Comparison of resident and mid-level provider productivity in a high-acuity emergency department setting

Hamden, Khalief E.; Jeanmonod, Donald; Gualtieri, Deno; Jeanmonod, Rebecca

doi:10.1136/emermed-2012-201904

Cited by 26 publications

(21 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Three small US studies of PAs in hospital settings published in 2013 and 2014 provided new positive evidence as to the contribution that PAs made to patient outcomes and resource use in a trauma-orthopaedic setting 32 and in low-and high-acuity emergency department (ED) settings. 33,34 One study 35 had reported that the indirect impact of employing PAs in a general surgical residency programme was to reduce the resident doctor workload, increase the doctors' ability to attend their training activities and improve results in their American Board of Surgery in Training Examination. In 2014, a study protocol was published for research investigating the substitution of medical doctors with PAs in hospitals in the Netherlands.…”

Section: Physician Associatesmentioning

confidence: 99%

The role of physician associates in secondary care: the PA-SCER mixed-methods study

Drennan

Halter

Wheeler

et al. 2019

Health Serv Deliv Res

View full text Add to dashboard Cite

BackgroundIncreasing demand for hospital services and staff shortages has led NHS organisations to review workforce configurations. One solution has been to employ physician associates (PAs). PAs are trained over 2 years at postgraduate level to work to a supervising doctor. Little is currently known about the roles and impact of PAs working in hospitals in England.Objectives(1) To investigate the factors influencing the adoption and deployment of PAs within medical and surgical teams in secondary care and (2) to explore the contribution of PAs, including their impact on patient experiences, organisation of services, working practices, professional relationships and service costs, in acute hospital care.MethodsThis was a mixed-methods, multiphase study. It comprised a systematic review, a policy review, national surveys of medical directors and PAs, case studies within six hospitals utilising PAs in England and a pragmatic retrospective record review of patients in emergency departments (EDs) attended by PAs and Foundation Year 2 (FY2) doctors.ResultsThe surveys found that a small but growing number of hospitals employed PAs. From the case study element, it was found that medical and surgical teams mainly used PAs to provide continuity to the inpatient wards. Their continuous presence contributed to smoothing patient flow, accessibility for patients and nurses in communicating with doctors and releasing doctors’ (of all grades) time for more complex patients and for attending to patients in clinic and theatre settings. PAs undertook significant amounts of ward-based clinical administration related to patients’ care. The lack of authority to prescribe or order ionising radiation restricted the extent to which PAs assisted with the doctors’ workloads, although the extent of limitation varied between teams. A few consultants in high-dependency specialties considered that junior doctors fitted their team better. PAs were reported to be safe, as was also identified from the review of ED patient records. A comparison of a random sample of patient records in the ED found no difference in the rate of unplanned return for the same problem between those seen by PAs and those seen by FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57;p = 0.40). In the ED, PAs were also valued for the continuity they brought and, as elsewhere, their input in inducting doctors in training into local clinical and hospital processes. Patients were positive about the care PAs provided, although they were not able to identify what or who a PA was; they simply saw them as part of the medical or surgical team looking after them. Although the inclusion of PAs was thought to reduce the need for more expensive locum junior doctors, the use of PAs was primarily discussed in terms of their contribution to patient safety and patient experience in contrast to utilising temporary staff.LimitationsPAs work within medical and surgical teams, such that their specific impact cannot be distinguished from that of the whole team.ConclusionsPAs can provide a flexible advanced clinical practitioner addition to the secondary care workforce without drawing from existing professions. However, their utility in the hospital setting is unlikely to be fully realised without the appropriate level of regulation and attendant authority to prescribe medicines and order ionising radiation within their scope of practice.Future researchComparative investigation is required of patient experience, outcomes and service costs in single, secondary care specialties with and without PAs and in comparison with other types of advanced clinical practitioners.Study registrationThe systematic review component of this study is registered as PROSPERO CRD42016032895.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

show abstract

Section: Physician Associatesmentioning

confidence: 99%

The role of physician associates in secondary care: the PA-SCER mixed-methods study

Drennan

Halter

Wheeler

et al. 2019

Health Serv Deliv Res

View full text Add to dashboard Cite

show abstract

“…There are many ways to determine provider efficiency in the literature . We chose number of new patients per resident per hour as one of the resident efficiency measurements for the following reasons: 1) it is a simple and easy way to measure; 2) residents tended to see relatively high‐acuity patients in the study ED, and therefore the patient acuity seemed to be less biased across different residents; 3) different shift lengths among residents, where PGY‐1 residents had 10‐hour shifts with the last 2 hours dedicated to “finishing up” and not picking up new patients and senior residents had 9‐hour shifts with the last hour dedicated to “finishing up” and not picking up new patients; and 4) crowding was measured hourly at the study ED, which matched well as the number of new patients per provider per hour, since such crowding statuses change dynamically and patient flow may be affected by different levels of crowding at the ED .…”

Section: Discussionmentioning

confidence: 99%

“…Such diverse provider efficiency reported in the literature raises the question of whether it is necessary to provide standard training on provider efficiency during EM residency training. Unfortunately, few studies in the current literature report on resident efficiency . Although previous studies addressed resident efficiency in general, there were neither efficiency comparisons among residents of different training levels nor dynamic comparisons during the entire academic year, which makes resident efficiency assessment less informative.…”

mentioning

confidence: 99%

“…In recent years, studies focusing on various provider efficiencies have been reported including physicians working in community hospitals and academic attending physicians supervising residents, medical students, or advanced practice providers (APPs; e.g., physician assistants, nurse practitioners) . Different provider efficiency measurements were used in different studies including new patients per provider per hour, relative value units (RVUs) generated per shift, or mean patient emergency department (ED) length of stay . Study results had variable conclusions on provider efficiency due to the differences of efficiency measurements, ED volumes, interventions, patient acuity, and ED crowding conditions .…”

mentioning

confidence: 99%

See 1 more Smart Citation

Emergency Medicine Resident Efficiency and Emergency Department Crowding

Kirby

Robinson

Dib

et al. 2019

AEM Education and Training

View full text Add to dashboard Cite

Objectives: Provider efficiency has been reported in the literature but there is a lack of efficiency analysis among emergency medicine (EM) residents. We aim to compare efficiency of EM residents of different training levels and determine if EM resident efficiency is affected by emergency department (ED) crowding. Methods:We conducted a single-center retrospective observation study from July 1, 2014, to June 30, 2017. The number of new patients per resident per hour and provider-to-disposition (PTD) time of each patient were used as resident efficiency markers. A crowding score was assigned to each patient upon the patient's arrival to the ED. We compared efficiency among EM residents of different training levels under different ED crowding statuses. Dynamic efficiency changes were compared monthly through the entire academic year (July to next June). Results:The study enrolled a total of 150,920 patients. A mean of 1.9 patients/hour was seen by PGY-1 EM residents in comparison to 2.6 patients/hour by PGY-2 and -3 EM residents. Median PTD was 2.8 hours in PGY-1 EM residents versus 2.6 hours in PGY-2 and -3 EM residents. There were no significant differences in acuity across all patients seen by EM residents. When crowded conditions existed, residency efficiency increased, but such changes were minimized when the ED became overcrowded. A linear increase of resident efficiency was observed only in PGY-1 EM residents throughout the entire academic year.

show abstract

“…8,10,11 Although the clinical value of residents compared to midlevel providers remains unknown in neurology, comparisons in emergency medicine and primary care suggest similar clinical value. [26][27][28] Our study explores some of the ways that departments and programs employ their new and existing faculty to assist with the loss of resident work, finding that faculties are frequently assisting residents in leading family meetings. This may have unintended consequences on the value of resident education.…”

Section: Discussionmentioning

confidence: 99%

Impact of 2011 Resident Duty Hour Requirements on Neurology Residency Programs and Departments

George

Probasco

Dorsey

et al. 2014

The Neurohospitalist

View full text Add to dashboard Cite

Objective: In 2011, the Accreditation Council on Graduate Medical Education (ACGME) redefined resident duty hour requirements by reducing in-hospital duty hour requirements for residents in an effort to improve patient care, resident wellbeing, and resident education. We sought to determine the cost of adoption based on changes made by neurology residency programs and departments due to these requirements. Methods: We surveyed department chairs or residency program directors at 123 ACGME-accredited US adult neurology training programs on programmatic changes and resident expansion, hiring practices, and development of new computer-based resources in direct response to the 2011 ACGME duty hour requirements. Using data from publicly available resources, we estimated respondents' financial cost of adoption. Results: In all, 63 responded (51% response rate); 76% were program directors. The most common changes implemented by programs were adding night float systems (n ¼ 31; 49%) and increasing faculty responsibility (n ¼ 26; 41%). In direct response to the requirements, 21 programs applied to ACGME for 40 additional residents, 29 of which were fully covered by institutional funds. In direct response to the requirements, nearly half of the departments (n ¼ 26) hired individuals for a total of 80 hires (or 64 full-time equivalents), most commonly mid-level practitioners. The total estimated cost to responding departments was US $12.7 million or US $201,000 per department annually. When projecting expenses of planned changes for the following year, costs increased to US $360,000 per department, with 5-year costs exceeding US $1 million. Conclusions: The most recent restriction on resident duty hours comes at substantial cost to neurology departments and residency programs.

show abstract

Comparison of resident and mid-level provider productivity in a high-acuity emergency department setting

Abstract: In a high-acuity area of the ED, MLPs see more patients per hour than residents, but generate fewer RVUs per patient. This suggests that residents may document more thoroughly than MLPs. Alternatively, MLPs may elect to see less sick patients even when working in a high-acuity area.

Cited by 26 publications

References 13 publications

The role of physician associates in secondary care: the PA-SCER mixed-methods study

The role of physician associates in secondary care: the PA-SCER mixed-methods study

Emergency Medicine Resident Efficiency and Emergency Department Crowding

Impact of 2011 Resident Duty Hour Requirements on Neurology Residency Programs and Departments

Contact Info

Product

Resources

About