Comparing physician associates and foundation year 1 doctors-in-training undertaking emergency medicine consultations in England: a quantitative study of outcomes

Summary of findings

Our study presents evidence from one English ED and has demonstrated no difference in wait time to consultation, LWBS or reattendance rates within 72 hours, but a significant difference in LOS between patients seen by PAs and FY1 doctors-in-training. We report those patients seen by a PA had a longer average LOS in the ED than those seen by FY1s even when statistical adjustments were made for patient age, time and day of the week and area of the department the patient was seen in, omitting those LWBS and those who were admitted. PAs saw more patients in Majors and Resus while FY1s saw more UTC patients.

How this study is similar or different from prior studies

We believe this to be the first empirical study of the quantitative impact on ED metrics provided by UK-trained PAs in the ED in comparison to FY1 doctors-in-training. The primary outcome of wait times to consultation was reported to be not significantly different in patients waiting to be seen by PA compared with an FY1 doctor in training. This finding was similar to that reported in other studies abroad.23–25 LOS was shown to be significantly increased in those patients seen by a PA compared with those seen by an FY1-doctor in training. This was comparable to a study comparing ED PAs to ED physicians. Here, the overall LOS was increased by 8 min if seen by a PA versus ED physician (82 min vs 75 min, 95% CI −10 to −6; p<0.001).26 Other studies abroad have shown PAs presence to improve the ED LOS.27–29 It may be that UK PAs methods of consultation differ to those overseas. Despite this, the adjusted total average LOS in the department of patients seen by a PA or FY1 was 228 min, which is within the target 4 hour standard (the time a patient waits between arriving to the ED to a decision being made about their onward care or discharge) used by NHS England trusts to measure performance.30

There are differences in the practice of care between the two clinicians; in addition to the lack of prescribing rights and ordering of ionising radiation; PAs tended to work more in higher acuity areas—Resus and Majors, whereas FY1s worked more in the UTC. At the hospital investigated the PAs also covered more shift hours as their core hours than FY1s; working beyond 1600 until midnight and included cover at weekends. FY1 doctors rotate every 4 months, whereas PAs are permanent members of staff. Despite adjusting for the area of the department the patient was seen, actual time and day of the week, nesting the individual clinician and omitting those who were admitted or LWBS, there was still significantly longer LOS for patients seen by PAs in comparison to those seen by FY1 doctors-in-training. A previous study of PAs in the ED showed PAs performance to be higher in lower acuity areas.31 Through assessment of clinical notes as Halter et al performed when comparing PAs and FY2—doctors-in-training; we could have obtained a fuller picture of the process involved in seeing more complex patients, that is, the number of patient investigations required, medications to be prescribed by a doctor; senior reviews or discussions; level of documentation, time taken to refer the patient for example. In their study patients seen by a PA were more likely to have an X-ray performed in the ED compared with patients seen by FY2s.22 This could result in additional time taken with the patients since the PA would have to get the investigations ordered on their behalf from a doctor post discussion.

Our finding of no significant difference in the secondary outcome of ED reattendance rate within 72 days with the same presenting complaint for patients of PAs and FY1 doctors-in-training is consistent with a study comparing the reattendance rates of patients seen by PAs compared with ED physicians in 72 hours.32 The findings were also similar to comparisons of FY2 doctors-in-training and PAs patients reattendance within 7 days.22 Other PA literature from the USA such as Merdler et al reported a reduction in the readmission rates within 48 hours in patients seen by PAs compared with ED doctors.23

Those LWBS have been shown to have a considerable effect of the efficiency and quality of care in EDs.33 Our finding of no significant difference of patients LWBS waiting for a PA versus FY1 doctor in training could suggest similar quality and efficiency of care between the two clinicians. Other studies have shown there to be a difference between PAs and ED doctors in terms of the number of patients LWBS. For example, de la Roche et al found that PA presence reduced the number of those LWBS compared with when a doctor was on duty in the absence of a PA (3.4% vs 1.5%, p<0.001).24 Similarly, Ducharme et al discovered that the chances of a patient LWBS were reduced when a PA was present (44% (95% CI 31% to 63%)).27

This study’s strengths lie in the large data set (duration of four 16-week rotations) enabling a well-powered quantitative comparative analysis of the impact of work carried out by PAs and FY 1 doctors-in-training, in a busy UK ED, against national metrics. The study was also able to statistically control for variations within the department and patient characteristics, which may have affected levels of acuity and complexity.

Our study had some limitations. One such limitation is that the triage score was not yet documented on the electronic systems at the time of study, so adjustments according to triage score were unable to be performed. Also, the decision time to admit was not recorded at the time of the study so, LOS readings may have been lower for patients waiting for a hospital bed on a specialty ward. There was also no linkage to staffing levels and bed capacity on each day which would have been useful to adjust for. Furthermore, as this study was purely quantitative in nature, it is only able to describe numerical patterns. Contextual explanation of these patterns would require qualitative and ethnography methods as a mixed-method approach.

Implications for policy and practice

FY1s are not present in all EDs and this study demonstrates their impact working in the ED as being very efficient in all areas, especially in seeing UTC (lower acuity patients). PAs are particularly able to see large volumes of patients in higher acuity areas. Deployments of these type of clinicians within the ED have the potential to address increasing patient demand within the ED, relieving staffing pressures and ultimately assisting with the efficiency of patients seen in different areas of the ED. The findings of the study can assist the EPIC’s assessment of skill mix as to appropriately allocate staff on a busy ED shift. Improvements in overall ED wait times have been shown to stem from improvements in time to triage.34 This could be a potential area of the department the PA could also work in, as other studies have shown them to reduce wait times, LOS and those LWBS when working in triage.35 36

The findings of no statistical difference in those reattending within 72 hours or LWBS demonstrate similar safety and appropriateness practices between the two clinicians. To further assess safety, future studies could compare reported patient adverse events, near misses and errors between the two clinicians. Future studies could also look at patient’s willingness to not have a significant difference in their wait time to be seen but have a longer LOS in the department if being seen by a PA.

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