Nonphysician providers in hospital medicine: not so fast

The effects of substitution of hospital ward care from medical doctors to physician assistants on non-adherence to guidelines on medication prescribing

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.

Improving the quality and safety of care on the medical ward: A review and synthesis of the evidence base

Despite its place at the heart of inpatient medicine, the evidence base underpinning the effective delivery of medical ward care is highly fragmented. Clinicians familiar with the selection of evidence-supported treatments for specific diseases may be less aware of the evolving literature surrounding the organisation of care on the medical ward. This review is the first synthesis of that disparate literature. An iterative search identified relevant publications, using terms pertaining to medical ward environments, and objective and subjective patient outcomes. Articles (including reviews) were selected on the basis of their focus on medical wards, and their relevance to the quality and safety of ward-based care. Responses to medical ward failings are grouped into five common themes: staffing levels and team composition; interdisciplinary communication and collaboration; standardisation of care; early recognition and treatment of the deteriorating patient; and local safety climate. Interventions in these categories are likely to improve the quality and safety of care in medical wards, although the evidence supporting them is constrained by methodological limitations and inadequate investment in multicentre trials. Nonetheless, with infrequent opportunities to redefine their services, institutions are increasingly adopting multifaceted strategies that encompass groups of these themes. As the literature on the quality of inpatient care moves beyond its initial focus on the intensive care unit and operating theatre, physicians should be mindful of opportunities to incorporate evidence-based practice at a ward level.

The effectiveness of substitution of hospital ward care from medical doctors to physician assistants: a study protocol

Background

Because of an expected shrinking supply of medical doctors for hospitalist posts, an increased emphasis on efficiency and continuity of care, and the standardization of many medical procedures, the role of hospitalist is increasingly allocated to physician assistants (PAs). PAs are nonphysician clinicians with medical tasks. This study aims to evaluate the effects of substitution of hospital ward care to PAs.

Methods/Design

In a multicenter matched controlled study, the traditional model in which the role of hospitalist is taken solely by medical doctors (MD model) is compared with a mixed model in which a PA functions as a hospitalist, contingent with MDs (PA/MD model). Twenty intervention and twenty control wards are included across The Netherlands, from a range of medical specialisms. Primary outcome measure is patients’ length of hospital stay. Secondary outcomes include indicators for quality of hospital ward care, patients experiences with medical ward care, patients health-related quality of life, and healthcare providers’ experiences. An economic evaluation is conducted to assess the cost implications and potential efficiency of the PA/MD model. For most measures, data is collected from medical records or questionnaires in samples of 115 patients per hospital ward. Semi-structured interviews with healthcare professionals are conducted to identify determinants of efficiency, quality and continuity of care and barriers and facilitators for the implementation of PAs in the role of hospitalist.

Discussion

Findings from this study will help to further define the role of nonphysician clinicians and provides possible key components for the implementation of PAs in hospital ward care. Like in many studies of organizational change, random allocation to study arms is not feasible, which implies an increased risk for confounding. A major challenge is to deal with the heterogeneity of patients and hospital departments.

Trial registration

ClinicalTrials.gov ID NCT01835444

Learning needs of physician assistants working in hospital medicine

BACKGROUND

Hospital Medicine is growing rapidly, and the number of physician assistants (PAs) in this field is expected to grow. However, there is no available data related to the learning needs of PA hospitalists.

OBJECTIVE

To conduct a needs assessment for PA hospitalists who may be embarking on a hospitalist career.

DESIGN

Cross-sectional survey based on the Core Competencies in Hospital Medicine.

SETTING/PARTICIPANTS

A sample of hospitalist PAs working in the United States.

MEASUREMENTS

Amount of experience with core diagnoses and procedures, preferences for additional training that would have prepared them to function as hospitalist PAs.

RESULTS

Sixty-nine PAs responded (response rate, 67%). Among the core clinical conditions, respondents had the most experience in managing diabetes and urinary tract infections and were least experienced with health care-associated pneumonias and sepsis syndrome. Over 90% rarely performed core competency procedures other than electrocardiogram and chest X-ray interpretations. The top 3 content areas that PA hospitalists believed would have helped to better prepare them to care for inpatients were palliative care (percent of PAs who agreed or strongly agreed: 85%), nutrition for hospitalized patients (84%), and consultations (64%). Almost all (91%) indicated that they would have been interested in formal postgraduate hospital medicine training even if it meant having a lower stipend during the first year on the job.

CONCLUSIONS

This is the first national data on self-perceived learning needs of PA hospitalists. The results may prove helpful for both PAs entering hospitalist careers and for the physician groups looking to hire them.