The contribution of Physician Assistants in primary care: a systematic review

Abstract

BackgroundPrimary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). Objective: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems.MethodsMedline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. Eligibility criteria: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care.Results2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. Process: the majority of PAs’ workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. Outcomes: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time.Limitations: identification of a broad range of studies examining ‘contribution’ made meta analysis or meta synthesis untenable.ConclusionsThe research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs’ contribution to the international primary care workforce.

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

“…The deployment of PAs in UK primary care to patients attending mainly same-day appointment surgeries has been reported qualitatively before 72 and confirmed here, similar to the international literature. 176,193 The lack of legal authority to prescribe in the UK deterred the GPs and practice managers from deploying PAs to home visits. This concurs with evidence from previous studies in the UK.…”

Introducing Physician Assistants to Ontario

“…Each PA's scope of practice is defined by what has been delegated to them by their supervising physician and guided by a National Competency Profile that defines how and under what circumstances the PA may exercise their competencies (Mikhael, There is limited research evidence about the efficacy of PAs in any context, but most of what exists is primarily relevant to the American healthcare context, creating difficulty in finding generalizable, transferable evidence about PA performance that is useful to Canadian decision-makers (Doan et al 2011;Halter et al 2013;Kleinpell, Ely and Grabenkort 2008). Systematic reviews of evidence about PAs in the context of primary care, intensive care, and emergency care have demonstrated that most existing publications focus on describing the types of tasks and roles that PAs are employed in, and very little generalizable evidence is available about their efficacy at performing those tasks, impact on patient outcomes, or cost-effectiveness (Doan et al 2011;Halter et al 2013;Kleinpell, Ely and Grabenkort 2008). These systematic reviews comment on the difficulty of comparing or synthesizing the data that do exist, due to the heterogeneous contexts in which PAs work and the challenge of extracting PA data from that related to other health care providers.…”

The association of medical student debt on choice of primary care specialty and rural practice location.

“…213,214 Like NPs, PAs' emergence sprung in the late 1960s to fill physician shortages, specialty maldistributions as physicians shifted to specialty practices 186 , and geographical maldistributions. 215 After the Korean War, the PA profession took returning…”

“…186,215,216 PAs' influence on unmet healthcare needs was meaningful, although diminished by there being fewer than 20,000 actively practicing PAs until the 1990s. 216 A "primary care"-focused healthcare system that became vogue in the 1990s called for the PA profession to increase its numbers.…”

“…219 Further, PAs have similar or less risk than physicians in being liable for malpractice according to actuarial studies. 218,219 Patients' acceptance of PAs is high, 219 especially when it alleviates time delays in seeing a PCP, 215,221 when patients had prior exposure to PAs, 221 or when patients had uncomplicated health ailments.…”