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Physician associates in secondary care (PA-SCER) SYSTEMATIC REVIEW: PROTOCOL Authors: Halter M, Wheeler C, Pelone F, Drennan VM. Faculty of Health, Social Care and Education Kingston University and St George’s, University of London Correspondence to: [email protected] Collaborators (alphabetical): Begg P. Royal National Orthopaedic Hospital Brearley S. Kingston University and St George’s, University of London de Lusignan S. University of Surrey Ennis J. University of Birmingham Gabe J. Royal Holloway, University of London Gage H. University of Surrey Grant R. Kingston University and St George’s, University of London Parle J. University of Birmingham Disclaimer and acknowledgement for all communications The study is called Health Services & Delivery Research Programme Project: 14/19/26 - Investigating the contribution of physician associates (PAs) to secondary care in England: a mixed methods study. This is independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this protocol are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department. 160203_PA-SCER_SYSTEMATIC REVIEW_Protocol_Finalised 1 CONTENTS PROJECT TITLE.................................................................................................................................... 3 1. BACKGROUND ................................................................................................................................ 3 2. REVIEW OBJECTIVES AND QUESTIONS .................................................................................... 3 3. METHODS ......................................................................................................................................... 6 3.2 Inclusion and exclusion criteria .................................................................................................... 9 3.2.1 Inclusion criteria .................................................................................................................... 9 3.3 Search strategy ............................................................................................................................ 10 3.4 Methods for study selection .................................................................................................. 11 3.4.1 Selection for full text reading from abstracts ................................................................ 11 3.4.2 Selection for inclusion after full text reading ................................................................ 11 3.5 Assessment of quality of the studies ..................................................................................... 12 3.6 Data extraction ............................................................................................................................ 13 3.7 Approaches for data synthesis..................................................................................................... 13 3.7 Review Panel .............................................................................................................................. 14 4. REPORTING .................................................................................................................................... 14 5. PROJECT TIMETABLE .................................................................................................................. 14 6. REFERENCES ................................................................................................................................. 18 APPENDIX 1: Scoping review (Preliminary Medline search strategy – 24/11/2015) ......................... 22 APPENDIX 2: MeSH --Medical Subject Headings definition of search terms used ........................... 24 160203_PA-SCER_SYSTEMATIC REVIEW_Protocol_Finalised 2 PROJECT TITLE Evidence of impact of Physician Associates in secondary care: a systematic mixed studies review 1. BACKGROUND Physician Associates (PAs), previously known as physician assistants, are a new and rapidly growing occupational group to the United Kingdom (UK) National Health Service (NHS). PAs are an occupational group whose employment in medical teams in secondary care is being advocated by bodies such as the Royal College of Physicians [1,2], the College of Emergency Medicine [3], the Centre for Workforce Intelligence [4], and Health Education England [5]. Despite actual and predicted exponential growth in PAs in the UK [6] and the role’s 50 year history in the USA [7], there is little published evidence as to their contribution and impact. We identified two systematic reviews of PAs - one across all specialties, published in 2009 [8] and another of primary care alone in 2011 [9] in 2014 when preparing our research protocol (http://www.nets.nihr.ac.uk/projects/hsdr/141926). Since then a number of studies in hospital settings have been published which have reported positive evidence about the contribution PAs make to patient outcomes and resource use in particular specialties in the USA [10-13]. For this reason, alongside the absence of any review of the evidence pertaining to PAs in secondary care specifically, a systematic review is considered justified. This review has been designed to meet the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [14]. 2. REVIEW OBJECTIVES AND QUESTIONS The objective for the review is: To appraise and synthesise the published literature of the impact on patients’ experience and outcomes, service organisation, working practices, costs and other professional groups for the specialties most frequently employing PAs in England drawing on primary research of any method. The specialties were identified from the annual UK Association of Physician Associates Census [15]. 160203_PA-SCER_SYSTEMATIC REVIEW_Protocol_Finalised 3 The review investigates the following overall review question: What is the impact of Physician Associates on patients’ experience and outcomes, service organisation, working practices, costs and other professional groups for the secondary care specialties of acute medicine, care of the elderly, emergency medicine, mental health and trauma and orthopaedics? The review will also include the following sub-questions, to be addressed as the weight of evidence allows: What is the impact of employing PAs with regard to different specialties? What is the impact of employing PAs with regard to different outcomes in each specialty? What contextual factors have an influence on the impact of PAs e.g. specialty, organisational structure, working practices, supervision, length or breadth of experience, personal characteristics? Is evidence of impact transferable across specialty? What gaps appear in the existing evidence? As this review question contains broad terms, these have been defined at the outset, as follows: Physician Associates: trained in a medical model to work in all settings and undertake physical examinations, investigations, diagnosis, treatment, and prescribe within their scope of practice as agreed with their supervising doctor [16,17]. Physician Associates are sometimes described within the term ‘mid-level providers’ in developed economies: ‘…..the term mid-level practitioner means an individual practitioner, other than a physician, dentist, veterinarian, or podiatrist, who is licensed, registered, or otherwise permitted by the United States or the jurisdiction in which he/she practices, to dispense a controlled substance in the course of professional practice. Examples of mid-level practitioners include, but are not limited to, health- care providers such as nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists and physician assistants who are authorized to dispense controlled substances by the state in which they practice.’ [18]. While this term is contested as an appropriate umbrella term due to its hierarchical connotations [19,20] and international variation in usage [21], it appears in the literature regarding Physician Associates. 160203_PA-SCER_SYSTEMATIC REVIEW_Protocol_Finalised 4 Impact: using the broad headings of the components of quality as suggested by Maxwell (1992)[22], augmenting that of Donabedian [23], that is, effectiveness, efficiency, appropriateness, acceptability, access and equity; further consolidated in the aspects of quality set out in the NHS Next stage Review (2008)[24]: patient safety, patient experience and effectiveness of care. Specialties most frequently employing PAs in England [15]: - acute medicine ‘Acute medicine is the part of general (internal) medicine concerned with the immediate and early specialist management of adult patients who present to, or from within, hospitals as urgencies or emergencies’.[25] - care of the elderly ‘…geriatric medicine is mainly concerned with people over the age of 75, although many ‘geriatric’ patients are much older. However, geriatric medicine in the UK is broadly from the age of 65 onwards. Frail older people are those with multiple diseases, that often includes dementia, with reduced functional reserve who tend to present to hospital with ‘geriatric syndromes’ such as falls, confusion and immobility.’[26] - emergency medicine ‘Emergency medicine is a field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum

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