Healthcare systems across the world face a number of challenges, such as a rising demand for healthcare services, a growing number of chronic ill patients and rising patient expectations. Concurrently, the supply of medical doctors (MDs) is constrained in most countries, leading to workforce shortages . Nonphysician clinicians have been introduced into the medical domain in order to take over tasks from MDs . An example of a nonphysician clinician is the Physician assistant (PA), a health care professional licensed to practice medicine in defined domains, in collaboration with MDs but with a substantial degree of professional autonomy . PAs obtain medical history, perform physical examinations, request and interpret additional testing, render medical diagnoses and treatment procedures, and prescribe medication. They also perform specific medical procedures, such as endoscopies, catheterizations, elective cardioversion and minor surgeries [3, 4]. In addition, PAs contribute to the quality of care by developing protocols, initiate or participate in quality projects and education programs .
The PA was first introduced in the sixties in the United States and then rapidly spread across the country . In the Netherlands, the first PAs were introduced in 2001 [6, 7]. Currently approximately 630 graduated PAs are employed in the Dutch healthcare system, on a total of about 65 000 registered physicians . In the next few years, about 120 PAs will yearly complete their Master program. Contrary to the USA, where the majority of PAs work in primary care settings, most Dutch PAs (about 75%) work in the hospital settings . The majority works at general surgery, surgical subspecialties, cardiology, anesthesiology or internal medicine . The main features of Dutch PA’s are [7, 10]:
PAs follow a 30 month training program at a Master’s degree level.
The Dutch PA programs incorporate a dual work-education model, which means that students are employed within a particular medical specialty while enrolled in the master’s PA program. The students undertake didactic and clinical education within this medical specialty from the beginning till the end of the curriculum.
PA students are professionals with a health care-related bachelor’s degree and at least 2 years of clinical work experience in the health care domain.
PAs conduct low to moderately complex medical tasks within a certain specialty, both in primary and secondary care. Most PAs practice in the hospital setting.
Since January 2013, PAs are authorized to indicate and perform predefined medical procedures and subscribe medication without supervision. The scope of practice will be re-evaluated in 2017.
Physician Assistant is a protected title by law. The legislation is written in the Individual Health Care Professions Act (Wet BIG), article 36a.
Since the first introduction of the PA, several studies have examined their performance. This body of evidence suggests that PAs can provide high-quality care in a large range of medical disciplines [11–14]. The studies indicate that they provide care that is comparable to that of MDs, with high levels of patient satisfaction [15–18]. Although there is international evidence for both efficacy and effectiveness supporting the reallocation of care from MDs to PAs, current research does not cover all settings and professions [2, 13]. Many studies concern primary and critical care settings, while studies assessing the effects of substitution of non-acute inpatient medical care are limited. Some studies show methodological limitations like single centered, non-randomized, a relatively small sample size or no control condition. Besides, concerns have been expressed regarding potential adverse effects of involving PAs, such as negative impacts on patient safety and continuity of healthcare delivery.
In this study we focus on patients admitted to a hospital, who are taken care by a hospitalist. Hospitalists are responsible for the coordination of the daily medical care of hospitalized patients . This role has traditionally been fulfilled by medical residents (MRs) and occasionally by medical specialists. In recent years, the role of hospitalist has been increasingly reallocated to PAs [3, 11], facilitated by technological innovations and the standardization of many medical procedures by clinical protocols [20, 21]. In 2013, approximately 200 graduated PAs were employed as hospitalist in the Netherlands. When PAs are employed as hospitalists, the applied model to cover 24/7 ward care is often a mixed model that contains both PAs and MDs as hospitalist, comprising a patient medical care team. The tasks of PAs in such a team are comparable to those of the MDs. The PAs, however, tend to work during daytime on weekdays, while MDs often work during evenings, nights and weekends. It is anticipated that within the next decades PAs will be increasingly employed in the management of hospitalized patients for a range of different specialism. However, empirical evidence about the consequences of reallocating medical ward care from MDs to PAs for the quality and safety of care is currently limited.