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

2. CONDUCTING Research

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

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

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

11. 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.

12. AAPA Bibliography

13. 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

14. 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 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.

15. 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.

16. 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 ( ). 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.

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

18. 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.

19. 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

20. 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

21. 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
>

22. 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

23. 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

24. 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

25. 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.

26. 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

27. 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):
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 ;22(1):83-89.

28. 2015 Mean Compensation
Source: AAPA AAPA salary survey. Unpublished data.

29. 2015 Mean Compensation
Source: AAPA AAPA salary survey. Unpublished data.

30. 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 AAPA Salary Survey. Unpublished data.

31. 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 AAPA Salary Survey. Unpublished data.

32. 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 AAPA salary survey. Unpublished data.

33. AAPA Research research@aapa.org
Questions?
AAPA Research