Primary Care Physician Assistants Research Articles

Physician assistant and nurse practitioner onboarding in primary care: The participant perspective

Many new graduate primary care physician assistants (PAs) and nurse practitioners (NPs) can experience stress and difficulty as they transition to practice. Feelings of anxiety and role ambiguity are common and can lead to costly turnover, impact care continuity, and place patients at risk for poor clinical outcomes. Onboarding, the process of helping new hires adjust to social and performance aspects of their new job and has the potential to ease transition to practice for PAs and NPs. Recent research has linked PA/NP onboarding programs to increased engagement, decreased turnover, and higher clinical productivity. To describe new graduate PA and NP perspectives of onboarding programs they completed in their first primary care position. Thirteen semistructured interviews were conducted with new graduate PAs and NPs who participated in onboarding programs. Interviews were transcribed and then analyzed using an inductive coding methodology. Analyses revealed nine thematic concepts that are described within two frameworks. Structural components include improving competence, training on the electronic health record, promoting mentorship, orienting to organizational dynamics, tailoring ramp-up of patient scheduling, clarifying expectations, and providing clear organizational support. Psychosocial factors include creating comfort and building self-confidence. Understanding participants' experiences with onboarding programs is essential for ensuring successful transition to practice for new graduate PAs and NPs. These findings are beneficial to the health care workforce. Administrators can incorporate these findings into existing and future programs, and new graduate PAs and NPs can negotiate for the inclusion of these components in their first position.

Patient Experience With Primary Care Physician Assistants in Ontario, Canada: Impact of Trust, Knowledge, and Access to Care.

Physician assistants (PAs) have been integrated into primary care settings to reduce wait times and to optimize continuity of care. Though previous studies suggest that PA utilization leads to improved healthcare access, few studies have investigated patient experience with primary care PAs in Canada. The objective of this study is to explore patient perspectives on primary care PAs in Ontario. A patient survey was developed and distributed to patients seen by PAs in 4 family medicine practices across Ontario, Canada. Results demonstrate that many patients are highly satisfied with their experience including the PA's ability to address their medical needs, establish rapport, and provide fast access to care (including same-day and after-hours appointments). Despite preferring to see a physician for more complex concerns, participants felt that PAs demonstrate similar medical knowledge, competencies, and scope of practice as family physicians. Patients demonstrated a solid understanding of the PA role and recognized the collaborative PA-physician relationship. These findings describe successful patient awareness and acceptance of the PA profession, largely due to positive PA-patient interactions in family medicine settings.

Antecedents of geographical expansion: The case of federally qualified health centers.

Federally qualified health centers (FQHCs) are pivotal safety net primary care providers for the medically underserved. FQHCs have complex organizational designs, with many FQHCs providing care at multiple physical locations ("sites"). The number of sites, however, varies considerably between FQHCs, which can have important implications for differential access that may perpetuate disparities in quality of care. The objective of this study is to explore the organizational and environmental antecedents of the number of sites operated by each FQHC. The findings of this study contribute to a better understanding of FQHCs' expansion that has vital implications for cost and access outcomes. The study is based on data between the years 2012 and 2018. Using multivariate growth curve modeling, we analyzed the final sample, consisting of 5,482 FQHC-years. The level of competition, measured as the number of FQHC sites in the Primary Care Service Area (PCSA) and the number of primary care physicians per 1,000 PCSA residents, was positively associated with the number of FQHC sites. The number of patients, the level of federal grant, and the year were also positively associated with the number of FQHC sites, whereas percentage of Medicaid patients; workforce supply, measured as primary care physician assistants per 1,000 PCSA residents; Medicaid expansion; and state/local funding available for FQHCs were not. Findings of this study indicate that competition, especially between peer FQHCs, is significantly associated with FQHC expansion. This result suggests that FQHC managers and policymakers may closely monitor cost, access, and quality implications of competition and FQHC expansion.

Primary care workforce paradox: A physician shortage and a PA and NP surplus.

Primary care workforce projections continue to predict significant physician shortages. An oversupply of primary care physician assistants (PAs) and NPs also is predicted. This paradox calls into question the assumptions that underlie workforce projection models, which likely underestimate the primary care contributions of PAs and NPs. Federally qualified health center data from the 2016-2019 Uniform Data System were used to calculate the number of clinic visits per full-time equivalent (FTE) physician, PA, and NP. Visits per FTE were compared across provider type to determine provider-specific productivity ratios. The combined PA and NP productivity ratio increased relative to physicians in each year, ranging from 0.85 in 2016 to 0.88 in 2019. Clinic visits per FTE for PAs and family physicians were nearly equivalent. Primary care workforce projection models should be reexamined to more accurately capture the productivity of PAs and NPs.

Physician Assistant Roles in Prevention and Management of Anterior Cruciate Ligament Injury

With incidence of anterior cruciate ligament (ACL) injuries on the rise and a predicted impending shortage of physicians in medical fields, including orthopaedics, demand could soon outweigh supply for optimal care of these injuries. Physician assistants (PAs) are uniquely suited to care for patients in the screening, prevention, and management of ACL injuries. PAs frequently practice in primary care and in this setting can screen for at-risk patients and promote preventative techniques such as neuromuscular training. Primary care PAs can perform patient education about preventative measures and provide resources on a variety of available prevention programs that exist which aim to decrease the likelihood of ACL injury. Primary care PAs frequently use standardized scales or questionnaires in clinic to screen for health risks in their patients such as the Patient Health Questionnaire-9 (PHQ-9) for depression; the creation of a similarly standardized screening tool which assesses for ACL injury risk factors may be beneficial to aid primary care PAs in performing such screenings moving forward. Recovery from an ACL injury, regardless of operative or conservative management, can be a lengthy and complex process that is defined by months of follow-up appointments, rehabilitation exercises, and psychological management. Psychological impairment is a vital component in ACL injury recovery and has been identified as a preeminent factor in prolonging or inhibiting return to sport. By using available psychological measurement tools such as the ACL-Return to Sport after injury, as well as the patient education and counseling skills emphasized in their training, PAs can incorporate a psychologically based approach in management to promote a patient’s safe and timely return to sport. Maximizing efficiency and effectiveness of ACL rupture recovery can occur with the utilization of PAs. PAs embody the training, skills, and scope of practice to prevent and manage ACL injury; therefore, it becomes imperative to promote PA involvement in this injury. Proposed methods to achieve this objective include enhancing orthopaedic training in PA programs and integrating the work of national orthopaedic and PA organizations. More investigation is needed on this topic because having a comprehensive understanding of the potential roles of PAs in ACL care could have a profound, far-reaching impact on this increasingly prevalent injury.

Physician Assistant's Knowledge and Confidence Regarding Prescribing Preexposure Prophylaxis for HIV Prevention

Physician assistants (PAs) have an important role to play in increasing preexposure prophylaxis (PrEP) prescriptions. We surveyed PAs regarding knowledge of Centers for Disease Control and Prevention guidelines for PrEP and confidence regarding PrEP. Physician assistants in primary care reported more accurate knowledge and higher confidence. However, knowledge and confidence gaps were present among all PAs, regardless of specialty.

Characteristics of Physician Assistant Students Planning to Work in Primary Care: A National Study.

While the number of physician assistants (PAs) participating in the primary care workforce continues to rise, the proportion of PAs practicing in primary care rather than other specialties has decreased. The purpose of this study was to identify the characteristics of matriculating PA students planning to enter primary care specialties and compare them with students planning on entering other specialties. Data from the Physician Assistant Education Association Matriculating Student Survey (MSS) from 2013 and 2014 were analyzed. In a series of bivariate analyses, demographic characteristics, educational backgrounds, clinical experiences, and practice expectations of students intending to enter primary care practice were compared with those of their counterparts who did not intend to enter primary care. Logistic regression was used to assess the overall importance of demographic, background, and practice expectations variables on practice intentions. A total of 9283 students responded to the MSS from 2013 and 2014. More than half (58.3%) stated an intention to practice in primary care upon graduation. Those students were more likely than their counterparts to be married, to be Hispanic or Asian, and to have participated in community service prior to starting PA training. They were also less likely to view high income as essential to their careers and more likely to view practicing in rural or underserved areas favorably. The findings of this study could be used to identify student characteristics associated with an interest in primary care and could contribute to more successful student recruitment and PA curriculum design, especially for PA training programs with a mission focused on producing primary care PAs.

Predicted shortages of physicians might even disappear if we fully account for PAs and NPs.

Healthcare workforce projections have important policy implications. Provider shortages can shortchange patients, and overproduction of providers imposes costs on society. The most publicized physician supply and demand projections, commissioned annually by the Association of American Medical Colleges, regularly predict dire physician shortages. These projections are based on unrealistically low estimates of the amount of physician work that can be replaced by physician assistants (PAs) and NPs. For example, the projections factor in the contribution of one primary care PA or NP as one-fourth that of a physician. If workforce projections used evidence-based productivity estimates, the predicted physician shortfalls would be much smaller and perhaps even disappear.

The workforce trends of physician assistants in Iowa (1995-2015).

BackgroundPhysician assistants are expected to have an important role in providing both primary and specialty care. Iowa has a large rural (and aging) population and faces challenges to provide equitable access to care. This study examined changes in the Iowa physician assistant workforce (1995–2015) focusing on practice setting (primary v. subspecialty care) and geographic location (rural/urban, Health Professional Shortage Area). Documenting their current locations and service in HPSAs for primary care will help health planners track future changes.MethodsData from 1995–2015 from the Iowa Health Professions Inventory (Office of Statewide Clinical Education Programs, Carver College of Medicine, University of Iowa) were combined with US census data on rural location and HPSA status. SPSS was used to compare Iowa and national data. Growth trends were analyzed using joinpoint regression.ResultsThe overall Iowa physician assistant workforce increased 161% between 1995 and 2015. In 2015, more than two-thirds (71%) were female and more than 30% practiced in rural counties. The average annual growth rate of primary care PAs (per 100,000 population) was significantly higher in the periods from 1995–1997 and 1997–2001 (22.4% and 7.4% respectively) than in period from 2001–2015 (3.8%). By 2015, 56% of Iowa’s physician assistants practiced in primary care (versus 29.6% nationally). Of these, 44% of primary care physician assistants in Iowa practiced in counties, geographic locations or worksites designated as Health Professional Shortage Areas for primary care.ConclusionsA high proportion of Iowa’s physician assistant workforce practiced in primary care and many served patients in Health Professional Shortage Areas. The number of physician assistants in Iowa will continue to grow and serve an important role in providing access to health care, particularly to rural Iowans.

Perspectives: Using Results from HRSA's Health Workforce Simulation Model to Examine the Geography of Primary Care.

Inform health planning and policy discussions by describing Health Resources and Services Administration's (HRSA's) Health Workforce Simulation Model (HWSM) and examining the HWSM's 2025 supply and demand projections for primary care physicians, nurse practitioners (NPs), and physician assistants (PAs). HRSA's recently published projections for primary care providers derive from an integrated microsimulation model that estimates health workforce supply and demand at national, regional, and state levels. Thirty-seven states are projected to have shortages of primary care physicians in 2025, and nine states are projected to have shortages of both primary care physicians and PAs. While no state is projected to have a 2025 shortage of primary care NPs, many states are expected to have only a small surplus. Primary care physician shortages are projected for all parts of the United States, while primary care PA shortages are generally confined to Midwestern and Southern states. No state is projected to have shortages of all three provider types. Projected shortages must be considered in the context of baseline assumptions regarding current supply, demand, provider-service ratios, and other factors. Still, these findings suggest geographies with possible primary care workforce shortages in 2025 and offer opportunities for targeting efforts to enhance workforce flexibility.

Patient characteristics associated with primary care PA and APRN roles.

Physician assistants (PAs) and advanced practice registered nurses (APRNs) can perform multiple roles on primary care teams, but limited research describes the patients they serve. We sought to identify patient characteristics associated with roles of primary care PAs and APRNs. We analyzed adult respondents to the 2010 Health Tracking Household Survey with a primary care usual provider (physician, PA, or APRN). The dependent variable is the PA or APRN role. Explanatory variables include sociodemographic characteristics, attitudes toward use, delayed care, and perceived health. Compared with respondents seen by physicians only, respondents seen by a PA or APRN in any role were more likely to be younger, female, living in rural areas, and put off needed medical care. Respondents seen by a PA or APRN as their usual provider were more likely to report better health. Patients seen by a PA or APRN in a supplemental role reported being sicker, more educated, and attitudinally less likely to use healthcare. PAs and APRNs perform different roles for different types of patients.

Scarcity of primary care positions may divert physician assistants into specialty practice

Background: Physician assistants (PAs) are often suggested as a partial solution to predicted primary care workforce shortages, but a declining proportion of PAs are entering primary care practice. Policy efforts have focused on increasing primary care PA supply, but low labor market demand might be constricting the primary care PA pipeline. Method: In this descriptive, cross-sectional study, we compare primary care and specialty job postings to each other and to occupied PA positions. Job posting data for 2014 are from a leading labor analytics firm. Results: Only 18% of job postings were in primary care, compared with 27% of occupied PA positions. The proportion of postings that were for primary care varied widely by state (9% to 40%) and were highest in the West. Discussion: Job availability is a potential barrier to PAs practicing in primary care, especially in some locations. Other job factors are examined and policy solutions are suggested.

The economic effect of a physician assistant or nurse practitioner in rural America.

Revenues generated by physician assistants (PAs) and NPs in clinics and hospitals create employment opportunities and wages, salaries, and benefits for staff, which in turn are circulated throughout the local economy. An input-output model was used to estimate the direct and secondary effects of a rural primary care PA or NP on the community and surrounding area. This type of model explains how input/output from one sector of industry can be the output/input for another sector. Given two example scenarios, a rural PA or NP can have an employment effect of 4.4 local jobs and labor income of $280,476 from the clinic. The total effect to a community with a hospital increases to 18.5 local jobs and $940,892 of labor income.

Scarcity of Primary Care Positions May Divert Physician Assistants Into Specialty Practice.

Physician assistants (PAs) are often suggested as a partial solution to predicted primary care workforce shortages, but a declining proportion of PAs are entering primary care practice. Policy efforts have focused on increasing primary care PA supply, but low labor market demand might be constricting the primary care PA pipeline. In this descriptive, cross-sectional study, we compare primary care and specialty job postings to each other and to occupied PA positions. Job posting data for 2014 are from a leading labor analytics firm. Only 18% of job postings were in primary care, compared with 27% of occupied PA positions. The proportion of postings that were for primary care varied widely by state (9% to 40%) and were highest in the West. Job availability is a potential barrier to PAs practicing in primary care, especially in some locations. Other job factors are examined and policy solutions are suggested.

Primary care physician assistant and advance practice nurses roles: Patient healthcare utilization, unmet need, and satisfaction

PurposeTeam-based care involving physician assistants (PAs) and advance practice nurses (APNs) is one strategy for improving access and quality of care. PA/APNs perform a variety of roles on primary care teams. However, limited research describes the relationship between PA/APN role and patient outcomes. We examined multiple outcomes associated with primary care PA/APN roles. MethodsIn this cross-sectional survey analysis, we studied adult respondents to the 2010 Health Tracking Household Survey. Outcomes included primary care and emergency department visits, hospitalizations, unmet need, and satisfaction. PA/APN role was categorized as physician only (no PA/APN visits; reference), usual provider (PA/APN provide majority of primary care visits) or supplemental provider (physician as usual provider, PA/APN provide a subset of visits). Multivariable logistic and multinomial logistic regressions were performed. ResultsCompared to people with physician only care, patients with PA/APNs as usual providers [5–9 visits RRR=2.4 (CI 1.8–3.4), 10+ visits RRR=3.0 (CI 2.0–4.5): reference 2–4 visits] and supplemental providers had increased risk of having 5 or more primary care visits [5–9 visits RRR=1.3 (CI 1.0–1.6)]. Patients reporting PA/APN as supplemental providers had increased risk of emergency department utilization [2+ visits: RRR 1.8 (CI 1.3, 2.5)], and lower satisfaction [very dissatisfied: RRR 1.8 (CI 1.03–3.0)]. No differences were seen for hospitalizations or unmet need. ConclusionsHealthcare utilization patterns and satisfaction varied between adults with PA/APN in different roles, but reported unmet need did not. These findings suggest a wide range of outcomes should be considered when identifying the best PA/APN role on primary care teams.

Physician assistants are not a “lifeline,” GPs say

Physician assistants in primary care are not a “lifeline” to save general practice and will divert attention from the need for more GPs, local medical committees (LMCs) have said. Delegates at a special BMA conference of LMCs were not persuaded that physician assistants were the solution to their workload concerns. Roberta King, of Dorset LMC, argued that it would take many years to increase GP …

Nurse practitioners and physician assistants in primary care: An update of changes since 2008

This article is an update to a 2008 article “Nurse Practitioners and Physician Assistants in Primary Care” which will provide not only a basic understanding of the Nurse Practitioner and Physician Assistant profession, but also developments in the professions over the last 8 years. Issues pertaining to healthcare quality, access to care, reimbursement, and increasing healthcare costs are influencing the United States healthcare system. The roles of the nurse practitioner (NP) and physician assistant (PA) in health care are crucial today in providing access to care and ensuring efficiency of care, while maintaining the quality of care given to the public. Since NPs and PAs have come into existence, they have helped with holding down healthcare costs, providing care to underserved populations, and enabling physician practices to serve their patients better. Availability of care and physician shortage became growing issues in health care. Increasing demands on physicians in terms of “intensity and complexity” of the care required began to exist. This increasing demand led to the development of these disciplines as a way to combat the challenges of health care. There are approximately 175,000 NPs and 90,000 PAs practicing in the U.S. today an increase from 100,000 and 60,000 8 years ago. Those numbers have more than doubled since 1990. In fact, according to Roblin, NP/PAs are capable of potentially seeing 50%–75% of all primary care visits. Given their track record, employing NPs and PAs in primary care settings seems like a logical choice. In all, 40% of NPs are trained as family NPs and 10% are trained in pediatrics. Other NPs are trained to specialize, unlike PAs who are always trained as generalists with half in medical offices and the other half in hospitals, public health, nursing homes, and other settings. NPs and PAs are used by approximately one-quarter of primary care physicians, seeing nearly the same types of patients as the physician. Family physicians are using NPs and PAs more than any other medical specialty. More than 60% of physician group practices are now employing NPs and

Diagnosis and medical and surgical management of cervical spondylotic myelopathy.

Cervical spondylotic myelopathy is a complex condition with subtle history and examination findings that mimic other conditions. Primary care physician assistants often are the first providers to evaluate these patients. This article describes cervical spondylotic myelopathy, its diagnosis and management, and recent data that offer strong evidence that patients who undergo surgical decompression show significant improvement over patients who are treated conservatively.

Investigating the contribution of physician assistants to primary care in England: a mixed-methods study

BackgroundPrimary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs.ObjectiveTo investigate the contribution of PAs to the delivery of patient care in primary care services in England.DesignA mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals.ResultsThe rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.ConclusionsPAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

The role of primary care physician assistants in managing chronic hepatitis B

This article informs physician assistants of an algorithm designed for primary care practice to guide the screening of patients for hepatitis B virus infection. The algorithm also provides guidance on evaluation, follow-up, and referral of patients who screen positive. The algorithm is a synthesis of several published, evidence-based practice guidelines and reports.