Blue Sky Thinking: Physician Assistant Accreditation and the Potential Impact on the Programs, Faculty, and the Profession.

ABSTRACT: Blue sky thinking references the opportunity to brainstorm about a topic without limits… to consider what things might be like if creative thoughts were unconstrained by current philosophies or other boundaries. This article is a call to our fellow educators to consider how blue sky thinking applied to physician assistant (PA) program accreditation might further advance programs, faculty, and the profession. To develop and maintain a PA program, institutions must voluntarily undergo evaluation by the Accreditation Review Commission on Education for the Physician Assistant. Compliance with accreditation encourages sound educational practices, promotes program self-study, stimulates innovation, maintains confidence with the public, and focuses on continuous quality improvement. In addition, accreditation "can hold institutions accountable for desired outcomes and professional standards." Indeed, while the PA profession has promulgated across the globe, the 50+ years of graduating PAs educated with the highest quality education assures that the United States remains a gold standard. As the 5th edition of the standards are implemented and planning for the 6th edition is underway, in the spirit of continuous quality improvement, we encourage stakeholders of the PA profession to contemplate ways in which accreditation might continue to purposefully advance a desired future state for the profession. In this article, we draw on examples from other health professions which might inform a discussion around the future of PA accreditation. Specifically, the topics of a unified profession title and degree, a specific title and position for program leadership, a modification to how PA programs receive medical direction, and efforts to advance scholarship are addressed.

Clinic-Based Eye Disease Screening Using Non-Expert Fundus Photo Graders at the Point of Screening: Diagnostic Validity and Yield.

PURPOSE: The intent of this study was to determine the diagnostic accuracy of several diagnostic tests for age-related macular degeneration (AMD), diabetic retinopathy (DR), glaucoma, and cataract, as well as the proportions of patients with eye disease from each of 3 enrolling clinics. DESIGN: Diagnostic accuracy study. METHODS: Patients ≥50 years old in a diabetes, thyroid, and general medicine clinic were screened using visual acuity, tonometry, and fundus photography. Photographs were graded at the point-of-screening by non-ophthalmic personnel. Participants with positive screening test results in either eye and a 10% random sample with negative results in both eyes were referred for an in-person, reference-standard ophthalmology examination. RESULTS: Of 889 participants enrolled, 229 participants failed at least 1 test in either eye, of which 189 presented for an ophthalmic examination. An additional 76 participants with completely normal screening test results were referred for examination, of which 50 attended. Fundus photography screening had the highest yield for DR (sensitivity: 67%; 95% confidence interval [CI]: 39%-87%), visual acuity screening for cataract (sensitivity: 89%; 95% CI: 86%-92%), and intraocular pressure screening for glaucoma or suspected glaucoma (sensitivity: 25%; 95% CI: 14%-40%). The burden of disease was relatively high in all 3 clinics, with at least 1 of the diseases of interest (ie, AMD, DR, glaucoma or suspected glaucoma, or cataract) detected in 25% of participants (95% CI: 17-35%) from the diabeteses clinic, 34% (95% CI: 22%-49%) from the thyroid clinic, and 21% (95% CI: 13%-32%) from the general clinic. CONCLUSIONS: Non-expert eye disease screening in health clinics may be a useful model for detection of eye disease in resource-limited settings.

Nuclear Medicine Advanced Associates: Physician Extenders in Nuclear Medicine-Now Is the Time.

From its inception in 2008 until 2020, the nuclear medicine advanced associate (NMAA) has evolved into a valuable member of the imaging team. Data show that NMAAs perform key services including supervision, interpretation, protocoling of adjunct studies, and management, freeing nuclear medicine physicians to concentrate on more complicated and time-intensive responsibilities. Additionally, the profession has gained ground by becoming recognized by the Nuclear Medicine Technology Certification Board (NMTCB), with the advent of a formal NMAA certification examination and recognition guidelines for institutions interested in establishing NMAA educational programs. Actions are under way for the creation of new NMAA programs with pathways to enhance and expand student recruitment. A special task force has been established by the Society of Nuclear Medicine and Molecular Imaging Advanced Associate Council to raise awareness of the advantages of the physician extender within the practice setting. Practicing NMAAs perform duties that are beyond the scope of nuclear medicine technologists.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

Redesigning Primary Care to Improve Diabetes Outcomes (the UNITED Study).

OBJECTIVE: The effective redesign of primary care delivery systems to improve diabetes care requires an understanding of which particular components of delivery consistently lead to better clinical outcomes. We identified associations between common systems of care management (SysCMs) and the frequency of meeting standardized performance targets for Optimal Diabetes Care (NQF#0729) in primary care practices. RESEARCH DESIGN AND METHODS: A validated survey of 585 eligible family or general internal medicine practices seeing ≥30 adult patients with diabetes in or near Minnesota during 2017 evaluated the presence of 62 SysCMs. From 419 (72%) practices completing the survey, NQF#0729 was determined in 396 (95%) from electronic health records, including 215,842 patients with type 1 or type 2 diabetes. RESULTS: Three SysCMs were associated with higher rates of meeting performance targets across all practices: 1) a systematic process for shared decision making with patients (P = 0.001), 2) checklists of tests or interventions needed for prevention or monitoring of diabetes (P = 0.002), and 3) physician reminders of guideline-based age-appropriate risk assessments due at the patient visit (P = 0.002). When all three were in place, an additional 10.8% of the population achieved recommended performance measures. In subgroup analysis, 15 additional SysCMs were associated with better care in particular types of practices. CONCLUSIONS: Diabetes care outcomes are better in primary care settings that use a patient-centered approach to systematically engage patients in decision making, remind physicians of age-appropriate risk assessments, and provide checklists for recommended diabetes interventions. Practice size and location are important considerations when redesigning delivery systems to improve performance.

A chemotherapy privileging process for advanced practice providers at an academic medical center.

PURPOSE: Nurse practitioners, physician assistants, and pharmacists are advanced practice providers who are highly trained and qualified healthcare professionals that can help support traditional demands on oncologists' increased time in direct patient care. The purpose of this study was to detail and assess the creation of a privileging process for this group of medical professionals within an academic medical center. Obtaining the designation of limited oncology practice provider (LOPP) gives the right to modify chemotherapy orders and to order supportive care medications. METHODS: An interdisciplinary team developed a comprehensive training process inclusive of required educational domains, knowledge goals, and educational activities to become an LOPP. In 2018, five years after the implementation of the privileging process, a survey was distributed to assess perceptions of the training process and integration of LOPPs within oncology practice. RESULTS: Most oncologists noted that working with LOPPs is beneficial to oncology practice (94%) and that they make modifying chemotherapy orders more efficient (87%). Greater than 82% of LOPPs also reported that their privileges streamline the chemotherapy process and make them feel valuable. CONCLUSION: The creation of the LOPP designation is an effective way to integrate nurse practitioners, physician assistants, and pharmacists within oncology practice. The inclusion of a focused privileging process ensures the safety of cancer care provided and has created a streamlined process for chemotherapy modifications and supportive care.

Robotic cardiac surgery impact of a new patient-side assistant on outcomes.

OBJECTIVE: Very few studies have focused on the experience of the patient-side assistant in robotic cardiac surgery. We investigated whether the retirement of a highly experienced robotic patient-side assistant and replacement with a new assistant had an effect on surgical outcomes. METHODS: In 4/2016, the established patient-side assistant retired after spending 8 months training a new patient-side assistant. A retrospective analysis of 216 patients was performed; 108 patients over a 9 month period just prior to arrival of the new patient-side assistant (Group 1), and 108 patients over 8 months just subsequent to departure of the established assistant (Group 2). Case distribution, pre-operative characteristics, and surgical outcomes were collected and compared. RESULTS: Case volume increased in Group 2 with the new assistant. The mean age and rate of pre-op CVA for Group 1 was lower, but, otherwise, patient demographics were not significantly different. Group 1 had more intracardiac cases and group 2 had more triple-vessel TECABs. Overall operative time was not different between the two groups. Perioperative outcomes including hospital length of stay major adverse cardiovascular events and mortality were similar between the two groups. CONCLUSIONS: We conclude that the transition to a new robotic cardiac surgical patient-side assistant does not have to affect the progress of a busy robotic program. If adequate time for training and gradual assumption of responsibility is ensured, it is feasible to make this transition without loss of volume or compromise in patient outcomes.

Towards Earlier Identification: Physicians Assistants' Perceptions of their Ability to Identify, Diagnose, and Refer Patients with Autism Spectrum Disorder.

Early detection is imperative for children with autism spectrum disorder (ASD) to achieve optimal functioning. Knowledge of early signs of ASD, as well as open communication, can mitigate delayed diagnosis. This study explored physician assistants' (PA) abilities to diagnosis ASD as well as gathered information on their training. A majority of respondents who see pediatric patients received training on developmental milestones, but far fewer received training to identify red flags for ASD. Few PAs are talking with every patient's caregivers about a variety of behavioral health conditions, not just ASD. Overall, PAs rated their current skills working with patients with ASD lower than their desired level, suggesting a desire to become more adept at meeting their patients' needs.

Adopting Graduate Competencies in Opioid Prescribing for Massachusetts Physician Assistant Programs: A Statewide Public Health Response.

Opioid addiction has become a national epidemic. Morbidity and mortality from prescription and synthetic opioid use and abuse have increased at an alarming rate in recent years. Ensuring that physician assistant (PA) graduates have the knowledge to become safe prescribers of medications, including opiates, is a goal of PA training programs. Achieving that goal requires fostering PA student competence regarding current issues in pain control, drug use and misuse, polypharmacy, diversion, self-medication, and substance use disorder. We present a public health approach to addressing that need. Our approach involved developing consensus among the 9 PA programs in Massachusetts concerning the adoption and implementation of statewide, graduate core competencies for the prevention and management of prescription drug misuse. The process implemented in Massachusetts could be used as a model in other states and might be relevant to addressing other public health crises. We present the adopted competencies as well as individual PA programs' curricular approaches.

PAEA End of Rotation™ Exams Accurately Identify Students at Risk of Physician Assistant National Certifying Exam Failure.

PURPOSE: Physician Assistant Education Association (PAEA) End of Rotation™ exams are used by programs across the country. However, little information exists on the predictive ability of the exams' scale scores and Physician Assistant National Certifying Exam (PANCE) performance. The purpose of this study was to evaluate End of Rotation exam scores and their relationship with poor PANCE performance (PPP). METHODS: In an IRB-approved, multi-center, multi-year study, associations between PAEA End of Rotation exam scale scores and PANCE scores were explored. A taxonomy of nested linear regression models with random intercepts was fit at the program level. Fully adjusted models controlled for year, timing of the exam, student age, and gender. RESULTS: Fully adjusted linear models found that 10-point increases in End of Rotation exam scores were associated with a 16.8-point (95% confidence interval [CI]: 14.1-19.6) to 23.5-point (95% CI: 20.6-26.5) increase in PANCE score for Women's Health and Emergency Medicine, respectively. Associations between exams did not significantly vary (P = .768). Logistic models found End of Rotation exam scores were strongly and consistently associated with lower odds of PPP, with higher exam scores (10-point increase) associated with decrements in odds of PPP, ranging between 37% and 48% across exams. The effect estimate for the Emergency Medicine exam was consistently stronger in all models. CONCLUSIONS: PAEA End of Rotation exam scores were consistently predictive of PPP. While each End of Rotation exam measures a specialty content area, the association with the overall PANCE score varied only by a change in odds of low performance or failure by a small percentage. Low End of Rotation exam scores appear to be consistent predictors of PPP in our multi-center cohort of physician assistant students.

Current evidence and controversies: advanced practice providers in healthcare.

The authors compare advanced practice providers' education, training, scope of practice, and quality of care with that of physicians. A framework is essential to promote team-based primary care.

Impact of Variations in PACKRAT Administration: A Retrospective Review.

The Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT) was developed to be an objective, comprehensive self-assessment tool for students. When the PACKRAT exam was initially developed, its goal was to help students determine what level of knowledge they currently possessed and what they had to learn prior to graduation. The purpose of this study was to review PACKRAT test-taker scores over the past 5 years and analyze the variations in test administration. Deidentified PACKRAT scores, exam length in minutes, and proctored or unproctored status, along with time extensions were analyzed from 2013 to 2018. Descriptive statistics and frequency counts were used to summarize the data. An independent samples t-test was used to determine if there was a difference in test-taker scores between proctored and unproctored exams. The 83,271 student test-taker exam data were analyzed, and time ranged from 180 to 360 minutes with a mean of 226.5 minutes. When comparing test-taker scores between proctored and unproctored exams, the mean scores were 145.02 and 144.77, respectively, with no significant difference. The Physician Assistant Clinical Knowledge Rating and Assessment Tool can be confidently used and compared to national scores whether a program administers the exam proctored or without a proctor. The average time taken for exam completion is close to the recommended 225 minutes that is suggested by Physician Assistant Education Association PACKRAT exam developers.

Preparedness for Clinical Practice and the Development of Professional Competencies.

PURPOSE: To assess students' level of perceived preparedness for clinical competencies and simultaneously identify the effective curricular methods to develop these competencies. METHODS: Prior to graduation students reported their level of preparedness for clinical practice using a modified Preparation for Hospital Practice Questionnaire and rated the most effective teaching methods to improve the development of clinical and professional competencies. RESULTS: Students gave a high rating to group dynamics and teamwork, along with continuous professional development. They felt least prepared in pharmacotherapeutics and the handling of medical emergencies. Rated most effective were didactic lecturing instruction for the acquisition of medical knowledge, standardized patient encounters and simulations for the promotion of interpersonal skills, case groups for the integration of knowledge and critical thinking, and interprofessional events for the maintenance of professional accountability. CONCLUSION: This survey approach may lead to an efficient and focused method for improving clinical and professional competencies and serve as an additional self-assessment tool to support curriculum development and reform.

Physician Assistant Students' Perceptions of Cultural Competence in Providing Care to Diverse Populations.

PURPOSE: To determine physician assistant (PA) students' perceived levels of preparedness to treat patients from culturally diverse backgrounds. METHODS: An online survey with quantitative and qualitative components was distributed to students at 8 PA programs in different geographic locations of the United States. The survey used a modified version of the previously validated Self-Assessment of Perceived Level of Cultural Competence Questionnaire and evaluated PA students' knowledge, skills, encounters, attitudes, awareness, and abilities regarding cultural competence, as well as students' evaluation of these components of their education. Descriptive statistics were generated using SPSS software, and qualitative findings were analyzed for common themes. RESULTS: PA students rated their attitudes, awareness, and abilities about cultural competence as significantly greater than their cultural knowledge, skills, and encounters. Second-year students and racial minority students reported higher personal ratings for levels of cultural competence. Most PA students reported being well prepared (39%) or moderately prepared (46%), compared to those who did not feel at all prepared (15%). Students indicated that specific classes focusing on cultural topics, discussions about cultural issues, and clinical experiences were the most useful for promoting cross-cultural education. CONCLUSION: While PA students perceive cultural competence to be important, they appear to be deficient in the areas of cultural knowledge, skills, and encounters. Integrating cultural competence courses, cultural discussions, and clinical rotations involving diverse patient populations should be encouraged throughout PA training as they may strengthen students' preparedness to provide cross-cultural care.

A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors.

BACKGROUND: Rising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians. METHODS: We used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences. RESULTS: At baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores-7.4% and 7.6%, respectively (P < .001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation. CONCLUSIONS: We found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.

Considerations Around Predicting Physician Assistant National Certifying Exam Scores From PACKRAT®: A Multiprogram Study.

PURPOSE: The Physician Assistant Clinical Knowledge Rating and Assessment Tool (PACKRAT®) is a known predictor of performance on the Physician Assistant National Certifying Exam (PANCE). It is unknown, however, whether these associations (1) vary across programs; (2) differ by PACKRAT metrics (first-year [PACKRAT 1], second-year [PACKRAT 2], and composite score [arithmetic mean of PACKRAT 1 and PACKRAT 2]); or (3) are modified by demographic or socioeconomic variables. METHODS: Linear and logistic hierarchical regression models (HRMs) were used to evaluate associations between PACKRAT metrics and (1) continuous PANCE scores and (2) odds of low PANCE performance (LPP), respectively. Likelihood ratio tests were used to evaluate differences in associations between programs and effect modification by demographic and socioeconomic variables. Receiver operating characteristic (ROC) curves were used to examine the sensitivity, specificity, positive predictive values, and negative predictive values for various PACKRAT metrics/cut points. Models were adjusted for demographic and socioeconomic variables. The PACKRAT scores were standardized for each year to the national mean and SD. RESULTS: Adjusted HRMs across 5 programs (n = 1014) found the composite score to have the strongest association, with a 10-percentile-point increase associated with a 22-point (95% confidence interval [CI]: 19-26) increase in PANCE score. The composite score also strongly predicted decrements in odds of LPP (odds ratio: 0.46; 95% CI: 0.38-0.55). Hierarchical regression models and ROC curves identified significant variability in associations among programs. Effect modification was not observed by any investigated variable. CONCLUSIONS: The composite score had the largest magnitudes of association with PANCE scores and odds of LPP. The significant difference in association identified between programs suggests that the predictive ability of the exam is not uniform. The lack of effect modification by demographic and socioeconomic variables suggests that associations do not significantly differ by these metrics.