physician perceptions regarding the role of the physician assistant and their utilization in indiana...

PHYSICIAN PERCEPTIONS REGARDING THE ROLE OF THE PHYSICIAN ASSISTANT AND THEIR UTILIZATION IN INDIANA Jessica M. Low, PA-S and Shawn R. Brady, PA-S, Graduate Students;

Jennifer A. Snyder, MPAS, PA-C, Associate ProfessorPhysician Assistant Program, Butler University, College of Pharmacy and Health Sciences, Indianapolis, Indiana

BACKGROUND• Of the nearly 600 PAs in Indiana, one-fourth are working in primary care (family practice, internal medicine,

pediatrics, and obstetrics / gynecology); three-fourths of all PAs are working in specialty care.1 • In July 2007, Indiana was the last state to grant prescribing privileges to PAs.2,3

• Indiana’s physician workforce is evenly divided between physicians who are graduates of the Indiana University School of Medicine (IU SM) (51.9%), the only medical school in the state, and elsewhere (48.1%).4

• In July 2009, there were 713 allopathic and forty-six osteopathic physicians supervising physician assistants and 15,297 non-supervising physicians.1,6

• This is the first randomized study to determine the perception of physicians in Indiana regarding the roles of physician assistants.

STUDY QUESTIONS• Is there a difference between the mean attitude rating of Indiana physicians who supervise physician

assistants and those who do not toward the utilization of physician assistants? • Is there a difference between the mean attitude rating of those Indiana physicians surveyed who graduated

from the IU SM and those who did not regarding the roles of physician assistants? • Is there a difference between the mean attitude rating of Indiana physicians surveyed that practice in primary

care, surgery, and emergency medicine and those who do not practice in those specialties respectively regarding the roles of physician assistants?

METHODS• Descriptive non-experimental and inferential analysis; University IRB approved• The Indiana Professional Licensing Agency (IPLA) database of active allopathic physicians was queried

April 29th, 2009• A disproportionate stratified, random sampling was performed at a 2:1 ratio, non-supervising (734):

supervising physicians (366), respectively• Supervision of a physician assistant was defined by using the Medical Licensing Board standards of having

a formally approved application with the state’s licensing agency • A survey first utilized by Burgess et al. (2003), was modified with demographic and fifteen Likert scale

questions ranging from 1 = strongly disagree to 5 = strongly agree and administered to a random sampling • Instrument was piloted to increase reliability• Survey data was analyzed by a t test of independent samples or a Mann Whitney U as statistically

indicated

RESULTS

RESPONDENT CHARACTERISTICS• One hundred and fifty-four surveys (14.8%) were returned from respondents for analysis• 125 male and 26 female physicians; 3 respondents gender unknown• Median age is 51 years with over 20 years of clinical practice experience (median 20.5 years)• 62% graduated from IU SM; 38% did not

RESULTS CONTINUED

For fourteen of the fifteen survey question responses, there was a statistically significant difference between the mean attitude rating toward the roles of physician assistants among Indiana physicians who have or had a supervisory role of physician assistants and those who do not or have not had that same responsibility

Recall however, that power was not obtained for the question, “I feel the lack of payer acceptance impedes their utilization.”

Perceptions of Surveyed Physicians who Graduated from Indiana University School of Medicine (IU SM)

RESULTS CONTINUED

Perceptions of Physicians with Supervisory Experience

RESULTS CONTINUED

Perceptions of Surveyed Physicians Working within Specific Specialties A Student t test for independent samples was utilized to determine if there was a difference between the mean attitudes of primary care physicians regarding the use of physician assistants who practice in primary care compared to those physicians who do not practice in primary care

There was no difference between the mean attitude ratings of those physicians surveyed who practice in primary care and those who practice in all other specialties (4.14 versus 4.45, non-primary care: primary care, respectively) regarding the role of physician assistants who practice in family practice, internal medicine, pediatrics, or obstetrics / gynecology. There was a statistically significant difference between the mean attitude rating of those physicians surveyed who practice in both emergency medicine and surgical specialties and those physicians who do not regarding the skills of physician assistants in those specialties, respectively (3.72 versus 4.42, non-emergency medicine: emergency medicine and 4.11 versus 4.60, non-surgical: surgical, respectively)

CONCLUSION• The results of this study showed in all, a more favorable outlook existed for the utilization

of PAs by those who have formally supervised physician assistants• Widespread education directed to non-supervising physicians regarding the role and

utilization of PAs in Indiana may be helpful in optimizing their attitudes • Since twenty-six percent of those surveyed admittedly did not know the law regarding

PA prescriptive privileges or did not know PAs had prescriptive privileges, this is a critical starting point in that education process.

• There was not a mean difference in attitude ratings between surveyed physicians graduating from IU SM and elsewhere.

• Surveyed physicians supervising physician assistants in emergency medicine and surgical specialties had a statistically more positive regard for PA utilization in those specialties than physicians who did not work in those specialties

• Of those physicians surveyed, overall forty-two percent are considering hiring (10%) or are planning to hire a PA (32%) in the next three years

Solo Group Hospital Urgent CareFamily Practice 9 35 2 1Obstetrics / Gynecology 2 2 0 0Pediatrics 1 2 0 0Internal Medicine 1 4 1 0Emergency Medicine 0 3 16 0Surgical Specialty / Subspecialty 1 21 8 0Medical Subspecialty 5 22 15 0Total 19 89 42 1

Question Histogram Curve Type Test Statistic

PAs have the skills to provide health care services in…

…emergency situations Negatively skewed Non-parametric Mann Whitney U

…primary care Negatively skewed Non-parametric Mann Whitney U

…surgery Negatively skewed Non-parametric Mann Whitney U

…prescribing medications Negatively skewed Non-parametric Mann Whitney U

…basic office procedures Negatively skewed Non-parametric Mann Whitney U

I feel that…

…PAs are an asset to a physician’s practice Negatively skewed Non-parametric Mann Whitney U

…the lack of payer acceptance impedes their utilization Normal distribution

Parametric T test

…employing PAs increases the risk of malpractice in patient care

Normal distribution

Parametric T test

… employing PAs decreases malpractice in patient care Normal distribution

Parametric T test

… PAs provide an economic advantage to physicians who hire them

Normal distribution

Parametric T test

… PAs are too limited in their knowledge base to provide adequate care

Negatively skewed Non-parametric Mann Whitney U

… PAs can see the same amount of patients in a given day as a physician

Positively skewed Non-parametric Mann Whitney U

... hiring a PA would free up the physician’s time for critical care or higher level of care

Normal distribution

Parametric T test

… working with a PA would adversely increase my time spent in administrative duties

Negatively skewed Non-parametric Mann Whitney U

… PAs increase the accessibility of healthcare to patients Negatively Skewed Non-parametric Mann Whitney U

Histogram, Mandated Analysis, and Test Statistic Used to Compare the Mean Attitude Ratings of Physicians Who Supervise Physician Assistants and Those Who Don’t

Student T Test Levene’s Test for Equality of Variances

T test for Equality of Means

Question F Sig t Sig (2-Tailed)

95% Confidence Interval

I feel that… Upper Lower…the lack of payer acceptance impedes their utilization

6.745 .010 -2.190 .030* -.663 -.034


.063 .802 4.636 .000* 1.119 .450

… employing PAs decreases malpractice in patient care

.002 .968 -5.190 .000* -.939 -.422


5.669 .019 -5.496 .000* -1.005 -.473


38.700 .000 -6.980 .000* -1.245 -.694

Question Mann Whitney U

Asymp. Sig(2-tailed)

PAs have the skills to provide health care services in……emergency situations 1494 .000*…primary care 1318.5 .000*…surgery 1742 .000*…prescribing medications 1336 .000*…basic office procedures 1399 .000*

I feel that……PAs are an asset to a physician’s practice 830 .000*… PAs are too limited in their knowledge base to provide adequate care 1355.5 .000*… PAs can see the same amount of patients in a given day as a physician 2277 .051… working with a PA would adversely increase my time spent in administrative duties 1107 .000*… PAs increase the accessibility of healthcare to patients 1140 .000*

For all fifteen questions, there was no difference between the mean attitude ratings of those physicians surveyed regarding the roles of physician assistants in Indiana from those physicians who graduated from the IU SM and those who did not

Levene’s Test for Equality of Variances

T test for Equality of Means

Question F Sig t Sig 95% Confidence Interval


Upper Lower

…emergency situations 1.549 .215 -.750 .454 -.513 .231

…primary care 4.311 .040 -.991 .324 -.463 .154

…surgery 2.226 .138 -1.018 .310 -.506 .162

…prescribing medications 2.561 .112 -1.664 .098 -.686 .059

…basic office procedures .138 .711 -1.012 .313 -.557 .180

I feel that…

…PAs are an asset to a physician’s practice .393 .532 -.146 .884 -.378 .326

…the lack of payer acceptance impedes their utilization

3.963 .048 -.504 .615 -.387 .230


.163 .687 -.205 .838 -.400 .325


.463 .497 -.296 .768 -.033 .244


4.352 .039 .008 .994 -.272 .274


.808 .370 -1.046 .297 -.578 .178


.254 .615 -.368 .713 -.371 .254


.320 .572 .129 .897 -.323 .368

… PAs increase the accessibility of healthcare to patients

.065 .800 -.373 .710 -.404 .275

Levene’s Test for Equality of Variances T test for Equality of Means

Question F Sig t Sig 95% Confidence Interval

PAs have the skills to provide health care services in… Upper Lower…primary care 5.802 .017 -1.767 .080 -.648 .038

Question Mann Whitney U Asymp. Sig(2-tailed)


…emergency situations 764.5 .004*…surgery 1316.5 .009*

REFERENCES1. Indiana Professional Licensing Agency, Physician Assistant List Acquired April 29, 20092. Indiana Code Accessed August 25, 2009 http://www.in.gov/legislative/ic/code/title25/ar27.5/ch5.html 3. Indiana Governor Signs Legislation Allowing Physician Assistants to Prescribe Medicines Accessed August 25, 2009 http://www.aapa.org/news/media-resources/news-release-archive/56-indiana-governor-signs-legislation-allowing-physician-assistants-to-prescribe-medicines 4. Indiana University School of Medicine Physician Workforce Task Force. Task Force Findings and Recommendations: Indiana Physician Profile, Analysis and Projection - Final Report, 2006. Indianapolis, IN: Indiana University School of Medicine; November 2006.5. Burgess, SE, RH Pruitt, P Maybee, AE Metz, and J Leuner. Rural and urban physicians’ perceptions regarding the role and practice of the nurse practitioner, physician assistant, and certified nurse midwife. Journal Rural Health. 2003; 19 (5): 321-3286. Indiana Professional Licensing Agency, Physician List Acquired April 29, 2009

ACKNOWLEDGMENTS• Permission to utilize the original Likert survey was granted from Burgess, SE, RH Pruitt, P Maybee, AE Metz, and J

Leuner. Rural and urban physicians’ perceptions regarding the role and practice of the nurse practitioner, physician assistant, and certified nurse midwife. Journal Rural Health. 2003; 19 (5): 321-328

• Jennifer A. Snyder, Associate Professor and Jennifer S. Zorn, Assistant Professor at Butler University received a Butler University College of Pharmacy and Health Sciences Lilly Endowment Grant to financially support this study

PAs should have greater

prescribing privileges than

they currently do

PAs have the appropriate level

of prescribing privileges

PAs should have more restricted

prescribing privileges than

they currently do

PAs should not have

prescriptive privileges

PAs do not have prescriptive privileges

Do not know the Indiana law

regarding prescriptive privileges

Per

ce

nt

40

30

20

10

0

Which describes your attitude regarding prescriptive privileges

Did not respondPlans to hire a PA within the next 3 years

Already has a PA and plans to

hire another within the next 3

years

Already has a PA and does not

plan to hire another within

the next 3 years

Is considering hiring a PA

within the next 3 years

No plans to hire a PA within the next 3 years

Per

ce

nt

40

30

20

10

0

My practice…

Question PAs have the skills to provide health care services in…

N Group 1Group 2

Mean Group 1Group 2

SD Group 1Group 2

Power 2 tail

Effect SizeCohen’s d

…emergency situations 7178

3.314.24

1.166.900

.999718 .8929199

…primary care 7178

3.834.78

1.121.526

.999998 1.0849822

…surgery 7178

3.834.38

1.134.768

.993435 .7331324

…prescribing medications 7178

3.304.38

1.212.777

.999996 1.0608973

…basic office procedures 7178

3.454.46

1.181.817

.999976 .9946395

I feel that……PAs are an asset to a physician’s practice 71

783.394.73

1.115.475

1.000 1.5636195

…the lack of payer acceptance impedes their utilization

6877

3.353.70

.8061.101

.581325 .3627540


7178

3.172.38

1.0551.009

0.95263 .7653138


7178

2.563.24

.788

.809.999306 .8515231


7178

3.484.22

.892

.732.999794 .9069390


7078

2.811.71

1.277.705

.999996 1.0664659

… PAs can see the same amount of patients in a given day as a physician

7178

2.382.79

1.0051.166

0.95086 .3766718


7178

3.344.31

1.027.588

1.00 1.1591759


7077

3.102.03

.903

.9031.00 1.1849391

… PAs increase the accessibility of healthcare to patients

7178

3.324.41

1.039.711

1.00 1.2243938

Post hoc Power and Effect Size Analysis Used to Compare the Mean Attitude Ratings of Physicians Who Supervise Physician Assistants and Those Who Don’t

http://www.in.gov/legislative/ic/code/title25/ar27.5/ch5.html

http://www.aapa.org/news/media-resources/news-release-archive/56-indiana-governor-signs-legislation-allowing-physician-assistants-to-prescribe-medicines

http://www.aapa.org/news/media-resources/news-release-archive/56-indiana-governor-signs-legislation-allowing-physician-assistants-to-prescribe-medicines

physician perceptions regarding the role of the physician assistant and their utilization in indiana...

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