Scope of practice and autonomy of physician assistants in rural versus urban emergency departments

Objectives This was a study of the scope of practice and autonomy of emergency medicine (EM) physician assistants (PAs) practicing in rural versus urban emergency departments (EDs). Methods Using the American Academy of Physician Assistants (AAPA) Masterfile, a random sample of 200 U.S. EM PAs were surveyed, with oversampling of an additional 200 rural PAs. Location was classified by zip code–based rural–urban commuting area codes, and responses were compared about conditions managed, procedures performed, and physician supervision between rural versus urban groups. Results A total of 237 responses were received from PAs in 44 U.S. states, of which (201) were valid responses (105 rural, 96 urban) from PAs currently practicing in EDs (59.3% exclusion-adjusted response rate). Compared to urban PAs, rural PAs more frequently managed cardiac arrest (67% vs. 44%), stroke (86% vs. 72%), multisystem trauma (83% vs. 70%), active labor (44% vs. 23%), and critically ill children (82% vs. 65%) in the past year. They were more likely to have performed intubation (65% vs. 44%), needle thoracostomy (21% vs. 8%), and tube thoracostomy (46% vs. 26%). Rural PAs more often reported never having a physician present in the ED (38% vs. 0%) and less often reported always having a physician present (50% vs. 98%). Rural PAs were also less likely to report that a physician evaluates more than 75% of their patients (8% vs. 18%) and more likely that a physician never evaluates all of their patients (19% vs. 7%). Conclusions Rural PAs reported a broader scope of practice, more autonomy, and less access to physician supervision than urban PAs. Resumen Objetivos Estudio del ambito de la practica clinica y la autonomia de los asistentes medicos (AM) en Medicina de Urgencias y Emergencias (MUE) que ejercen en servicios de urgencias (SU) urbanos frente a los rurales. Metodologia Se uso el fichero de la American Academy of Physician Assistants. Se encuesto a una muestra aleatoria de 200 AM de MUE en EEUU, con sobremuestreo de 200 AM rurales adicionales. La ubicacion se clasifico por codigos de area de desplazamiento rural-urbana basados en codigos postales, y las respuestas sobre las enfermedades manejadas, los procedimientos realizados y la supervision medica se compararon entre los grupos urbano y rural. Resultados Se recibieron 237 respuestas de AM de 44 estados de EEUU, de las cuales 201 fueron respuestas validas (105 rurales, 96 urbanas) de AM que actualmente ejercen en un SU (proporcion de respuesta ajustada, por exclusion de un 59,3%). En comparacion con los AM urbanos, los AM rurales manejaron con mas frecuencia en el ano previo el paro cardiaco (67% vs. 44%), el ictus (86% vs. 72%), el traumatismo multisistemico (83% vs. 70%), los partos naturales (44% vs. 23%) y los ninos con patologia critica (82% vs. 65%). Los AM rurales tuvieron mayor probabilidad de haber realizado intubacion (65% vs. 44%), toracostomia con aguja (21% vs. 8%) y toracostomia con tubo (46% vs. 26%). Los AM rurales contestaron mas a menudo no tener nunca un medico presente en el SU (38% vs. 0%), y con menos frecuencia contestaron tenerlo siempre presente (50% vs. 98%). Los AM rurales tambien fueron menos propensos a contestar que un medico evalue mas del 75% de sus pacientes (8% vs. 18%) y mas probable que un medico nunca evaluase la totalidad de sus pacientes (19% vs 7%). Conclusiones Los AM rurales reportaron un ambito mas amplio de la practica clinica, mas autonomia y menos acceso a la supervision medica que los AM urbanos.