1. Joint Replacement Group Orthopedic Physician Assistants in Manitoba Dr. Eric Bohm BEng MD MSc FRCSC Mr. Kerry Ten Eyck CA(Cert.) University of Manitoba Joint Replacement Group Concordia Hospital Winnipeg

2. Joint Replacement Group University of Manitoba Joint Replacement Group 4 Arthroplasty trained surgeons 1400 joints per year (2006) –24% revisions Additional 500 procedures/yr –Trauma / Surgical Add-Ons Used physician assistants extensively –Few residents / GP assists

3. Joint Replacement Group University of Manitoba Joint Replacement Group PA Program January 2003 hired 2 PAs May 2006: added 3rd UMJRG “Clinical Assistants” (CAs): –take first call with their supervising physician –provide first assist services in the OR –write post-operative orders & operative note –undertake daily rounds on patients –complete discharge summaries.

4. Joint Replacement Group University of Manitoba Joint Replacement Group PA Program Hospital based Paid for by regional health authority Insured by health authority’s carrier Directly responsible to the 4 surgeons

5. Joint Replacement Group Four Areas Examined 1.Time savings for orthopedic surgeons 2.Perceptions 1.Patients 2.OR & Ward nurses 3.Orthopedic residents 4.Attending orthopedic surgeons 3.Cost analysis: salaries vs GP assist fees 4.Impact on the waiting times for THR/TKR

6. Joint Replacement Group Time Savings

7. Joint Replacement Group Time Savings PA’s involved with 69.4% of 1409 joints Surgeon time savings: –815 hours per year –204 hours per surgeon Four 50 hour work weeks per surgeon

8. Joint Replacement Group Orthopaedic Surgeon Survey Surgical assistance = R5 Improved job satisfaction Safely increased volumes Patient care improved Decrease paperwork / phone calls

9. Joint Replacement Group OR Nurse Survey Improve patient care in OR Provide assistance superior to GPs Necessary for the 2 room model Important team members Occasionally perform some nursing tasks

10. Joint Replacement Group Ward Nurse Survey Improve patient care on Ward Improve information flow Facilitate rounds Important team members Occasionally perform some nursing tasks

11. Joint Replacement Group Orthopedic Resident Survey Relieve residents of workload Allow residents to attend teaching Positive impact on service / education ratio Don’t play large role in teaching residents

12. Joint Replacement Group Patient Survey Improve care Improve information flow PAs are a good idea Important team members Satisfied with care from PAs

13. Joint Replacement Group Costing Analysis Reviewed last 400 procedures of 2006 PAs involved with 69.4% (no GP assist) Forgone GP assist fees $270K Salary for 3 PAs: $270-327K Huge Value Add but Cost Neutral

14. Joint Replacement Group Impact on Primary Care Access? No GP required for 1344 cases Estimate 2 hours of GP time/case 1.5 GPs working 40 hr/wk for 44 wks/yr

15. Joint Replacement Group Impact on Wait Times 8 hour OR day = 3 joint replacements 1.Room & instrument set up 2.Bringing patient into room 3.Anesthetization 4.Positioning, Prepping & Draping 5.Inserting the joint replacement 6.Transporting patient out of room 7.Room clean up >50% of OR time is consumed by non-op steps!

16. Joint Replacement Group “Double Rooms” 1 surgeon 2 clinical assistants 2 anesthesiologists 2 nursing teams 7 patients

17. Joint Replacement Group Waiting Times Permitted double room model Only way for group to  primary volumes Increased 42% from 754 to 1070 cases Median wait times  from 44 to 30 weeks

18. Joint Replacement Group Conclusions PAs important team members that are felt by surgeons, nurses and/or patients to: Improve care Safely increase volumes Improve information flow Decrease surgeon paper work / scutwork Improve surgeon job satisfaction

19. Joint Replacement Group Conclusions Large “Value Add” Salary cost for 3 PAs of approximately $300K allows: –$270K in forgone GP assist fees –1.5 GPs working 40 hrs/wk, 44 wks/yr in primary care –815 hours of “freed up” surgeon time –42% increase in surgical volumes –Reduction in wait times to near benchmark Basically Cost Neutral

20. Joint Replacement Group Concluding Comments My group’s PA experience very positive Different remuneration models possible –Salary –Fee for service –Blended Different work environments possible –Hospital based –Office based IMGs make good PAs Key to HHR issues / service delivery

21. Joint Replacement Group Acknowledgements Mr David Pitman, research, NSC COA Dr Ted Rumble, past chair, NSC COA Mr Chris Rhule, CA discipline director WRHA Mr Jose Araneta CA, WRHA Mr Kerry Ten-Eyck CA(cert.), WRHA