American Journal of Kidney Diseases, 33

American Journal of Kidney Diseases, 33

Heather Locking-Cusolito

Anderson, J.E., Torres, J.R., Bitter, D. C., Anderson, S.C. & Briefel, G.R. (1999). Role of physician assistants in dialysis units and nephrology. American Journal of Kidney Diseases, 33(4), 647-651.

Summary. The basis for this study was the disturbing prediction by the Nephrology Manpower Study that there will be a critical shortage of nephrologists by the year 2010. Consequently, the authors set out to examine the impact of physician extenders on nephrologists’ ability to care for patients. The authors described demographic data and the responsibilities assumed by a sample of 67 physician assistants (PA) working in nephrology. The information was obtained from a survey mailed to all members of the American Academy of Physician Assistants plus members of the Nephrology Physician Assistants Association — 97 PAs were identified for the survey. The authors also described characteristics of nephrologists who work with PAs or nurse practitioners (NPs). This information was obtained from the Nephrology Manpower Study, which sampled 428 of the estimated 5,000 U.S. nephrologists. Nurse practitioners were excluded from the study because the authors found no central database for NPs working in nephrology.

The following findings were reported in this article. PAs work an average 42.8 [+ or -] 8.2 hours per week. Their usual salary range is $50,000 – $74,999. They care for an average 111 [+ or -] 111 hemodialysis patients (median 88, range 0 – 550). Their responsibilities include a broad cross section of dialysis and nondialysis direct care responsibilities. In addition, the majority participate in quality assurance (67.3%) and staff education (59.6%). Few ([is less than] 5%), however, have significant administrative responsibilities. Nephrologists who work with PAs and NPs spend less time with direct patient care (33.8 [+ or -] 19.5 hours per week versus 41.7 [+ or -] 16.8 hours per week and 35.8 [+ or -] 18.1 versus 42.7 [+ or -] 16.9 hours per week, respectively). However, renal fellows were associated with significantly (p [is less than] .001) less direct nephrologist patient care than either PAs or NPs (30.0 [+ or -] 15.9 hours/week versus 47.3 [+ or -] 14.9 hours per week). The authors concluded that, although PAs perform many of the tasks required to reduce the workload of nephrologists, the data were too limited to assume that the use of PAs allows nephrologists to manage more patients at lower or similar costs with acceptable quality.

Commentary. This study provides a beginning understanding of the role of PAs in the care of nephrology patients. The article emphasizes the direct care responsibilities of the PA in both dialysis-related and nondialysis-related primary and preventive care responsibilities. The direct care responsibilities are characterized by medically delegated psychomotor skills such as femoral or jugular cannulization or Papanicolaou (PAP) smears, and by the writing of medical orders. Notable is the fact that the majority of PAs have their dialysis orders cosigned by physicians. Thirty-six percent report their prescriptions must be cosigned. The majority of PAs participate in quality assurance (67.3%) and staff education (59.6%), but the nature of their participation is not made explicit. Because the impetus for this study was concern about nephrologists’ workload, the overall impact of the PA role on outcomes was not clearly described.

Also notable in this study is the absence of information on NPs. It is unfortunate that at the time this study was conducted there was no central database for nephrology nurse practitioners, which the researchers could have accessed for the survey. According to the Nephrology Manpower Study, there are almost twice as many NPs as PAs working in nephrology.

Heather Locking-Cusolito, MScN, RN, CNeph(C), is a nurse practitioner/CNS in dialysis at St. Joseph’s Health Centre, London, Ontario, Canada.

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