1 Physician Associates in Secondary Care (PA-SCER) SYSTEMATIC REVIEW: PROTOCOL Authors: Halter M, Wheeler C, Pelone F, Drennan V

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.

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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

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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].

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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, healthcare 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.

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 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 of episodic undifferentiated physical and behavioural disorders; it further encompasses an understanding of the development of prehospital and in hospital emergency medical systems and the skills necessary for this development.’ [27]  mental health /psychiatry ‘Mental health problems can take many forms including depression, schizophrenia, eating disorders, anxieties, phobias, drug and alcohol abuse, post-traumatic stress disorder, and dementia.’[28] Psychiatry includes the sub specialties of child and adolescent, forensic, general adult, old age, psychotherapy and psychiatry of learning disabilities. [29] - trauma and orthopaedics Trauma and orthopaedics is an area of surgery concerned with injuries and conditions that affect the musculoskeletal system (the bones, joints, ligaments, tendons, muscles and nerves).[30]

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3. METHODS

3.1 Scoping review

A preliminary assessment of potentially relevant literature and its size for review was carried out via a scoping search using Medline to identify papers relevant to the study’s objectives [31]. The ‘scoping’ search yielded 1,513 articles (see appendix 1). Although this search was clearly limited by its use of just one database, it was indicative that a body of literature was available for review and that a search strategy that aimed to be inclusive identified a potentially large number of studies for review.

However, review of the titles and abstracts of these search results, alongside discussion with the wider research team for the National Institute for Health Research (NIHR) study (http://www.nets.nihr.ac.uk/projects/hsdr/141926) - investigating the contribution of physician associates to secondary care - within which this review is being carried out, led to refinements to the three main search components – role terms for physician associates, specialties included and terms to measure impact – and to the search limits. The agreed search strategy for Medline is shown in Table 1.

The scoping also suggests that studies of diverse designs, including qualitative, quantitative and mixed methods designs may be included and that a mixed studies review, addressing a complex review question [32] is desirable in order to combine the strengths of quantitative and qualitative research [33].

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Table 1: Medline search strategy – 10th December 2015 # Searches Results 1 exp Physician Assistants/ 4728 2 exp Pediatric Assistants/ 66 3 ("assistant practitioner" or "assistant practitioners" or "associate practitioner" or "associates practitioner" or "clinical assistant" or "clinical 3038 assistants" or "clinical associate" or "clinical associates" or "medical assistant" or "medical assistants" or "medical associate" or "medical associates" or "physician assistant" or "physician assistants" or "physician associate" or "physician associates" or "surgical assistant" or "surgical assistants" or "surgical associate" or "surgical associates").tw. 4 1 or 2 or 3 6327 5 exp Emergency Medicine/ and (speciali?ed or specialty or hospital$ or secondary or care or medicine).tw. 6322 6 ((accident and emergency) or A&E department or emergency department or casualty or emergency Medicine).tw. 58505 7 (emergency adj3 (medic* or servic* or ward* or department)).tw. 67661 8 (exp critical care/ or exp intensive care/) and (speciali?ed or specialty or hospital$ or secondary care or medicine).tw. 12476 9 ((intensive adj3 care) and (speciali?ed or specialty or hospital$ or secondary care or medicine)).tw. 42397 10 exp Internal Medicine/ and (speciali?ed or specialty or hospital$ or secondary care or medicine).tw. 16860 11 (internal medicine and (speciali?ed or specialty or hospital$ or secondary care or medicine)).tw. 17537 12 (Acute Medicine or acute internal medicine or acute medical unit$ or medical assessment unit$ or acute ward$).tw. 805 13 (exp Orthopedics/ or exp Traumatology/) and (speciali?ed or specialty or hospital$ or secondary care or medicine).tw. 2676 14 ((Trauma or Orthop?dic$) adj3 (speciali?ed or specialty or hospital$ or secondary care or medicine)).tw. 3688 15 (Orthop?dic surgery or trauma surgery).tw. 6291 16 ((bone$ or joint$ or ligament$ or tendon$ or muscle$ or nerve$) adj3 (operation$ or surgery or replacement$)).tw. 20173 17 (exp geriatrics/ or Aging/ or exp Aged/ or older people.mp. or exp Frail Elderly/) and (speciali?ed or specialty or hospital$ or secondary 272499 care).tw. 18 ((Older adult or Aged or elderly or geriatric* or older people* or ag?ng) adj3 (speciali?ed or specialty or hospital$ or secondary care or 9377 medicine)).tw. 19 (speciali?ed or specialty or hospital$ or secondary care or medicine).tw. 1188465 20 exp hospital department/ or exp Outpatients/ or Outpatient Clinics, Hospital/ or ambulatory care/ 198409 21 exp Inpatients/ or Hospitalization/ 93008 Continued overleaf

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Table 1: Medline search strategy – 10th December 2015 continued # Searches Results 22 (ambulatory care or ambulatory emergency care).tw. 6841 23 ((outpatient$ or out-patient$) adj3 (speciali?ed or specialty or hospital$ or secondary care or medicine)).tw. 8876 24 ((inpatient$ or in-patient$) adj3 (speciali?ed or specialty or hospital$ or secondary care or medicine)).tw. 14838 25 Mental Health/ or exp "Behavioral Disciplines and Activities"/ or exp "Mental Disorders"/ or exp Psychiatry/ or exp Mental Health Services/ 1532514 26 ((mental* or psychiatr* or psychological* or substance*) adj (ill* or disorder* or disease* or distress* or disab* or problem* or health* or 186606 well-being or wellbeing or patient* or treatment)).tw. 27 exp Primary Health Care/ or exp preventive medicine/ or exp physicians, Primary Care/ 122339 28 (primary care or primary healthcare or primary health care or primary health service$).tw. 86543 29 27 or 28 168039 30 exp Family Practice/ or exp Physicians, Family/ or exp General Practitioners/ or exp General Practice/ 81191 31 (family practice$ or family practitioner$ or family physician$ family medicine$ or General practice$ or General practitioner$ or GPs).ti,ab. 75942 32 30 or 31 118738 33 29 not 32 142532 34 or/5-26,33 2905187 35 exp Treatment Outcome/ or exp "Outcome and Process Assessment (Health Care)"/ or "exp Outcome Assessment (Health Care)"/ or exp 890588 Medical Audit/ or exp Clinical audit/ or exp Program Evaluation/ 36 (experience$ or perception$ or view$ or rate or rates or rating or review or audit or outcome$ or performance or quality or indicator$).tw. 4930861 37 35 or 36 5288431 38 4 and 34 and 37 1054 39 limit 38 to last 20 years 871

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3.2 Inclusion and exclusion criteria

The scoping exercise and research team discussion was used to draft inclusion and exclusion criteria for this systematic review, as follows:

3.2.1 Inclusion criteria

Peer-reviewed papers will be included if they meet the following criteria: - Population: Physician Associates working in the defined specialties [25-30] and in countries according to the UK definition [16,17] are identifiable by separate data in the studies included in the review - Intervention: The implementation of PAs in the following secondary health care specialties: acute medicine, care of the elderly, emergency medicine, mental health and trauma and orthopaedics. - Comparison: The comparison group will be any health care professional to whom PAs are being compared, where a comparator is given. - Study design: Any study design that allows measurement of impact (of interventions and of processes of care whose outcome is measured other than through self-report) in a primary study (including papers meeting our inclusion criteria from within reviews identified in the search strategy). - Outcomes: The outcomes included will depend on the types of impact measured in the studies included but will be related to measures of effectiveness, safety and experience and are likely to include measures of impact on structures, on processes and on outcomes. Papers published in any language will be included initially in order to increase precision and reduce bias [34].

3.2.2 Exclusion criteria

Peer-reviewed papers will be excluded if they meet the following criteria:

- Studies that report on mid-level providers as internationally defined [35], but working in countries that are not defined by the International Monetary Fund as advanced economies [36]. - Studies that do not report impact of PAs as defined in the inclusion criteria, including descriptive accounts of PA demography or workload; descriptive or PA self-report of process of care, competency or clinical practice where no outcome is measured; where PAs are included as

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deliverers of an intervention rather than being the focus of the intervention; or where the focus is on educational processes - Reviews - Papers that do not report empirical findings - Papers published only in abstract form - Studies that present their results for PAs in an amalgamated form with the results for other professions/mid-level providers - Studies that do not describe or distinguish the specialties they are reporting on - Papers published before 1995.

3.3 Search strategy

The search strategy and terms for the review will be guided by a systematic approach to the research questions (table 2).

Table 2: Search strategy development

Aspect Definitions A health professional trained in a medical model to work in all settings and Population undertake physical examinations, investigations, diagnosis, treatment, and characteristic prescribe within their scope of practice as agreed with their supervising doctor. Any intervention regarding the implementation of PAs in the following Intervention secondary health care specialties: acute medicine, care of the elderly, emergency medicine, mental health and trauma and orthopaedics Any health care professional to whom PAs are being compared, where a Comparator comparator is given. Impact on patients’ experience and outcomes, service organisation, working Outcomes practices, costs and other professional groups

Study Design Any

We will conduct our searches using the following data sources:

 MEDLINE (Ovid)  EMBASE (Ovid)  Applied Social Sciences Index and Abstracts (ASSIA)

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 CINAHL Plus (EBSCO)  SCOPUS –V.4 (Elsevier)  PsycInfo  Social Policy and Practice (Ovid)  EconLit (EBSCO)  The Cochrane Library

In addition the following additional ‘lateral searching’ techniques will also be used for papers included in the review following the full text selection process:  checking reference lists  using the ‘Cited by’ option on Scopus, and the ‘Related articles’ option on PubMed, as recommended in searching for studies of complex interventions [37]  contacting leading researchers and expert practitioners in the field (defined as the authors of the papers included in the full text included articles and their reference lists) to help identify any other empirical research published in peer-reviewed journals they know of that we have not identified through our search strategy.

3.4 Methods for study selection

3.4.1 Selection for full text reading from abstracts

The results of the electronic search will be downloaded into an Excel spreadsheet. Article duplicates will be removed. Relevant reviews will be selected according to eligibility criteria using a two-step screening process: 1) Title and abstract screening; and 2) full-text screening. Two reviewers in parallel will review titles and abstracts of all the articles resulted to ascertain their eligibility. Disagreements will be resolved by peer discussion and a third view from the project lead or other research team members if required.

3.4.2 Selection for inclusion after full text reading

All the full-texts of the potentially relevant citations will be examined in parallel by two reviewers to analyse whether they meet all the inclusion criteria using specific checklists (including objective, methodological features and conclusion of each review). A small sample will be reviewed by a third

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reviewer from the research team. Disagreements will be resolved by peer discussion and a third view from the project lead (VMD) if required.

Each paper that is included in the review will then be read to carry out an assessment of the risk of bias/assessment of quality, and data extraction, as described below.

3.5 Assessment of quality of the studies

We will follow guidance in the assessment of quality appropriate to the study’s design and we anticipate quantitative, qualitative and mixed methods papers to be included. As a general principle we will assess quality by the potential sources of bias and credibility of the discussion and conclusions as suggested by the results. For quantitative research, quality will be assessed by “the extent to which a study's design, conduct, and analysis have minimized selection, measurement, and confounding biases…..” [38, 39] For qualitative research, emphasis will be placed on integrity, transparency and transferability [40, 41].

Following the Centre for Reviews and Dissemination guidance [31], we will take a systematic approach to the assessment of quality of the included studies, using a published checklist that does not focus on producing a composite score of quality, rather is explicit about assessing the components of a study that determine quality. We have selected to use the following assessment tools:  QualSyst [42], that provides two sets of questions, one for qualitative and one for quantitative studies, the latter of which can be applied to quantitative studies of any design and aims to distinguish studies of higher quality by design. As scoring systems are seen to be problematic in systematic reviews [31] we will not use Kmet’s summary score [42] to inform the selection of a minimum threshold of quality of studies selected for inclusion in the review, rather for the following purpose: “differences in the scores within study designs, and across research paradigms, should prove useful when synthesizing information and exploring the heterogeneity of study results.” [42: p10]  the Mixed Methods Appraisal Tool (MMAT) [43], that allows reviewers to concomitantly assess the methodological quality of studies with diverse designs [44]. The tool has undergone content validity checks and continues to undergo reliability checks. While improvement in relation to some aspects have been recommended, it has been confirmed to be an efficient tool [33].

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3.6 Data extraction

Two review authors will independently extract data from the studies using a predefined data extraction form. Discrepancies will be resolved through discussion. The data extraction forms will provide information on:  General characteristics of studies: author, year, setting (including country and health care system), theoretical framing, authors’ aims/ research question(s);  Descriptive characteristics: study design; population, sample, recruitment, outcome measures  Results: key findings / results,  Limitations: noted by authors and reviewers  Conclusions: noted by authors  Reviewer(s)’ notes. If necessary, we will seek additional information from the study authors.

3.7 Approaches for data synthesis

Dependent on the numbers of papers in the review we will group them initially for analysis into the five clinical specialties we are investigating. Within each of these specialties, as we anticipate carrying out a mixed studies review, we expect to encounter heterogeneity of settings, populations, samples, interventions and outcome measures, lending complexity to synthesis. Overall, data will therefore be analysed qualitatively to identify broad conclusions across the included studies. Within this, however, we will consider separating the narrative about quantitative, qualitative and mixed methods studies, should that be appropriate to the presentation of impact. For the quantitative results we will carry out an assessment of the potential for undertaking a meta-analysis once papers for review have been finalised and data extraction completed. Qualitative and quantitative evidence will be treated equally in this review, and presented as a thematic meta- synthesis [45]. This narrative synthesis will be conducted against the four elements in guidance on the conduct of narrative synthesis in systematic reviews [46,47]:  developing a theory of how the intervention works, why and for whom (considering whether a causal chain linking the intervention to the outcomes of interest has emerged in the quantitative studies or developing a theory of the elements that contribute to an aspect of PA impact from qualitative studies);

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 developing a preliminary synthesis of findings of included studies (using tabulation and grouping against individual outcome measures (e.g. patient throughput) if the number of papers allows this, or against the generic outcomes of effectiveness, efficiency, appropriateness, acceptability, access and equity [22] where heterogeneity of detailed outcome measures is found;  exploring relationships within and between studies (using conceptual mapping and visual representations of relationships between study characteristics and outcomes);  assessing the robustness of the synthesis (through formal quality assessment as well as reflection).

The concepts of ‘signal’ and ‘noise’ will be used here to ensure the weight of evidence is systematically and transparently considered in this process. [48]

3.7 Review Panel

The study lead will review progress and check adherence to the review protocol at three points: completion of searches, completion of the selection of articles for inclusion, completion of data extraction. At each of these stages the study lead will be sent a record of the processes and outcomes of decisions made by the review team and will be asked to check the team’s decisions and offer general guidance on progressing the review. In addition, progress against the systematic review will be presented to the PA-SCER Research Team bi-monthly meetings in December 2015, February and April 2017, with opportunities there and between to comment on the protocol and its application, with a view to PA-SCER team authorship on any publication, according to contributions made

4. REPORTING

We will register the reviews on PROSPERO and will also seek to publish the review of interventions in an open access, peer reviewed journal.

We will adhere to the PRSIMA guidelines for reporting [15].

5. PROJECT TIMETABLE

The project is scheduled to produce a completed review by the end of April 2016. Completion is defined as the production of a summary written report for insertion into the PA-SCER NIHR Final

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Report, with an update in September 2017, and a paper prepared for submission to a journal in April 2016. This will be achieved against the timetable in Table 3.

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Table 3: Proposed timetable for delivery of the combined reviews

Month Week Task Who is responsible Amount of time Issues/Contingencies beginning November 2015 16th Write draft review protocol inc. draft search strategy and MH 2 days identification of quality assessment tools 23rd Protocol /search strategy revisions VMD,CW,FP 3 days 30th Protocol revisions and out to steering group (Dec 2nd) MH 1 day Provisional selections from Medline draft search strategy (= CW,FP,MH 1 day each skim read of titles and abstracts and propose any refinements) December 2015 7th Steering group discussion Mary 2 hours (Following steering group) CW,FP,MH 1 day? Amount/type of core Revise protocol / searches team feedback Write PROSPERO submission CW,FP,MH 3 hours Run initial searches against protocol search strategies/ FP,CW 2 days organise search results into Excel/ distribute spreadsheets for parallel selections 14th Continue Run initial searches against protocol search FP,CW 1 day strategies/ organise search results into Excel/ distribute spreadsheets for parallel selections Start Parallel selections (apply inc/exc criteria to all search CW,FP,MH 1 day each Size of database hits results 21st Team discussion of selection process CW,FP,MH 3 hours Continue Parallel selections (apply inc/exc criteria to all CW,FP,MH 1 day each Size of database hits search results January 2016 4th Continue Parallel selections (apply inc/exc criteria to all CW,FP,MH 1 day each Size of database hits search results Team discussion of selection process CW,FP,MH 1 hour 11th Continue Parallel selections (apply inc/exc criteria to all CW,FP,MH 2 days each Size of database hits search results Team discussion of selection process CW,FP,MH 3 hours 18th Locate all full text articles CW 2 days Number of articles included Start Parallel selection of full text articles for inclusion CW,FP,MH 2 days each Number of articles included Team discussion of selection process CW,FP,MH 2 hours 25th Continue Parallel selection of full text articles for inclusion CW,FP,MH 2 days each Number of articles included Team discussion of selection process CW,FP,MH 2 hours PRISMA flowchart CW 3 hours Write up method MH 1/2 day 160203_PA-SCER_SYSTEMATIC REVIEW_Protocol_Finalised 16

Table 3: Proposed timetable for delivery of the combined reviews February 2016 1st Data extraction and quality assessment CW,FP,MH 2 days each Number of articles included / case study workload Team discussion of extraction and QA CW,FP,MH 2 hours 8th Data extraction and quality assessment CW,FP,MH 2 days each Number of articles included / case study workload Team discussion of extraction and QA CW,FP,MH 2 hours 15th Data extraction and quality assessment CW,FP,MH 2 days each Number of articles included / case study workload Team discussion of extraction and QA CW,FP,MH 2 hours 22nd Start thematic analysis / meta analysis if supported MH,CW Start Tabulation of included articles MH,CW 29th continue thematic analysis / meta analysis if supported MH,CW continue Tabulation of included articles MH,CW March 2016 7th continue thematic analysis MH,CW continue Tabulation of included articles MH,CW 14th continue thematic analysis / meta analysis if supported MH,CW continue Tabulation of included articles MH,CW 21st Write up analysis/report section MH,CW,VMD 28th Write up analysis / report section MH,CW,VMD April 2016 4th Write paper MH,CW,VMD 11th Write paper MH,CW,VMD 18th Paper to all team members and collaborators MH

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20. Pappas MD. Stop calling nurse practitioners mid-level providers. 2014 Kevin MD.com. http://www.kevinmd.com/blog/2014/07/stop-calling-nurse-practitioners-mid-level-providers.html. Accessed 24 November 2015.

21. Brown A, Cornetto G, Cumbi A, de Pinho H, Kamwendo F, Lehmann U et al. Mid-level health providers: a promising resource. Rev Peru Med Exp Salud Publica. 2011; 28(2): 308-15.

22. Maxwell R. Dimensions of quality revisited: from thought to action. Quality in Health Care 1992:1:171-177. 23. Donabedian A. The quality of care. How can it be assessed? JAMA 1988;260:1743–8. http://dx.doi.org/10.1001/jama.1988.03410120089033 24. Department of Health. High Quality Care For All NHS Next Stage Review Final Report. 2008. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/228836/7432.pdf Accessed 10 December 2015. 25. Royal College of Physicians. Acute medical care; the right person, in the right setting—first time. Report of a working party. London: RCP, 2007. 26. Conroy S, Cooper N. Executive summary. British Geriatrics Society, 2012. http://www.bgs.org.uk/index.php/topresources/publicationfind/goodpractice/44-gpgacutecare%20 Accessed 24 Nov 2015.

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27. International Federation for Emergency Medicine. About IFEM IFEM Definition of Emergency Medicine. 2008. http://www.ifem.cc/About_IFEM.aspx Accessed Nov 24 2015. 28. Royal College of Psychiatrists. Glossary of Terms Professionals involved in the care of people with mental health problems. 2015. http://www.rcpsych.ac.uk/healthadvice/moreinformation/definitions/professionalsinpsychiatry.asp x. Accessed 10 December 2015. 29. Royal College of Psychiatrists. A Career in Psychiatry. 2015. http://www.rcpsych.ac.uk/discoverpsychiatry/acareerinpsychiatry.aspx Accessed 10 December 2015. 30. NHS Choices. Trauma and Orthopaedics (Orthopeadic Surgery) 2015. http://www.nhs.uk/Conditions/orthopaedics/Pages/Introduction.aspx 31. Centre for Reviews and Dissemination. Systematic Reviews CRD’s guidance for undertaking reviews in healthcare CRD, University of York, 2009. 32. Pluye, P., Hong, Q.N., 2014. Combining the power of stories and the power of numbers: mixed methods research and mixed studies reviews. Annu. Rev. Public Health 35, 29–45. 33. Souto RQ, Khanassov V, Hong QN, Bush PL, Vedel I, Pluye P. Systematic mixed studies reviews: Updating results on the reliability and efficiency of the mixed methods appraisal tool. Int J Nurs Stud. 2014: DOI: http://dx.doi.org/10.1016/j.ijnurstu.2014.08.010 34. Moher D, Fortin P, Jadad A et al. Completeness of reporting trials published in languages other than English: implications for conduct and reporting of systematic reviews. Lancet 1996; 347: 363–366. 35. World Health Organization Global Health Workforce Alliance. Mid-level health providers a promising resource to achieve the Health Millennium Development Goals. World Health 2010. http://www.who.int/workforcealliance/knowledge/resources/Final_MLP_web_2.pdf Accessed 14 December 2015. 36. International Monetary Fund. Table B1. Advanced Economies: Unemployment, Employment, and Real GDP per Capita. https://www.imf.org/external/pubs/ft/weo/2015/01/pdf/tblpartb.pdf Accessed 14 December 2015. 37. Greenhalgh T, Peacock R. Effectiveness and efficiency of search methods in systematic reviews of complex evidence: Audit of primary sources. BMJ 2005;331:1064–65 38. Agency for Healthcare Research and Quality. (2002). Systems to Rate the Strength of Scientific Evidence: Summary (pp. 1–11). 39. Altman DG, Sterne JAC. Chapter 8: assessing risk of bias in included studies. In: Higgins JPT, Green S. eds. Cochrane handbook for systematic reviews of interventions Version 5.1.0 Chichester: The Cochrane Collaboration and John Wiley & Sons Ltd, 2009.] 40. Walsh D, Downe S. (2006). Appraising the quality of qualitative research. Midwifery, 22(2), 108–19. doi:10.1016/j.midw.2005.05.004

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41. Public Health Resource Unit, Critical Appraisal Skills Program. (2009). Critical appraisal tool for qualitative studies. Retrieved from http://www.phru.nhs.uk/Doc_Links/Qualitative%20Appraisal%20Tool.pdf 42. Kmet LM, Lee RC, Cook LS. Standard quality assessment criteria for evaluating primary research papers from a variety of fields. Edmonton: Alberta Heritage Foundation for Medical Research (AHFMR). http://files.deslibris.ca/cppc/200/200548.pdf Accessed November 24 2015. 43. Pluye P, Robert E, Cargo M., Bartlett G, O’Cathain A, Griffiths F, Boardman F, Gagnon MP, & Rousseau MC. (2011). Proposal: A mixed methods appraisal tool for systematic mixed studies reviews. Retrieved on 24 November 2015 from http://mixedmethodsappraisaltoolpublic.pbworks.com 44. Crowe M, Sheppard L. 2011. A review of critical appraisal tools show they lack rigor: alternative tool structure is proposed. J. Clin. Epidemiol. 64;79–89. 45. Thomas J, Harden A: Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Meth 2008;8:45. 46. Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews. ESRC Research Methods Programme; 2006. 47. Noyes J & Lewin S. Chapter 6: Supplemental Guidance on Selecting a Method of Qualitative Evidence Synthesis, and Integrating Qualitative Evidence with Cochrane Intervention Reviews. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, Lockwood C (editors), Supplementary Guidance for Inclusion of Qualitative Research in Cochrane Systematic Reviews of Interventions. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. Available from URL http://cqrmg.cochrane.org/supplemental-handbook-guidance Last accessed January 2015. 48. Edwards A, Elwyn G, Hood K, Rollnick S. Judging the ‘weight of evidence’ in systematic reviews: introducing rigour into the qualitative review stage by assessing Signal and Noise. Journal of Evaluation in Clinical Practice 6(2):177-184.

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APPENDIX 1: SCOPING REVIEW (PRELIMINARY MEDLINE SEARCH STRATEGY – 24/11/2015) See Appendix 2 for definitions of MeSH terms used

# Concept Search Terms Results 1 exp Physician Assistants/ 2410 2 exp Pediatric Assistants/ 26 3 Physician Assistant$.tw. 1498 4 Feldsher$.tw. 17 5 Clinical Officer$.tw. 135 6 Physician Associates Paramedical Practitioner&.tw. 0 7 Medical Assistant$.tw. 324 8 Allied Health Personnel.tw. 48 9 physician associate$.tw. 37 10 (mid level adj3 provider$).tw. 124 11 ((assistant* or technician* or officer* or associate$) adj2 (physician$ or surgical or clinical$ or practitioner$ or medical$ or provider$)).tw. 24985 12 exp Emergency Medicine/ and (speciali?ed or specialty or hospital$ or secondary or care or medicine).tw. 4983 13 ((accident and emergency) or A&E department or emergency department or casualty or emergency Medicine).tw. 47842 Emergency 14 (emergency adj3 (medic* or servic* or ward* or department)).tw. 54262 Medicine 15 (exp critical care/ or exp intensive care/) and (speciali?ed or specialty or hospital$ or secondary or care or medicine).tw. 23791 16 ((intensive adj3 care) and (speciali?ed or specialty or hospital$ or secondary or care or medicine)).tw. 71552 17 exp Internal Medicine/ and (speciali?ed or specialty or hospital$ or secondary or care or medicine).tw. 16968 Acute 18 (internal medicine and (speciali?ed or specialty or hospital$ or secondary or care or medicine)).tw. 10752 Medicine 19 (Acute Medicine or acute internal medicine or acute medical unit$ or medical assessment unit$ or acute ward$).tw. 690 20 (exp Orthopedics/ or exp Traumatology/) and (speciali?ed or specialty or hospital$ or secondary or care or medicine).tw. 3015 Trauma or 21 ((Trauma or Orthop?dic$) adj3 (speciali?ed or specialty or hospital$ or secondary or care or medicine)).tw. 7280 Orthopaedi 22 (Orthop?dic surgery or trauma surgery).tw. 4466 Secon cs 23 ((bone$ or joint$ or ligament$ or tendon$ or muscle$ or nerve$) adj3 (operation$ or surgery or replacement$)).tw. 13668 dary (exp geriatrics/ or Aging/ or exp Aged/ or older people.mp. or exp Frail Elderly/) and (speciali?ed or specialty or hospital$ or secondary or 24 Care 361294 care).tw. Care of the ((Older adult or Aged or elderly or geriatric* or older people* or ag?ng) adj3 (speciali?ed or specialty or hospital$ or secondary or care or 25 Elderly 15561 medicine)).tw. 26 or/12-25 508965 27 exp Primary Health Care/ or exp preventive medicine/ or exp physicians, Primary Care/ 75166 28 (primary care or primary healthcare or primary health care or primary health service$).tw. 68593 29 27 or 28 111510 Primary 30 exp Family Practice/ or exp Physicians, Family/ or exp General Practitioners/ or exp General Practice/ 47498 care 31 (family practice$ or family practitioner$ or family physician$ family medicine$ or General practice$ or General practitioner$ or GPs).tw. 47129 32 30 or 31 72038 33 29 not 32 91680

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Outpatient (exp Outpatients/ or Outpatient Clinics, Hospital/ or ambulatory care/) and (speciali?ed or specialty or hospital$ or secondary or care or 34 18427 and medicine).tw. 35 inpatient (exp Inpatients/ or Hospitalization/) and (speciali?ed or specialty or hospital$ or secondary or care or medicine).tw. 49797 36 care (ambulatory care or ambulatory emergency care).tw. 3948 37 ((outpatient$ or out-patient$) adj3 (speciali?ed or specialty or hospital$ or secondary or care or medicine)).tw. 11455 38 ((inpatient$ or in-patient$) adj3 (speciali?ed or specialty or hospital$ or secondary or care or medicine)).tw. 24157 Treatment Outcome/ or "Outcome and Process Assessment (Health Care)"/ or "Outcome Assessment (Health Care)"/ or Medical Audit/ or 39 769470 Program Evaluation/ 40 exp Patient Readmission/ or exp Length of Stay/ or exp Clinical Audit/ or exp Medical Audit/ 68267 41 Health Planning/ and (organi?ation* or system* or hospital* or Physician* or workforce or staff or professional*).tw. 2686 42 Efficiency, Organizational/ and (organi?ation* or system* or hospital* or Physician* or workforce or staff or professional*).tw. 8952 43 Resource Allocation/ and (organi?ation* or system* or hospital* or Physician* or workforce or staff or professional*).tw. 1377 44 Health Personnel/ and (organi?ation* or system* or hospital* or Physician* or workforce or staff or professional*).tw. 11958 45 Health Manpower/ and (organi?ation* or system* or hospital* or Physician* or workforce or staff or professional*).tw. 2123 46 Medical Staff/ and (organi?ation* or system* or hospital* or Physician* or workforce or staff or professional*).tw. 899 47 Delivery of Health Care/ and (productivity or efficiency or performance or guideline* or quality).tw. 8411 ((equity or difference$ disparit$ or inequalit$ or inequit$) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or 48 2048 impact or influence or effect or outcome or performance or quality)).tw. Impact ((Acceptability or compassion or dignity or satisfaction or dissatisfaction) adj5 (experience$ or perception$ or view$ or rates or rating or 49 16604 review or audit or impact or influence or effect or outcome or performance or quality)).tw. ((Efficiency or productivity or economic$ or benefit) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or impact 50 34565 or influence or effect or outcome or performance or quality)).tw. ((Effectiveness or efficacy or effectivity or capability) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or 51 35758 impact or influence or effect or outcome or performance or quality)).tw. ((Effectiveness or efficacy or effectivity or capability) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or 52 35758 impact or influence or effect or outcome or performance or quality)).tw. ((Access$ or responsiveness or timely or timeliness) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or impact 53 16251 or influence or effect or outcome or performance or quality)).tw. ((Appropriate$ or relevance or relevant) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or impact or influence 54 32405 or effect or outcome or performance or quality)).tw. ((Cost$ or afford$ value for money or financ$) adj5 (experience$ or perception$ or view$ or rates or rating or review or audit or impact or 55 33373 influence or effect or outcome or performance or quality)).tw. 56 or/1-11 26515 57 Impact in Secondary 26 or 33 or 34 or 35 or 36 or 37 or 38 621770 58 Care of Physician or/39-55 959419 59 Associates 56 and 57 and 58 1575 60 limit 59 to (english language and last 20 years) 1513

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APPENDIX 2: MESH --MEDICAL SUBJECT HEADINGS DEFINITION OF SEARCH TERMS USED

(alphabetical [US spellings]) http://www.ncbi.nlm.nih.gov/mesh

Aged: A person 65 through 79 years of age. For a person older than 79 years, AGED, 80 AND OVER is available. Year introduced: 1966. By exploding this term, we do include MeSH terms found below it in the MeSH hierarchy as follows: Aged, 80 and over; Frail Elderly.

Aging: The gradual irreversible changes in structure and function of an organism that occur as a result of the passage of time. By exploding this term, we do include MeSH terms found below it in the MeSH hierarchy as follows: Longevity.

Ambulatory care: Health care services provided to patients on an ambulatory basis, rather than by admission to a hospital or other health care facility. The services may be a part of a hospital, augmenting its inpatient services, or may be provided at a free-standing facility. Year introduced: 1968(1966)

Behavioral Disciplines and Activities: The specialties in psychiatry and psychology, their diagnostic techniques and tests, their therapeutic methods, and psychiatric and psychological services. Year introduced: 1998

Clinical Audit: A detailed review and evaluation of selected clinical records by qualified professional personnel to improve the quality of patient care and outcomes. The clinical audit was formally introduced in 1993 into the United Kingdom's National Health Service. Year introduced: 2008

Critical Care: Health care provided to a critically ill patient during a medical emergency or crisis. Year introduced: 1975

Emergency medicine: The branch of medicine concerned with the evaluation and initial treatment of urgent and emergent medical problems, such as those caused by accidents, trauma, sudden illness, poisoning, or disasters. Emergency medical care can be provided at the hospital or at sites outside the medical facility.

Family Practice: A medical specialty concerned with the provision of continuing, comprehensive primary health care for the entire family.

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Frail Elderly: Older adults or aged individuals who are lacking in general strength and are unusually susceptible to disease or to other infirmity. Year introduced: 1991

General Practice: Patient-based medical care provided across age and gender or specialty boundaries. Year introduced: 2011

General Practitioners: Physicians whose practice is not restricted to a specific field of medicine

Geriatrics: The branch of medicine concerned with the physiological and pathological aspects of the aged, including the clinical problems of senescence and senility.

Hospitalization: The confinement of a patient in a hospital.

Inpatients: Persons admitted to health facilities which provide board and room, for the purpose of observation, care, diagnosis or treatment.

Intensive care: Advanced and highly specialized care provided to medical or surgical patients whose conditions are life-threatening and require comprehensive care and constant monitoring. It is usually administered in specially equipped units of a health care facility. Year introduced: 1992

Internal Medicine: A medical specialty concerned with the diagnosis and treatment of diseases of the internal organ systems of adults. By exploding this term, we do include MeSH terms found below it in the MeSH hierarchy as follows: Cardiology; Cardiac electrophysiology; Endocrinology; Gastroenterology; Hematology; Transfusion Medicine; Infectious Disease Medicine; Medical Oncology Radiation; Oncology; Nephrology; Pulmonary Medicine; Rheumatology; Sleep Medicine Specialty.

Medical Audit: A detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of medical care. Year introduced: 1968

Mental Disorders: Psychiatric illness or diseases manifested by breakdowns in the adaptational process expressed primarily as abnormalities of thought, feeling, and behavior producing either distress or impairment of function. Year introduced: use pre-explosion 1974-1997

Mental Health Services: Organized services to provide mental health care. Year introduced: 1967 Mental Health: The state wherein the person is well adjusted. Year introduced: 1967

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Orthopedics: A surgical specialty which utilizes medical, surgical, and physical methods to treat and correct deformities, diseases, and injuries to the skeletal system, its articulations, and associated structures.

Outcome and Process Assessment (Health Care): Evaluation procedures that focus on both the outcome or status (OUTCOMES ASSESSMENT) of the patient at the end of an episode of care - presence of symptoms, level of activity, and mortality; and the process (ASSESSMENT, PROCESS) - what is done for the patient diagnostically and therapeutically. Year introduced: 1979. By exploding this term, we do include MeSH terms found below it in the MeSH hierarchy as follows: Outcome Assessment (Health Care); Patient Outcome Assessment; Treatment Outcome; Process Assessment (Health Care)

Outcome Assessment (Health Care): Research aimed at assessing the quality and effectiveness of health care as measured by the attainment of a specified end result or outcome. Measures include parameters such as improved health, lowered morbidity or mortality, and improvement of abnormal states (such as elevated blood pressure). Year introduced: 1992

Outpatient Clinics, Hospital: Organized services in a hospital which provide medical care on an outpatient basis. Year introduced: 1978

Outpatients: Persons who receive ambulatory care at an outpatient department or clinic without room and board being provided. Year introduced: 1991(1980)

Pediatric Assistants: Persons academically trained to provide medical care, under the supervision of a physician, to infants and children. Year introduced: 1991(1975)

Physician Assistants: Health professionals who practice medicine as members of a team with their supervising physicians. They deliver a broad range of medical and surgical services to diverse populations in rural and urban settings. Duties may include physical exams, diagnosis and treatment of disease, interpretation of tests, assist in surgery, and prescribe medications. (from http://www.aapa.orglabout-pas accessed 2114/2011) Year introduced: 1995

Physicians, Family: Those physicians who have completed the education requirements specified by the American Academy of Family Physicians. Year introduced: 1974(1972)

Physicians, Primary Care: Providers of initial care for patients. These PHYSICIANS refer patients when appropriate for secondary or specialist care. Year introduced: 2011

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Preventive medicine: A medical specialty primarily concerned with prevention of disease (PRIMARY PREVENTION) and the promotion and preservation of health in the individual. By exploding this term, we do include MeSH terms found below it in the MeSH hierarchy as follows: Environmental Medicine; Occupational Medicine; Preventive Psychiatry.

Primary Health Care: Care which provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (JAMA 1995;273(3):192) Year introduced: 1974(1972).

Program Evaluation: Studies designed to assess the efficacy of programs. They may include the evaluation of cost-effectiveness, the extent to which objectives are met, or impact. Year introduced: 1989. By exploding this term, we do include MeSH terms found below it in the MeSH hierarchy as follows: benchmarking.

Psychiatry: The medical science that deals with the origin, diagnosis, prevention, and treatment of mental disorders.

Traumatology: The medical specialty which deals with wounds and injuries as well as resulting disability and disorders from physical traumas.

Treatment Outcome: Evaluation undertaken to assess the results or consequences of management and procedures used in combating disease in order to determine the efficacy, effectiveness, safety, and practicability of these interventions in individual cases or series. Year introduced: 1992

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