BackgroundMedical 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.MethodsIn 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.ResultsData 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).ConclusionsThis 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 registrationClinicalTrials.gov Identifier: NCT01835444

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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.

Dietary restriction (DR), defined as reduced energy intake without malnutrition, confers protection against renal ischemia and reperfusion injury in animal models. This pilot study investigates for the first time the feasibility of pre-operative DR in the clinical setting. Live-kidney donors were randomized between pre-operative DR or ad libitum intake. Seventeen participants were instructed to follow a 30% calorie-restricted diet, followed by one day of water-only fasting prior to surgery. Thirteen participants were allowed to eat ad libitum pre-operatively. Ninety-four percent of the donors adhered to the diet, 31.4% reduction in caloric intake was achieved. Post-operative well-being, appetite and ability to perform daily tasks were not different between both groups. There was no difference in post-transplant graft function of kidneys obtained from DR donors or control donors as determined by serum creatinine levels during the first post-operative month and renograms at post-operative day one. This study shows that mild dietary restriction is feasible in the setting of live-kidney donation. No effect was observed regarding post-operative graft function. Additional studies are warranted to investigate the appropriate regimen of dietary restriction to protecting against ischemia and reperfusion injury, such as increasing the magnitude and/or duration of the reduction in daily caloric intake.

ObjectiveTo investigate the cost-effectiveness of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs).DesignCost-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).Setting34 hospital wards across the Netherlands.Participants2292 patients were followed from admission until 1 month after discharge. Patients receiving daycare, terminally ill patients and children were excluded.Primary and secondary outcome measuresAll 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).ResultsWe 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).ConclusionsThis 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 numberNCT01835444.

BackgroundBecause 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/DesignIn 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.DiscussionFindings 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 registrationClinicalTrials.gov ID NCT01835444

Objectives: To identify determinants of the initial employment of physician assistants (PAs) for inpatient care as well as of the sustainability of their employment.

Worldwide, quality registries for cardiovascular diseases enable the use of real-world data to monitor and improve the quality of cardiac care. In the Netherlands Heart Registration (NHR), cardiologists and cardiothoracic surgeons register baseline, procedural and outcome data across all invasive cardiac interventional, electrophysiological and surgical procedures. This paper provides insight into the governance and processes as organised by the NHR in collaboration with the hospitals. To clarify the processes, examples are given from the percutaneous coronary intervention and coronary artery bypass grafting registries. Physicians who are mandated by their hospital to instruct the NHR to process their data are united in registration committees. The committees determine standard sets of variables and periodically discuss the completeness and quality of data and patient-relevant outcomes. In the case of significant variation in outcomes, processes of healthcare delivery are discussed and good practices are shared in a non-competitive and safe setting. To create new insights for further improvement in patient-relevant outcomes, quality projects are initiated on, for example, multivessel disease treatment, cardiogenic shock and diagnostic intracoronary procedures. Moreover, possibilities are explored to expand the quality registries through additional relevant indicators, such as resource use before and after the procedure, by enriching NHR data with other existing data resources.