2011 08 Hooker Everett Primary Care Pa Review

Health and Social Care in the Community (2011) doi: 10.1111/j.1365-2524.2011.01021.x

The contributions of physician assistants in primary care systems
1 2
Roderick S. Hooker PhD MBA PA and Christine M. Everett PhD-Candidate MPH PA-C
1 2
The Lewin Group, Falls Church, VA, USA and Physician Assistant Program, University of Wisconsin, Madison

Accepted for publication 1 June 2011

Correspondence Abstract
Roderick S. Hooker Shortages of primary care doctors are occurring globally;
The Lewin Group one means of meeting this demand has been the use of
3130 Fairview Park Dr #800 physician assistants (PAs). Introduced in the United States
Falls Church in the late 1960s to address doctor shortages, the PA
VA 22042-4517
movement has grown to over 75 000 providers in 2011
USA
and spread to Australia, Canada, Great Britain, the
E-mail: rodhooker@msn.com
Netherlands, Germany, Ghana and South Africa. A pur-
poseful literature review was undertaken to assess the
What is known about this topic contribution of PAs to primary care systems. Contempo-
rary studies suggest that PAs can contribute to the suc-
• Physician assistants (PAs) function under doctor
supervision. cessful attainment of primary care functions, particularly
• The generalist training of PAs permits widespread the provision of comprehensive care, accessibility and
use in most areas of medicine. accountability. Employing PAs seems a reasonable strat-
• PAs are educated in the physician model of medi- egy for providing primary care for diverse populations.
cine.
Keywords: collaboration, physician assistant, primary care,
What this paper adds
teams
• The contributions of PAs to primary care involve
effectiveness, safety, patient satisfaction and out-
comes of care comparable to a physician.
• The addition of PAs to primary care teams tends
to improve care that is coordinated and compre-
hensive and helps to maintain the continuity of
care.
• Role delineation of PAs in primary care appears to
be underdeveloped.

to whether PAs are suitable providers and how they
Introduction
may best be utilised in primary care.
We undertook a review about physician assistants (PAs) Physician assistants are recognised as health profes-
in primary care – a foundation for understanding how sionals who practise medicine in collaboration with
they contribute to the provision of primary care. The lit- doctors through delegated clinical tasks and patient
erature is large enough to offer some generalisations, but management (Cooper et al. 1998, Lowes 2000, Larsson
a secondary goal is to alert the reader to signiﬁcant gaps & Zulkowski 2002, Hooker 2004, Parle et al. 2006). As
in current knowledge. For historical reasons, it is written of 2011, the United States has approximately 75 000
with an American backdrop but with an eye on the glo- clinically active PAs and produces approximately 7000
bal expansion of PAs and an international readership. graduates annually; there are almost 1000 PAs in other
Nurse practitioners (NPs) are mentioned when the litera- countries (with substantial growth predicted over the
ture reviewed combines PAs ⁄ NPs into a single provider next decade) (Hooker 2010a). Their ﬂexibility and gen-
category. However, Laurant et al. (2009) have extensively eralist training permits them to function as providers
reviewed the combined literature on PAs and NPs in a under the supervision of a doctor in a variety of medi-
variety of roles, and this work will not be repeated here. cal specialties and healthcare settings (American Acad-
Instead, this undertaking focuses on useful and contem- emy of Physician Assistants [AAPA] 2009, Hooker
porary studies to guide employers and policy-makers as et al. 2010b). One-third (34%) is employed in primary

ª 2011 Blackwell Publishing Ltd 1

R. S. Hooker & C. M. Everett

care settings (defined as family medicine, general med- tal design was utilised, primary care physicians and PAs
icine and general paediatrics). Because of the unique- were compared relative to an outcome of interest, and
ness of the American healthcare system, it is unclear studies were subjected to peer review. Post priori, the
whether the benefits experienced from the introduction studies were sorted into the following areas of interest:
of PAs as primary care providers will be experienced description of PAs in primary care (distribution, skills,
similarly in other healthcare systems (Hooker 2005). productivity and role) and contributions to the key func-
Nor has their use in primary care been consolidated tions of primary care (WHO 2008) (comprehensiveness,
in any systematic fashion that would be useful to coordinated care, continuity of care, accessibility to care
potential employers. To address this gap, a review of and patient centred), effectiveness, safe care and effi-
PAs in primary care was undertaken. A description of ciency. The majority of the included studies were con-
PAs in primary care in the United States is provided ducted in the United States, with 11 undertaken in four
and one question was posed: To what extent do PAs other countries. Studies excluded were grey literature,
contribute to effective, safe and efficient team-based editorials, reworked original data and anecdotal findings.
primary care? A total of 93 papers and one monograph had com-
Because of the nature of introducing a new health parisons of doctors and PAs in primary care. Primary
professional into a doctor-dominated system, policy ana- care was mentioned in each of these papers but some-
lysts must assess the performance of PAs in relation to times the use was broad and included emerging roles
contemporary healthcare delivery. Healthcare organisa- such as hospitalist, oncology, psychiatry, geriatrics or
tions interested in evaluations that are not revenue based experiments in healthcare delivery such as telemedicine
are likely to be interested in the effectiveness of PAs. At and retail medicine. When this search was refined, 42
the heart of the question is identifying the services PAs papers and one monograph were considered useful to
can perform within the context of a physician–PA pri- make comparisons between primary care doctors and
mary care team that will be beneficial to the practice, the PAs.
patient, the employer and society.
US physician assistants in primary care
Method
From the beginning of the concept of the PA, and before
The purpose of this review is to synthesise the available the term ‘primary care’ was widely used, the PA occupa-
evidence regarding the contribution of PAs to primary tion was created to diagnose and treat common medical
care. While the PA profession has been in existence for conditions in a general practice environment (Jones
over 40 years, the empirical study of this profession has 2007a,b). It may have been this generalist background
been limited and definitive studies that comprehensively that led to their success. The emergence of the PA as an
evaluate PA contributions to the functions of primary adjunct in delivering primary care services occurred in
care are lacking. In the light of these limitations, a pur- the early 1980s when the roles between family medicine
poseful, policy-relevant review was conducted which doctors and PAs became less distinct and primary care
categorised the studies based on a generally accepted more broadly defined (Bodenheimer & Pham 2010).
theoretical model of primary care and relevance to the National studies of primary care visits to PAs, NPs
review question rather than evaluations of study meth- and doctors in the United States suggest utility in the
odology (Gough 2007). public sector, especially in the Department of Veterans
The English language literature for all publications Affairs and the Department of Defence, where ratios of
that include PAs in primary care was searched in these PAs to doctors is high (Hooker 2008, Wozniak 1995).
citation indices: Google Scholar, PubMed, CINAHL, Similar ratios of PAs to doctors are not as common
Medline, Cochrane Database of Systematic Reviews, across the private sector, although some vertically inte-
DARE, Embase, AHRQ, British Library Integrated Cata- grated healthcare systems have staffing ratios of PAs to
logue, ProQuest Dissertations and Theses, Sociological family practitioners as high as 50% (Hooker & Freeborn
Abstracts, World Health Organization (WHO) and Web 1991). Nationally, the tendency to employ PAs in private
of Science. Search terms included ‘physician assistant’, practice family and general medicine settings are consid-
‘physician’s assistant,’ ‘Medex,’ ‘physician associate,’ erably less than in publicly funded community health
‘primary care,’ ‘family medicine’ and ‘general practice.’ centres (Hing et al. 2010). Reasons drawing PAs into
Because PA development during the first two decades non-primary care centres on higher remuneration in pro-
was small and the contributions to the literature of mar- cedural specialties – surgery, dermatology and emer-
ginal value and relevance to contemporary primary care, gency medicine – lead the list (Morgan & Hooker 2010)
the search was limited to 1990 through 2010. Studies were By the 1990s, evidence had emerged that PAs could
included in the review if an observational or experimen- expand the delivery of traditional physician-directed ser-

2 ª 2011 Blackwell Publishing Ltd

The primary care contributions of physical assistants

vices (Osterweis & Garfinkel 1993, Schroeder 2002). Con- graphical distribution of PAs in other countries is not
sequently, federal policies were enacted to ensure ade- known.
quate reimbursement for PA services and to encourage
the employment of PAs in rural underserved areas Skills
(Henry et al. 2011). Some of these primary care PAs serve A national US practice analysis was undertaken in 2004
rural and remote populations that could not attract a to assess the knowledge and clinical performance of PAs
doctor (Henry & Hooker 2007). in practice. Such practice analysis is important to identify
As of 2011, approximately 75 000 PAs are considered the range of skills and the set of beliefs about the
clinically active across seven countries (Australia, Can- domains of knowledge PAs need to possess to be compe-
ada, the Netherlands, South Africa, UK, Ghana and the tent in their careers. A total of 5282 completed surveys
United States). In the United States, PAs ⁄ NPs provide at were considered representative of the PA population in
least 11% of all outpatient medical services. They work years of experience, geographical distribution and prac-
in every state and many domains of the federal govern- tice specialty. The three skills required for most medical
ment (Hooker 2008, AAPA 2009). All of the major medi- encounters were formulating the most likely diagnosis,
cal and surgical specialties employ PAs and their role basic science concepts and pharmaceutical therapeutics;
continues to expand (Morgan & Hooker 2010). The per it also revealed eight content domains. Overall, survey
cent of PAs in primary care has also been undergoing a responses showed few differences in the tasks performed
shift since the mid-1990s owing to a number of influ- by PAs based on the length of time worked in the profes-
ences. The most often cited reason is decreasing federal sion (Arbett et al. 2009).
funding for PA education, that at one time emphasised Another study described the characteristics of provid-
primary care and deployment to underserved areas ers, patients and the type of prescriptions written by PAs
(Cawley 2008). Other influences include high-wage dif- and NPs and compared these activities to those in metro-
ferentials for emergency medicine, dermatology, surgery politan and non-metropolitan settings. A PA or NP was
and procedure-based roles, along with career dissatisfac- the provider of record for 3% of the primary care visits.
tion based on long hours, high stress, poor reimburse- The three providers wrote prescriptions for 60% of all
ment and erosion of scope of practice (Phillips et al. visits, and the number of prescriptions was 1.3 per visit.
2009). Approximately 30–40% of clinically active PAs PAs were more likely to prescribe a controlled substance
practise in primary care–related specialties (Hooker than were physicians or NPs. In rural areas, NPs wrote
2004, 2008, AAPA 2009). more prescriptions than physicians and PAs, but both
appear to prescribe in a manner similar to physicians in
The distribution of physician assistants in primary care the type of medications used in their patient manage-
All of the states, four US territories and four Canadian ment (Hooker 2005). The majority of PAs in clinical prac-
provinces enable PAs to practise; however, the ratio of tice appeared to be providing care in a manner similar to
PA to population is irregular, and the distribution is each other and similar to what ambulatory care doctors
uneven (Sutton et al. 2010; Jones & Hooker 2011). Gener- provide.
ally speaking, those states ⁄ provinces that have high con-
centrations of universities hosting PA programmes have Productivity
high ratios of PAs, with the Northeastern states having Analysis of productivity data from a national represen-
the highest concentration of PAs, PA education pro- tative sample showed that, on average over 1 year, PAs
grammes, and people than the rest of the United States performed 61.4 outpatient visits per week compared
(Liang 2010). Five universities in the Netherlands, four in with 74.2 visits performed by physicians, for an overall
Canada, three in the UK and one in Australia and Saudi physician full-time equivalent (FTE) estimate of 0.83.
Arabia also educate PAs (Hooker & Kuilman 2011). However, the productivity of PAs varied across practice
The distribution of PAs also varies by metropolitan specialty and location, with generalist PAs providing
status. Physician assistants are more likely to work in more visits than their specialist counterparts. Rural pro-
urban settings than in rural ones; usually, the larger the ductivity was higher than urban, largely because of the
metropolitan area, the greater the concentration of PAs. concentration of generalist PAs in rural settings (Larson
When non-metropolitan practices are examined, how- et al. 2001). Additionally, a policy analysis compared
ever, the proportion of PAs in rural practice is at least the productivity of solo practice physicians who
9%; in some geographical regions such as the far west employed PAs ⁄ NPs with those who did not, demon-
of the United States, the ratio of PAs ⁄ NPs to population strating that solo practice physicians who do employ
is greater than doctors (Grumbach et al. 2003, Pedersen PAs ⁄ NPs see an increase in the number of patient visits
et al. 2008). The vast majority of rural practice PAs are per week (127.2 vs. 116.4), a decrease in the number of
in primary care (AAPA 2009, Henry et al. 2010). Geo- weeks worked per year (47.7 vs. 48.6) and an increase



in net income ($220 000 vs. $186 900), despite lower functions of primary care in a manner similar to physi-
office visit fees ($90 vs. $96.50 for a new patient) cians, they perform substitute roles. According to the
(Wozniak 1995). philosophical ideal for primary care, this translates into
Additional productivity documentation can be found assuming the tangible (the provision of the full comple-
in a state-level analysis in Utah. Even though PAs make ment of primary care services) as well as intangible
up only 6.3% of the state’s combined clinician (physician, (patient–provider relationship) attributes of a physician’s
PA, NP) workforce, they contribute approximately 7.2% professional role for a subset of the patients (i.e. serve as
of the patient care full-time equivalents in the state. The a usual provider of care). One study examined the ability
majority (73%) of Utah PAs work at least 36 hours per of practice attributes to predict PA performance in a sub-
week and spend a greater percentage of total hours stitute role and found that the most significant correlates
working in patient care when compared with physicians. included years in practice as a PA, years in practice with
The rural PA workforce reported working a greater the supervising physician, annual income from the prac-
number of total hours and patient care hours when tice, practice in a rural county, recognition as the exclu-
compared with the overall statewide PA workforce sive provider of primary care to patients and
(Pedersen et al. 2008). employment in a single-specialty group practice (Chum-
In a Dutch study of a family practice doctor and an bler et al. 2001).
American-trained PA, the productivity, based on con- Physician assistants can also perform complementary
tacts per 1000 patients, increased by 17% over 1 year roles in which they substitute for physicians for
after the PA was added to a solo practice office. Mea- particular tasks. For example, they may be responsible
sured per FTE of a GP, the number of GP contacts for providing acute or preventive care to the population
decreased slightly (2.3%). Types of contacts, diagnoses, served by the provider team. Several studies have
drug prescriptions and new referrals to primary care of highlighted this type of labour for PAs and NPs in the
the GPs changed significantly. The number of PA con- provision of preventive care. A qualitative study that
tacts per 1 FTE PA was about 60% of that of the GPs, interviewed providers and administrators at nine large
with clinical activities overlapping substantially. In the healthcare organisations examined the role of NPs and
aggregate, the PA saw more women, children and PAs. The researchers found that organisations perceived
patients aged 25–44 years, performed more practice con- an important role of NPs and PAs in the delivery of
sultations, made more women’s health-related diagnoses preventive care to women owing to women’s preference
and prescribed more drugs for dermatological and respi- for female providers, the shortage of female doctors and
ratory problems (Simkens et al. 2009). the tendency for PAs ⁄ NPs to place a higher focus on
prevention (Coulter et al. 2000). Another study surveyed
Roles of the physician assistant in primary care 1363 doctors about cancer screening in primary care
Physician assistants practice collaboratively with physi- patients and demonstrated that the majority of those
cians to address the health needs of the population surveyed (73–79% of family physicians and 60–70%
served. The role performed by any individual PA is of internists) are amenable to PAs providing such
negotiated with the supervising doctor and reflects the examinations. Of these, 631 physicians (46%) reported a
experience, training and preferences of all providers on PAs ⁄ NP performing at least one type of cancer screen-
the team, the needs of the patient population and the ing examination on their patients, with family physi-
level of trust the physician has with the PA (Jacobson cians more likely than general internists to use
et al. 1998). As a result, there is the potential for signifi- PAs ⁄ NPs to perform cancer screening examinations.
cant overlap in the competencies of PAs and doctors. Some evidence suggests that PAs and NPs may perform
Five cross-sectional studies have compared visits per- better at prevention tasks. One retrospective cohort
formed by primary care doctors to PAs and NPs using a study of 472 patient records that represented 16 million
federal data set, which demonstrated that the main rea- preventive healthcare visits among women aged
son for a visit and the characteristics of patients seen by 50–69 years was conducted. The relative risk ratios for
doctors and PAs ⁄ NPs were similar (Mills et al. 1998, breast examination and mammography during preven-
Aparasu & Hegge 2001, Lin et al. 2002, Mills & McSwee- tive visits across provider specialty and training types
ney 2002, Genova 2006). were compared. Across training degree types, PAs and
The clinical roles that PAs can perform within the NPs in primary care are more likely than medical
provider team context fall under two broad categories doctors to adhere to cancer screening guidelines
(substitute and complement) and impact the distribution of (Wallace et al. 2006).
patient care among team members (Jacobson et al. 1998, Evidence suggests that PAs can substitute for physi-
Starfield 1998). In both categories of labour, PAs are pro- cians on a wide range of patient care tasks, supporting
viding some form of substitution. When PAs perform all the contention that PAs have significant role flexibility



(Hooker 2010a, Morgan & Hooker 2010). However, few Coordinated care
empirical studies have evaluated the relationship Care is coordinated when patients receive appropriate
between the role of the PA within the provider team and care in a cost-effective manner (Scheffler et al. 1996).
outcomes (Richardson et al. 1998, Scheffler 2008). Many conceptualisations of care coordination exist, but
all agree that communication between primary care
practitioners, other healthcare professionals and patients
The contributions of physician assistants to
is a key component of coordination (Starfield 1998, Stille
primary care
et al. 2005, Bodenheimer & Pham 2010). Coordination of
care is generally viewed by primary care PAs as a func-
Comprehensiveness tion that falls within their clinical role (Jacobson et al.
Commonly used measures of comprehensiveness 1998). Specialist physicians report willingness to accept
include the scope of services provided and the rate of patient referrals from primary care PAs and general sat-
referral. Multiple studies have compared the scope of isfaction with the appropriateness and timeliness of the
patient care services provided by PAs and physicians in referrals (Enns et al. 2003, Hooker 2004, Rubenstein et al.
primary care settings and have concluded that PAs can 2007, Kimball & Rothwell 2008, Simkens et al. 2009).
perform 85–90% of services traditionally provided by
primary care physicians (Hooker 2010a). Ongoing Continuity of care
national surveys of ambulatory medical care delivery Continuity of care can refer to the transfer of information
systems demonstrate that PAs perform similarly to doc- between episodes of care (informational continuity) or
tors within visits when types of patients are compared the provision of care over time by consistent providers
by primary diagnoses. In a study of 1200 US Community (longitudinally and ⁄ or relational continuity) (Donaldson
Health Centers, a higher percentage of PA visits were et al. 1996c, Haggerty et al. 2003, Cabana & Jee 2004). A
because of an acute condition (48%) compared with phy- patient–clinician relationship is a central feature of pri-
sician (34%) and NP visits (33%). Acute conditions were mary care; the potential for decreased relationship exists
typically injury and illness. Patients with a comorbid when a provider team approach is implemented. Two
chronic condition made up nearly half of all visits. The studies have evaluated the relationship between continu-
most frequent chronic conditions reported were hyper- ity and quality of care using a cross-sectional analysis of
tension, hyperlipidaemia, diabetes, depression, obesity, patient surveys. One evaluated the effects of visit continu-
arthritis, asthma and chronic and obstructive pulmonary ity for patients (N = 14 835) of a large multispecialty prac-
disease. The per cent of visits made by patients with any tice served by primary care provider teams with PAs or
of these specific conditions did not vary by the type of NPs and the patient perceptions of the quality of primary
clinician. Nor were there differences in the percentages care. Patients who only saw their primary care physician
of established patients seen by each type of clinician reported significantly higher physician–patient relation-
(87–89%). In these federally funded community health ship quality and better assessments of organisational fea-
centres, which almost exclusively provide primary care, tures of care (such as access and integration of care) than
the staffing ratio of PA ⁄ NP to doctor averages 30% visits with providers other than their primary care physi-
(range: 0–40%) (Hing et al. 2010). cian. However, patients who had visits only with provid-
Results from a study in Iowa suggest that compre- ers on their primary care team had significantly higher
hensiveness of primary care services varies by geo- assessments of the clinical team, but lower assessments of
graphic location. Findings indicated that rural primary their physician’s knowledge of them as a person than did
care providers performed more procedures than their those who had visits with providers off the team. The
metropolitan counterparts. Among 55 responding PAs, subgroup of patients that experienced visits with their
all reported patient education, prescribing, interpreting primary care PA or NP team members reported better
radiographs, referring patients and providing a wide primary care experiences (Rodriguez et al. 2007).
range of services similar to their physician counterparts. Another survey of attendees of primary care clinics at
Few differences emerged when comparing family medi- five Department of Veterans Affairs medical centres
cine doctors with PAs in rural areas, suggesting that both (N = 21 689) evaluated the extent to which self-reported
clinicians are providing a broad array of medical services continuity of care related to patient satisfaction after
(Dehn & Hooker 1999). adjusting for patient, provider and clinic characteristics.
Five studies on referral rates and patterns by PAs in The mean adjusted humanistic score for patients who
primary care indicate that referring is an activity that reported always seeing the same provider was 17.3
does not substantially differ between PAs and doctors points higher than for those who rarely saw the same
(Enns et al. 2003, Hooker 2004, Rubenstein et al. 2007, provider. Similarly, the mean adjusted organisational
Kimball & Rothwell 2008, Simkens et al. 2009). score was 16.3 points higher for patients who always



saw the same provider compared with those who rarely 16%. Continuity of care followed a similar pattern of
saw the same provider. Demographic factors, socioeco- improvement. Staff satisfaction neither improved nor
nomic status, health status, clinic site and patient utilisa- declined. No significant differences in outcomes were
tion of services were all associated with both the seen by provider type, suggesting that PAs and doctors
adjusted humanistic and organisational scores of the are similar in their adaptability to complex organisational
scale. There were no differences in type of provider changes aimed at improving access (Bundy et al. 2005).
(PAs ⁄ NPs or doctors) when distinguished by the patient,
suggesting it was continuity of care, and not necessarily Patient-centred care
the type of provider, that was associated with higher Patient-centred care is recognised as a critical function of
patient satisfaction (Fan et al. 2005). primary care, but agreement of the definition of this
function is lacking. Most of the studies that have evalu-
Accessibility to care ated patient-centred care include patient satisfaction as
Accessible care is care that is easy for patients to obtain an outcome (Mead & Bower 2002). Satisfying care, in this
in a timely fashion (Donaldson et al. 1996a). Empirical regard, means the patient completes the visit feeling their
evidence suggests that PAs can improve access to care to needs were met. No amount of quality care by the PA
underserved patients and open access practices. The pri- will overcome the stigma of unsatisfactory care if that is
mary care patients of PAs, rather than doctors, are the way the patient perceives it.
slightly more likely to be women, rural, uninsured or To assess the extent to which the experiences of
publicly insured. One study utilised administrative data patients vary according to the type of primary care pro-
and surveyed primary care clinicians including doctors, vider (PA, NP or doctor), a national, cross-sectional survey
NPs, PAs and midwives in California and Washington of the elderly patients receiving US government health
to determine whether practice in underserved areas var- insurance (Medicare) was undertaken. The beneficiaries
ied by provider type. PAs demonstrated a greater pro- completing the survey identified a primary care provider
clivity for providing care to the underserved as they and recorded satisfaction data, patient socio-demographic
ranked first or second in both states as the providers with characteristics, healthcare experience, types of care and
the highest proportion of members practicing in rural types of supplemental insurance. A total of 146 880 com-
areas, health professional shortage areas and vulnerable pleted surveys were analysed. While a small number
population areas (Grumbach et al. 2003). The finding that (3770 or 2.8%) of respondents identified a PA or an NP as
PAs practise in greater proportion than physicians and their sole personal provider, for questions on satisfaction
nurses in areas of low population density (i.e. rural areas) with their personal care clinician, results were similar
has also been identified in studies in Iowa and Utah across the three providers. Patients who reported a physi-
(Dehn & Hooker 1999, Pedersen et al. 2008). cian as their primary care provider were more likely to
When compared with patients reporting primary care have supplemental insurance as compared with patients
doctors as a usual source of care, patients of PAs were who reported receiving care from a PA or NP. The conclu-
more likely to live in rural areas, lack insurance or have sion was that Medicare beneficiaries are generally satis-
public insurance other than Medicare, report lower per- fied with their medical care and do not distinguish
ceived access to care and ⁄ or have decreased likelihood preferences based on the type of provider. For this group,
of having some preventive care such as comprehensive the patient viewed all clinicians in primary care similarly
health examination or mammograms. Despite these dif- across all patient characteristics (Hooker et al. 2005).
ferences in characteristics and utilisation, there were no
differences in patient complexity or in self-rated health
Effective care
between primary care patients of physicians and PAs,
suggesting PAs can provide access to a usual source of Effectiveness of primary care delivery may depend, at
care for a broad range of patients (Everett et al. 2009). least in part, on using the correct mix of personnel. Star-
Appointment delays impede access to primary field (1993) showed that the division of labour and econ-
healthcare, and open access (OA) scheduling may omy of scale maximises the clinical capabilities of
improve the quality of primary health-care. A study healthcare professionals. In primary care practice, it is
assessed whether implementing OA during a 12-month neither necessary nor particularly efficient for each
period impacted practice and patient outcomes and dif- patient to be seen by a physician. As PAs are, by defini-
fered by provider type. Providers (doctors, PAs and NPs) tion, physician-supervised clinicians, the very nature of
in four practices successfully implemented OA. On aver- their clinical role is to work with doctors in collaborative
age, providers reduced their delay to the next available provider teams. To be effective, the PA needs to provide
preventive care appointment from 36 to 4 days. No-show quality care to similar patients for similar diagnoses that
rates declined and overall patient satisfaction improved result in outcomes comparable with those of a doctor.



Several studies have been conducted which compare the goals for diabetes, dyslipidaemia and hypertension. One
care provided by PAs and doctors on quality measures cross-sectional analysis of 19 660 patients with diabetes,
including processes of care and ⁄ or patient outcomes for coronary artery disease or hypertension was conducted
specific diagnoses. in the VA Connecticut Health Care System. While signifi-
cant differences were seen in the type of patients cared
Back pain for by PAs ⁄ NPs and resident physicians, the attainment
In an effort to improve the cost-effectiveness of primary of goals for each condition was similar, with one excep-
care for low back pain, an inclinic education intervention tion; PAs ⁄ NPs were more likely than resident physicians
programme was designed to provide family practice to attain a haemoglobin A1c (HgbA1c) goal of <7.5
doctors and PAs with specific information, tools and (Federman et al. 2005). Another cross-sectional study of
techniques that the literature suggested should be associ- 46 family medicine practices measured adherence to
ated with more satisfying and cost-effective care. The American Diabetes Association guidelines via chart
back pain-related beliefs, attitudes and behaviours of 15 audits of 846 patients with diabetes. Compared with
primary care providers in a large health maintenance practices employing PAs, practices employing NPs were
organisation (HMO) clinic and of 14 family physicians in more likely to measure HgbA1c levels (66% vs. 33%),
six group practices were assessed before and after the lipid levels (80% vs. 58%) and urinary microalbumin lev-
intervention. Significant increases were noted in the pro- els (32% vs. 6%) and to have treated for high lipid levels
portions of providers who felt confident they knew how (77% vs. 56%). Practices with NPs were more likely than
to manage low back pain, who believed their patients physician-only practices to assess HgbA1c levels (66% vs.
were satisfied and who claimed they reassured patients 49%) and lipid levels (80% vs. 68%). However, these pro-
that they did not have serious disease (whether they cess improvements did not translate into improved out-
were PAs or doctors) (Bush et al. 1993). comes, with the exception of better attainment of lipid
targets in practices employing NPs. These effects could
HIV not be attributed to the use of diabetes registries, health
PAs and NPs are primary care providers for patients risk assessments, nurses for counselling or patient remin-
with HIV in some clinics, but little is known about the der systems. Those practices employing either PAs or
quality of care they provide. A cross-sectional analysis NPs were perceived as busier and had larger total staffs
compared eight quality-of-care measures assessed by than physician-only practices. With regard to diabetes
medical record review. The quality of care provided by process measures in this study, family practices employ-
PAs ⁄ NPs was compared with that provided by physi- ing NPs performed better than those with physicians
cians in 68 HIV care sites. The authors surveyed 243 only and with those employing PAs (Ohman-Strickland
clinicians (177 physicians and 66 NPs ⁄ PAs) and et al. 2008). Similarly, a cohort study conducted on 88 682
reviewed medical records of 6651 persons with HIV or primary care patients in 198 Veterans Administration
AIDS. After adjustments for patient characteristics, most clinics demonstrated that clinics that included NPs were
of the quality measures did not differ between NPs and associated with lower HbA1cs (approximately 0.31 per-
PAs (and did not differ when compared with infectious centage points) and clinics with PAs did not show a sta-
disease specialists or generalist HIV experts). Adjusted tistically significant difference in HbA1c when compared
rates of purified protein derivative testing and Papanico- with clinics without PAs or NPs (Jackson et al. 2011).
laou cervical screens were higher for NPs and PAs (0.63
and 0.71, respectively) than for infectious disease special- Common geriatric conditions
ists (0.53) or generalist HIV experts (0.47). PAs and NPs A randomised trial assessed the impact of a PA case
had higher performance scores than generalist non–HIV manager responsible for screening, case finding and
experts on six of the eight quality measures. The authors referral of geriatric primary care patients for common
concluded that for the measures examined, the quality of geriatric conditions (n = 792). Despite finding no differ-
HIV care provided by PAs ⁄ NPs was similar to that of ence in functional outcomes or hospital utilisation,
physician HIV experts and generally better than physi- patients who were provided with a PA case manager
cians (non–HIV experts). Preconditions for this level of were more likely to have the target conditions identified
performance included high levels of experience, focus on (depression, cognitive and functional impairment, falls
a single condition, participation in teams and easy access and urinary incontinence) than patients receiving stan-
to clinicians with HIV expertise (Wilson et al. 2005). dard care (Rubenstein et al. 2007). The findings suggest
that incorporating PAs in supplemental roles for target
Metabolic diseases populations can increase case finding, assessment and
Three studies have evaluated the relationship between referral for previously underdiagnosed and treated con-
the type of provider and the attainment of treatment ditions.



Parkinson’s disease HMO saw four common acute medical conditions over
A study compared PA, NP and physician knowledge of 1 year. An episode approach was undertaken to identify
the pharmacological management of Parkinson’s disease all institutional resources used for a condition, and
(PD) and their preferences for referring PD patients to 12 700 medical office visits were analysed for each type
specialists. PAs ⁄ NPs answered 46% and physicians of provider. Patient characteristics were controlled for
answered 50% of questions about PD pharmacotherapy, age, gender and health status. A multivariate analysis
in agreement with recommended clinical practice identified significant cost differences in each cohort of
(P = 0.14). None of the providers differed in their prefer- patients. In every condition managed by PAs, the total
ence to refer a PD patient to a specialist for management, cost of the visit was less than that of a physician in the
but PAs and NPs were more likely to refer a patient to a same department. In no instance was a PA statistically
specialist for diagnostic confirmation. The authors con- different from physicians in use of laboratory and imag-
cluded that given trends for more PA and NP autonomy ing costs and, in each instance, the total cost of the epi-
in patient care, it was reassuring that all providers had sode was less when treated by a PA. In some instances,
similar knowledge of PD pharmacotherapy. They also PAs ordered fewer laboratory tests than physicians for
added that policies to substitute PAs and NPs for physi- the same episode of care. There were no differences in
cians might increase referrals to specialty providers for the rate of return visits for a diagnosis. When the type of
diagnostic confirmation (Swarztrauber & Graf 2007). provider encounters were further delineated by depart-
ments of family medicine, general internal medicine and
paediatrics, the results remained the same. These find-
Safe care
ings suggest that PAs are not only cost-effective from a
The results of the inputs and throughputs of care are crit- labour standpoint but also cost-beneficial to employers.
ical, but if outcomes are unfavourable, the PA will be In most cases, they order resources for diagnoses and
viewed as less effective than the doctor. The examination treatment in a manner similar to physicians for an epi-
of differences in liability among professions is one way sode of care, but the cost of an episode of an illness is
to assess the safety of care provided by healthcare profes- more economical overall when the PA delivers the care,
sionals. A study assessing whether PA and NP utilisa- which can be explained in part by the PA’s lower salary
tion increased liability analysed the malpractice (Hooker 2002).
incidence, payment amount and other measures of liabil- To estimate the savings in labour costs that might be
ity among doctors, PAs and advanced practice nurses realised per primary care visit from increased use of PAs
(APNs). From 1991 to 2007, 324 285 entries were logged and NPs in primary care, the practices of another HMO
involving 273 693 providers of interest. Significant differ- were examined; 26 primary care practices and data on
ences in liability reports were found among doctors, PAs approximately two million visits delivered by 206 practi-
and APNs. Physicians made, on average, malpractice tioners were extracted from computerised visit records.
payments twice that of PAs, but less than that of APNs. On average, PAs ⁄ NPs provided one in three adult
The probability of making a malpractice payment was 12 medicine visits and one in five paediatric medicine visits.
times less for PAs and 24 times less for APNs than physi- Likelihood of a PA ⁄ NP visit was significantly higher
cians during the study period. For all three providers, than average among patients presenting with minor
missed diagnosis was the leading reason for a malprac- acute illness (e.g. acute pharyngitis). In adult medicine,
tice report; female providers incurred higher payments the likelihood of a PA ⁄ NP visit was lower than average
than men. Trend analysis suggests that the rate of mal- among older patients. Practitioner labour costs per
practice payments for physicians, PAs and APNs has visit (and total labour costs per visit) were lower among
been steady and consistent with the growth in the num- practice arrangements with greater use of PAs ⁄ NPs,
ber of providers. There were no observations or trends to standardised for casemix. The authors concluded
suggest that PAs and APNs increase liability. From a that primary care practices that used more PAs ⁄ NPs in
policy standpoint, it appears that the incorporation of care delivery realised lower practitioner costs per visit
PAs and APNs into American society has been a safe than practices that used fewer PAs ⁄ NPs (Roblin et al.
undertaking, at least when compared with doctors (Hoo- 2004, Roblin et al. 2011).
ker et al. 2009).
Summary
Efficiency: cost-beneficial use of PAs in primary
The literature regarding PAs in team-based primary care,
care
spanning 1990 through 2010, demonstrates that these
One analysis focused on whether PAs were cost-benefi- providers have enhanced certain aspects of the delivery
cial to employers. PAs and physicians within a large of primary care. One of the attributes is that PAs have



significant role flexibility, allowing healthcare systems generalist training of the profession allows for overlap-
multiple options for incorporating PAs into primary care ping competency with primary care doctors and has
provider teams. Evidence to date suggests that PAs can been a critical aspect of its adaptability. Access to safe
make significant contributions to select functions of and effective care is enhanced when PAs are part of the
primary care. These clinicians have also demonstrated primary care provider team, and some patients will pref-
inclination to provide care to underserved populations, erentially select them. These observations stand up to
thereby improving access to primary care. Available scrutiny and suggest that PAs are cost-effective to
evidence suggests that the care provided by PAs is safe, employers and probably cost-beneficial to institutions.
effective and satisfying to patients insofar as it is compa- However, limited empirical research has been under-
rable to doctors. Provision of care by PAs has a favour- taken comparing the process and the patient outcomes
able cost benefit, thereby improving efficiency. The of coordination when performed by primary care PAs–
strength of this undertaking is that it identifies work doctor teams.
where PAs are both cost-effective and complementary As the maximum substitution model of incorporating
with primary care doctors in attaining the functions of PAs in primary care was proposed by Record (1981), a
primary care. number of policies have been enacted that not only per-
mit the PA to work but to thrive. These primary care pol-
icies are being played out in a growing number of
Limitations
countries (Ashton et al. 2007; Mullan & Frehywot 2007;
This study identifies where and how PAs can be utilised Jolly 2008, Farmer et al. 2009; Simkens et al. 2009). As
in primary care and at the same time demonstrates that demand for care rises and the supply of doctors fails to
the literature is far from complete. While the research keep pace, the need for more primary care PAs will
conducted on PAs in primary care suggests their utilisa- increase. Sustainability of any medical system involves
tion is favourable, all included studies had less than opti- organisational challenges and novel solutions. PAs may
mal scope and sample, limiting our capacity to make be one tool for meeting those challenges.
definitive statements about PAs in primary care. Signifi-
cant work remains to be completed before we can claim
Funding
to have a reasonable understanding of the scope of PA
contributions to primary care. CE received financial support from AHRQ National
Three broad areas of research are critical to optimis- Research Service Award (T32 HS00083); Community-
ing the contribution of PAs to primary care: role delinea- Academic Partnerships core of the University of Wis-
tion, team processes and patient outcomes. Current consin Institute for Clinical and Translational
theories regarding the roles of PAs in primary care have Research (UL1RR025011); and Health Innovation
face validity, but the impact of these roles will not be Program.
understood until the theories are operational and empiri-
cally studied. Qualitative studies on team member per-
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