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Shortages of primary care doctors are occurring globally; one means of meeting this demand has been the use of physician assistants (PAs). Introduced in the United States in the late 1960s to address doctor shortages, the PA movement has grown to over 75,000 providers in 2011 and spread to Australia, Canada, Great Britain, The Netherlands, Germany, Ghana, and South Africa. A purposeful literature review was undertaken to assess the contribution of PAs to primary care systems. Contemporary studies suggest that PAs can contribute to the successful attainment of primary care functions, particularly the provision of comprehensive care, accessibility, and accountability. Employing PAs seems a reasonable strategy for providing primary care for diverse populations.
PMCID: PMC3903046  PMID: 21851446
Primary Care; Physician Assistant; Collaboration; Teams
2.  Working with the medically underserved 
Canadian Family Physician  2013;59(4):339-340.
PMCID: PMC3625069  PMID: 23585592
4.  Are Dutch patients willing to be seen by a physician assistant instead of a medical doctor? 
The employment of physician assistants (PAs) is a strategy to improve access to care. Since the new millennium, a handful of countries have turned to PAs as a means to bridge the growing gap between the supply and demand of medical services. However, little is known about this new workforce entity from the patient’s perspective. The objective of this study was to assess the willingness of Dutch patients to be treated by a PA or a medical doctor (MD) under various time constraints and semi-urgent medical scenarios.
A total of 450 Dutch adults were recruited to act as surrogate patients. A convenience sample was drawn from patients in a medical office waiting room in a general hospital awaiting their appointments. Each participant was screened to be naive as to what a PA and a nurse practitioner are and then read a definition of a PA and an MD. One of three medical scenarios was assigned to the participants in a patterned 1-2-3 strategy. Patients were required to make a trade-off decision of being seen after 1 hour by a PA or after 4 hours by a doctor. This forced-choice method continued with the same patient two more times with 30 minutes and 4 hours and another one of 2 hours versus 4 hours for the PA and MD, respectively.
Surrogate patients chose the PA over the MD 96 % to 98 % of the time (depending on the scenario). No differences emerged when analysed by gender, age, or parenthood status.
Willingness to be seen by a PA was tested a priori to determine whether surrogate Dutch patients would welcome this new health-care provider. The findings suggest that employing PAs, at least in concept, may be an acceptable strategy for improving access to care with this population.
PMCID: PMC3462730  PMID: 22947130
Physician assistants; Trade-off; Willingness
5.  Predictive Modeling the Physician Assistant Supply: 2010–2025 
Public Health Reports  2011;126(5):708-716.
A component of health-care reform in 2010 identified physician assistants (PAs) as needed to help mitigate the expected doctor shortage. We modeled their number to predict rational estimates for workforce planners.
The number of PAs in active clinical practice in 2010 formed the baseline. We used graduation rates and program expansion to project annual growth; attrition estimates offset these amounts. A simulation model incorporated historical trends, current supply, and graduation amounts. Sensitivity analyses were conducted to systematically adjust parameters in the model to determine the effects of such changes.
As of 2010, there were 74,476 PAs in the active workforce. The mean age was 42 years and 65% were female. There were 154 accredited educational programs; 99% had a graduating class and produced an average of 44 graduates annually (total n=6,776). With a 7% increase in graduate entry rate and a 5% annual attrition rate, the supply of clinically active PAs will grow to 93,099 in 2015, 111,004 in 2020, and 127,821 in 2025. This model holds clinically active PAs in primary care at 34%.
The number of clinically active PAs is projected to increase by almost 72% in 15 years. Attrition rates, especially retirement patterns, are not well understood for PAs, and variation could affect future supply. While the majority of PAs are in the medical specialties and subspecialties fields, new policy steps funding PA education and promoting primary care may add more PAs in primary care than the model predicts.
PMCID: PMC3151188  PMID: 21886331
6.  Canadians’ willingness to receive care from physician assistants 
Canadian Family Physician  2012;58(8):e459-e464.
To determine the willingness of Canadians to accept treatment from physician assistants (PAs).
Respondents were asked to be surrogate patients or parents under 1 of 3 conditions selected at random. Two scenarios involved injury to themselves, with the third involving injury to their children. The wait time for a physician was assumed to be 4 hours, whereas to explore the sensitivity of patients’ preferences for a range of times, PA wait times were 30 minutes, 1 hour, and 2 hours.
Vancouver, BC.
Two hundred twenty-nine mothers attending a hospital with their children.
Main outcome measures
The main outcome measure was the proportion of individuals in each scenario who were willing to be treated by PAs for at least one of the time trade-off options offered. A secondary outcome was the proportion of individuals who changed their answers when the waiting time to see the PA varied.
Regardless of the scenarios, 99% of participants opted for PAs under the personal circumstances; 96% opted for PAs when the issue involved their children. The choice favouring the PA persisted, albeit at slightly lower proportions, as the difference in wait time between PAs and physicians decreased (85% and 67% for a difference in PA and physician wait time of 3 and 2 hours, respectively).
These findings suggest that British Columbians are willing to be treated by PAs under most circumstances, whether this includes themselves or their children. The high level of willingness to be treated by PAs demonstrates public confidence in PA care, and suggests that the use of PAs in Canadian emergency departments or clinics is a viable policy response to decreasing primary care capacity.
PMCID: PMC3419003  PMID: 22893348
7.  Anti-CCP antibody and rheumatoid factor concentrations predict greater disease burden in U.S. veterans with rheumatoid arthritis 
Annals of the rheumatic diseases  2010;69(7):1292-1297.
To examine associations of anti-cyclic citrullinated peptide antibody (aCCP) and rheumatoid factor (RF) concentrations with future disease burden in patients with rheumatoid arthritis (RA).
Outcome measures were examined in U.S. veterans with RA and included: 1) proportion of observation in remission (Disease Activity Score [DAS]28 ≤ 2.6), 2) remission for ≥ 3 consecutive months, and 3) area under the curve [AUC] for DAS28. Associations of autoantibody concentration (per 100 unit increments) with outcomes were examined using multivariate regression.
Patients (n = 855) were predominantly men (91%) with mean (SD) age of 66 (11) years and 2.3 (1.2) years of follow-up. Most were aCCP (75%) and RF (80%) positive. After multivariate adjustment, aCCP (OR 0.93; 95% CI 0.91-0.96) and RF concentrations (OR 0.92; 95% CI 0.90-0.95) were associated with a lower odds of remission, a lower proportion of observation in remission (p = 0.054 and p = 0.014, respectively), and greater AUC DAS28 (p = 0.05 and p = 0.002, respectively). In aCCP+ / RF- patients, higher aCCP concentrations were associated with an increased likelihood of remission (OR 1.10; 95% CI 1.00-1.20). Among aCCP- / RF+ patients, higher RF concentrations trended towards an inverse association with remission (OR 0.81; 95% CI 0.58-1.13).
aCCP concentrations (particularly in RF positive patients) are associated with poor prognosis in U.S. veterans with RA. Analyses of autoantibody discordant patients suggest that RF concentrations may be a stronger predictor of disease burden than aCCP concentration.
PMCID: PMC3122886  PMID: 20439294
rheumatoid arthritis; cyclic citrullinated peptide; rheumatoid factor; disease activity; clinical remission
8.  Physician assistants in Canada 
Canadian Family Physician  2011;57(3):e83-e88.
To analyze the health policies related to physician assistants (PAs) and to understand the factors influencing this medical work force movement.
Quality of evidence
This work combines a review of the literature and qualitative information, and it serves as a historical bookmark. The approach was selected when attempts to obtain reports or literature using customary electronic bibliography (PubMed, CINAHL, Google Scholar, EBSCO, and MEDLINE) searches in English and French, from 1970 through 2010, identified only 14 documents (including gray literature) of relevance. Reports, provincial documents, and information from developers of the PA movement supplemented the literature base.
Main message
The historical development of the role of PAs in Canada spans 2 decades. There are now more than 250 PAs, most working in family medicine and emergency medicine. Enabling legislation for PAs has been formalized in Manitoba, and 3 provinces have recognized PAs in various policy statements or initiatives. Three universities and 1 military training centre have enrolled more than 120 students in PA programs. Retired PAs of the Canadian Forces, returning ex-patriot Canadians who had trained as PAs in PA programs in the United States, and American immigrants are working as PAs in Canada. Demonstration projects are under way to better understand the usefulness of PAs in various medical settings.
For a public health policy enactment of this size and effect, the literature on PAs in Canada is sparse and limited. In spite of this, PA employment is expanding, family medicine practices are using PAs, and there is enabling legislation planned. The result will likely be increased use of PAs. Documentation about PAs, review of their use, and outcomes research are needed to evaluate this new type of clinician in Canadian society.
PMCID: PMC3056699  PMID: 21402955
9.  Anticitrullinated protein antibody (ACPA) in rheumatoid arthritis: influence of an interaction between HLA-DRB1 shared epitope and a deletion polymorphism in glutathione s-transferase in a cross-sectional study 
Arthritis Research & Therapy  2010;12(6):R213.
A deletion polymorphism in glutathione S-transferase Mu-1 (GSTM1-null) has previously been implicated to play a role in rheumatoid arthritis (RA) risk and progression, although no prior investigations have examined its associations with anticitrullinated protein antibody (ACPA) positivity. The purpose of this study was to examine the associations of GSTM1-null with ACPA positivity in RA and to assess for evidence of interaction between GSTM1 and HLA-DRB1 shared epitope (SE).
Associations of GSTM1-null with ACPA positivity were examined separately in two RA cohorts, the Veterans Affairs Rheumatoid Arthritis (VARA) registry (n = 703) and the Study of New-Onset RA (SONORA; n = 610). Interactions were examined by calculating an attributable proportion (AP) due to interaction.
A majority of patients in the VARA registry (76%) and SONORA (69%) were positive for ACPA with a similar frequency of GSTM1-null (53% and 52%, respectively) and HLA-DRB1 SE positivity (76% and 71%, respectively). The parameter of patients who had ever smoked was more common in the VARA registry (80%) than in SONORA (65%). GSTM1-null was significantly associated with ACPA positivity in the VARA registry (odds ratio (OR), 1.45; 95% confidence interval (CI), 1.02 to 2.05), but not in SONORA (OR, 1.00; 95% CI, 0.71 to 1.42). There were significant additive interactions between GSTM1 and HLA-DRB1 SE in the VARA registry (AP, 0.49; 95% CI, 0.21 to 0.77; P < 0.001) in ACPA positivity, an interaction replicated in SONORA (AP, 0.38; 95% CI, 0.00 to 0.76; P = 0.050).
This study is the first to show that the GSTM1-null genotype, a common genetic variant, exerts significant additive interaction with HLA-DRB1 SE on the risk of ACPA positivity in RA. Since GSTM1 has known antioxidant functions, these data suggest that oxidative stress may be important in the development of RA-specific autoimmunity in genetically susceptible individuals.
PMCID: PMC3046521  PMID: 21087494

Results 1-9 (9)