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Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles
Author's Accepted Manuscript Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles Joshua P. Langston, MD, Venetia L. Orcutt, PhD, PA-C, Angela B. Smith, MD, MS, Heather Schultz, RN, MSN, FNP-C, Brad Hornberger, MPAS, PA-C, Allison B. Deal, MS, Todd J. Doran, Ed.D, PA-C, Maxim J. McKibben, MD, E. Will Kirby, MD, Matthew E. Nielsen, MD, MS, Chris M. Gonzalez, MD, MBA, Raj S. Pruthi, MD
PII: DOI: Reference:
S2352-0779(16)30228-X 10.1016/j.urpr.2016.09.012 URPR 246
To appear in: Urology Practice Accepted Date: 27 September 2016 Please cite this article as: Langston JP, Orcutt VL, Smith AB, Schultz H, Hornberger B, Deal AB, Doran TJ, McKibben MJ, Kirby EW, Nielsen ME, Gonzalez CM, Pruthi RS, Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles, Urology Practice (2016), doi: 10.1016/ j.urpr.2016.09.012. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles
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Joshua P. Langston, MD1; Venetia L. Orcutt, PhD, PA-C2; Angela B. Smith, MD, MS3; Heather Schultz, RN, MSN, FNP-C3; Brad Hornberger, MPAS, PA-C4; Allison B. Deal, MS5; Todd J. Doran, Ed.D, PA-C6; Maxim J. McKibben, MD3; E. Will Kirby, MD3; Matthew E. Nielsen, MD, MS3; Chris M. Gonzalez, MD, MBA7; Raj S. Pruthi, MD3
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Department of Urology, Eastern Virginia Medical School, and Urology of Virginia PLLC, Norfolk, Virginia
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Department of Physician Assistant Studies, School of Health Professions, University of Texas Southwestern Medical Center, Dallas, Texas
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Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas Lineberger Comprehensive Cancer Center, Cancer Outcomes Research Group, Biostatistics and Clinical Data Management, Chapel Hill, North Carolina
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Department of Family and Preventive Medicine, Physician Associate Program, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Department of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio
Corresponding Author & Address: Joshua P. Langston, MD 225 Clearfield Ave Virginia Beach, VA 23462 [email protected]
Keywords: healthcare workforce, advanced practice nursing, physician assistants, advanced practice providers, urology 1
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Abstract
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Purpose: Future projections suggest a significant shortage of urologists coupled with an increasing burden of urologic disease due to an aging population. To meet this need, urologists have increasingly partnered with Advanced Practice Providers (APPs). However, to this point the APP workforce has not been comprehensively evaluated. Understanding the impact of APPs on the urology workforce is essential to maximize our collaborative care as we strive for value and quality in evolving delivery models.
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Materials and Methods: A 29-item, web-based survey was administered to APPs identified by the American Urological Association (AUA), Urological Association of Physician Assistants (UAPA) and Society of Urologic Nurses and Associates (SUNA), querying many aspects of their practice.
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Results: 296 APPs completed the survey. Advanced Practice Nurses comprised 62% of respondents, while Physician Assistants comprised the remaining 38%. Over twothirds were female, and the median age was 46. Only 6% reported having participated in formal post-graduate urological training. APPs were evenly divided between institutional and private practice settings, and overwhelmingly in urban or suburban environments. The majority of APPs practice in the ambulatory setting (74%) and characterize their practice as General Urology (72%). 81% report performing procedures independently, with 63% performing some procedures considered to be of moderate- or high-complexity.
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Conclusions: APPs are active in the provision of urologic care in many roles, including complex procedures. Given future workforce needs, APPs will likely assume additional responsibilities. As roles evolve we must ensure educational and training opportunities necessary to equip this vital part of our workforce.
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Introduction
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As the American population ages and the burden of urologic disease increases, the supply of urologists will not meet the demands of patient care. While projections estimate that demand for urologic services will increase 37.5% over 20 years, the number of per-capita practicing urologists will actually decline over that time.1,2 This decline is attributable to an aging workforce reaching retirement age coupled with stagnation and possible contraction of the number of training posts.3 This imbalance between supply and demand requires a serious conversation about how we will meet the needs of our patient population.4 Further, as market forces demand disruption of our traditional care delivery systems we must rethink the personnel and methods by which we can continue to provide essential care.
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Partnering with Advanced Practice Providers (APPs), a term which within urology functionally comprises Physician Assistants (PAs) and Nurse Practitioners (NPs), has enabled urologists to extend high-quality care to patients in ambulatory, inpatient, and surgical settings.5 Despite this increasing role, little is known of their current workforce and clinical responsibilities. Understanding the demographics and clinical roles of APPs in urology is essential to maximize the value of our collaboration as the urologic community addresses the workforce shortage and strives for value and quality in evolving delivery models.
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Materials and Methods
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We partnered with the three national organizations representing APPs in urology – The American Urological Association (AUA), Society of Urologic Nurses and Associates (SUNA), and the Urological Association of Physician Assistants (UAPA) – to administer an anonymous 29 item, web-based survey to their membership. The combined organizational mailing lists comprised 1,347 members, but did not account for APPs who were members of multiple organizations. The survey was sent via email with instructions to complete the survey once if received through multiple organizations.
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Analyses included descriptive statistics, nonparametric procedures (Kruskal-Wallis), and regression models. As this was an exploratory study without a hypothesis, a power calculation was not performed. Exact 95% binomial confidence intervals were reported for percentages as appropriate. Multivariable linear regression models were used to evaluate associations of independent versus shared practice, ambulatory versus inpatient or procedural practice, and procedure complexity after controlling for covariates of interest. P-values of less than 0.05 were deemed statistically significant. For procedural analyses, three categories of complexity were created as determined by procedure invasiveness, difficulty, and the morbidity and mortality associated with adverse outcomes. All analyses were conducted using SAS v9.4 statistical software (Cary, NC).
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Results APP Characteristics
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Of 1347 email addresses on organizational mailing lists, inclusive of duplicates, 296 APPs returned a completed survey. The majority of APPs identified themselves as Advanced Practice Nurses (62%), mainly Nurse Practitioners with a single Certified Nurse Specialist. Physician Assistants comprised the remaining 38% (Table 1). The majority of respondents were female (81%), and this percentage was even higher among nurse practitioners (96%). Median age of providers was 46 years (Figure 1). Only 6% reported participating in a formal post-graduate urologic training program, or “residency”, although 75% were “likely” or “very-likely” to recommend this training to new graduates. While 41% of respondents had been in urology practice for 5 years or less, nearly 50% had been in practice as an APP for more than 10 years (Table 1). Practice Characteristics
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Clinical Roles
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Overall, APP employment was evenly distributed between private practice and institutional (e.g. academic, government, and hospital-employed) models (Table 2). Of those in private practice, the majority were employed in mid-sized practices, with 2-9 urologists. Seventy-seven percent of respondents worked with 1 or more APPs in their group. APPs were found to collaborate with physicians from a broad age range, though 52% of collaborating physicians were between 46 and 55 years old (Table 2). Most APPs worked in urban or suburban settings, with only 9% working in self-described rural locations. When considering geographic location by AUA section, the respondents were evenly distributed across the U.S. Geographic distribution was similar to previous estimates of urologist distribution with few exceptions, notably the suggestion of increased integration of APPs in the North Central region and decreased integration in the Mid-Atlantic region. (Table 3).
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The majority of care provided by APPs is done in the ambulatory setting (74%) with roughly 9% devoted to inpatient care, 8% procedures/OR, and the remainder administration (Table 4). To examine differences in clinical roles, we performed separate multivariable regression analyses with time spent in each clinical setting as the dependent variable. Independent variables remained constant in each analysis and included: gender, geographic location, APP age, years in urologic practice, collaborating physician age, practice setting, practice model, practice size, and post-graduate education. We found that males spent 16% less time in clinic than females and were 8% more likely to spend time in the operative setting (P<0.001, <0.002 respectively). Those in rural practice spent 17% more time in clinic than urban practitioners, while those in suburban practice spent 9% more time in clinic than their urban colleagues (P= .01, .02 respectively). With regard to inpatient care, those collaborating with physicians 46-55 years of age were 6-8% more likely to focus time on inpatients (P<0.05). Importantly,
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geographic location, post-graduate training, APP age, practice model, and practice size did not have a significant impact on APP practice setting.
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Similar analyses were conducted to evaluate factors affecting the degree to which patient care was performed independently versus in shared visits with physicians. Ambulatory patient encounters were found to be predominantly conducted and billed independently (74%), while inpatient care and procedures were less likely to be independent (30% and 37%, respectively) (Table 4). Multivariable regression models, with time spent in independent care as the dependent variable, revealed no significant predictors of independent versus shared patient care when considering the same independent variables modeled previously.
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Personal practice focus was queried of each APP with the option to select up to 3 areas of specialization. While 72% characterized their practice as general urology, stone disease, female/neuro-urology, and oncology/minimally invasive surgery were popular areas of sub-specialization (Figure 2). Procedures
Overall, 81% of APPs in the survey report performing procedures as part of their practice, with 63% performing some degree of procedures considered to be of moderate- or high-complexity (Table 5).
Discussion
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To further examine predictive factors, we employed logistic regression analysis with independent performance of moderate/high complexity procedures as the independent variable. Notably, APPs in private practice were significantly less likely to perform moderate/high complexity procedures independently compared to those in academic practice (OR: 0.45 [0.23, 0.89]). Geographically, those in the AUA Northeast Section were less likely to perform moderate/high complexity procedures independently (OR: 0.26 [ 0.05, 1.395]), but this did not reach statistical significance.
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To our knowledge, this study represents the first attempt to directly characterize the APP workforce in urology. Previously, conclusions regarding APP activity were drawn from our groups’ 2013 AUA workforce survey of urologists6 and subsequently from AUA census data. Our results indicate that APPs represent a large and integral part of the urologic workforce in the United States, mirroring their integration throughout American, as well as global, healthcare systems across all specialty groups. The concept for both the Nurse Practitioner and Physician Assistant roles were developed in the 1960’s as a strategy to improve the delivery of medical services.7,8 While there has been a steady progression of their integration into care teams, the physician shortages and evolving models of care in recent years have seen a dramatic rise in APP popularity. Recent figures show nearly 109,000 PAs in practice in the U.S. 5
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in 2015, representing about 10% of available medical providers, compared to about 80,000 at the end of 2010, demonstrating an increase of 36% in 5 years.9 Workforce modeling anticipates the expected PA workforce to increase to over 140,000 by 2025.10 Likewise, there are currently 192,000 licensed NPs practicing nationally, with projections to increase to 244,000 by 2025.11 Accompanying this supply is a significant national demand for APP services with studies showing patients’ acceptance of, and satisfaction with, APPs equal to that of physicians in many scenarios, although specific studies in surgical settings are lacking.12,13,14
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Consistent with what is known of these workforces nationally, our study demonstrates that urology APPs are predominantly female and comprise a very young group overall, with 50% being younger than 44. Geographic distribution of APPs, as reported by state of practice, demonstrates broad utilization throughout the country. Interestingly, comparing this to MD distribution data published by the AUA, the distribution of APPs is proportional in 6 of 8 AUA regions. Exceptions to this include the Mid-Atlantic Section, where APPs were underrepresented with just 4% of the workforce versus 10% of urologists, and the North Central Section where APPs represented 24% of the national workforce versus urologists’ 18% (Table 3). Historic practice patterns and state-based regulations governing the scope of APP practice could contribute to this variation in utilization throughout the country even though location did not play a statistically significant role in the specific practice patterns queried in our multivariate analyses.
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Further, our data show that just 9% of APPs work in self-described rural locations. A substantial part of the movement to promote the role of APPs in American medicine has been to meet the needs of rural communities. However, interpreting our results alongside AUA census reports, which show that just 2% of urologists work in small towns or rural areas, reveals that this much higher percentage of APPs in rural areas may in fact indicate a more significant collaboration between rural urologists and APP colleagues in the provision of rural care. Promoting the role of APPs in rural communities becomes even more important when considering that the majority of urologists who maintain rural practices are over 55 years old.15 Additionally, census data have consistently shown that 62% of U.S. counties do not have a urologist, so the role of APPs to extend care to these locations must be considered.15,16 When examining practice types, APPs are equally distributed between private practice and institutional positions. While the demands of these practice settings are quite variable, our data show that APPs are able to integrate across practice types, patient populations, and different economic circumstances. The acceptance of APPs into academic settings has been previously described as a supplement to resident physicians, which is increasingly relevant given modern work hour restrictions. One study demonstrated that over 90% of residents agreed with the integration of APPs into their service, and another reported that 81% of academic medical centers felt that APPs served as adequate resident substitutes up to the PGY-4 level.17,18 Our data support this integration and demonstrate that APPs have been incorporated into academic 6
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practices more readily than private practice, hiring proportionally more APPs than their private practice colleagues. This is consistent with the findings of our prior study which showed that 80% of academic urologists reported working with APPs versus just 52% of private practicioners.6
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Not unexpectedly, the majority of an APP’s time (73%) is spent in the ambulatory setting. Also of importance, the vast majority of this care (74%) is independently conducted. Independent care can free the urologist to address surgical and complex clinical demands, and allows each team member to maximally utilize their skill sets. On multivariable analyses, factors such as geographic location, post-graduate training, APP age, years in urologic practice, and practice model did not affect whether providers engaged in shared or independent care. It is surprising somewhat that age and experience did not play a role in determining whether providers worked independently, indicating that new providers must quickly become independent. While the majority of guidance is provided by the collaborating physician, this further highlights the need for organized educational opportunities for APPs.
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While APPs spend most of their time in the ambulatory clinic setting, a significant number (81%) perform procedures, including 63% who perform moderate to highcomplexity procedures (Table 5). Notably, multivariate modeling suggested regional and practice model variation, with APPs in the North-Central Section and private practice performing fewer moderate/high-complexity procedures independently, indicating a possible sensitivity to differing clinical expectations, historic practice patterns, and regional scope of practice regulations.
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Of particular interest, responses showed that 8% of APPs perform cystoscopy for diagnostic or cancer surveillance purposes, and 6% perform prostate biopsy for potential cancer diagnosis. Whether these consequential procedures should be performed by APPs continues to present a degree of debate within American urology. Interestingly, there is significant precedent for this globally. In 2000, the British Association of Urologic Surgeons (BAUS) created guidelines to govern the intensive training and certification of ‘nurse-cystoscopists’ in the UK to perform surveillance flexible cystoscopy for bladder cancer patients.19 Subsequent reports have now confirmed that nearly 50% of UK hospitals utilize nurse-cystoscopists in some capacity.20 Building on this, similar programs were developed in Sweden and Australia with published results showing equivalent outcomes to physician-performed procedures.21,22 In these resource-limited, nationalized systems, the expectations and legalities of clinical care differ greatly from the U.S. system but nonetheless offer insight into the additional clinical roles in which APPs can serve to provide a focused service like flexible cystoscopy for bladder cancer surveillance. In the United States, a similar concept has been developed for sigmoidoscopy and colposcopy after studies showed equivalent outcomes (e.g. diagnostic accuracy and complication rates) between physician and non-physician providers. 23,24,25,26,27
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While some have concerns over developing a similar role in urology, our data suggest that these procedures are already being performed by APPs, which supports the furthering of educational opportunities on the local and national levels. A focused conversation regarding the development of these standards in a fashion similar to other disciplines is warranted. Part of this conversation could include the role, availability, and formality of post-graduate “residency” training programs for APPs. Currently only 4 oneyear training programs exist in the U.S.28 While only 6% of survey respondents reported participating in formal post-graduate training, an overwhelming 75% recommended this experience for new graduates.
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As the role of APPs within urology is explored and refined, it is important to remember that they cannot be the only solution to our workforce needs. In contrast to some fields of medicine, an APP cannot take the place of a urologist given the fundamental surgical nature of our field. In fact, increasing access and addressing patient’s clinical needs may increase the need for surgical procedures and thus the urologists to perform them. The solution will require a multifaceted approach, but certainly APPs will play a central role in the provision of urologic care in the future. Conclusions
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Our study represents the first effort to directly characterize this important part of our workforce, and demonstrates the APP’s important role in every aspect of patient care. The increasing burden of urologic disease in America, coupled with a lagging supply of urologists, will continue to impact access to care. APPs will be increasingly used to fill this gap. As roles continue to evolve, we must determine how to best partner together to maximize the quality and value of our patient care, and provide educational and training opportunities sufficient to equip this vital part of the urologic workforce.
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Etzioni DA, Liu JH, Maggard MA et al: The aging population and its impact on the surgery workforce. Ann Surg 2003; 238: 170. 2 Pruthi RS, Neuwahl S, Nielsen ME et al: Recent trends in the urology workforce in the United States. Urology 2013; 82: 987. 3 McKibben MJ, Kirby EW, Langston JP, et al. Projecting the Urology Workforce over the Next 20 Years. Urology, ePub ahead of print, 2016. 4 Williams TE,Jr, Satiani B, Thomas A et al: The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg 2009; 250: 590. 5 American Urologic Association (AUA): AUA Consensus Statement on Advanced Practice Providers 2014; http://www.auanet.org/common/pdf/advocacy/advocacy-by-topic/AUAConsensus-Statement-Advanced-Practice-Providers-Full.pdf. 6 Langston JL, Kirby EW, Pruthi RS. AUA Workforce and Compensation Survey. Nov 2013. 7 Cawley JF, Hooker RS. Physician assistants in American medicine: the half-century mark. Am J Manag Care. 2013 Oct 1;19(10):e333-41. 8 American Association of Nurse Practitioners, historical timeline. https://www.aanp.org/allabout-nps/historical-timeline. Accessed on March 31, 2016 9 2015 Statistical Profile of Certified Physician Assistants. An Annual Report of the National Commission on
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Certification of Physician Assistants. https://www.nccpa.net/Uploads/docs/2015StatisticalProfileofCertifiedPAs PhysicianAssistantsAnAnnualReportoftheNCCPA.pdf. Accessed March 31, 2016. 10 Hooker RS, Cawley JF, Everett CM. Predictive Modeling the Physician Assistant Supply: 2010-2025. Public Health Reports. 2011. Sept-Oct, 126:708-716. 11 American Association of Nurse Practitioners. https://www.aanp.org/images/aboutnps/npgraphic.pdf. Accessed March 31, 2016. 12 Hooker RS, Cipher DJ, Sekscenski E. Patient satisfaction with physician assistant, nurse practitioner, and physician care: a national survey of Medicare beneficiaries. Journal of Clinical Outcomes Management, 12: 88, 2005. 13 Larkin GL, Hooker RS. Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis? Am J Bioeth, 10: 1, 2010. 14 Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. The Permanente Journal, 1: 38, 1997. 15 AUA Annual Census. The State of the Urology Workforce and Practice in the United States 2014. American Urological Association, 2015. (note: drawn from NPI file using rural area code data) 16 AUA Annual Census. The State of the Urology Workforce and Practice in the United States 2015. American Urological Association, 2016. 17 Resnick AS, Todd BA, Mullen JL, Morris JB. How do surgical residents and non-physician practitioners play together in the sandbox? Curr Surg, 63: 155, 2006. 18 Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual, 26: 452, 2011. 19 Ellis B. W. (Chairman) (2000) Nurse Cystoscopy. Report of a Working Party of the British Association of Urological Surgeons. Updated 2012, http://www.baus.org.uk/_userfiles/pages/files/Publications/FlexiGuidelines.pdf. Accessed March 31st, 2016. 20 Kerr RR. UK experience with NPs may be harbinger for U.S. urology. Urology Times. Aug 2013. http://urologytimes.modernmedicine.com/urology-times/content/tags/baus/uk-experience-npsmay-be-harbinger-us-urology. Accessed 05/29/2015. 21 Sapre N, Bugeja P, Hayes E, Corcoran NM, Costello A, Anderson PD. Nurse-led flexible cystoscopy in Australia: initial experience and early results. BJU International. 110: 46–50, December 2012. 22 Fagerberg M, Nostell PO. Follow up of urinary bladder cancer--a task for the urology nurse? Lakartidningen. 2005 Jul 25-Aug 7;102(30-31):2149-50. 23 Ikenberry SO, Anderson MA, Banerjee S, et al. Endoscopy by Non-physicians. Gastrointestinal Endoscopy. 2009; 69 (4): 767-770. 24 Schoenfeld P, Lipzcomb S, Crook J, et al. Accuracy of polyp detection by gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: a randomized trial. Gastroenterology 1999;117:312-8 25 Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994;330:183-7 26 Kilic G, England J, Borahay M, et al. Accuracy of physician and nurse practitioner colposcopy to effect improved surveillance of cervical cancer. Eur J Gynaecol Oncol. 2012;33(2):183-186. 27 McPherson G, Horsburgh M, Tracy C. A clinical audit of a nurse colposcopist. Colposcopy: cytology: histology correlation. Nurs Prax N Z. 2005;21(3):13-23. 9
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http://appap.org/post-graduate-pa-programs/pa-program-quick-reference-chart/. Accessed May 22, 2016.
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Table 1: Demographics
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32% 20% 19% 30%
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Physician Assistants Male Female Nurse Practitioners Male Female Age, median Years in Clinical Practice 0 – 5 years 6 – 10 years 11 – 15 years > 15 years Years in Urology Practice 0 – 5 years 6 – 10 years 11 – 15 years > 15 years Completed Post-Graduate Training in Urology
% Respondents (n=296) 38% 40% 60% 62% 4% 96% 46 years
41% 27% 16% 16% 6%
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Table 2: Practice Characteristics % Respondents
Practice Model
(n=296) 46%
University/Academic
18%
Hospital employed (owned/inpatient only) Government
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48%
Solo Urologist
5%
25%
>10 Urologists Independent Practice
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2-9 Urologists
Other (Research, OR only, Surgical Center, other) Practice Setting
16%
6%
9%
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Rural
Urban
20% 8%
Private
Suburban
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Institutional Setting
38% 53%
35 – 45 years 46 – 55 years
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> 56 years
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Supervising Physician Age
29% 52% 19%
2%
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Table 3: Practice Location by AUA Section of APPs and MDs (variance >2% noted in bold underline) MD Distribution* (%)
4.9
4
New England
5.2
5.8
New York
9.6
8.4
Mid-Atlantic
4.3
10.3
Southeastern
19.6
21.3
North Central
23.6
17.8
South Central
15.4
Western
17.1
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Northeastern
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APP Distribution (%)
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AUA Section
13.7
18.8
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*From: AUA Annual Census. The State of the Urology Workforce and Practice in the United States 2014. American Urological Association, 2015.
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Table 4: Percentage of Time Spent in Independent versus Shared/Joint Visit % of time spent in clinical setting 73.4
Inpatient Care
9.4
Procedures
8.2
Administration
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30.3
37.0
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*(administration time not queried regarding independent vs. shared)
74.2
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Ambulatory Clinic
% of time working Independently
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Visit Type
*
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Table 5: Percentage of APPs Reporting Procedures Performed Independently
Low Complexity Bladder Installations
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Percentage APPs Performing Procedure
56
Intracavernosal Injections for Erectile Dysfunction
36
Urodynamics (Place catheters and perform test) Chemotherapy Injections
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Neuromodulation with Interstim Programming
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Urodynamics Interpretation
43
Pelvic Floor Muscle Rehabilitation +/- biofeedback
Intermediate Complexity
31 29 27 26
31
LHRH Antagonist Insertion
28
Priapism Injection Treatment
21
Cystoscopy for Stent Removal
18
Implant Insertion (e.g. Testopel, Vantas)
18
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Percutaneous Tibial Nerve Stimulation
13
Cystoscopy for Difficult Catheter Placement
12
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Aspirate Hydrocele
Ultrasound: Renal
6
Ultrasound: Transrectal (without biopsy)
6
Ultrasound: Scrotal
4
Ultrasound: Penile Doppler
4
High Complexity Cystoscopy: Diagnostic or Cancer Surveillance
8
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6
Xiaflex Injections
3
Circumcision
2
Cystoscopy: Bladder/Prostate Botox Injection
2
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Transrectal Ultrasound: Biopsy
Cystoscopy: Bladder Biopsy
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Vasectomy
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Figure 1: Age and Gender of Advanced Practice Providers
Percentage of APPs by Age Group and Gender
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65 years old or over 55 to 64 years old 45 to 54 years old
< 35 years old 5
10
15
20
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35 to 44 years old
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Male
Female
25
30
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Figure 2: Practice Focus Transplant Pediatrics
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Other Practice Focus Minimally Invasive Robotic Surgery Men's Health/Infertility Oncology Female/Neuro-urology
General Urology 0
10
20
30
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Stone Disease
40
50
60
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Percentage of Respondents Selecting Focus
70
80
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APP = Advanced Practice Provider AUA = American Urological Association
NP = Nurse Practitioner SUNA = Society of Urologic Nurses and Associates
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UAPA = Urological Association of Physician Assistants
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PA = Physician Assistant
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To appear in: Urology Practice Accepted Date: 27 September 2016 Please cite this article as: Langston JP, Orcutt VL, Smith AB, Schultz H, Hornberger B, Deal AB, Doran TJ, McKibben MJ, Kirby EW, Nielsen ME, Gonzalez CM, Pruthi RS, Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles, Urology Practice (2016), doi: 10.1016/ j.urpr.2016.09.012. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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Advanced Practice Providers in U.S. Urology: A National Survey of Demographics and Clinical Roles
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Joshua P. Langston, MD1; Venetia L. Orcutt, PhD, PA-C2; Angela B. Smith, MD, MS3; Heather Schultz, RN, MSN, FNP-C3; Brad Hornberger, MPAS, PA-C4; Allison B. Deal, MS5; Todd J. Doran, Ed.D, PA-C6; Maxim J. McKibben, MD3; E. Will Kirby, MD3; Matthew E. Nielsen, MD, MS3; Chris M. Gonzalez, MD, MBA7; Raj S. Pruthi, MD3
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Department of Urology, Eastern Virginia Medical School, and Urology of Virginia PLLC, Norfolk, Virginia
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Department of Physician Assistant Studies, School of Health Professions, University of Texas Southwestern Medical Center, Dallas, Texas
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Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas Lineberger Comprehensive Cancer Center, Cancer Outcomes Research Group, Biostatistics and Clinical Data Management, Chapel Hill, North Carolina
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Department of Family and Preventive Medicine, Physician Associate Program, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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Department of Urology, Case Western Reserve University School of Medicine, Cleveland, Ohio
Corresponding Author & Address: Joshua P. Langston, MD 225 Clearfield Ave Virginia Beach, VA 23462 [email protected]
Keywords: healthcare workforce, advanced practice nursing, physician assistants, advanced practice providers, urology 1
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Abstract
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Purpose: Future projections suggest a significant shortage of urologists coupled with an increasing burden of urologic disease due to an aging population. To meet this need, urologists have increasingly partnered with Advanced Practice Providers (APPs). However, to this point the APP workforce has not been comprehensively evaluated. Understanding the impact of APPs on the urology workforce is essential to maximize our collaborative care as we strive for value and quality in evolving delivery models.
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Materials and Methods: A 29-item, web-based survey was administered to APPs identified by the American Urological Association (AUA), Urological Association of Physician Assistants (UAPA) and Society of Urologic Nurses and Associates (SUNA), querying many aspects of their practice.
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Results: 296 APPs completed the survey. Advanced Practice Nurses comprised 62% of respondents, while Physician Assistants comprised the remaining 38%. Over twothirds were female, and the median age was 46. Only 6% reported having participated in formal post-graduate urological training. APPs were evenly divided between institutional and private practice settings, and overwhelmingly in urban or suburban environments. The majority of APPs practice in the ambulatory setting (74%) and characterize their practice as General Urology (72%). 81% report performing procedures independently, with 63% performing some procedures considered to be of moderate- or high-complexity.
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Conclusions: APPs are active in the provision of urologic care in many roles, including complex procedures. Given future workforce needs, APPs will likely assume additional responsibilities. As roles evolve we must ensure educational and training opportunities necessary to equip this vital part of our workforce.
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Introduction
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As the American population ages and the burden of urologic disease increases, the supply of urologists will not meet the demands of patient care. While projections estimate that demand for urologic services will increase 37.5% over 20 years, the number of per-capita practicing urologists will actually decline over that time.1,2 This decline is attributable to an aging workforce reaching retirement age coupled with stagnation and possible contraction of the number of training posts.3 This imbalance between supply and demand requires a serious conversation about how we will meet the needs of our patient population.4 Further, as market forces demand disruption of our traditional care delivery systems we must rethink the personnel and methods by which we can continue to provide essential care.
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Partnering with Advanced Practice Providers (APPs), a term which within urology functionally comprises Physician Assistants (PAs) and Nurse Practitioners (NPs), has enabled urologists to extend high-quality care to patients in ambulatory, inpatient, and surgical settings.5 Despite this increasing role, little is known of their current workforce and clinical responsibilities. Understanding the demographics and clinical roles of APPs in urology is essential to maximize the value of our collaboration as the urologic community addresses the workforce shortage and strives for value and quality in evolving delivery models.
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Materials and Methods
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We partnered with the three national organizations representing APPs in urology – The American Urological Association (AUA), Society of Urologic Nurses and Associates (SUNA), and the Urological Association of Physician Assistants (UAPA) – to administer an anonymous 29 item, web-based survey to their membership. The combined organizational mailing lists comprised 1,347 members, but did not account for APPs who were members of multiple organizations. The survey was sent via email with instructions to complete the survey once if received through multiple organizations.
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Analyses included descriptive statistics, nonparametric procedures (Kruskal-Wallis), and regression models. As this was an exploratory study without a hypothesis, a power calculation was not performed. Exact 95% binomial confidence intervals were reported for percentages as appropriate. Multivariable linear regression models were used to evaluate associations of independent versus shared practice, ambulatory versus inpatient or procedural practice, and procedure complexity after controlling for covariates of interest. P-values of less than 0.05 were deemed statistically significant. For procedural analyses, three categories of complexity were created as determined by procedure invasiveness, difficulty, and the morbidity and mortality associated with adverse outcomes. All analyses were conducted using SAS v9.4 statistical software (Cary, NC).
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Results APP Characteristics
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Of 1347 email addresses on organizational mailing lists, inclusive of duplicates, 296 APPs returned a completed survey. The majority of APPs identified themselves as Advanced Practice Nurses (62%), mainly Nurse Practitioners with a single Certified Nurse Specialist. Physician Assistants comprised the remaining 38% (Table 1). The majority of respondents were female (81%), and this percentage was even higher among nurse practitioners (96%). Median age of providers was 46 years (Figure 1). Only 6% reported participating in a formal post-graduate urologic training program, or “residency”, although 75% were “likely” or “very-likely” to recommend this training to new graduates. While 41% of respondents had been in urology practice for 5 years or less, nearly 50% had been in practice as an APP for more than 10 years (Table 1). Practice Characteristics
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Clinical Roles
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Overall, APP employment was evenly distributed between private practice and institutional (e.g. academic, government, and hospital-employed) models (Table 2). Of those in private practice, the majority were employed in mid-sized practices, with 2-9 urologists. Seventy-seven percent of respondents worked with 1 or more APPs in their group. APPs were found to collaborate with physicians from a broad age range, though 52% of collaborating physicians were between 46 and 55 years old (Table 2). Most APPs worked in urban or suburban settings, with only 9% working in self-described rural locations. When considering geographic location by AUA section, the respondents were evenly distributed across the U.S. Geographic distribution was similar to previous estimates of urologist distribution with few exceptions, notably the suggestion of increased integration of APPs in the North Central region and decreased integration in the Mid-Atlantic region. (Table 3).
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The majority of care provided by APPs is done in the ambulatory setting (74%) with roughly 9% devoted to inpatient care, 8% procedures/OR, and the remainder administration (Table 4). To examine differences in clinical roles, we performed separate multivariable regression analyses with time spent in each clinical setting as the dependent variable. Independent variables remained constant in each analysis and included: gender, geographic location, APP age, years in urologic practice, collaborating physician age, practice setting, practice model, practice size, and post-graduate education. We found that males spent 16% less time in clinic than females and were 8% more likely to spend time in the operative setting (P<0.001, <0.002 respectively). Those in rural practice spent 17% more time in clinic than urban practitioners, while those in suburban practice spent 9% more time in clinic than their urban colleagues (P= .01, .02 respectively). With regard to inpatient care, those collaborating with physicians 46-55 years of age were 6-8% more likely to focus time on inpatients (P<0.05). Importantly,
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geographic location, post-graduate training, APP age, practice model, and practice size did not have a significant impact on APP practice setting.
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Similar analyses were conducted to evaluate factors affecting the degree to which patient care was performed independently versus in shared visits with physicians. Ambulatory patient encounters were found to be predominantly conducted and billed independently (74%), while inpatient care and procedures were less likely to be independent (30% and 37%, respectively) (Table 4). Multivariable regression models, with time spent in independent care as the dependent variable, revealed no significant predictors of independent versus shared patient care when considering the same independent variables modeled previously.
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Personal practice focus was queried of each APP with the option to select up to 3 areas of specialization. While 72% characterized their practice as general urology, stone disease, female/neuro-urology, and oncology/minimally invasive surgery were popular areas of sub-specialization (Figure 2). Procedures
Overall, 81% of APPs in the survey report performing procedures as part of their practice, with 63% performing some degree of procedures considered to be of moderate- or high-complexity (Table 5).
Discussion
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To further examine predictive factors, we employed logistic regression analysis with independent performance of moderate/high complexity procedures as the independent variable. Notably, APPs in private practice were significantly less likely to perform moderate/high complexity procedures independently compared to those in academic practice (OR: 0.45 [0.23, 0.89]). Geographically, those in the AUA Northeast Section were less likely to perform moderate/high complexity procedures independently (OR: 0.26 [ 0.05, 1.395]), but this did not reach statistical significance.
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To our knowledge, this study represents the first attempt to directly characterize the APP workforce in urology. Previously, conclusions regarding APP activity were drawn from our groups’ 2013 AUA workforce survey of urologists6 and subsequently from AUA census data. Our results indicate that APPs represent a large and integral part of the urologic workforce in the United States, mirroring their integration throughout American, as well as global, healthcare systems across all specialty groups. The concept for both the Nurse Practitioner and Physician Assistant roles were developed in the 1960’s as a strategy to improve the delivery of medical services.7,8 While there has been a steady progression of their integration into care teams, the physician shortages and evolving models of care in recent years have seen a dramatic rise in APP popularity. Recent figures show nearly 109,000 PAs in practice in the U.S. 5
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in 2015, representing about 10% of available medical providers, compared to about 80,000 at the end of 2010, demonstrating an increase of 36% in 5 years.9 Workforce modeling anticipates the expected PA workforce to increase to over 140,000 by 2025.10 Likewise, there are currently 192,000 licensed NPs practicing nationally, with projections to increase to 244,000 by 2025.11 Accompanying this supply is a significant national demand for APP services with studies showing patients’ acceptance of, and satisfaction with, APPs equal to that of physicians in many scenarios, although specific studies in surgical settings are lacking.12,13,14
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Consistent with what is known of these workforces nationally, our study demonstrates that urology APPs are predominantly female and comprise a very young group overall, with 50% being younger than 44. Geographic distribution of APPs, as reported by state of practice, demonstrates broad utilization throughout the country. Interestingly, comparing this to MD distribution data published by the AUA, the distribution of APPs is proportional in 6 of 8 AUA regions. Exceptions to this include the Mid-Atlantic Section, where APPs were underrepresented with just 4% of the workforce versus 10% of urologists, and the North Central Section where APPs represented 24% of the national workforce versus urologists’ 18% (Table 3). Historic practice patterns and state-based regulations governing the scope of APP practice could contribute to this variation in utilization throughout the country even though location did not play a statistically significant role in the specific practice patterns queried in our multivariate analyses.
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Further, our data show that just 9% of APPs work in self-described rural locations. A substantial part of the movement to promote the role of APPs in American medicine has been to meet the needs of rural communities. However, interpreting our results alongside AUA census reports, which show that just 2% of urologists work in small towns or rural areas, reveals that this much higher percentage of APPs in rural areas may in fact indicate a more significant collaboration between rural urologists and APP colleagues in the provision of rural care. Promoting the role of APPs in rural communities becomes even more important when considering that the majority of urologists who maintain rural practices are over 55 years old.15 Additionally, census data have consistently shown that 62% of U.S. counties do not have a urologist, so the role of APPs to extend care to these locations must be considered.15,16 When examining practice types, APPs are equally distributed between private practice and institutional positions. While the demands of these practice settings are quite variable, our data show that APPs are able to integrate across practice types, patient populations, and different economic circumstances. The acceptance of APPs into academic settings has been previously described as a supplement to resident physicians, which is increasingly relevant given modern work hour restrictions. One study demonstrated that over 90% of residents agreed with the integration of APPs into their service, and another reported that 81% of academic medical centers felt that APPs served as adequate resident substitutes up to the PGY-4 level.17,18 Our data support this integration and demonstrate that APPs have been incorporated into academic 6
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practices more readily than private practice, hiring proportionally more APPs than their private practice colleagues. This is consistent with the findings of our prior study which showed that 80% of academic urologists reported working with APPs versus just 52% of private practicioners.6
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Not unexpectedly, the majority of an APP’s time (73%) is spent in the ambulatory setting. Also of importance, the vast majority of this care (74%) is independently conducted. Independent care can free the urologist to address surgical and complex clinical demands, and allows each team member to maximally utilize their skill sets. On multivariable analyses, factors such as geographic location, post-graduate training, APP age, years in urologic practice, and practice model did not affect whether providers engaged in shared or independent care. It is surprising somewhat that age and experience did not play a role in determining whether providers worked independently, indicating that new providers must quickly become independent. While the majority of guidance is provided by the collaborating physician, this further highlights the need for organized educational opportunities for APPs.
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While APPs spend most of their time in the ambulatory clinic setting, a significant number (81%) perform procedures, including 63% who perform moderate to highcomplexity procedures (Table 5). Notably, multivariate modeling suggested regional and practice model variation, with APPs in the North-Central Section and private practice performing fewer moderate/high-complexity procedures independently, indicating a possible sensitivity to differing clinical expectations, historic practice patterns, and regional scope of practice regulations.
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Of particular interest, responses showed that 8% of APPs perform cystoscopy for diagnostic or cancer surveillance purposes, and 6% perform prostate biopsy for potential cancer diagnosis. Whether these consequential procedures should be performed by APPs continues to present a degree of debate within American urology. Interestingly, there is significant precedent for this globally. In 2000, the British Association of Urologic Surgeons (BAUS) created guidelines to govern the intensive training and certification of ‘nurse-cystoscopists’ in the UK to perform surveillance flexible cystoscopy for bladder cancer patients.19 Subsequent reports have now confirmed that nearly 50% of UK hospitals utilize nurse-cystoscopists in some capacity.20 Building on this, similar programs were developed in Sweden and Australia with published results showing equivalent outcomes to physician-performed procedures.21,22 In these resource-limited, nationalized systems, the expectations and legalities of clinical care differ greatly from the U.S. system but nonetheless offer insight into the additional clinical roles in which APPs can serve to provide a focused service like flexible cystoscopy for bladder cancer surveillance. In the United States, a similar concept has been developed for sigmoidoscopy and colposcopy after studies showed equivalent outcomes (e.g. diagnostic accuracy and complication rates) between physician and non-physician providers. 23,24,25,26,27
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While some have concerns over developing a similar role in urology, our data suggest that these procedures are already being performed by APPs, which supports the furthering of educational opportunities on the local and national levels. A focused conversation regarding the development of these standards in a fashion similar to other disciplines is warranted. Part of this conversation could include the role, availability, and formality of post-graduate “residency” training programs for APPs. Currently only 4 oneyear training programs exist in the U.S.28 While only 6% of survey respondents reported participating in formal post-graduate training, an overwhelming 75% recommended this experience for new graduates.
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As the role of APPs within urology is explored and refined, it is important to remember that they cannot be the only solution to our workforce needs. In contrast to some fields of medicine, an APP cannot take the place of a urologist given the fundamental surgical nature of our field. In fact, increasing access and addressing patient’s clinical needs may increase the need for surgical procedures and thus the urologists to perform them. The solution will require a multifaceted approach, but certainly APPs will play a central role in the provision of urologic care in the future. Conclusions
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Our study represents the first effort to directly characterize this important part of our workforce, and demonstrates the APP’s important role in every aspect of patient care. The increasing burden of urologic disease in America, coupled with a lagging supply of urologists, will continue to impact access to care. APPs will be increasingly used to fill this gap. As roles continue to evolve, we must determine how to best partner together to maximize the quality and value of our patient care, and provide educational and training opportunities sufficient to equip this vital part of the urologic workforce.
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Etzioni DA, Liu JH, Maggard MA et al: The aging population and its impact on the surgery workforce. Ann Surg 2003; 238: 170. 2 Pruthi RS, Neuwahl S, Nielsen ME et al: Recent trends in the urology workforce in the United States. Urology 2013; 82: 987. 3 McKibben MJ, Kirby EW, Langston JP, et al. Projecting the Urology Workforce over the Next 20 Years. Urology, ePub ahead of print, 2016. 4 Williams TE,Jr, Satiani B, Thomas A et al: The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg 2009; 250: 590. 5 American Urologic Association (AUA): AUA Consensus Statement on Advanced Practice Providers 2014; http://www.auanet.org/common/pdf/advocacy/advocacy-by-topic/AUAConsensus-Statement-Advanced-Practice-Providers-Full.pdf. 6 Langston JL, Kirby EW, Pruthi RS. AUA Workforce and Compensation Survey. Nov 2013. 7 Cawley JF, Hooker RS. Physician assistants in American medicine: the half-century mark. Am J Manag Care. 2013 Oct 1;19(10):e333-41. 8 American Association of Nurse Practitioners, historical timeline. https://www.aanp.org/allabout-nps/historical-timeline. Accessed on March 31, 2016 9 2015 Statistical Profile of Certified Physician Assistants. An Annual Report of the National Commission on
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Certification of Physician Assistants. https://www.nccpa.net/Uploads/docs/2015StatisticalProfileofCertifiedPAs PhysicianAssistantsAnAnnualReportoftheNCCPA.pdf. Accessed March 31, 2016. 10 Hooker RS, Cawley JF, Everett CM. Predictive Modeling the Physician Assistant Supply: 2010-2025. Public Health Reports. 2011. Sept-Oct, 126:708-716. 11 American Association of Nurse Practitioners. https://www.aanp.org/images/aboutnps/npgraphic.pdf. Accessed March 31, 2016. 12 Hooker RS, Cipher DJ, Sekscenski E. Patient satisfaction with physician assistant, nurse practitioner, and physician care: a national survey of Medicare beneficiaries. Journal of Clinical Outcomes Management, 12: 88, 2005. 13 Larkin GL, Hooker RS. Patient willingness to be seen by physician assistants, nurse practitioners, and residents in the emergency department: does the presumption of assent have an empirical basis? Am J Bioeth, 10: 1, 2010. 14 Hooker RS, Potts R, Ray W. Patient satisfaction: comparing physician assistants, nurse practitioners, and physicians. The Permanente Journal, 1: 38, 1997. 15 AUA Annual Census. The State of the Urology Workforce and Practice in the United States 2014. American Urological Association, 2015. (note: drawn from NPI file using rural area code data) 16 AUA Annual Census. The State of the Urology Workforce and Practice in the United States 2015. American Urological Association, 2016. 17 Resnick AS, Todd BA, Mullen JL, Morris JB. How do surgical residents and non-physician practitioners play together in the sandbox? Curr Surg, 63: 155, 2006. 18 Moote M, Krsek C, Kleinpell R, Todd B. Physician assistant and nurse practitioner utilization in academic medical centers. Am J Med Qual, 26: 452, 2011. 19 Ellis B. W. (Chairman) (2000) Nurse Cystoscopy. Report of a Working Party of the British Association of Urological Surgeons. Updated 2012, http://www.baus.org.uk/_userfiles/pages/files/Publications/FlexiGuidelines.pdf. Accessed March 31st, 2016. 20 Kerr RR. UK experience with NPs may be harbinger for U.S. urology. Urology Times. Aug 2013. http://urologytimes.modernmedicine.com/urology-times/content/tags/baus/uk-experience-npsmay-be-harbinger-us-urology. Accessed 05/29/2015. 21 Sapre N, Bugeja P, Hayes E, Corcoran NM, Costello A, Anderson PD. Nurse-led flexible cystoscopy in Australia: initial experience and early results. BJU International. 110: 46–50, December 2012. 22 Fagerberg M, Nostell PO. Follow up of urinary bladder cancer--a task for the urology nurse? Lakartidningen. 2005 Jul 25-Aug 7;102(30-31):2149-50. 23 Ikenberry SO, Anderson MA, Banerjee S, et al. Endoscopy by Non-physicians. Gastrointestinal Endoscopy. 2009; 69 (4): 767-770. 24 Schoenfeld P, Lipzcomb S, Crook J, et al. Accuracy of polyp detection by gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: a randomized trial. Gastroenterology 1999;117:312-8 25 Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med 1994;330:183-7 26 Kilic G, England J, Borahay M, et al. Accuracy of physician and nurse practitioner colposcopy to effect improved surveillance of cervical cancer. Eur J Gynaecol Oncol. 2012;33(2):183-186. 27 McPherson G, Horsburgh M, Tracy C. A clinical audit of a nurse colposcopist. Colposcopy: cytology: histology correlation. Nurs Prax N Z. 2005;21(3):13-23. 9
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http://appap.org/post-graduate-pa-programs/pa-program-quick-reference-chart/. Accessed May 22, 2016.
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Table 1: Demographics
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32% 20% 19% 30%
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Physician Assistants Male Female Nurse Practitioners Male Female Age, median Years in Clinical Practice 0 – 5 years 6 – 10 years 11 – 15 years > 15 years Years in Urology Practice 0 – 5 years 6 – 10 years 11 – 15 years > 15 years Completed Post-Graduate Training in Urology
% Respondents (n=296) 38% 40% 60% 62% 4% 96% 46 years
41% 27% 16% 16% 6%
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Table 2: Practice Characteristics % Respondents
Practice Model
(n=296) 46%
University/Academic
18%
Hospital employed (owned/inpatient only) Government
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48%
Solo Urologist
5%
25%
>10 Urologists Independent Practice
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2-9 Urologists
Other (Research, OR only, Surgical Center, other) Practice Setting
16%
6%
9%
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Rural
Urban
20% 8%
Private
Suburban
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Institutional Setting
38% 53%
35 – 45 years 46 – 55 years
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> 56 years
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Supervising Physician Age
29% 52% 19%
2%
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Table 3: Practice Location by AUA Section of APPs and MDs (variance >2% noted in bold underline) MD Distribution* (%)
4.9
4
New England
5.2
5.8
New York
9.6
8.4
Mid-Atlantic
4.3
10.3
Southeastern
19.6
21.3
North Central
23.6
17.8
South Central
15.4
Western
17.1
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Northeastern
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APP Distribution (%)
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AUA Section
13.7
18.8
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*From: AUA Annual Census. The State of the Urology Workforce and Practice in the United States 2014. American Urological Association, 2015.
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Table 4: Percentage of Time Spent in Independent versus Shared/Joint Visit % of time spent in clinical setting 73.4
Inpatient Care
9.4
Procedures
8.2
Administration
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30.3
37.0
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*(administration time not queried regarding independent vs. shared)
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Ambulatory Clinic
% of time working Independently
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Visit Type
*
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Table 5: Percentage of APPs Reporting Procedures Performed Independently
Low Complexity Bladder Installations
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Percentage APPs Performing Procedure
56
Intracavernosal Injections for Erectile Dysfunction
36
Urodynamics (Place catheters and perform test) Chemotherapy Injections
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Neuromodulation with Interstim Programming
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Urodynamics Interpretation
43
Pelvic Floor Muscle Rehabilitation +/- biofeedback
Intermediate Complexity
31 29 27 26
31
LHRH Antagonist Insertion
28
Priapism Injection Treatment
21
Cystoscopy for Stent Removal
18
Implant Insertion (e.g. Testopel, Vantas)
18
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Percutaneous Tibial Nerve Stimulation
13
Cystoscopy for Difficult Catheter Placement
12
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Aspirate Hydrocele
Ultrasound: Renal
6
Ultrasound: Transrectal (without biopsy)
6
Ultrasound: Scrotal
4
Ultrasound: Penile Doppler
4
High Complexity Cystoscopy: Diagnostic or Cancer Surveillance
8
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Xiaflex Injections
3
Circumcision
2
Cystoscopy: Bladder/Prostate Botox Injection
2
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Transrectal Ultrasound: Biopsy
Cystoscopy: Bladder Biopsy
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Vasectomy
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Figure 1: Age and Gender of Advanced Practice Providers
Percentage of APPs by Age Group and Gender
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65 years old or over 55 to 64 years old 45 to 54 years old
< 35 years old 5
10
15
20
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35 to 44 years old
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Male
Female
25
30
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Figure 2: Practice Focus Transplant Pediatrics
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Other Practice Focus Minimally Invasive Robotic Surgery Men's Health/Infertility Oncology Female/Neuro-urology
General Urology 0
10
20
30
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Stone Disease
40
50
60
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Percentage of Respondents Selecting Focus
70
80
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APP = Advanced Practice Provider AUA = American Urological Association
NP = Nurse Practitioner SUNA = Society of Urologic Nurses and Associates
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UAPA = Urological Association of Physician Assistants
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PA = Physician Assistant