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The involvement of physician assistants in inpatient care in hospitals in the Netherlands: a cost-effectiveness analysis
  1. Marijke J C Timmermans1,2,
  2. Geert T van den Brink2,
  3. Anneke J A H van Vught2,
  4. Eddy Adang3,
  5. Charles L H van Berlo4,
  6. Kim van Boxtel5,
  7. Weibel W Braunius6,7,
  8. Loes Janssen8,
  9. Alyssa Venema9,
  10. Frits J van den Wildenberg10,
  11. Michel Wensing1,11,
  12. Miranda G H Laurant1,2
  1. 1 Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ Healthcare), Nijmegen, The Netherlands
  2. 2 HAN University of Applied Sciences, Faculty of Health and Social Studies, Nijmegen
  3. 3 Department of Health Evidence, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
  4. 4 Department of Surgery Venlo, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
  5. 5 Department of Gastroenterology, Jeroen Bosch Hospital, Den Bosch, The Netherlands
  6. 6 Department of Head and Neck Surgical Oncology, UMC Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
  7. 7 Department of Otorhinolaryngology, University Medical Center Utrecht, Utrecht, The Netherlands
  8. 8 Department of Orthopaedics, VieCuri Medical Center Noord-Limburg, Venlo, The Netherlands
  9. 9 Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
  10. 10 Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
  11. 11 Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany
  1. Correspondence to Marijke J C Timmermans; Marijke.Timmermans{at}


Objective To investigate the cost-effectiveness of substitution of inpatient care from medical doctors (MDs) to physician assistants (PAs).

Design Cost-effectiveness analysis embedded within a multicentre, matched-controlled study. The traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which, besides MDs, PAs are also employed (PA/MD model).

Setting 34 hospital wards across the Netherlands.

Participants 2292 patients were followed from admission until 1 month after discharge. Patients receiving daycare, terminally ill patients and children were excluded.

Primary and secondary outcome measures All direct healthcare costs from day of admission until 1 month after discharge. Health outcome concerned quality-adjusted life years (QALYs), which was measured with the EuroQol five dimensions questionnaire (EQ-5D).

Results We found no significant difference for QALY gain (+0.02, 95% CI −0.01 to 0.05) when comparing the PA/MD model with the MD model. Total costs per patient did not significantly differ between the groups (+€568, 95% CI −€254 to €1391, p=0.175). Regarding the costs per item, a difference of €309 per patient (95% CI €29 to €588, p=0.030) was found in favour of the MD model regarding length of stay. Personnel costs per patient for the provider who is primarily responsible for medical care on the ward were lower on the wards in the PA/MD model (−€11, 95% CI −€16 to −€6, p<0.01).

Conclusions This study suggests that the cost-effectiveness on wards managed by PAs, in collaboration with MDs, is similar to the care on wards with traditional house staffing. The involvement of PAs may reduce personnel costs, but not overall healthcare costs.

Trial registration number NCT01835444.

  • Professional role revision
  • substitution
  • physician assistant
  • hospital care
  • resource use
  • costs

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors MGHL and MJCT are responsible for the design of the study, with comments of AJAHvV, MW, EA and GTvdB. MJCT is responsible for the data collection and data management, with direct supervision and feedback from MGHL. MJCT and EA conducted the data analyses. CLHvB, KvB, WWB, LJ, AV and FJvdW were involved in the data collection of the study. MJCT wrote the first draft of the manuscript, and all other authors reviewed this critically. All authors read and approved the final manuscript.

  • Funding This work was funded by the Netherlands Organisation for Health Research and Development (ZonMw), grant number 171202006.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval The Research Ethics Committee of the Radboud university medical center, Nijmegen.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data files are available from the authors on reasonable request.

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