Physician Assistants in Geriatric Medicine

Background: The US population is maturing. As of 2020, over 16% (52 million people) are age 65 or older. With a citizenry that is increasingly "gray," the nation is short of medical providers who specialize in geriatric medical care. For example, the number of geriatrician physicians per 10,000 adults 65 years and older has decreased since 2000, with approximately 5,300 in 2018. Nurse practitioners in geriatric medical care numbered 598 in 2018. Considering that the projected needs by 2030 will be over 30,000, the trajectory of geriatricians is becoming increasingly inadequate for the aging population. Physician assistants (PA) are another class of providers that are lling this geriatric medical care role, although little has been published. To address this role of PAs a study was undertaken. Methods: The National Commission on Certication of Physician Assistants databank provided the number and characteristics of PAs in geriatric medicine and compared them to all other certied PAs. Analyses included descriptive statistics, Chi-Square, and Wilcoxon Rank Sum tests for comparisons between PAs practicing in geriatric medical care vs. all other specialties. Where a comparison between PAs in geriatrics and other specialties was made, a P value of .05 or less was considered statistically signicant. Results: As of 2018, there were 794 certied PAs, or 0.8% of the certied PA workforce, in geriatric medical care. This cadre has grown signicantly since 2013, both in total number (increasing over 373%) and as a percentage of the PA workforce. The median age of certied PAs in geriatrics is 45 years, and 79% are female. Almost half (46%) of PAs in geriatric medicine work in extended care facilities or nursing homes, which differs from PAs in non-geriatrics care. Another 8% work in government facilities and 8% in rehabilitation facilities. In 2018, the mean annual income for this PA group was $106,680. Conclusions: As the American population continues to age, the relative growth of PAs in geriatric medicine makes them a natural part of the solution to the projected physician geriatrician decit. The role of PAs in geriatric medical care remains to be explored.

PAs in geriatrics and other specialties was made, a P value of .05 or less was considered statistically signi cant.
Results: As of 2018, there were 794 certi ed PAs, or 0.8% of the certi ed PA workforce, in geriatric medical care. This cadre has grown signi cantly since 2013, both in total number (increasing over 373%) and as a percentage of the PA workforce. The median age of certi ed PAs in geriatrics is 45 years, and 79% are female. Almost half (46%) of PAs in geriatric medicine work in extended care facilities or nursing homes, which differs from PAs in non-geriatrics care. Another 8% work in government facilities and 8% in rehabilitation facilities. In 2018, the mean annual income for this PA group was $106,680.
Conclusions: As the American population continues to age, the relative growth of PAs in geriatric medicine makes them a natural part of the solution to the projected physician geriatrician de cit. The role of PAs in geriatric medical care remains to be explored.

Background
Increased life expectancy and declining birth rates are changing the demographics of America. At the end of the second decade of the 21 st century, over 52 million people are age 65 or older, making up 16% of the population (USCB, 2018). According to the US Census Bureau, by 2030, all baby boomers will be 65 or older. This will enlarge the older adult population such that one in every ve will be "retirement age" (USCB, 2018). With a population that is increasingly older the nation faces a shortage of medical providers who specialize in geriatric medical care. The number of geriatrician physicians per 10,000 adults older than 65 years has decreased steadily since 2000, and the total geriatrician workforce numbers were approximately 5,300 as of 2018 (Rowe 2016). Nurse practitioners (NPs) in geriatric care are an order of magnitude smaller, numbering 598 in 2018 (HRSA, 2018). Considering that the projected geriatricians needed by 2030 will be over 30,000, the trajectory of medical providers will become increasingly inadequate for the aging population (HRSA, 2017).
To address this "geriatric imperative," greater demands are placed on medical educators to mentor and clinically train clinicians who can meet the needs of the aging population. The National Academy of Medicine recommends that comprehensive humanistic medical education in geriatrics be integrated throughout the curricula of medical schools along with PA and NP education programs (Rowe 2016).
Based on their broad-based primary care medical training, PAs are ideally situated to help meet this increasing shortfall, but there is limited information on the trajectory and practice characteristics of the PA geriatric workforce. To address the limited literature on the subject, we set out to build a pro le of PAs in geriatric medicine. The aim of this project was to describe the stock of PAs in geriatric medical care and set the stage for needed investigation essential to inform research, clinical managers, medical workforce analysts, and policymakers about this overlooked medical workforce.

Method
This study draws on data collected by the National Commission on Certi cation of Physician Assistants (NCCPA). These data contain speci c demographic and self-reported practice information on all certi ed PAs in the US (NCCPA 2020). The NCCPA is the only certifying entity for PAs in the US and thus is uniquely positioned to provide a comprehensive snapshot of certi ed PAs. NCCPA developed an online data collection tool, the PA Professional Pro le, to e ciently gather PA health workforce data. The PA Professional Pro le is based on the US Health Resources and Services Administration (HRSA) recommendations for minimum data sets (MDS) for healthcare professionals. MDS facilitates the creation of national databases with consistent and essential data elements encompassing demographic, educational, credentialing, and practice characteristics of health professionals. This helps to establish comparable data for national workforce research, policy, and planning across different health professions. Certi ed PAs regularly update the data collected via the PA Professional Pro le as they access the secure online portal or when they log Continuing Medical Education activity. Reminders are provided to PAs who have not refreshed the pro le in the last three years. The PA Professional Pro le is an optional algorithm-driven survey consisting of a set of questions about the type and characteristics of the practice where the PA is employed (Glicken 2013).
Certi ed PAs each have a unique login (a PA identi cation number) and a password. NCCPA uses twofactor authentication as an added safeguard. All data are securely stored within NCCPA, and data extraction is permission-based. Researchers external to NCCPA can request de-identi ed and aggregated data from NCCPA for research purposes by completing an application available online.
Data for this study were extracted from the PA Professional Pro le and NCCPA's database. The variables in the pro le instrument are standard variables and remain mostly unchanged since being launched in 2012; however, a few new variables are added yearly. In addition to demographics such as age, gender, and state where licensed the following were the PA Professional Pro le questions used in the present study: Which of the following best describes your principal area of clinical practice? Response options were medical and surgical specialties and sub-specialties.
Which of the following best describes the type of practice setting in which your principal clinical PA position is located? Response options included a hospital, extended care/nursing home, o ce-based private practice etc.
Please estimate your total income before taxes from January -December of the last calendar year from all of your PA positions combined.
Of the total number of certi ed PAs at the end of 2018 (n=131,152), excluded were those who a) did not update their NCCPA pro le in the last three years, or b) indicated they were not active clinically, or c) did not answer the practice specialty question. These criteria resulted in the exclusion of 24.8% of all certi ed PAs, for a nal study population of 98,625. Data on the number of PAs in geriatrics, their distribution, income, and how they compare to certi ed PAs in all other specialties were extracted. Analysis included descriptive statistics as well as Chi-Square and Wilcoxon Rank Sum tests, as appropriate, for demographic and practice characteristics comparisons between PAs practicing in geriatrics vs. all other clinical specialties. For all analyses where a comparison between PAs in geriatrics and other specialties was made, a P value of .05 or less was considered statistically signi cant. Statistical analyses were conducted using R (R Core Team 2020. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria -URL https://www.R-project.org/).

Results
At year's end 2018, 794 certi ed PAs in the US self-identi ed as working in geriatrics, representing 0.8% of the study population (n=98,625). Of note, the proportion of PAs working in geriatrics has grown by over 167% since 2013, while the absolute number of PAs working in geriatrics has increased by 373% since 2013 (Figure 1).
The PA geriatric medicine workforce is, on average, older than PAs practicing in disciplines other than geriatric medicine (median age 45 versus 39, respectively). Over 62% of PAs working in geriatrics are <49 years old (Figure 2). However, geriatrician PAs are underrepresented among the youngest PA age band compared to PAs working in all other specialties (<30 years: 6.8% PAs in geriatrics versus 11.3% nongeriatric specialties), and overrepresented among the oldest PA age group (60+ years: 15.7% geriatrician PAs versus 8.4% non-geriatrician PAs -Chi-Square = 124.966, DF = 4, p <0.001).
The PA geriatric workforce is composed of a higher percentage of female providers than the remainder of the PA workforce. Approximately 79% of PAs working in geriatrics are female as compared to 68% of PAs in non-geriatrics specialties (Figure 3) (Chi-Square = 41.580, DF = 1, p <0.001).
When comparing years of practice between certi ed PAs in geriatric medicine and all certi ed PAs, on average, PAs working in geriatrics tend to have been in practice longer (Table 1). Among recently certi ed PAs (1-5 years), the percent working in geriatrics is less than that of all other specialties (18.3% vs. 28.6%, respectively) (Chi-Square = 81.780, DF = 8, p <0.001). Moreover, PAs working in geriatrics have, on average, been certi ed and practicing longer (W = 46101336, p <0.001); and for those PAs certi ed over 15 years, there is a signi cantly larger percent practicing in geriatric medicine relative to all other specialties ( Table 1).
The principal clinical practice setting of PAs employed in geriatric medicine differs substantially from PAs working outside of geriatrics as a specialty (Figure 4). Almost half (46%) of PAs who report working in geriatrics identify their primary location of employment as extended care facilities or nursing homes, while less than one percent (0.3%) of PAs in non-geriatric specialties work in such settings. Another 23% are o ce-based in private practices, which is less than the 42% of PA in all other specialties who selfreport this employment setting. Additionally, 8% of PAs in geriatrics work in federal government facilities (such as the Department of Veterans Affairs or federal prison), and an additional 8% of PAs in geriatrics work in rehabilitation facilities (Chi-Square = 25906.57, DF = 10, p <0.001).
The distribution of PAs in geriatric practice by state is shown in Figure 5. The ve states with the largest numbers of geriatrician PAs are -Florida, California, Colorado, New York, and Texas.
Self-reported income from PAs in geriatrics was compared to PAs in all other specialties ( Figure 6). The mean income of PAs in geriatrics was $106,680, while the median was $105,000. For PAs in all other specialties, the mean and median were $111,073 and $105,000, respectively. PAs working in geriatric medicine were more likely to earn between $100,001 to $120,000, compared to those in all other specialties (Chi-Square = 14.751, DF = 7, p = 0.039).

Discussion
To the best of the author's knowledge, this is the rst study to describe the demographic and occupational pro le of PAs working in geriatric medicine. At year's end 2018, 0.8% of certi ed PAs were practicing in geriatrics, with signi cant growth (167%) in this specialty practice area over a six-year span.
During this time, the absolute number of PAs practicing in geriatrics grew by 373%. The median age of the 2018 PA cohort practicing geriatric medicine is 45 years, and 79% are female.
The trajectory of PA growth in geriatric medicine is in an acceleration phase, suggesting that this medical specialty is in strong demand. This growth is not matched by physicians and nurse practitioners (HRSA, 2017; HRSA, 2018). For example, the physician geriatrician workforce is anticipated to grow just 17.5% by 2025, to a total of 6,230, with a projected de cit of physician geriatrician providers of 26,980 by 2025 (HRSA, 2017). Nor is it matched by change in the PA workforce during this same time period, which is projected to increase by 31% (2016-2026) (BLS 2020). Not unlike physician geriatricians, the majority of PAs who work with older adults are female (NCCPA, 2018). Moreover, PAs in geriatric medicine practice in states with the highest proportion of older adults such as Florida, California and Texas (US Census).
An important practice distinction for PAs in geriatric medicine is their presence in long term care facilities -almost half (46%) identify working in an extended care or nursing home facility. Less than one percent of PAs in all other specialties list their practice setting as a nursing home or comparable care institution. Another 8% work in rehabilitation localities, compared to <1% of PAs in non-geriatrics specialties. This is similar to the geriatric NP workforce, which is also concentrated in long term care facilities but smaller in number than PAs in geriatric medicine (HRSA, 2019).
Knowing the number and characteristics of the PA geriatric medical workforce is the rst step in taking stock of how medical care is being delivered to an aging American population by a cadre of medical providers. Such medical provider information is needed in planning for a society with a growing number and proportion of older adults, as well as the characteristics of those focused on the care of the aged (Lovink, 2019). This new knowledge holds implications for health workforce planning, deployment projections, policymaking, and estimating numbers of physicians (AAMC, 2019).
In summary, the American physician assistant movement is in a growth phase, and geriatrics is one of the 70 medical and surgical roles where they are represented (NCCPA, 2018). Their numbers are signi cant, and their employment settings suggest this is where high concentrations of older adults are located.

Limitations and Strengths
This study draws upon data from NCCPA's PA Professional Pro le, which is the most comprehensive national collection of workforce data on PAs. The use of self-report data is always subject to misinterpretation of the question and the option of not completing the algorithm-driven questionnaire embedded in the NCCPA secure portal (Barnhill 2017). However, survey participation and validation attestation research suggest the NCCPA data are reliable and overlap well using federal data comparisons (Smith et al., 2020). This authentication is reassuring that the reported results are valid and representative. Future research could triangulate these ndings with national data rooted in state and federal agencies, such as the US Census, Bureau of Labor Statistics, American Community Survey, and others.

Conclusion
Understanding PA characteristics and employment settings is an important footing in how this profession is responding to medical labor supply and demand forces. In this undertaking, a six-year trend analysis revealed that the percent of the PA workforce in geriatric medicine is growing substantially and represents a needed source of expertise in American medical care delivery. That the majority are working in extended care facilities and private physician o ces suggests they are deployed where the older adult medical interface is occurring. With this foundation of the contemporary PA geriatric medical workforce, the next step is to understand the economics of such labor, outcomes of care, relationships with other members of the medical team, and patient satisfaction. Table 1 Years Since Certified -PAs in geriatrics versus non-geriatric specialties 2018