 2018 and the physicians, NPs, and PAs who submitted charges to Medicare for their care.MethodsWe measured the percentage of provider charges for services rendered in nursing homes, in addition to resident and facility characteristics.ResultsFull-time nursing home providers increased from 26.0% of all nursing home providers in 2008 to 44.6% in 2017. The largest increase was in NPs: from 1986 in 2008 to 4479 in 2017. Resident age, sex, Medicaid eligibility, and race/ethnicity had minimal association with the odds of having a full-time provider, whereas residents with an NP primary care provider were 23.0 times more likely (95% confidence interval = 21.6, 24.6) to have a full-time provider. Residents who received care from both a physician and an NP or PA increased from 33.6% in 2008 to 62.5% in 2018. There was large variation among facilities in the percentage of residents with full-time providers, from 5.72% of residents with full-time providers in the bottom quintile of facilities to 91.44% in the top quintile. Individual nursing homes accounted for 59% of the variation in whether a resident had a full-time provider.Conclusions and ImplicationsThe percentage of nursing home residents with full-time providers continues to grow, with very large variation among nursing homes.     

The rural nurse practitioner: a challenge and a response.

From a cohort of 525 employed nurse practitioners (NPs) who graduated between May 1975 and June 1976, 85 (16 per cent) reported practicing in rural areas. While 91 per cent of the rural NPs chose the short-term certificate programs rather than the master's degree for their NP preparation, 47 per cent had already earned a baccalaureate or master's degree prior to NP training. Family NPs comprised the most frequent specialty area chosen, followed by pediatric and adult specialties. Of the 85, 99 per cent were actually providing a broad array of primary care services to clients over a wide age range. Physicians were periodically available on site in about 80 per cent of the practices, by telephone in 97 per cent of the practices, and in 60 per cent of the practices provided additional consulation by record review. Major motivations of the NPs for entering rural practice were to participate in a creative approach to health care delivery (50 per cent of the practice setting were less than five years old), and for the opportunity for role autonomy. Over 95 per cent of these NPs and employers were satisfied with the NP role.     

Costs of providing dental services for children in public and private practices.

This study compares the costs of providing children's dental services in three practice settings: private practices, public mobile clinics, and public fixed clinics. Some 15,000 children were provided comprehensive dental care over a three-year period. Results indicate that costs per visit and per child were lowest in mobile clinics and highest in private practices. The differential was partially explained by differences in productivity but mostly by the fact that the price of services in public practices represented costs of production, whereas in private practices they represented market values.     

Physician assistant practice in Minnesota; providing care as part of a physician-directed team

Physician assistants (PAs) practice medicine with physician supervision, which allows physicians to see more patients and concentrate their efforts on the needs of those with complex medical conditions. Physician assistants have been practicing in Minnesota since 1970. They work in a variety of settings and specialties, although most are in primary care practices. This article profiles the PA profession and describes the type of work PAs do, the training and credentialing required to become a PA, and the relationship between physicians and PAs.     

Barriers and attitudes towards cervical cancer screening in primary healthcare in Poland - doctors’ perspective

Background

Physician associates (PA) form part of the policy-driven response to increased primary care demand and a general practitioner (GP) recruitment and retention crisis. However, they are novel to the primary care workforce and have limitations, for example, they cannot prescribe. The novel 1 year Staffordshire PA Internship (SPAI) scheme, introduced in 2017, was established to support the integration of PAs into primary care. PA interns concurrently worked in primary and secondary care posts, with protected weekly primary care focussed education sessions. This evaluation established the acceptability of PA interns within primary care.

Methods

All ten PAs from the first two SPAI cohorts, the nine host practices (supervising GPs and practice managers) and host practice patients were invited to participate in the evaluation. A conceptual framework for implementing interventions in primary care informed data collection and analysis. Data were gathered at three time points over the internship from practices, through discussions with the supervising GP and/or practice manager, and from the PAs via discussion groups. To enrich discussion data, PA and practices were sent brief surveys requesting information on PA/practice characteristics and PA primary care roles. Patient acceptability data were collected by the host practices. Participation at every stage was optional.

Results

By evaluation end, eight PAs had completed the internship. Seven PAs and six practices provided data at every time point. Five practices provided patient acceptability data. Overall PA interns were acceptable to practices and patients, however ambiguity about the PA role and how best to communicate and operationalise PA roles was revealed. An expectation-preparedness gap resulted in PAs needing high levels of supervision early within the internship. SPAI facilitated closure of the expectation-preparedness gap and its funding arrangements made the high supervision requirements more acceptable to practices.

Conclusions

The test-of-concept SPAI successfully integrated new PAs into primary care. However, the identified challenges risk undermining PAs roles in primary care before they have attained their full potential. Nationally, workforce leaders should develop approaches to support new PAs into primary care, including commitments to longer-term, sustainable, cohesive and appropriately funded schemes, including structured and standardised education and supervision.

     

National estimates of physician assistant productivity

Analysis of productivity data from a nationally representative sample of physician assistants (PAs) showed that PAs performed 61.4 outpatient visits per week compared with 74.2 visits performed by physicians, for an overall physician full-time equivalent (FTE) estimate of 0.83. However, productivity of PAs varies strongly across practice specialty and location, with generalist PAs performing more visits than their specialist counterparts. Rural PA productivity is higher than urban productivity because of the concentration of generalist PAs in rural settings. A generalist PA physician FTE estimate of 0.75 appears to be more accurate than the 0.5 currently under consideration in proposed modifications to Health Personnel Shortage Area designation regulations.     

Time allocation in primary care office visits

OBJECTIVES: To use an innovative videotape analysis method to examine how clinic time was spent during elderly patients' visits to primary care physicians. Secondary objectives were to identify the factors that influence time allocations. DATA SOURCES: A convenience sample of 392 videotapes of routine office visits conducted between 1998 and 2000 from multiple primary care practices in the United States, supplemented by patient and physician surveys. RESEARCH DESIGN: Videotaped visits were examined for visit length and time devoted to specific topics--a novel approach to study time allocation. A survival analysis model analyzed the effects of patient, physician, and physician practice setting on how clinic time was spent. PRINCIPAL FINDINGS: Very limited amount of time was dedicated to specific topics in office visits. The median visit length was 15.7 minutes covering a median of six topics. About 5 minutes were spent on the longest topic whereas the remaining topics each received 1.1 minutes. While time spent by patient and physician on a topic responded to many factors, length of the visit overall varied little even when contents of visits varied widely. Macro factors associated with each site had more influence on visit and topic length than the nature of the problem patients presented. CONCLUSIONS: Many topics compete for visit time, resulting in small amount of time being spent on each topic. A highly regimented schedule might interfere with having sufficient time for patients with complex or multiple problems. Efforts to improve the quality of care need to recognize the time pressure on both patients and physicians, the effects of financial incentives, and the time costs of improving patient-physician interactions.     

Health status and health professional visits in a rural area.

Visits to physicians (MDs), physician assistants (PAs) or nurse practitioners (NPs) by residents of a rural county in the upper-middle west of the United States were analysed in this study. A telephone survey yielded 250 responses. The dependent variable was the natural logarithm of the number of times the respondent had seen a health professional (MD, PA or NP) in the past two years. Predisposing, enabling and medical need variables were tested as potential predictors of visits. Self-rated health status, being unable to perform usual activities, and feeling upset or 'down in the dumps' proved to be important predictors, as was having a usual source of care. Health insurance coverage and family income was not, however. Unexpectedly, smokers also reported more visits. The implications for policy and future research are discussed.     

Physician Assistants and Nurse Practitioners as a Usual Source of Care

ABSTRACT:  Purpose: To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. Methods: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). Findings: Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (β=−0.22, 95% CI =−0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. Conclusions: Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.