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Jolly Graham A, Platt A, Knutsen K, Fletcher E, Gallagher D. Impact of geographical cohorting, multidisciplinary rounding and incremental case management support on hospital length of stay and readmission rates: a propensity weighted analysis. BMJ Open Qual 2024; 13:e002737. [PMID: 38782488 PMCID: PMC11116874 DOI: 10.1136/bmjoq-2023-002737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Hospital length of stay (LOS) in the USA has been increasing since the start of the COVID-19 pandemic, with numerous negative outcomes, including decreased quality of care, worsened patient satisfaction and negative financial impacts on hospitals. While many proposed factors contributing to prolonged LOS are challenging to modify, poor coordination of care and communication among clinical teams can be improved.Geographical cohorting of provider teams, patients and other clinical staff is proposed as a solution to prolonged LOS and readmissions. However, many studies on geographical cohorting alone have shown no significant impact on LOS or readmissions. Other potential benefits of geographical cohorting include improved quality of care, learning experience, communication, teamwork and efficiency.This paper presents a retrospective study at Duke University Hospital (DUH) on the General Medicine service, deploying a bundled intervention of geographical cohorting of patients and their care teams, twice daily multidisciplinary rounds and incremental case management support. The quality improvement study found that patients in the intervention arm had 16%-17% shorter LOS than those in the control arms, and there was a reduction in 30-day hospital readmissions compared with the concurrent control arm. Moreover, there was some evidence of improved accuracy of estimated discharge dates in the intervention arm.Based on these findings, the health system at DUH recognised the value of geographical cohorting and implemented additional geographically based medicine units with multidisciplinary rounds. Future studies will confirm the sustained impact of these care transformations on hospital throughput and patient outcomes, aiming to reduce LOS and enhance the quality of care provided to patients.
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Affiliation(s)
- Aubrey Jolly Graham
- Hospital Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alyssa Platt
- Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kristian Knutsen
- Performance Services, Duke University Health System, Durham, North Carolina, USA
| | - Emily Fletcher
- Hospital Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - David Gallagher
- Hospital Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Khoo JEJ, Lim CW, Lai YF. Performance management of generalist care for hospitalised multimorbid patients-a scoping review for value-based care. FRONTIERS IN HEALTH SERVICES 2024; 3:1147565. [PMID: 38469170 PMCID: PMC10925702 DOI: 10.3389/frhs.2023.1147565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 12/29/2023] [Indexed: 03/13/2024]
Abstract
Objectives Given the shift towards value-based healthcare and the increasing recognition of generalist care, enacting value-based healthcare for generalist care is critical. This work aims to shed light on how to conduct performance management of generalist care to facilitate value-based care, with a focus on medical care of hospitalised patients. Design and setting A scoping review of published literature was conducted. 30 publications which were relevant to performance management of generalist medical inpatient care were included in the review. Outcome measures The performance measures used across the studies were analysed and other qualitative findings were also obtained. Results We report an overall lack of research on performance management methods for generalist inpatient care. Relevant performance measures found include both outcome and process of care measures and both clinical and reported measures, with clinical outcome measures the most frequently reported. Length of stay, readmission rates and mortality were the most frequently reported. The insights from the papers emphasise the relevance of process of care measures for performance management, the advantages and disadvantages of types of measures and provide suggestions relevant for performance management of generalist inpatient care. Conclusion The findings of this scoping review outline a variety of performance measures valuable for generalist inpatient care including clinical outcome measures, reported outcome measures and process of care measures. The findings also suggest directions for implementation of such performance management, including emphasis on physician level performance management and the importance of documentation training. Further research for selecting and operationalising the measures for specific contexts and developing a comprehensive performance management system involving these measures will be important for achieving value-based healthcare for generalist inpatient care.
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Affiliation(s)
- Jia En Joy Khoo
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Department of Life Sciences, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Cher Wee Lim
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yi Feng Lai
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
- School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
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Raver C, Bunker J, Caldwell M, Eldore L, Columbus C, Ogola G, Ahmed K, Au C, Schick A, Perez G. Comparison of hospitalist service staffing models at Baylor University Medical Center. Proc AMIA Symp 2023; 37:70-77. [PMID: 38173989 PMCID: PMC10761084 DOI: 10.1080/08998280.2023.2260671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/08/2023] [Indexed: 01/05/2024] Open
Abstract
Background Baylor University Medical Center benefits from being a quaternary care center with 900+ licensed beds and multiple different models to staff patients on the hospitalist service. These models include hospitalist only, resident teaching teams, and two different advanced practice practitioner teams. The primary goal of this study was to assess these different staffing models and to ascertain which model, if any, has better outcomes related to length of stay, total hospital charges, 30-day readmission rates, patient satisfaction, hospital-acquired infections, mortality, and early discharges. Methods The study was an observational retrospective chart review of all discharges from the hospitalist service at Baylor University Medical Center from October 1, 2021, to February 28, 2022. Patients were included if the hospitalist team was the primary team of record at the time of discharge. A total of 7803 patients were included. Results There was no difference in patient satisfaction, hospital-acquired infections, and mortality between the groups. The teaching teams had a shorter length of stay before the removal of outliers. Independent advanced practice practitioners reliably had more patients discharged before 11:30 am. Results support the concept of continuity of care, as well as lower patient-to-provider ratios. Conclusions These results have actionable implications that support the use of different advanced practice practitioner teams for the safe care of hospitalized patients as well as the safe integration of residents into patient care.
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Affiliation(s)
- Catherine Raver
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TexasUSA
| | - John Bunker
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TexasUSA
| | - Mary Caldwell
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TexasUSA
| | - Luke Eldore
- Texas A&M School of Medicine, Baylor University Medical Center, Dallas, TexasUSA
| | - Cristie Columbus
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TexasUSA
| | - Gerald Ogola
- Department of Biostatistics, Baylor University Medical Center, Dallas, TexasUSA
| | - Kashif Ahmed
- Office of Graduate Medical Education, Baylor University Medical Center, Dallas, TexasUSA
| | - Chieu Au
- Department of Biostatistics, Baylor University Medical Center, Dallas, TexasUSA
| | - Alissa Schick
- Department of Patient Relations, Baylor University Medical Center, Dallas, TexasUSA
| | - Gabriela Perez
- Department of Infection Control, Baylor University Medical Center, Dallas, TexasUSA
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Barry CL, Coombs J, Buchs S, Kim S, Grant T, Henry T, Parente J, Spackman J. Professionalism in Physician Assistant Education as a Predictor of Future Licensing Board Disciplinary Actions. J Physician Assist Educ 2023; 34:278-282. [PMID: 37467183 PMCID: PMC10653293 DOI: 10.1097/jpa.0000000000000515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
PURPOSE The purpose of this study was to evaluate associations between postgraduate disciplinary actions (PGDA) by state licensing boards and physician assistant (PA) school documented professionalism violations (DPV) and academic probation. METHODS This was a retrospective cohort study comprising PA graduates from 2001 to 2011 at 3 institutions (n = 1364) who were evaluated for the main outcome of PGDA and independent variable of DPV and academic probation. Random-effects multiple logistic regression and accelerated failure time parametric survival analysis were used to investigate the association of PGDA with DPV and academic probation. RESULTS Postgraduate disciplinary action was statistically significant and positively associated with DPV when unadjusted (odds ratio [OR] = 5.15; 95% CI: 1.62-16.31; P = .01) and when adjusting for age, sex, overall PA program GPA (GPA), and Physician Assistant National Certifying Exam Score (OR = 5.39; 95% CI: 1.54-18.85; P = .01) (fully adjusted). Academic probation increased odds to 8.43 times (95% CI: 2.85-24.92; P < .001) and 9.52 times (95% CI: 2.38-38.01; P < .001) when fully adjusted. CONCLUSION Students with professionalism violation or academic probation while in the PA school had significant higher odds of receiving licensing board disciplinary action compared with those who did not. Academic probation had a greater magnitude of effect and could represent an intersection of professionalism and academic performance.
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Affiliation(s)
- Carey L Barry
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Jennifer Coombs
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Shalon Buchs
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Sooji Kim
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Travis Grant
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Trenton Henry
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Jason Parente
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
| | - Jared Spackman
- Carey L. Barry, MHS, PA-C, DFAAPA, is a chair of the Department of Medical Sciences and Associate Clinical Professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jennifer Coombs, PhD, MPAS, PA-C, DFAAPA, is a director of graduate studies and is a professor, Division of Physician Assistant Studies, Department of Family and Preventive Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
- Shalon Buchs, MHS, PA-C, DFAAPA, is a director of evaluation for the Office of Continuous Quality Improvement and is an associate professor, Florida State University College of Medicine, Tallahassee, Florida
- Sooji Kim, BS, is a research assistant, PA Program, Northeastern University, Boston, Massachusetts
- Travis Grant, MS, PA-C, is an assistant clinical professor, University of Florida School of Physician Assistant Studies, Gainesville, Florida
- Trenton Henry, MSPH, is a research associate at Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jason Parente, MS, PA-C, is an associate program director and is an associate clinical professor, Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts
- Jared Spackman, MPAS, PA-C, is a PA program director and is an associate professor at University of Utah School of Medicine, Salt Lake City, Utah
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Shannon EM, Cauley M, Vitale M, Wines L, Chopra V, Greysen SR, Herzig SJ, Kripalani S, O'Leary KJ, Vasilevskis EE, Williams MV, Auerbach AD, Mueller SK, Schnipper JL. Patterns of utilization and evaluation of advanced practice providers on academic hospital medicine teams: A national survey. J Hosp Med 2022; 17:186-191. [PMID: 35504577 DOI: 10.1002/jhm.12788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 11/09/2022]
Abstract
This survey study aimed to provide a contemporary appraisal of advanced practice provider (APP) practice and to summarize perceptions of the benefits and challenges of integrating APPs into adult academic hospital medicine (HM) groups. We surveyed leaders of academic HM groups. We received responses from 43 of 86 groups (50%) surveyed. Thirty-four (79%) reported that they employed APPs. In most groups (85%), APPs were reported to perform daily tasks of patient care, including rounding and documentation. Less than half of the groups reported that APPs had completed HM-specific postgraduate training. The reported benefits of APPs included improved perceived quality of care and greater volume of patients that could be seen. Reported challenges included training requirements and support for new hires. Further investigation is needed to determine which APP team structures deliver the highest quality care. There may be a role for expanding standardized competency-based postgraduate training for APPs planning to practice HM.
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Affiliation(s)
- Evan M Shannon
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, California, USA
| | - Marissa Cauley
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew Vitale
- Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Leanne Wines
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Vineet Chopra
- Department of Medicine, Division of Hospital Medicine, University of Denver, Denver, Colorado, USA
| | - S Ryan Greysen
- Section of Hospital Medicine, Perelman School of Medicine at the University of Pennsylvania, Division of General Internal Medicine, Philadelphia, Pennsylvania, USA
- The Wharton School at the University of Pennsylvania, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania, USA
| | - Shoshana J Herzig
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Division of General Medicine, Boston, Massachusetts, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Vanderbilt University Medical Center, Division of General Internal Medicine and Public Health, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin J O'Leary
- Department of Medicine, Northwestern University Feinberg School of Medicine, Division of Hospital Medicine, Chicago, Illinois, USA
| | - Eduard E Vasilevskis
- Section of Hospital Medicine, Vanderbilt University Medical Center, Division of General Internal Medicine and Public Health, Nashville, Tennessee, USA
- Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research Education and Clinical Center, VA Tennessee Valley, Nashville, Tennessee, USA
| | - Mark V Williams
- Washington University School of Medicine, Division of Hospital Medicine, St. Louis, Missouri, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California San Francisco, San Francisco, California, USA
| | - Stephanie K Mueller
- Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey L Schnipper
- Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Bendicksen D, Pflugeisen CM, Slot FV. A novel inpatient PA staffing model for a community hospital. JAAPA 2022; 35:43-48. [PMID: 34845170 PMCID: PMC8683074 DOI: 10.1097/01.jaa.0000795020.20041.2e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to create a novel physician assistant (PA) and physician hospital medicine co-management strategy, employing a 3:1 PA:physician structure, under which the physician oversees all PA patients, but without a separate independent panel. METHODS This is a retrospective cohort pre-post design, comparing metrics for a traditional physician-only hospitalist model with a PA-physician team model. Outcomes included length of stay (LOS), readmissions, discharge destination, patient satisfaction, and in-hospital mortality. RESULTS LOS for patients under the PA-physician model (74 hours) was lower than for the physician-only model (83 hours; P < .001). The PA-physician model team discharged more patients home than to another facility (PA-physician 77.6%, physician-only 74.3%; P = .03). Thirty-day readmissions were about 10% (P = .97) and patients reported respectful treatment in about 80% (P = .53) of cases in each cohort. CONCLUSIONS Our 3:1 PA-physician model team showed equal to superior outcomes compared with the physician-only hospitalist model.
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Affiliation(s)
- Danielle Bendicksen
- Danielle Bendicksen practiced as a hospitalist PA at MultiCare Health System in Tacoma, Wash. Chaya Mangel Pflugeisen is a research scientist at the MultiCare Institute for Research and Innovation in Tacoma. Franchot van Slot is a hospitalist physician and medical director of the Inpatient Advanced Practice Provider Fellowship at MultiCare Health System and an adjunct professor in the PA program at Pacific University in Forest Grove, Ore. The authors have disclosed no potential conflicts of interest, financial or otherwise
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van den Brink GTWJ, Hooker RS, Van Vught AJ, Vermeulen H, Laurant MGH. The cost-effectiveness of physician assistants/associates: A systematic review of international evidence. PLoS One 2021; 16:e0259183. [PMID: 34723999 PMCID: PMC8559935 DOI: 10.1371/journal.pone.0259183] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 10/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. METHODS AND FINDINGS Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies-of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician's care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. CONCLUSIONS Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity.
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Affiliation(s)
- G. T. W. J. van den Brink
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - R. S. Hooker
- Adjunct Professor, Health Policy, Northern Arizona University, United States of America
| | - A. J. Van Vught
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - H. Vermeulen
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
| | - M. G. H. Laurant
- Radboud Institute for Health Sciences, IQ healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
- HAN University of Applied Sciences, School of Health Studies, Nijmegen, The Netherlands
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8
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Malone R. The role of the physician associate: an overview. Ir J Med Sci 2021; 191:1277-1283. [PMID: 34351601 DOI: 10.1007/s11845-021-02661-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/25/2021] [Indexed: 10/20/2022]
Abstract
The physician assistant role in healthcare delivery was first introduced during the 1960s in the USA as a solution to doctor shortages, greater population healthcare needs and increasing healthcare provision costs. Since then, many countries worldwide have utilized the successful USA physician assistant model as a benchmark to guide both physician assistant training and the incorporation of the role into their healthcare systems. While the USA retained the title physician assistant, Ireland and the UK use the title physician associate. Physician assistants/associates are trained in the generalist medical model and function under the supervision of a doctor. Tasks relating to the role include the following: taking patient's medical histories, performing examinations, making diagnosis, requesting tests, analysing results and the initiation of treatment. They practice across a broad range of specialities and settings. Physician assistants in the USA and the Netherlands have prescribing privileges. Statutory regulation for physician assistants/associates lays the groundwork for prescribing privileges and such regulation is under consideration by the government in the UK. Studies indicate that doctors and patients are largely satisfied with the contribution of this profession to healthcare services and physician assistants/associates report good job satisfaction.
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Affiliation(s)
- Rachel Malone
- Beaumont Hospital, Beaumont Road, Dublin 9, Ireland.
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Walker RJ, Segon A, Good J, Nagavally S, Gupta N, Levine D, Neuner J, Egede LE. Differences in length of stay by teaching team status in an academic medical center in the Midwestern United States. Hosp Pract (1995) 2021; 49:119-126. [PMID: 33499682 DOI: 10.1080/21548331.2021.1882238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 01/25/2021] [Indexed: 06/12/2023]
Abstract
Background: Given the high cost of inpatient stays, hospital systems are investigating ways to decrease lengths of stay while ensuring high-quality care. The goal of this study was to determine if patients in teaching teams (hospitalist teams with residents and interns) had a higher length of stay after adjusting for relevant confounders compared to hospitalist-only teams (staffed only by attending physicians).Methods: Using a retrospective design, we investigated differences in length of stay for 17,577 inpatient encounters over a 2-year period. Length of stay was calculated based on the time between hospital admission and hospital discharge with no removal of outliers. Encounters were assigned to teams based on the discharge provider. Teams were grouped based on whether they were teaching teams or nonteaching teams. Since the length of stay was not normally distributed, it was modeled first using generalized linear models with gamma distribution and log link, and secondly by quantile regression. Models were adjusted for age, gender, race, medicine vs. non-medicine unit, MS-DRGs, and comorbidities.Results: Using gamma models to account for the skewed nature of the data, the length of stay for encounters assigned to teaching teams was 0.56 days longer (β = 0.10 95% CI 0.06 0.14) than for nonteaching teams after adjustment. Using quantile regression, teaching teams had encounters on average 0.63 days longer (95% CI 0.44 0.81) than nonteaching teams at the 75th percentile and 1.19 days longer (95% CI 0.77 1.61) compared to nonteaching teams at the 90th percentile after adjustment.Conclusions: After adjusting for demographics and clinical factors, teaching teams on average had lengths of stay that were over half day longer than nonteaching teams. In addition, for the longest encounters, differences between teaching and nonteaching teams were over 1-day difference. Given these results, process improvement opportunities exist within teaching teams regarding length of stay, particularly for longer encounters.
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Affiliation(s)
- Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ankur Segon
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer Good
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sneha Nagavally
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Navdeep Gupta
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Doug Levine
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Joan Neuner
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
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Johnson SA, Ciarkowski CE, Lappe KL, Kendrick DR, Smith A, Reddy SP. Comparison of Resident, Advanced Practice Clinician, and Hospitalist Teams in an Academic Medical Center: Association With Clinical Outcomes and Resource Utilization. J Hosp Med 2020; 15:709-715. [PMID: 33231541 DOI: 10.12788/jhm.3475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures. OBJECTIVE Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams. DESIGN Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization. SUBJECTS Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716). MAIN MEASURES Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization. KEY RESULTS Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams. CONCLUSION We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.
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Affiliation(s)
- Stacy A Johnson
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Claire E Ciarkowski
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Katie L Lappe
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
- Division of General Internal Medicine, Department of Internal Medicine, George E. Wahlen VA Hospital, Salt Lake City, Utah
| | - David R Kendrick
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Adrienne Smith
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Santosh P Reddy
- Division of General Internal Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah
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Shahlaie K, Harsh GR. Editorial. The financial value of a neurosurgery resident. J Neurosurg 2020; 135:164-168. [PMID: 32916648 DOI: 10.3171/2020.4.jns20836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Watson MD, Elhage SA, Scully C, Peterson S, Gulledge M, Cunningham K, Sachdev G. Electronic health record usage among nurse practitioners, physician assistants, and junior residents. J Am Assoc Nurse Pract 2020; 33:200-204. [PMID: 32740334 DOI: 10.1097/jxx.0000000000000466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies demonstrate significant electronic health record (EHR) use by junior residents; however, few studies have investigated this for nurse practitioners and physician assistants (NPs/PAs). PURPOSE The aim of this study was to quantify the time spent on the EHR by NPs/PAs and junior residents. METHODS Electronic health record usage data were collected from April 2015 through April 2016. Monthly EHR usage was compared between NPs/PAs and postgraduate second and third year residents. Further subgroup analysis of NPs/PAs and residents from surgical or nonsurgical fields was conducted. RESULTS Data for 22 NPs/PAs (16 surgical and six nonsurgical) and 125 residents (31 surgical and 94 nonsurgical) were analyzed. Nurse practitioners/physician assistants opened fewer charts per day (4.9 ± 1.5 vs. 5.4 ± 3.1), placed more orders per month, and spent more daily time on the EHR (176.5 ± 51.7 minutes vs. 152.3 ± 71.9 minutes; p < .0001). Compared with residents, NPs/PAs spent more time per patient in all categories (chart review, documentation, order entry) and in total time per patient chart (all p < .05). Comparing surgical NPs/PAs to surgical residents, findings were similar with fewer charts per day, more total daily EHR time, and more EHR time per patient in every tracked category (all p < .05). IMPLICATIONS FOR PRACTICE This is the first study to quantify time on the EHR for NPs/PAs. Nurse practitioners/physician assistants spent more time on the EHR than residents, and this is accentuated with surgical NPs/PAs. Electronic health record utilization appears more burdensome for NPs/PAs; however, the reason for this is unclear and highlights the need for targeted interventions.
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Affiliation(s)
- Michael D Watson
- Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, North Carolina
| | - Sharbel A Elhage
- Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, North Carolina
| | - Casey Scully
- Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, North Carolina
| | - Sabrina Peterson
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Marialice Gulledge
- Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, North Carolina
| | - Kyle Cunningham
- Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, North Carolina
| | - Gaurav Sachdev
- Department of Surgery, Atrium Health, Carolinas Medical Center, Charlotte, North Carolina
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Sugiyama S, Asakura K, Takada N. Japanese nurse practitioners' legal liability ambiguity regarding their medical practice: a qualitative study. BMC Nurs 2020; 19:62. [PMID: 32669968 PMCID: PMC7346369 DOI: 10.1186/s12912-020-00458-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 07/02/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Nurse practitioners' role is always expanding. The Japanese Nurse Practitioner (JNP) system was initiated in 2015 to shift some aspects of doctors' work to various other healthcare professionals, including nurses. JNPs' fulfillment of their roles was shown to have a certain degree of efficacy and provide positive outcomes for patients (e.g., shortening hospitalization period). Nurse practitioners are considered legally liable for their medical practices because they are performed on doctors' behalf; however, in real life, there is ambiguity regarding such practice. It is necessary to clarify nurse practitioners' legal liability in order to ensure the safety of their medical practice and protect them in medical procedures performed on physicians' behalf. This study aimed to clarify how JNPs understand their own legal liability in medical practice. METHODS A qualitative, inductive research design was adopted to record participants' opinions. The survey was conducted from October 2017 to February 2018. Participants were nurses working as JNPs at general hospitals in eastern Japan. We recruited participants via snowball sampling. RESULTS With regard to JNPs' legal liability in their medical practice, three themes understanding were observed: "determining whether the JNP has the ability to perform the assigned medical procedure," "exercising caution when performing medical procedures on a doctor's behalf" and "an urge to follow up with appropriate medical practice until the end of care." CONCLUSIONS We demonstrated that JNPs recognized their own legal liability in medical practice. They had to protect themselves because their legal position was ambiguous. Furthermore, JNPs accepted that diagnosis and drug prescription could be performed on behalf of doctors if trusting relationships had been previously established.
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Affiliation(s)
- Shoko Sugiyama
- Tohoku University, Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575 Japan
| | - Kyoko Asakura
- Tohoku University, Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575 Japan
| | - Nozomu Takada
- Tohoku University, Graduate School of Medicine, 2-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8575 Japan
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Gross CJ, Chiel LE, Gomez AR, Marcus CH, Michelson CD, Winn AS. Defining the Essential Components of a Teaching Service. Pediatrics 2020; 146:peds.2020-0651. [PMID: 32487591 DOI: 10.1542/peds.2020-0651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES A large portion of residency education occurs in inpatient teaching services without widely accepted consensus regarding the essential components that constitute a teaching service. We sought to generate consensus around this topic, with the goal of developing criteria programs that can be used when creating, redesigning, or evaluating teaching services. METHODS A list of potential components of teaching services was developed from a literature search, interviews, and focus groups. Eighteen pediatric medical education experts participated in a modified Delphi method, responding to a series of surveys rating the importance of the proposed components. Each iterative survey was amended on the basis of the results of the previous survey. A final survey evaluating the (1) effort and (2) impact of implementing components that had reached consensus as recommended was distributed. RESULTS Each survey had 100% panelist response. Five survey rounds were conducted. Fourteen attending physician characteristics and 7 system characteristics reached consensus as essential components of a teaching service. An additional 25 items reached consensus as recommended. When evaluating the effort and impact of these items, the implementation of attending characteristics was perceived as requiring less effort than system characteristics but as having similar impact. CONCLUSIONS Consensus on the essential and recommended components of a resident teaching service was achieved by using the modified Delphi method. Although the items that reached consensus as essential are similar to those proposed by the Accreditation Council for Graduate Medical Education, those that reached consensus as recommended are less commonly discussed and should be strongly considered by institutions.
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Affiliation(s)
- Caroline J Gross
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and .,Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Laura E Chiel
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
| | - Amanda R Gomez
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
| | - Carolyn H Marcus
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
| | - Catherine D Michelson
- Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Ariel S Winn
- Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts; and
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DeWolfe C, Birch S, Callen Washofsky A, Gardner C, McCarter R, Shah NH. Patient Outcomes in a Pediatric Hospital Medicine Service Staffed With Physicians and Advanced Practice Providers. Hosp Pediatr 2020; 9:121-128. [PMID: 30679202 DOI: 10.1542/hpeds.2018-0028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
| | - Sarah Birch
- Departments of Advanced Practice Nursing and
| | | | | | - Robert McCarter
- Biostatistics and Informatics, Children's National Medical Center, Washington, District of Columbia; and
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Hooker RS, Moloney-Johns AJ, McFarland MM. Patient satisfaction with physician assistant/associate care: an international scoping review. HUMAN RESOURCES FOR HEALTH 2019; 17:104. [PMID: 31881896 PMCID: PMC6935095 DOI: 10.1186/s12960-019-0428-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 10/25/2019] [Indexed: 05/30/2023]
Abstract
BACKGROUND As the role of the physician assistant/associate grows globally, one question is: what is the level of patient satisfaction with PAs? Driven by legislative enactments to improve access to care, the PA has emerged as a ready and able medical professional to address workforce shortages. The aim of this study was to review the literature on patient satisfaction of PAs. OBJECTIVES The basis for this review was to clarify working definitions, synthesize the evidence, and establish conceptual boundaries around the topic of patient satisfaction with PAs. The intent was to identify gaps in the literature and offer suggested undertakings for more clarification on the subject. METHODS A scoping review was undertaken. Literature from 1968 to 2019 was searched and filtered for eligibility. Those that met criteria were categorized by date, method, geography, themes, and design. RESULTS In total, there were 987 papers or reports that were identified through bibliography database searching. Additional articles found through snowball methodology-reviewing references (n = 11). Only English language articles emerged for analysis. From this effort, 25 articles surfaced from the filtering process for final inclusion. Most (72%) of the articles came from the United States of America, three from the United Kingdom, and one each from Ireland, the Netherlands, and New Zealand. Most articles were descriptive in nature. Some variations in methods emerged. CONCLUSION PAs are operational in 15 nations; their acceptance appears successful and satisfaction with their care largely indistinguishable from physicians. Findings from this analysis highlight one theory that when patient's needs are met, satisfaction is high regardless of the medical provider. Areas for further research are identified.
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Affiliation(s)
- Roderick S Hooker
- Health Policy Analyst, 15917 NE Union Rd, Unit 45, Ridgefield, WA, USA.
| | - Amanda J Moloney-Johns
- Department of Family and Preventive Medicine, Physician Assistant Program, The University of Utah, Salt Lake City, Utah, USA
| | - Mary M McFarland
- Eccles Health Sciences Library, The University of Utah, Salt Lake City, Utah, USA
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Maniaci MJ, Dawson NL, Cowart JB, Richie EM, Suryaprasad AG, Hodge DO, Joyce NE, Kernan CA, Stone LA, Burton MC. Goal-Directed Achievement Through Geographic Location (GAGL) Reduces Patient Length of Stay and Adverse Events. Am J Med Qual 2019; 35:323-329. [PMID: 31581786 DOI: 10.1177/1062860619879977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This prospective cohort study aimed to improve hospital outcomes through geographic location of hospitalist patients and conducting daily multidisciplinary team rounds-Goal-directed Achievements through Geographic Location (GAGL). Patients were admitted to a geographic (GAGL) study unit where daily multidisciplinary rounds took place among nursing, case management, a hospitalist, pharmacy, physical and occupational therapy, respiratory therapy, and nutrition services. A total of 985 (56.4%) patients were admitted to the GAGL study unit and 760 patients (43.6%) were admitted to non-GAGL units. Patients admitted to the GAGL study unit had a shorter average length of stay (3.64 days vs 4.35 days, P = .0001) and a lower number of risk events (91 [9.2%] vs 93 [12.2%], P = .038). There was no significant difference in 30-day readmissions, avoidable day events, or code blue team activations. GAGL provides a framework for hospital organizations to improve provider communication, hospital efficiency, and patient safety.
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Efficacy of the Well-Being Index to identify distress and stratify well-being in nurse practitioners and physician assistants. J Am Assoc Nurse Pract 2019; 31:403-412. [DOI: 10.1097/jxx.0000000000000179] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm. J Am Assoc Nurse Pract 2019; 31:93-103. [PMID: 30747805 DOI: 10.1097/jxx.0000000000000155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rapid changes in health care are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity. LOCAL PROBLEM The Directors of the APP-Best Practice Center conducted assessments of each clinical area at MUSC Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (nurse practitioners/physician assistants) but also in the utilization of APPs to practice to the fullest extent of their license, education, and experience. METHODS By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built while following updated practice laws, compliance/legal standards, and hospital bylaws/regulations. INTERVENTIONS A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation. RESULTS This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity. CONCLUSIONS With the APP work force growing, the implementation of electronic medical record systems, and today's health care financial constraints, it is imperative that health care systems standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.
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Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm. JAAPA 2019; 32:1-10. [PMID: 30694959 DOI: 10.1097/01.jaa.0000550293.01522.01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Rapid changes in healthcare are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity. LOCAL PROBLEM The directors of the APP-Best Practice Center conducted assessments of each clinical area at the Medical University of South Carolina (MUSC) Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (NPs and physician assistants) but also in the use of APPs to practice to the fullest extent of their license, education, and experience. METHODS By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built that follows updated practice laws, compliance/legal standards, and hospital bylaws and regulations. INTERVENTIONS A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation. RESULTS This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity. CONCLUSIONS With the APP workforce growing, the implementation of electronic medical record systems, and today's healthcare financial constraints, healthcare systems must standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.
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Will KK, Johnson ML, Lamb G. Team-Based Care and Patient Satisfaction in the Hospital Setting: A Systematic Review. J Patient Cent Res Rev 2019; 6:158-171. [PMID: 31414027 DOI: 10.17294/2330-0698.1695] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose Limited research examining the relationship between team-based models of care and patient satisfaction in the hospital setting is available. The purpose of this literature review was to explore this relationship as well as the relationships between team composition, team-based interventions, patient satisfaction, and other outcomes of care when measured as part of the study. Methods A systematic appraisal of research studies published through February 2017 was conducted using PubMed, Cochrane Library, CINAHL, Embase, Ovid, gray literature and Google Scholar. Inclusion criteria were 1) experimental (randomized control trials), quasi-experimental, or non-experimental (cross-sectional) study design; 2) team-based care interventions; 3) hospital setting; 4) patient satisfaction measured as an outcome; and 5) published in English. Results The literature search yielded 15,247 citations. In total, 142 articles were retrieved for full-text screening; 21 studies met inclusion criteria. Overall, 57% of the studies identified a statistically significant improvement in patient satisfaction associated with team-based care. Team-based care interventions ranged from single team activities such as multidisciplinary rounds to comprehensive team-based models of care. Patient satisfaction scores were greater with teams that had more than two professions and more comprehensive team-based models. About one-quarter of studies that measured patient satisfaction and at least one additional outcome demonstrated improvement in both. Conclusions Team-based care may positively affect patient satisfaction. Team composition and type of team intervention appears to influence the strength of the relationship. Improvements in satisfaction are not consistently accompanied by improvements in other outcomes.
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Affiliation(s)
- Kristen K Will
- College of Health Solutions, Arizona State University, Phoenix, AZ
| | | | - Gerri Lamb
- Center for Advancing Interprofessional Practice, Education and Research, Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ
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Salim SA, Elmaraezy A, Pamarthy A, Thongprayoon C, Cheungpasitporn W, Palabindala V. Impact of hospitalists on the efficiency of inpatient care and patient satisfaction: a systematic review and meta-analysis. J Community Hosp Intern Med Perspect 2019; 9:121-134. [PMID: 31044043 PMCID: PMC6484472 DOI: 10.1080/20009666.2019.1591901] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/01/2019] [Indexed: 12/29/2022] Open
Abstract
Background: Over the past 20 years, hospitalists have assumed a greater portion of healthcare service for hospitalized patients. This was mainly due to reducing the length of stay (LOS) and hospital costs shown by many studies. In contrast, other studies suggested increased cost and resources utilization associated with hospitalist-run care models. Aim: We aimed to provide class 1 evidence regarding the effect of hospitalist-run care models on the efficiency of care and patient satisfaction. Design: Meta-analysis. Methods: Four electronic medical databases were searched to retrieve all relevant studies. Two authors screened titles and abstracts of search results for eligibility according to predefined criteria. Initially eligible studies were screened for full text inclusion. Included studies were reviewed for data on LOS, hospital cost, readmission, mortality, and patient satisfaction. Available data were abstracted and analyzed using Comprehensive Meta-Analysis. Results: Sixty-one studies were included for analysis. The overall effect size favored hospitalist-run care models in terms of LOS (MD = -0.67 day, 95% CI [-0.78, -0.56], p < 0.001). There was no significant difference in terms of hospital cost (MD = $92.1, 95% CI [-910.4, 1094.6], p = 0.86) whereas patient satisfaction was similar or even better in hospitalist compared to non-hospitalist (NH) service. Conclusion: Our analysis showed that hospitalist care is associated with decreased LOS and increased patient satisfaction compared to NH. This indicates an increase in the efficiency of care that does not come at the expense of care quality.
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Affiliation(s)
- Sohail Abdul Salim
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Ahmed Elmaraezy
- Global Clinical Scholars Research Training (GCSRT) Program, Harvard Medical School, Boston, MA, USA.,Faculty of Medicine, Al-Azhar University, Cairo, Egypt.,Al-Razi Medical Research Academy, Cairo, Egypt
| | - Amaleswari Pamarthy
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
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Pino-Jones AD, Wolfe B, Wimmer K, Bowden K, Rosenthal L, Nogar C, Furfari K, Cumbler E. Physician Perceptions of Advanced Practice Providers on Hospitalist Teams. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2018.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Bos JM, Timmermans MJC, Kalkman GA, van den Bemt PMLA, De Smet PAGM, Wensing M, Kramers C, Laurant MGH. The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing. PLoS One 2018; 13:e0202626. [PMID: 30138432 PMCID: PMC6107206 DOI: 10.1371/journal.pone.0202626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 08/07/2018] [Indexed: 11/18/2022] Open
Abstract
AIM This study determined the effect of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs) on non-adherence to guidelines on medication prescribing. METHODS A multicenter matched-controlled study was performed comparing wards on which PAs provide medical care in collaboration with MDs (PA/MD model), with wards on which only MDs provide medical care (MD model). A set of 17 quality indicators to measure non-adherence to guidelines on medication prescribing by PAs and MDs was composed by 14 experts in a modified Delphi procedure. The indicators covered different pharmacotherapeutic subjects, such as gastric protection in case of use of NSAID or prevention of obstipation in case of use of opioids. These indicators were expressed in proportions by dividing the number of patients in which the prescriber did not adhere to a guideline, by all patients that were applicable. Multivariable regression analysis was performed in order to adjust for potential confounders. RESULTS 1021 patients from 17 hospital wards in the 'PA/MD model' group and 1286 patients from 17 hospital wards in the 'MD model' group were included. Two of the 17 quality indicators showed significantly less non-adherence to guidelines for the PA/MD model; the indicators concerning prescribing gastric protection in case of use of NSAID in combination with corticosteroids (OR 0.42, 95% CI 0.19-0.90) and in case of use of NSAID in patients older than 70 years (OR 0.47, 95% 0.23-0.95). For none of the other quality indicators for prescribing of medication a difference between the MD model and the PA/MD model was found. CONCLUSION This study suggests that the non-adherence to guidelines on medication prescribing on wards with the PA/MD model does not differ from wards with traditional house staffing by MDs only. Further research is needed to determine quality, efficiency and safety of prescribing behavior of PAs.
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Affiliation(s)
- Jacqueline M. Bos
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- * E-mail:
| | - Marijke J. C. Timmermans
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
| | - Gerard A. Kalkman
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | | | - Peter A. G. M. De Smet
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
- Department of Clinical Pharmacology and Toxicology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Miranda G. H. Laurant
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, the Netherlands
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Goodwin JS, Salameh H, Zhou J, Singh S, Kuo YF, Nattinger AB. Association of Hospitalist Years of Experience With Mortality in the Hospitalized Medicare Population. JAMA Intern Med 2018; 178:196-203. [PMID: 29279886 PMCID: PMC5801052 DOI: 10.1001/jamainternmed.2017.7049] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Substantial numbers of hospitalists are fresh graduates of residency training programs. Current data about the effect of hospitalist years of experience on patient outcomes are lacking. OBJECTIVE To describe the association of hospitalist years of experience with 30-day mortality and hospital mortality of their patients. DESIGN, SETTING, AND PARTICIPANTS We used a 5% sample of national Medicare data of patient and hospital characteristics to build a multilevel logistic regression model to predict mortality as a function of years of experience of the hospitalists. We created 2 cohorts. The first was a cross-sectional cohort of 21 612 hospitalists working between July 1, 2013, and June 30, 2014, with a 5-year look-back period to assess their years of prior experience as a hospitalist, and the second was a longitudinal cohort of 3860 hospitalists in their first year of practice between July 1, 2008, and June 30, 2011, who continued practicing hospital medicine for at least 4 years. MAIN OUTCOMES AND MEASURES Thirty-day postadmission mortality adjusted for patient and hospital characteristics in a 3-level logistic regression model. Hospital mortality was a secondary outcome. RESULTS Among 21 612 hospitalists caring for Medicare inpatients from July 1, 2013, to June 30, 2014, 5445 (25%) had 1 year of experience or less, while 11 596 (54%) had 4 years of experience or more. We then identified 3860 physicians in their first year as hospitalists who continued to practice as hospitalists for 4 years. There was a significant association between hospitalist experience and mortality. Observed 30-day mortality was 10.50% for patients of first-year hospitalists vs 9.97% for patients of hospitalists in their second year. The mortality odds for patients of second-year hospitalists were 0.90 (95% CI, 0.84-0.96) compared with patients of first-year hospitalists. Observed hospital mortality was 3.33% for patients cared for by first-year hospitalists vs 2.96% for second-year hospitalists. (odds ratio, 0.84; 95% CI, 0.75-0.95). For both 30-day and hospital mortality, there was little change in odds of mortality between the second year and subsequent years of experience. CONCLUSIONS AND RELEVANCE Patients cared for by hospitalists in their first year of practice experience higher mortality. Early-career hospitalists may require additional support to ensure optimal outcomes for their patients.
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Affiliation(s)
- James S Goodwin
- Department of Medicine, University of Texas Medical Branch, Galveston.,Sealy Center on Aging, University of Texas Medical Branch, Galveston
| | - Habeeb Salameh
- Department of Medicine, University of Texas Medical Branch, Galveston
| | - Jie Zhou
- Sealy Center on Aging, University of Texas Medical Branch, Galveston
| | | | - Yong-Fang Kuo
- Sealy Center on Aging, University of Texas Medical Branch, Galveston.,Office of Biostatistics, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston
| | - Ann B Nattinger
- Department of Medicine, Medical College of Wisconsin, Milwaukee
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Repp AB, Bartsch JC, Pasanen ME. What the "Nonteaching" Service Can Teach Us. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2018; 93:41-44. [PMID: 28746070 DOI: 10.1097/acm.0000000000001833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
"Teaching" services usually incorporate a cadre of learners such as resident physicians and medical students as part of the care team, led by a faculty physician. "Nonteaching" services, in contrast, are usually defined by the absence of resident physicians on the care team. The care for patients on a nonteaching service is frequently managed directly by a faculty or nonfaculty physician. Nonteaching services have grown in number and size at academic medical centers (AMCs) in response to regulatory requirements, operational demands, and efforts to improve clinical education. The allocation of patients to teaching and nonteaching services is frequently based on perceived teaching value of hospitalized patients, which can potentially lead to a number of unintended consequences for medical education, professional satisfaction, and patient care. Through a series of four lessons, the authors describe how the structure of nonteaching services can result in curricular gaps, devalue attending physicians, and undermine the educational and clinical missions of AMCs. Anticipating the continued expansion and evolution of nonteaching services, the authors propose seven design principles for nonteaching services to ensure robust education for students and resident physicians, advance quality of care, and enhance attending physician and patient experience.
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Affiliation(s)
- Allen B Repp
- A.B. Repp is associate professor and vice chair for quality, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont; ORCID: http://orcid.org/0000-0001-7513-532X. J.C. Bartsch is assistant professor, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont. M.E. Pasanen is associate professor, internal medicine residency program director, and chief, Division of Hospital Medicine, Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont
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Timmermans MJC, van Vught AJAH, Peters YAS, Meermans G, Peute JGM, Postma CT, Smit PC, Verdaasdonk E, de Vries Reilingh TS, Wensing M, Laurant MGH. The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study. PLoS One 2017; 12:e0178212. [PMID: 28793317 PMCID: PMC5549960 DOI: 10.1371/journal.pone.0178212] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/09/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Medical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients' length of stay (LOS), quality and safety of care, and patient experiences with the provided care. METHODS In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients' LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients' experiences with the provided care. RESULTS Data on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (β 1.20, 95%CI 0.99-1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (β 0.49, 95% CI 0.22-0.76, p = .001). CONCLUSIONS This study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01835444.
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Affiliation(s)
- Marijke J. C. Timmermans
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
- * E-mail:
| | | | - Yvonne A. S. Peters
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
| | - Geert Meermans
- Department of Orthopaedics, Bravis Hospital, Bergen op Zoom and Roosendaal, The Netherlands
| | - Joseph G. M. Peute
- Department of Cardiology, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
| | - Cornelis. T. Postma
- Department of Internal Medicine, Radboud university Nijmegen medical center, Nijmegen, The Netherlands
| | - P. Casper Smit
- Department of Surgery, Reinier Haga Groep, Delft, The Netherlands
| | - Emiel Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, ‘s-Hertogenbosch, The Netherlands
| | | | - Michel Wensing
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Miranda G. H. Laurant
- Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Radboud university medical center, Nijmegen, The Netherlands
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
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Timmermans MJC, van den Brink GT, van Vught AJAH, Adang E, van Berlo CLH, van Boxtel K, Braunius WW, Janssen L, Venema A, van den Wildenberg FJ, Wensing M, Laurant MGH. The involvement of physician assistants in inpatient care in hospitals in the Netherlands: a cost-effectiveness analysis. BMJ Open 2017; 7:e016405. [PMID: 28698344 PMCID: PMC5541617 DOI: 10.1136/bmjopen-2017-016405] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To investigate the cost-effectiveness of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs). DESIGN Cost-effectiveness analysis embedded within a multicentre, matched-controlled study. The traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which, besides MDs, PAs are also employed (PA/MD model). SETTING 34 hospital wards across the Netherlands. PARTICIPANTS 2292 patients were followed from admission until 1 month after discharge. Patients receiving daycare, terminally ill patients and children were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES All direct healthcare costs from day of admission until 1 month after discharge. Health outcome concerned quality-adjusted life years (QALYs), which was measured with the EuroQol five dimensions questionnaire (EQ-5D). RESULTS We found no significant difference for QALY gain (+0.02, 95% CI -0.01 to 0.05) when comparing the PA/MD model with the MD model. Total costs per patient did not significantly differ between the groups (+€568, 95% CI -€254 to €1391, p=0.175). Regarding the costs per item, a difference of €309 per patient (95% CI €29 to €588, p=0.030) was found in favour of the MD model regarding length of stay. Personnel costs per patient for the provider who is primarily responsible for medical care on the ward were lower on the wards in the PA/MD model (-€11, 95% CI -€16 to -€6, p<0.01). CONCLUSIONS This study suggests that the cost-effectiveness on wards managed by PAs, in collaboration with MDs, is similar to the care on wards with traditional house staffing. The involvement of PAs may reduce personnel costs, but not overall healthcare costs. TRIAL REGISTRATION NUMBER NCT01835444.
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Affiliation(s)
- Marijke J C Timmermans
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen
| | | | | | - Eddy Adang
- Department of Health Evidence, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Charles L H van Berlo
- Department of Surgery Venlo, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
| | - Kim van Boxtel
- Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
| | - Weibel W Braunius
- Department of Head and Neck Surgical Oncology, UMC Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Loes Janssen
- Department of Orthopaedics, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
| | - Alyssa Venema
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Michel Wensing
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
- Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
| | - Miranda G H Laurant
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
- HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen
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Decesare JZ, Bush SY, Morton AN. Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit. J Patient Saf 2017; 16:e179-e181. [PMID: 28594650 PMCID: PMC7447117 DOI: 10.1097/pts.0000000000000397] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective Because internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency, and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to the obstetrics and gynecology field. Our objective was to compare outcomes measured by occurrence of safety events before and after implementation of an OB hospitalist program in a mid-sized OB unit. Methods From July 2012 to September 2014, 11 safety events occurred on the labor and delivery floor. A full-time OB hospitalist program was implemented in October 2014. Results From October 2014 to December 2016, there was 1 safety event associated with labor and delivery. Conclusion It has been speculated that implementation of an OB hospitalist model would be associated with improved maternal and neonatal outcomes; our regional OB referral hospital demonstrated a statistically significant decrease in OB safety events after the OB hospitalist program implementation.
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Affiliation(s)
- Julie Z Decesare
- From the Obstetrics and Gynecology Residency Program, University of Florida
| | - Suzanne Y Bush
- College of Medicine, Florida State University, Pensacola, Florida
| | - Ashley N Morton
- College of Medicine, Florida State University, Pensacola, Florida
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Chaney AJ, Harnois DM, Musto KR, Nguyen JH. Role Development of Nurse Practitioners and Physician Assistants in Liver Transplantation. Prog Transplant 2016; 26:75-81. [DOI: 10.1177/1526924816632116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Nurse practitioners (NPs) and physician assistants (PAs) are increasingly utilized in health care. However, their roles in liver transplantation (LT) have not been investigated. Materials and Methods: In this study, we reviewed the employment and development of NPs and PAs and their impact on our deceased-donor LT (DDLT) program. Results: We found a safe and efficient way to utilize NPs and PAs in a DDLT program. Since the beginning of our program, Model of End-Stage Liver Disease (MELD) scores have increased significantly, suggesting patients are sicker at the time of transplant, and wait times of patients have become longer. With the incorporation of NPs and PAs, we found that length of stay (LOS) was not affected. The overall median warm ischemic time did not increase. Outcomes of LT for both patient and graft survival actually improved and remain at or above the expected values. These results collectively support the usefulness and validity of NPs and PAs in a DDLT program. Conclusion: We have determined that surgical and medical NPs and PAs are essential for optimal patient outcomes. They facilitate a better learning experience for residents and fellows on their transplant rotations. Further investigations to assess the roles of these providers and their impact on the education of residents and fellows in transplantation are warranted. Further transplant hepatology education programs and/or fellowships are recommended to assist in the education and professional development of transplant NPs and PAs.
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Affiliation(s)
- Amanda J. Chaney
- Divisions of Transplant Medicine and Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Denise M. Harnois
- Divisions of Transplant Medicine and Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Kaitlyn R. Musto
- Divisions of Transplant Medicine and Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
| | - Justin H. Nguyen
- Divisions of Transplant Medicine and Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL, USA
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Timmermans MJC, van Vught AJAH, Van den Berg M, Ponfoort ED, Riemens F, van Unen J, Wobbes T, Wensing M, Laurant MGH. Physician assistants in medical ward care: a descriptive study of the situation in the Netherlands. J Eval Clin Pract 2016; 22:395-402. [PMID: 26695837 DOI: 10.1111/jep.12499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Medical ward care has been increasingly reallocated from medical doctors (MDs) to physician assistants (PAs). Insight into their roles and tasks is limited. This study aims to provide insight into different organizational models of medical ward care, focusing on the position, tasks and responsibilities of the involved PAs and MDs. METHODS In this cross-sectional descriptive study 34 hospital wards were included. Characteristics of the organizational models were collected from the heads of departments. We documented provider continuity by examination of work schedules. MDs and PAs in charge for medical ward care (n = 179) were asked to complete a questionnaire to measure workload, supervision and tasks performed. RESULTS We distinguished four different organizational models for ward care: medical specialists in charge of admitted patients (100% MS), medical residents in charge (100% MR), PAs in charge (100% PA), both MRs and PAs in charge (mixed PA/MR). The wards with PAs had the highest provider continuity. PAs spend relatively more time on direct patient care; MDs spend relatively more time on indirect patient care. PAs spend more hours on quality projects (P = 0.000), while MDs spend more time on scientific research (P = 0.030). CONCLUSION Across different organizational models for medical ward care, we found variations in time per task, time per bed and provider continuity. Further research should focus on the impact of these differences on outcomes and efficiency of medical ward care.
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Affiliation(s)
- Marijke J C Timmermans
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Anneke J A H van Vught
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | | | - Erik D Ponfoort
- Department of Surgery, Hospital Gelderse Vallei, Ede, The Netherlands
| | - Frank Riemens
- Department of Surgery, Van Weel Bethesda Hospital, Dirksland, The Netherlands
| | - Jacco van Unen
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | - Theo Wobbes
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michel Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands
| | - Miranda G H Laurant
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, The Netherlands.,Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
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A Framework for Improving Chronic Critical Illness Care: Adapting the Medical Home's Central Tenets. Med Care 2016; 54:5-8. [PMID: 26565528 DOI: 10.1097/mlr.0000000000000460] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Johnson-Martinez K, Wheeler R, Clevenger C, Tomolo A. Geographic Localization: The Need for Better Reporting and Outcome Selection. Am J Med Qual 2016; 31:489-90. [PMID: 27048702 DOI: 10.1177/1062860616640352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Carolyn Clevenger
- Atlanta VA Medical Center, Decatur, GA Emory University, Atlanta, GA
| | - Anne Tomolo
- Atlanta VA Medical Center, Decatur, GA Emory University, Atlanta, GA
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36
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Valentin VL, Dehn RW, Baker MD. Commentaries on health services research. JAAPA 2016. [DOI: 10.1097/01.jaa.0000476223.32259.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cawley JF, Hooker RS. Comments: Response to Iannuzzi et al. J Grad Med Educ 2015; 7:689. [PMID: 26692996 PMCID: PMC4675439 DOI: 10.4300/jgme-d-15-00394.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- James F Cawley
- Professor, Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University
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Kara A, Johnson CS, Nicley A, Niemeier MR, Hui SL. Redesigning inpatient care: Testing the effectiveness of an accountable care team model. J Hosp Med 2015; 10:773-9. [PMID: 26286828 DOI: 10.1002/jhm.2432] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 05/27/2015] [Accepted: 06/27/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care. OBJECTIVE Describe a model of inpatient care and measure its impact. DESIGN A quantitative assessment of the implementation of a new model of care. The graded implementation of the model allowed us to follow outcomes and measure their association with the dose of the implementation. SETTING AND PATIENTS Inpatient medical and surgical units in a large academic health center. INTERVENTION Eight interventions rooted in improving interprofessional collaboration (IPC), enabling data-driven decisions, and providing leadership were implemented. MEASUREMENTS Outcome data from August 2012 to December 2013 were analyzed using generalized linear mixed models for associations with the implementation of the model. Length of stay (LOS) index, case-mix index-adjusted variable direct costs (CMI-adjusted VDC), 30-day readmission rates, overall patient satisfaction scores, and provider satisfaction with the model were measured. RESULTS The implementation of the model was associated with decreases in LOS index (P < 0.0001) and CMI-adjusted VDC (P = 0.0006). We did not detect improvements in readmission rates or patient satisfaction scores. Most providers (95.8%, n = 92) agreed that the model had improved the quality and safety of the care delivered. CONCLUSIONS Creating an environment and framework in which IPC is fostered, performance data are transparently available, and leadership is provided may improve value on both medical and surgical units. These interventions appear to be well accepted by front-line staff. Readmission rates and patient satisfaction remain challenging.
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Affiliation(s)
- Areeba Kara
- Indiana University Health Physicians, Inpatient Medicine, Indiana University School of Medicine, IU Center for Health Innovation and Implementation Science, Indianapolis, Indiana
| | - Cynthia S Johnson
- Department of Biostatistics, Indiana University School of Medicine and Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Amy Nicley
- Inpatient Programs and Accountable Care Units, Indiana University Health, Indianapolis, Indiana
| | - Michael R Niemeier
- Retired Chief Medical Officer Indiana University Health Methodist Hospital, Indianapolis, Indiana
| | - Siu L Hui
- Regenstrief Institute and Professor Emeritus Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
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van Vught AJAH, Hettinga AM, Denessen EJPG, Gerhardus MJT, Bouwmans GAM, van den Brink GTWJ, Postma CT. Analysis of the level of general clinical skills of physician assistant students using an objective structured clinical examination. J Eval Clin Pract 2015; 21:971-5. [PMID: 26376735 DOI: 10.1111/jep.12418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The physician assistant (PA) is trained to perform clinical tasks traditionally performed by medical doctors (MDs). Previous research showed no difference in the level of clinical skills of PAs compared with MDs in a specific niche, that is the specialty in which they are employed. However, MDs as well as PAs working within a specialty have to be able to recognize medical problems in the full scope of medicine. The objective is to examine PA students' level of general clinical skills across the breadth of clinical cases. METHOD A cross-sectional study was conducted. PA students and recently graduated MDs in the Netherlands were observed on their clinical skills by means of an objective structured clinical examination comprising five stations with common medical cases. The level of mastering history taking, physical examination, communication and clinical reasoning of PA students and MDs were described in means and standard deviation. Cohen's d was used to present effect sizes. RESULTS PA students and MDs score about equal on history taking (PA 5.8 ± 0.8 vs. MD 5.7 ± 0.7), physical examination (PA 4.8 ± 1.3 vs. MD 5.4 ± 0.8) and communication (PA: 8.2 ± 0.8 vs. MD: 8.6 ± 0.5) in the full scope of medicine. In the quality of the report, including the patient management plan, PA students scored a mean of 6.0 ± 0.6 and MDs 6.8 ± 0.6. CONCLUSIONS In this setting in the Netherlands, PA students and MDs score about equal in the appraisal of common cases in medical practice. The slightly lower scores of PA students' clinical reasoning in the full scope of clinical care may have raise attention to medical teams working with PAs and PA training programmes.
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Affiliation(s)
- Anneke J A H van Vught
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands
| | - Agatha M Hettinga
- Institute for (Bio) Medical Education, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eddie J P G Denessen
- Behavioural Science Institute, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Martin J T Gerhardus
- Faculty of Health and Social Studies, HAN University of Applied Sciences, Nijmegen, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Geert A M Bouwmans
- Institute for (Bio) Medical Education, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Cornelis T Postma
- Institute for (Bio) Medical Education, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Shah NN, Kucharczuk CR, Mitra N, Hirsh R, Svoboda J, Porter D, Loren A, Frey N, Schapira MM. Implementation of an Advanced Practice Provider Service on an Allogeneic Stem Cell Transplant Unit: Impact on Patient Outcomes. Biol Blood Marrow Transplant 2015; 21:1692-8. [DOI: 10.1016/j.bbmt.2015.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 05/22/2015] [Indexed: 12/22/2022]
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Law MP, Orlando E, Baker GR. Organizational interventions in response to duty hour reforms. BMC MEDICAL EDUCATION 2014; 14 Suppl 1:S4. [PMID: 25558915 PMCID: PMC4304281 DOI: 10.1186/1472-6920-14-s1-s4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Changes in resident duty hours in Europe and North America have had a major impact on the internal organizational dynamics of health care organizations. This paper examines, and assesses the impact of, organizational interventions that were a direct response to these duty hour reforms. METHODS The academic literature was searched through the SCOPUS database using the search terms "resident duty hours" and "European Working Time Directive," together with terms related to organizational factors. The search was limited to English-language literature published between January 2003 and January 2012. Studies were included if they reported an organizational intervention and measured an organizational outcome. RESULTS Twenty-five articles were included from the United States (n=18), the United Kingdom (n=5), Hong Kong (n=1), and Australia (n=1). They all described single-site projects; the majority used post-intervention surveys (n=15) and audit techniques (n=4). The studies assessed organizational measures, including relationships among staff, work satisfaction, continuity of care, workflow, compliance, workload, and cost. Interventions included using new technologies to improve handovers and communications, changing staff mixes, and introducing new shift structures, all of which had varying effects on the organizational measures listed previously. CONCLUSIONS Little research has assessed the organizational impact of duty hour reforms; however, the literature reviewed demonstrates that many organizations are using new technologies, new personnel, and revised and innovative shift structures to compensate for reduced resident coverage and to decrease the risk of limited continuity of care. Future research in this area should focus on both micro (e.g., use of technology, shift changes, staff mix) and macro (e.g., culture, leadership support) organizational aspects to aid in our understanding of how best to respond to these duty hour reforms.
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Affiliation(s)
- Madelyn P Law
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Elaina Orlando
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - G Ross Baker
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Kartha A, Restuccia JD, Burgess JF, Benzer J, Glasgow J, Hockenberry J, Mohr DC, Kaboli PJ. Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. J Hosp Med 2014; 9:615-20. [PMID: 25224593 DOI: 10.1002/jhm.2231] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 06/03/2014] [Accepted: 06/10/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine. OBJECTIVE Describe APPs role in inpatient medicine. DESIGN Observational cross-sectional cohort study. SETTING One hundred twenty-four Veterans Health Administration (VHA) hospitals. PARTICIPANTS Chiefs of medicine (COMs) and nurse managers. MEASUREMENTS Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses. RESULTS One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. CONCLUSIONS NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs.
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Affiliation(s)
- Anand Kartha
- Center for Healthcare Organization and Implementation Research (CHOIR) at the VA Boston Healthcare System, Boston, Massachusetts; Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
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Kulkarni N, Cardin T. Hospital medicine workforce: the impact of nurse practitioner and physician assistant providers. J Hosp Med 2014; 9:678-9. [PMID: 25224751 DOI: 10.1002/jhm.2254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 08/17/2014] [Accepted: 08/19/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Nita Kulkarni
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Restuccia JD, Mohr D, Meterko M, Stolzmann K, Kaboli P. The association of hospital characteristics and quality improvement activities in inpatient medical services. J Gen Intern Med 2014; 29:715-22. [PMID: 24424776 PMCID: PMC4000331 DOI: 10.1007/s11606-013-2759-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 12/06/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Quality of U.S. health care has been the focus of increasing attention, with deficiencies in patient care well recognized and documented. However, relatively little is known about the extent to which hospitals engage in quality improvement activities (QIAs) or factors influencing extent of QIAs. OBJECTIVE To identify 1) the extent of QIAs in Veterans Administration (VA) inpatient medical services; and 2) factors associated with widespread adoption of QIAs, in particular use of hospitalists, non-physician providers, and extent of goal alignment between the inpatient service and senior managers on commitment to quality. DESIGN Cross-sectional, descriptive study of QIAs using a survey administered to Chiefs of Medicine (COM) at all 124 VA acute care hospitals. We conducted hierarchical regression, regressing QIA use on facility contextual variables, followed by use of hospitalists, non-physician providers, and goal alignment/quality commitment. MAIN MEASURES Outcome measures pertained to use of a set of 27 QIAs and to three dimensions--infrastructure, prevention, and information gathering--that were identified by factor analysis among the 27 QIAs overall. KEY RESULTS Survey response rate was 90 % (111/124). Goal alignment/quality commitment was associated with more widespread use of all four QIA categories [infrastructure (b = 0.42; p < 0.001); prevention (b = 0.24; p < 0.001); information gathering (b = 0.28; p = <0.001); and overall QIA (b = 0.31; p < 0.001)], as was greater use of hospitalists [infrastructure (b = 0.55; p = 0.03); prevention (b = 0.61; p < 0.001); information gathering (b = 0.75; p = 0.01); and overall QIAs (b = 0.61; p < 0.001)]; higher occupancy rate was associated with greater infrastructure QIAs (b = 1.05, p = 0.02). Non-physician provider use, hospital size, university affiliation, and geographic region were not associated with QIAs. CONCLUSION As hospitals respond to changes in healthcare (e.g., pay for performance, accountable care organizations), this study suggests that practices such as use of hospitalists and leadership focus on goal alignment/quality commitment may lead to greater implementation of QIAs.
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Affiliation(s)
- Joseph D Restuccia
- Center for Organizational Leadership and Management Research (COLMR), Boston VA Healthcare System, Boston, MA, USA,
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Au AG, Padwal RS, Majumdar SR, McAlister FA. Patient outcomes in teaching versus nonteaching general internal medicine services: a systematic review and meta-analysis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2014; 89:517-523. [PMID: 24448044 DOI: 10.1097/acm.0000000000000154] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE Patient care quality appears to be similar when delivered by trainee and attending physicians. The authors conducted a systematic review and meta-analysis to examine whether outcomes differ for general internal medicine (GIM) patients admitted to teaching versus nonteaching services. METHOD The authors searched Medline, EMBASE, and Cochrane Library databases in May 2012 to identify peer-reviewed, English-language studies with contemporaneous controls comparing inpatient mortality, 30-day readmission rate, and/or length of stay (LOS) for inpatients admitted to teaching or nonteaching GIM services. RESULTS The 15 included studies (1 randomized controlled trial, 14 observational) included 108,570 patients admitted to U.S. hospitals during 1987-2011. Inpatient mortality did not differ between teaching and nonteaching services (13 studies, 108,015 patients; 2.5% versus 2.8%; OR, 1.07; 95% CI, 0.87-1.32; I = 82%); results were consistent in risk-adjusted studies (adjusted OR, 0.91; 95% CI, 0.76-1.08) and higher-quality studies (OR, 0.94; 95% CI, 0.73-1.21). There were no differences in 30-day readmission rates (11 studies, 106,021 patients; 15.1% versus 13.1%; OR, 1.05; 95% CI, 0.93-1.18). Patients on teaching services appeared to have longer LOS (11 studies, 82,352 patients; unadjusted mean difference, 0.40 days; 95% CI, 0.04-0.77 days), but there was substantial heterogeneity (I = 95%). Differences disappeared in risk-adjusted studies (mean difference: -0.09 days; 95% CI, -0.24 to 0.06 days) and in higher-quality studies (mean difference: -0.05 days; 95% CI, -0.37 to 0.28 days). CONCLUSIONS There was no convincing evidence that outcomes differed substantively for patients admitted to teaching or nonteaching GIM services.
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Affiliation(s)
- Anita G Au
- Dr. Au is clinical lecturer, Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada. Dr. Padwal is associate professor of medicine, Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada. Dr. Majumdar is professor of medicine, Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada. Dr. McAlister is professor of medicine, Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada
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Michtalik HJ, Pronovost PJ, Marsteller JA, Spetz J, Brotman DJ. Identifying potential predictors of a safe attending physician workload: a survey of hospitalists. J Hosp Med 2013; 8:644-6. [PMID: 24124053 PMCID: PMC4087042 DOI: 10.1002/jhm.2088] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 08/19/2013] [Accepted: 08/25/2013] [Indexed: 11/06/2022]
Affiliation(s)
- Henry J. Michtalik
- Department of Medicine, of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Peter J. Pronovost
- Department of Health Policy & Management of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Jill A. Marsteller
- Department of Health Policy & Management of the Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland, USA
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California, USA
| | - Daniel J. Brotman
- Department of Medicine, of the Johns Hopkins University, Baltimore, Maryland, USA
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Ambulatory and Chronic Disease Care by Physician Assistants and Nurse Practitioners. J Ambul Care Manage 2013; 36:293-301. [DOI: 10.1097/jac.0b013e3182a12ea1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kociol RD, Hammill BG, Fonarow GC, Heidenreich PA, Go AS, Peterson ED, Curtis LH, Hernandez AF. Associations between use of the hospitalist model and quality of care and outcomes of older patients hospitalized for heart failure. JACC-HEART FAILURE 2013; 1:445-53. [PMID: 24621978 DOI: 10.1016/j.jchf.2013.07.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/17/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study sought to examine the associations of hospitalist and cardiologist care of patients with heart failure with outcomes and adherence to quality measures. BACKGROUND The hospitalist model of inpatient care has grown nationally, but its associations with quality of care and outcomes of patients hospitalized with heart failure are not known. METHODS We analyzed data from the Get With the Guidelines-Heart Failure registry linked to Medicare claims for 2005 through 2008. For each hospital, we calculated the percentage of heart failure hospitalizations for which a hospitalist was the attending physician. We examined outcomes and care quality for patients stratified by rates of hospitalist use. Using multivariable models, we estimated associations between hospital-level use of hospitalists and cardiologists and 30-day risk-adjusted outcomes and adherence to measures of quality care. RESULTS The analysis included 31,505 Medicare beneficiaries in 166 hospitals. Across hospitals, the use of hospitalists varied from 0% to 83%. After multivariable adjustment, a 10% increase in the use of hospitalists was associated with a slight increase in mortality (risk ratio: 1.03; 95% confidence interval [CI]: 1.00 to 1.06) and decrease in length of stay (0.09 days; 95% CI: 0.02 to 0.16). There was no association with 30-day readmission. Increased use of hospitalists in hospitals with high use of cardiologists was associated with improved defect-free adherence to a composite of heart failure performance measures (risk ratio: 1.03; 95% CI: 1.01 to 1.06). CONCLUSIONS Hospitalist care varied significantly across hospitals for heart failure admissions and was not associated with improved 30-day outcomes. Comanagement by hospitalists and cardiologists may help to improve adherence to some quality measures, but it remains unclear what care model improves 30-day clinical outcomes.
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Affiliation(s)
- Robb D Kociol
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Bradley G Hammill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Los Angeles, California
| | - Paul A Heidenreich
- Division of Cardiology, Department of Medicine, Palo Alto Veterans Affairs Medical Center, Stanford University School of Medicine, Palo Alto, California
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, California; Departments of Epidemiology and Biostatistics and Medicine, University of California, San Francisco
| | - Eric D Peterson
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lesley H Curtis
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F Hernandez
- CardioVascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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Glotzbecker BE, Yolin-Raley DS, DeAngelo DJ, Stone RM, Soiffer RJ, Alyea EP. Impact of Physician Assistants on the Outcomes of Patients With Acute Myelogenous Leukemia Receiving Chemotherapy in an Academic Medical Center. J Oncol Pract 2013; 9:e228-33. [DOI: 10.1200/jop.2012.000841] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The authors' findings suggest that the physician assistant service is associated with increased operational efficiency and decreased health service use without compromising health care outcomes.
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Affiliation(s)
| | | | - Daniel J. DeAngelo
- Dana-Farber Cancer Institute; and Brigham and Women's Hospital, Boston, MA
| | - Richard M. Stone
- Dana-Farber Cancer Institute; and Brigham and Women's Hospital, Boston, MA
| | - Robert J. Soiffer
- Dana-Farber Cancer Institute; and Brigham and Women's Hospital, Boston, MA
| | - Edwin P. Alyea
- Dana-Farber Cancer Institute; and Brigham and Women's Hospital, Boston, MA
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