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Contribution of physician assistants/associates to secondary care: a systematic review
  1. Mary Halter1,
  2. Carly Wheeler1,
  3. Ferruccio Pelone2,
  4. Heather Gage3,
  5. Simon de Lusignan4,
  6. Jim Parle5,
  7. Robert Grant1,
  8. Jonathan Gabe6,
  9. Laura Nice5,
  10. Vari M Drennan1
  1. 1 Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London, London, UK
  2. 2 National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
  3. 3 School of Economics, University of Surrey, Guildford, Surrey, UK
  4. 4 Department of Clinical and Experimental Medicine, University of Surrey, Guildford, Surrey, UK
  5. 5 Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
  6. 6 Centre for Criminology and Sociology, School of Law, Royal Holloway, University of London, London, UK
  1. Correspondence to Mary Halter; m.halter{at}


Objective To appraise and synthesise research on the impact of physician assistants/associates (PA) in secondary care, specifically acute internal medicine, care of the elderly, emergency medicine, trauma and orthopaedics, and mental health.

Design Systematic review.

Setting Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles.

Included articles Peer-reviewed articles of any study design, published in English, 1995–2017.

Interventions Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken.

Outcome measures Impact on: patients’ experiences and outcomes, service organisation, working practices, other professional groups and costs.

Results 5472 references were identified and 161 read in full; 16 were included—emergency medicine (7), trauma and orthopaedics (6), acute internal medicine (2), mental health (1) and care of the elderly (0). All studies were observational, with variable methodological quality. In emergency medicine and in trauma and orthopaedics, when PAs are added to teams, reduced waiting and process times, lower charges, equivalent readmission rate and good acceptability to staff and patients are reported. Analgesia prescribing, operative complications and mortality outcomes were variable. In internal medicine outcomes of care provided by PAs and doctors were equivalent.

Conclusions PAs have been deployed to increase the capacity of a team, enabling gains in waiting time, throughput, continuity and medical cover. When PAs were compared with medical staff, reassuringly there was little or no negative effect on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organised in teams is highlighted. Further rigorous evaluation is required to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting.

PROSPERO registration number CRD42016032895.

  • general medicine (see internal medicine)
  • quality in health care
  • physician assistant

This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Contributors MH led the design, execution and writing of this paper, under the direction of the study’s PI VMD and supported by discussion with and written feedback from all coauthors (CW, FP, HG, SL, JP, RG, JG, LN) on the design of the review and interpretation of findings. In addition, MH, CW, FP and VMD searched for literature and carried out data extraction and quality assessment. All authors (CW, FP, HG, SL, JP, RG, JG, LN, VMD) contributed intellectual content to the paper.

  • Funding This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 14/19/26).

  • Disclaimer The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.

  • Competing interests SL: University of Surrey runs a Physician Associate course. JP: chairs the UK and Ireland Board for Physician Associate Education and is the director of the Physician Associate programme at the University of Birmingham.

  • Patient consent Not required.

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

  • Data sharing statement No additional data are available.

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