AAPA President Reacts to New RAND Recertification Report

New Research from RAND Corporation on Recertification Requirements for Health Professionals

October 5, 2018

Dear PA Colleagues,

Last February, we announced that AAPA had signed an agreement with the RAND Corporation—a highly respected nonprofit, nonpartisan research organization—to undertake an objective analysis of the landscape and evidence surrounding closed-book examinations and other approaches to recertification.

RAND’s report is now available. In the report, “Identification of Alternative Physician Assistant Recertification Models,” RAND researchers reviewed and assessed existing literature about recertification requirements for PAs, APNs, and physicians in the U.S. and other countries. They also interviewed certifying organizations about recertification approaches.

You will find a brief overview of the findings we believe are most pertinent for PAs following my letter.

AAPA’s Take on Implications for PAs

AAPA believes the purpose of recertification should be to ensure that providers are meeting a standard associated with positive patient outcomes. As PAs, we recognize the critical importance of basing our clinical decisions on the best available evidence. Where evidence is lacking, we take precautions first to do no harm. We believe certifying organizations should apply a similar approach as they determine requirements for recertification.

RAND’s report explores the evidence of whether there is an association between recertification exams and improved patient outcomes. While RAND has identified some relevant evidence that is detailed below, it is limited, lacking in scope and specificity to PAs.

We encourage NCCPA to consider the findings of this RAND report and whether there is sufficient evidence to support the current practice of basing recertification decisions, and by extension, a PA’s ability to practice, on exam performance. As a nation, we simply cannot afford to lose any of our highly trained, experienced providers.

AAPA supports the movement toward longitudinal assessments. It will be important to evaluate the impact of the longitudinal assessment pilot for PAs that will begin in January 2019 and to broadly share the results of that evaluation. This type of research will help all health professions to make evidence-based decisions regarding recertification requirements.

AAPA believes that RAND’s findings suggest that using knowledge assessments to guide the selection of Continuing Medical Education (CME) may present an opportunity for certifying organizations to improve their recertification programs.

We encourage PAs to review the full report.

We hope this RAND review will help PAs and other health professionals, health professional societies, and health professional certifying bodies, make evidence-based decisions about recertification requirements.

Sincerely,

Jonathan E. Sobel, DMSc, MBA, PA-C, DFAAPA, FAPACVS
AAPA President and Chair of the Board

Overview of Recertification Requirements for Health Professionals

Requirements for maintaining, renewing, continuing, or updating certification vary among PAs, among types of APNs and within APN categories, and among physician specialty types. Requirements may involve one or more of the following: CME, Continuing Professional Development, practice improvement activities, self-assessment activities, practice hours or case logs, peer or patient reviews, and exams or longitudinal assessments.

Recertification for PAs: Recertification is required for continued PA licensure or prescribing privileges in 19 states. PA recertification requirements from NCCPA include a closed-book exam. Currently, PAs are the only health professionals who risk losing their license because of their performance on a recertification test. NCCPA’s longitudinal assessment pilot will begin in 2019.

Recertification for APNs: Among U.S. APNs, including nurse practitioners (NPs), certified nurse midwives (CNMs), and certified registered nurse anesthetists (CRNAs), certification is generally required to practice, but only CRNAs have a closed-book recertification exam. However, performance on the exam does not currently impact CRNA recertification, licensure, or the ability to practice, and is not scheduled to do so until 2028. Additionally, the National Board of Certification and Recertification for Nurse Anesthetists (NBCRNA) is currently looking at alternatives to testing.

Recertification for Physicians: RAND found that neither initial nor ongoing board specialty certification is required for physician licensure. Closed-book exams have been required for allopathic physician specialty board certification in the U.S., but three allopathic specialty boards have fully implemented longitudinal assessments as an alternative (Anesthesia, Pediatrics, and Obstetrics and Gynecology) and almost all others are currently implementing, piloting, or planning longitudinal assessments. In contrast, most osteopathic physician specialty boards have implemented closed-book written or computer-based exams into their recertification programs within the last five years.

Impact of Recertification Exams

In its comprehensive review of existing studies, RAND found no studies that estimated the effects of PA recertification requirements or APN recertification requirements on patient care quality or outcomes. RAND also reported that no studies addressed the costs and burdens of PA or APN recertification to individuals or healthcare overall.

RAND found several studies that looked at the connection between recertification exam performance and improved care. These observational studies all involved physician internists, not PAs, and revealed improvement in some, but not all, process quality measures. Two studies addressed intermediate outcome measures (e.g. hemoglobin A1c levels) and patient experience, finding a positive association. The RAND report notes, however, that even the studies that found positive correlations do not necessarily indicate that exams or preparation for them result in improvements in care; the same physicians may have performed better clinically regardless of an exam requirement.

Longitudinal Assessments as Alternative to Closed-Book Exams

RAND also searched for peer-reviewed and grey literature regarding the effectiveness of longitudinal assessments but found no studies that examined the impact of these relatively new assessment mechanisms on clinical process/quality or outcomes.

Longitudinal assessments, defined as “spaced, repeated testing and interleaving of related content,” have been implemented or are being piloted by some certifying organizations, including the National Commission on Certification of PAs (NCCPA). These assessments are expected to improve knowledge retention. They are generally shorter, more frequent, taken online at the convenience of the test-taker, and permit access to reference materials (open-book).

Evidence Regarding the Effectiveness of Continuing Medical Education

RAND’s literature review found numerous studies reporting that CME activities can improve knowledge and clinical practice, as well as studies showing that interactive, longitudinal, sequenced, and multimodal techniques appear to be more effective than passive methods (e.g., lectures) and single-session activities. However, RAND found that much of the evidence about the impact of CME is not methodologically rigorous and often focuses on participant satisfaction rather than changes in clinical care. RAND found several studies that addressed the question of whether CME improves health outcomes, but only one involved a randomized trial. That study involved a single CME activity and it produced mixed results.

RAND notes, however, that CME activities are usually self-selected by health professionals and evidence shows health professionals are not adept at identifying gaps in knowledge, which may reduce the impact of CME on improvements in care.

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