Research and Advocacy March 2017 First presented at the 2017 AAPA Leadership and Advocacy Summit March 2017 Presented by AAPA Research

CONDUCTING Research

Types of Data and Research Methods Sources and Methods to Consider Publicly Available Data Data for Hire/Purchase Peer-Reviewed Research Non-Peer-Reviewed Research Conducting Original Research Clinical, experimental, survey

Publicly Available Data Examples of sources CMS, CDC, HRSA/NPDB, US Census, State License Files Advantages Large data files with data from providers across the country, hard to collect data and variables Disadvantages Complex files that are difficult to manage; not always up to date; do not always breakout PA data

Data for Hire/Purchase Examples of sources Provider 360; MGMA, private organizations Advantages Access to large pre-collected data file on topic of choice; pre-formatted data files Disadvantages Can be quite costly; difficult to evaluate the robustness or quality of data and methods without first purchasing

Peer-Reviewed Research Examples Peer-refereed journals such as Health Affairs, NEJM, JAAPA, etc. Advantages Generally well regarded; reviewed, critiqued by members of the research community before publication; provides a “filter” for biased/bad research; easily searchable through databases Disadvantages Much requires subscriptions; may have limited generalizability Things to consider Different journals = different quality and topical standards for publication; publication does not guarantee high quality

Non-Peer Reviewed Research Examples White papers from think tanks and associations, government reports Advantages Often these type of projects involve in depth analyses of one particular cause or topic, and may provide unique views on publicly available data Disadvantages Not given the scientific scrutiny as peer-reviewed work; bias and agendas are more common Things to consider Authors and organization may have ideological or financial motives

Conducting Original Research Examples AAPA National Survey: topical data collection on the PA workforce; clinical trials; coupling data collected by your organization with publicly available data Advantages Ability to explore topics for which there is no data; complete control over the research process and data dissemination Disadvantages Substantial time and financial commitments; may not provide new insights or may duplicate efforts

Correlation does not imply causation Don’t make a rookie mistake! Correlation does not imply causation

Source: http://tylervigen.com/view_correlation?id=53855

Hypothetical (Unverified) Correlations States with more of the 6 key elements have more PAs One interpretation: The more PA-friendly a state is, the more PAs move to that state to work Another interpretation: The more PAs who are in a state, the more people to lobby legislators to pass PA-friendly laws What’s true? No way to tell from correlational data. Do not make this mistake by choosing a narrative and overstating a claim.

AAPA Bibliography

AAPA Maintains and Updates PA Research Sources AAPA has compiled citations and abstracts on research into PAs along with other members of the healthcare workforce AAPA Bibliography is a rich source of information on work and studies PA practice demographics and characteristics Comparisons between PAs/NPs and physicians Leadership Scope of practice and liability Other work of concern to PAs and advocates for the profession Ultimately, AAPA has a goal to make this document publicly available and searchable Supporting the broader PA research community and furthering advocacy efforts

Employment of PAs/NPs and Malpractice Claims / Liability Hooker, Nicolson, & Le (2009) Source: Journal of Medical Licensure and Discipline Methods: The United States National Practitioner Data Bank was reviewed from 2001-2007 and 324,285 entries were analyzed. Results: 37 percent of physicians, 3.1 percent of PAs and at least 1.5 percent of APNs would have made a malpractice payment during the study period. The physician mean payment was 1.7 times higher than PAs and 0.9 times that of APNs Conclusion: This report indicates there is no reason to suggest that PAs and/or NPs increase liability, but may decrease the rate of reporting malpractice and adverse events.

PAs as Primary Care Providers Everett, Schumacher, Wright, & Smith (2009) Source: The Journal of Rural Health Methods: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). Results: Populations served by PA/NPs and physicians differ demographically but not in complexity. Perceived access to care was lower for patients of PA/NPs, but there were few differences in utilization and no differences in difficulties/delays in care or outcomes. Conclusions: PA/NPs are acting as primary care providers to underserved patients with a range of disease severity.

A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers Kurtzman & Barnow (2017) Source: Medical Care Methods: Analysis of 23,704 patient visits to 1,139 practitioners using the National Ambulatory Medical Care Survey over a 5 year period (2006-2010). Results: There were no statistically significant differences detected between PA care compared with that of PCMD care in 8 of the 9* patient-level outcomes. Of the final outcome there was a significant difference between PAs and PCMDs, indicating visits to PAs received more health education/counseling services than visits to PCMDs (P≤0.01). *NP results not discussed. Conclusions: Based on the variables examined, results indicate that NP and PA care were largely comparable to PCMD care in Health Centers.

AAPA USES RESEARCH TO GUIDE ADVOCACY Previous and Ongoing Work AAPA USES RESEARCH TO GUIDE ADVOCACY

Colorado Practice Barriers We looked at how barriers to practice may impede PA mobility within Colorado. 1. Newly graduated PAs must have close supervision for the first five years; and 2. When a PA changes practice settings, there is a high level of chart review that must occur. We asked How often PAs change practice settings in CO compared to other states or nationally; and Is there any other data that supports the hypothesis that certain laws and regulations are creating unnecessary practice barriers.

Data sources AAPA conducted original research 2015 AAPA National Survey and 2016 AAPA Salary Survey Both are nationally representative sample of PAs in the US. Colorado Academy of PAs conducted a survey

Questions Asked 2015 AAPA National Survey - How often do PAs say that restrictive laws and regulations are a barrier that arises as they try to get the best outcome for their patients? - Time spent with their collaborating physician on site - Time spent consulting with their collaborating physician - Percent of patients collaborating physician sees 2016 AAPA Salary Survey - Percent who changed their role, employer, setting, or specialty in 2015

More Than 5 Years' Experience 5 Years or Less Experience What We Learned 2015 AAPA National Survey - How often do PAs say that restrictive laws and regulations are a barrier that arises as they try to get the best outcome for their patients? Restrictive laws and regulations are a barrier that arises as I try to get the best outcome for my patients More Than 5 Years' Experience 5 Years or Less Experience All PAs Not CO CO US % Other 65.8 64.6 64.0 56.3 63.8 65.0 61.5 64.9 Very Frequently 23.7 20.7 23.6 24.4 27.1 24.0 23.1 23.9 Almost Always 10.5 14.6 10.7 11.7 16.7 11.8 11.0 15.4 11.2 >

What We Learned 2015 AAPA National Survey - Time spent with their collaborating physician on site - Time spent consulting with their collaborating physician Other States Colorado Mean Median All PAs   % time collaborating physician on site 63.4 75.0 66.8 80.0 % time consulting with collaborating physician 18.4 10.0 15.2 PAs with 5 Years of Less Experience 66.0 72.0 85.0 20.0 17.0

What We Learned 2015 AAPA National Survey - Percent of patients collaborating physician sees Collaborating Physician Sees PA's Patients Other States Colorado   % All PAs Not Unless Asked 57.3 62.2 Few Patients (<50%) 13.9 11.5 Most Patients (>50%) 17.2 19.9 All Patients 11.6 6.4 PAs with 5 Years of Less Experience 53.7 53.3 14.0 15.0 19.0 21.7 13.3 10.0

What We Learned 2016 AAPA Salary Survey Percent who changed their role, employer, setting, or specialty in 2015 Changes more likely in Colorado US CO   % Changed role 5.6 5.9 Changed employer 10.8 16.8 Changed setting 9.4 Changed specialty 5.4 6.6 Made no changes 83.9 78.5

Where We Went Next 2016 CAPA Survey: 382 responses from Colorado PAs Of CO PAs surveyed who graduated in the last 5 years (since Jan 1, 2012): 67% respondents reported that CO's restrictions in state law and regulations to some extent hindered them from obtaining a PA position, changing jobs as a PA, or hindered them once they had made the change.   44% (almost half) report that the restrictions and regulations at least moderately hindered them from obtaining a PA position, changing jobs as a PA, or hindered them once they had made the change.  6.7% report that the restrictions and regulations prevented them from obtaining a job.

How We Applied What We Learned AAPA was the only source of data before fielding a survey with CAPA aimed specifically at answering questions regarding practice barriers in Colorado Data from AAPA and survey collaboration with CAPA demonstrated some of what we suspected to be true, and this information was used in advocacy efforts in the state of Colorado CO has only enacted 3 of 6 Key Elements AAPA used a data-driven approach to explore what we anecdotally knew

Compensation Disparity in the PA Profession Salary inequity among male and female PAs have been documented over several decades.1,3 This is despite comparable levels of experience and similar practice characteristics.2 These differences still exist. Oliver, DR, Carter, RD, Conboy JF. Practice characteristics of male and female physician assistants. Am J Public Health. 1984; 74(12): 1398-1400. Willis J. Explaining the salary discrepancy between male and female PAs. Journal of the American Academy of Physician Assistants. 1992;5:280–288.. Coplan B, Essary A, Virdan T, Cawley J, Stoehr J. Salary discrepancies between practicing male and female physician assistants. Women’s Health Issues. 2012;22(1):83-89.

2015 Mean Compensation Source: AAPA. 2016 AAPA salary survey. Unpublished data.

2015 Mean Compensation Source: AAPA. 2016 AAPA salary survey. Unpublished data.

Total Compensation Wage Disparity (Not Controlling for Practice Demographics) PA Gender Mean Base Salary Bonus Receive Mean W2 Total Compensation Men $109,207 $14,586 50.9% $115,815 Women $94,888 $9,503 46.1% $94,026 All PAs $99,718 $11,329 47.7% $101,351 Also: Men are more likely to receive a bonus Men’s bonuses are larger There must be variables that explain the compensation disparity … right? Source: AAPA. 2016 AAPA Salary Survey. Unpublished data.

Sequential Regression Analysis Sequential regression with gender in the final step is a conservative test Initial Steps: Compensation-relevant predictors Geographic Region Major Specialty Area Practice variables (total years as a PA, hours worked, weeks worked) Leadership and military (leadership position, practice ownership, active duty) Bonus: received? Final Step: Gender as a predictor of compensation Source: AAPA. 2016 AAPA Salary Survey. Unpublished data.

Practice Demographics Don’t “Explain Away” the Disparity Wage disparity exists after controlling for practice demographics. It is smaller, but still substantial, in magnitude – $12,838 Larger than the average bonus Source: AAPA. 2016 AAPA salary survey. Unpublished data.

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