Orthopedic Physician Assistants in Manitoba

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

6. Time Savings

7. 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. Orthopaedic Surgeon Survey • Surgical assistance = R5 • Improved job satisfaction • Safely increased volumes • Patient care improved • Decrease paperwork / phone calls

9. 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. Ward Nurse Survey • Improve patient care on Ward • Improve information flow • Facilitate rounds • Important team members • Occasionally perform some nursing tasks

11. 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. Patient Survey • Improve care • Improve information flow • PAs are a good idea • Important team members • Satisfied with care from PAs

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

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

17. 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. 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. 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. 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. 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