Hospital medicine workforce: The impact of nurse practitioner and physician assistant providers

Nurse practitioners (NPs) and physician assistants (PAs) have been caring for patients since the mid1960s. Although both roles grew out of a need for more primary care providers, more recently there has been an increase in the utilization of NPs and PAs in acute care roles. This meteoric rise of advanced practice providers in the inpatient setting has been driven by stressors from residency work-hour reforms and from growing financial pressures in healthcare systems, where NPs and PAs are seen as less expensive alternatives. Inadequate physician supply to meet the needs of growing healthcare service is also a driving factor. Despite increasing numbers of enrollees and increasing numbers of medical schools, many sources estimate a physician shortage of 50,000 providers by year 2025. To address this growing shortage, the number of NP and PA providers in acute care continues to grow as Kartha and colleagues clearly demonstrate in their study, published in this issue of Journal of Hospital Medicine. Their research shows that within hospitals in the Veterans Health Administration (VHA)—the largest coordinated healthcare association in the United States—fully half of all inpatient medical teams are utilizing NPs and PAs in some capacity, most commonly in staffing models working directly with attending physicians or on teams with housestaff. Many different practice models exist that incorporate NPs and PAs into acute care settings, including models in general medicine and intensive care settings, as well as in specialty care populations such as patients with diabetes or congestive heart failure. Few studies, however, delineate specific roles for NPs or PAs in inpatient acute care or provide outcomesbased evidence in support of the proposed models. This is in contrast to research available regarding NP and PA staffing models in the outpatient setting. In the current study, Kartha et al. shed light on the use of NPs and PAs in inpatient medical units at the VHA. Their findings show that the majority of NPs and PAs on the inpatient team function mostly autonomously and perform tasks including performing histories and physicals, writing progress notes, placing orders, and communicating with primary care providers and consultants. Almost half also serve on hospital committees and participate in quality improvement activities. Interestingly, although the training and regulation of NPs and PAs differ considerably, Kartha et al. found that the scope of practice of these providers is generally the same. PAs are more likely to perform procedures and teach nonphysician students but otherwise function similarly to NPs. The clinical workload for NPs and PAs also does not differ, with an average of 6.5 patients seen per day. This information is crucial when analyzing the cost-effectiveness of these providers, especially in light of evidence suggesting that hospitalist physicians typically care for approximately twice as many patients. Although Kartha et al. focus primarily on describing the scope of NPs and PAs in hospital medicine, they also report on outcomes. Their findings show that presence of NPs and PAs on inpatient teams did not alter patient or nurse satisfaction nor were there any consistent improvements in the perception of care coordination. Of note, assessment of care coordination was based on survey responses from nurse managers and chiefs of medicine, individuals who are not necessarily direct members of the inpatient team, thus questioning the validity of this measure. Other studies on NP/PA models have also focused on patientcentered outcomes. A study by Roy et al. found that an inpatient PA-run service supervised by hospitalists was comparable with a traditional resident-run service, with no significant differences in risk-adjusted length of stay (LOS), mortality, intensive care unit (ICU) transfers, or hospital readmissions. Although total costs were lower on the PA service, this difference was minimal. Gershengorn et al. examined the impact of nonphysician staffing in an ICU setting and again found equivalent care. In this study, an ICU team staffed by NPs and PAs had similar hospital mortality and LOS as compared with a standard housestaff ICU service. Both these studies have limitations in that they are retrospective analyses rather than randomized controlled trials, and they were conducted at academic medical centers, thus narrowing *Address for correspondence and reprint requests: Nita Kulkarni, MD, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, 251 E. Huron St., Suite 16-738, Chicago, IL 60611; Telephone: 312-926-5924; Fax: 312-926-6134; E-mail: nkulkarn@nmh.org