While questions and concerns about the use of advanced practice providers (APPs) in urology remain, the AUA's new consensus statement on the use of APPs provides a best practices framework for urology practices. Here are eight take-homes from the statement.
National Report-While questions and concerns about the use of advanced practice providers (APPs) in urology remain, the AUA’s new consensus statement on the use of APPs provides a best practices framework for urology practices.
COMMENTARY - APPs: Collaborators, not competitors
Christopher M. Gonzalez, MD, who led the committee for the consensus statement, says the use of APPs isn’t new to urology. An AUA survey conducted in 2013 revealed 62% of urologists surveyed are using APPs in practice. Urology Times’2014 State of the Specialty survey indicated that virtually the same number (64%) use a nurse practitioner or physician assistant, and usage varies significantly by practice setting. But until now there wasn’t much in the way of a roadmap of how to work with APPs. This document is the first effort to develop a roadmap for practicing urologists, according to Dr. Gonzalez.
Dr. KoganIt’s a step in a positive direction, says Barry A. Kogan, MD, professor of urology and pediatrics and urology chair at Albany Medical College, Albany, NY. The document clearly acknowledges that office-based procedures may be delegated to highly skilled, well-trained advanced practice registered nurses (APRNs) or physician assistants (PAs), Dr. Kogan wrote in an email to Urology Times.
The consensus statement, released in December 2014, is a collaboration among urologists, a nurse practitioner, and physician assistants. The document broadly defines APRNs and PAs and their roles in the specialty and how these are evolving; looks at APRNs’ and PAs’ competencies; offers information about state and federal regulations and legislation; and cites research findings about patient satisfaction and liability associated with practices employing APPs. The statement offers urology-specific scenarios on APP use, as well as an APP employment checklist of 15 items practices should complete in order to fully integrate the new provider.
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The consensus also helps to put into perspective why the use of APPs is currently such a big deal. And that’s where we start with the eight takeaway messages from the AUA statement.
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Urologists are in short supply, and it doesn’t look like that’s going to get better anytime soon.
“What we have here is a perfect storm,” said recently retired general surgeon Peter J. Fabri, MD, PhD. Dr. Fabri has worked along with urologist Howard Snyder, MD, who is on the AUA’s legislative affairs committee, on AUA courses on the use of APPs. Dr. Fabri supervised about 40 APPs during his 45-year career as a surgeon and chaired the American College of Surgeons’ committee on allied health personnel.
That perfect storm is the dwindling supply of new urologists, increases in those retiring or getting out of the specialty, and surging demand due in part to the Affordable Care Act and an aging baby boomer population.
In fact, urology might be in more of a pickle than other areas of medicine. The supply of urologic surgeons per capita in the U.S. has fallen more than all surgical specialties, except for general surgery and thoracic surgery, according to the January 2012 urology work force trends bulletin by the American College of Surgeons Health Policy Research Institute (Bull Am Coll Surg 2012; 97:46-9).
The number of urologists hasn’t always been a problem. The supply of urologic surgeons grew faster than the population until 1991. Then the trend reversed and the decline has since accelerated. After 2006, the number of urologic surgeons fell to 3.18 per 100,000 population, according to the bulletin.
Interestingly, urologists are second only to thoracic surgeons as the oldest specialty, with an average age of 52.5 years, according to the ACS bulletin. And more than 18% of urologists are 65 and older, according to a study by Pruthi et al (Urology 2013; 82:987-93).
Replacing urologists that leave the work force with newly trained specialists isn’t promising. Urology residents achieving American Board of Medical Specialties (ABMS) certification declined by 19.7% from 2000 to 2009, according to the Accreditation Council for Graduate Medical Education. (Also see, “Physician supply: The big picture")
One solution to the shrinking urologist work force is the use of APPs, which the AUA endorses “… in the care of genitourinary disease through a formally defined, supervisory role with a board-certified urologist under the auspices of applicable state law.”
“We need people who are capable of helping out,” Dr. Fabri said. “There is an increasing need for individuals to provide the primary care level of these specialties.”
Next: Team-based care
The goal is to integrate APPs in a team-based approach to patient care, with urologists having a supervisory role, according to Dr. Gonzalez. Examples of APP urology practice include: assisting in surgery, seeing postoperative patients, hospital consults, emergency room consults and office patients. Training the APP to handle these and other responsibilities in the practice frees the urologist to see more complex patients, according to the consensus statement.
Urologists, however, should not take that to mean APPs will take over their practice, Dr. Gonzalez says. Rather, APPs can help improve access and quality of care by becoming an integral part of a urologist-led health care team.
“I think that there are some parts of the urologist full-time equivalent [FTE] work that an APP can do almost as well as a physician. If you look at something like primary care, probably 75% to 80% of the FTE can be performed by the APP. In urology, we did a survey and found APPs account for approximately 41% of an MD/DO full-time equivalent. What that means is a vast majority still has to be done by the urologist; however, APPs can still play a valuable role in the practice,” Dr. Gonzalez said.
Susanne Quallich, ANP-BC, NP-C, the sole nurse practitioner involved in the creation of the AUA’s consensus statement, said in an email to Urology Times that the AUA’s document is similar to the Society of Urologic Nurses and Associates’ (SUNA) view of the role of the APRN in urology.
Ms. Quallich“Discussion within the AUA white paper suggests many of the scope of practice activities that are listed on the SUNA document, and the AUA white paper has the same emphasis on practicing within the scope of the state practice act this SUNA document does,” wrote Quallich, who was appointed to the AUA task force by the SUNA board. “The biggest area of contention, and I have already been contacted by other nurse practitioners regarding this, is specific language within the AUA white paper. The AUA emphasizes a supervisory relationship, which is not consistent with the scope of practice and licensing language for nurse practitioners in all 50 states.
“Some states laws use different language, such as independent practice or collaborative practice, making uniform statements about NP practice difficult, especially in a document such as this. But this is a document designed to hit a very middle ground, and could not address all of the licensing variations for nurse practitioners.”
Tim Irizarry, PA, immediate past president of the Urological Association of Physician Assistants and a member of the AUA consensus statement committee, says APPs are not here to compete with urologists.
“We’re not there to steal patients away from urologists. We’re there to accent the practice-to accent the work that they’re already doing,” Irizarry said.
Still, the relationship between urologists and APPs needs to be defined in a social contract, according to Dr. Fabri.
“What we currently don’t have is a formal understanding among physicians, physician assistants, and nurse practitioners about what the future is going to be,” Dr. Fabri said.
Next: Scope of practice
Urologists working with APPs or considering it should know that every state has different scope of practice laws. The AUA consensus statement provides that information for urologists, allowing them to look at their state and find out what an APP can do.
The more formal scope of practice, especially for hospital-based specialties, generally is mandated by the hospital credentialing committee, according to Dr. Fabri. State, institutional, and other checks and balances to define scope of practice are vital, he says.
“We have to have a set of rules so that the people doing things are actually trained to do them. This becomes increasingly important when you’re talking about technical activities,” Dr. Fabri said. “A urology residency is 5 years after 4 years of medical school. A nurse practitioner has 2 [years] and more than likely has never been in an operating room.
“I’m trained in general surgery and surgical-critical care. I did a medical-gastroenterology fellowship, a surgical oncology fellowship, and critical care fellowship. Even with all that training, I can’t do urology.”
Determining APP scope of practice in a practice is based on state laws, hospital credentialing, and a collaborative agreement between APPs and supervising urologists or urology groups based on the practice’s need and APP skill and ability, according to Dr. Fabri.
Federal issues regarding Medicare and Medicaid reimbursement are also spelled out in the statement.
“Advanced practice providers have more of an accepted role with most insurances, especially Medicare,” Irizarry said. “We are being reimbursed at 85% for non-incident to, and when we are incident to, we’re able to bill out at 100%.”
Next - Core competencies: PAs vs. NPs
Education for PAs and NPs differs markedly, as is shown in a handy table in the consensus statement comparing core competencies. Still, the statement authors agree that PAs and NPs are comparable in their abilities and skills once they are integrated into urology practices. “It becomes clear from the description of the NP and PA that while their training may be different, their roles after certification can be quite similar,” the statement says.
“The training for physician assistants is exactly the same in every single PA program in the U.S., but there is no standard curriculum in nurse practice,” Dr. Fabri said. “Having said that, with every nurse practitioner that I’ve ever worked with, the training is more than adequate. It’s just different.”
Irizarry says PA education is based on how physicians are trained in medical school. Advanced practice nurses approach the same set of skills but from how nurses are trained in nursing school.
Regardless of whether the provider is an NP or PA, Dr. Fabri says, the keys for successful integration into urology practice are proper and thorough training, communication, and supervision.
Next - Training: Current skill levels & future needs
APPs’ training is like an apprenticeship, which can be broken down into three skill levels, according to Dr. Gonzalez. At level three, the APP is newly graduated or new to urology and requires urology-specific training.
“Initially that’s going to be pretty hands-on by the physician basically watching what the APP does and teaching,” Dr. Gonzalez said. “Having level two skills is going up a notch, where the APP is a little more independent as far as what they can do. An APP with level one skills is a highly skilled clinician. So, you want to get them to level one skills.”
But adequate urologic training remains a stumbling block for APPs, according to Heather Schultz, NP, vice chair of the AUA’s APN/PA education committee and clinical instructor in urologic surgery at the University of North Carolina at Chapel Hill. She says it will be interesting to see if the consensus statement opens the door to expanding training and competencies for APPs in urology.
The bottom line, according to Schultz, is APPs are performing procedures, including cystoscopies and prostate biopsies.
“We’re desperate to have some standards and guidelines and training,” Schultz said. “If we don’t have that, [urologists’] liability will be increased and patient satisfaction will be poor. I think it all comes down to allowing us to have that education.”
Dr. Kogan says he supports furthering APP education through the AUA.
“I agree that APPs are doing these procedures, and it seems natural that the AUA should be a leader in educating practitioners in these procedures,” Dr. Kogan said.
Next - Patient satisfaction: What does the evidence suggest?
Available research suggests patients are satisfied with APP care.
“Certainly, in the primary care model, [patient satisfaction] hasn’t been a problem. In surgical subspecialties, the data is a little more sparse,” Dr. Gonzalez said. “But, at the end of the day, there’s no evidence to point to patient satisfaction being less with an advanced practice provider as compared to a urologist alone in the urologist-led team-based approach.”
Schultz says the University of North Carolina has ensured a smooth transition from MD to APP with communication. Physicians take the lead by talking with patients, initially, about the team-based approach to care and that the physicians in the practice communicate frequently with the APPs.
“Now that I have been following patients for 8 years, there is this strong level of trust. Patients like how accessible I am to them by appointment, phone, or patient portal. My position is designed to be accessible to the patients,” she said.
Next: Liability risk
What’s known about liability risk and APPs is much the same. There isn’t evidence to suggest APPs are a liability burden for physicians. However, that’s an evolving area of research and should be monitored, according to Dr. Gonzalez.
Urologists, nevertheless, are worried about liability. A recent Urology Times survey asking urologists what concerns them most about delegating to an APP shows increased liability risk is the number one concern, with 52% choosing this response.
“I think it all comes down to selection of the NPs and PAs that you’re hiring and the training that you give that person and the physician’s confidence that they will be able to implement the type of care, interventions, and care plans that the physician wants,” Schultz said.
In this video, Urology Times Content Specialist Annamarie Iannetta speaks with two malpractice attorneys to learn more about the potential liability risk associated with the use of PAs and NPs.
Next: The urologist as 'CEO'
The consensus statement refers to the future urologist as more focused on providing care for complex urologic patients, as well as managing large patient populations with the help of APPs and technology, including telemedicine. The urologist, according to the statement, “will function more like a CEO whose responsibility is to ensure that a population is provided with high-quality, rapidly available urological care.”
As a result, medical school and residency training might need to better prepare urologists for those supervisory and increasingly complex surgical roles.
Irizarry says APPs are not yet generally utilized to their full potential. APPs at the large group practice in Little Rock, AR where Irizarry works are trained to do prostate ultrasounds and biopsies. The urologists in the group, he says, made the decision to delegate these procedures based on the APPs’ skill and practice need.
“This need may not be identified at other practices, but it does work well in ours and is very beneficial in freeing up our urologists to perform other duties,” Irizarry said.
Change is the only sure thing, Dr. Fabri says.
“I think things are going to change and that’s uncomfortable for people. But we don’t have an option. We really need to come up with a social contract that allows us to evolve into a meaningful approach for providing health care,” he said.
U.S. patients face a shortage of more than 130,600 primary care and specialty physicians by 2025, according to the Association of American Medical Colleges (AAMC). That number includes nearly 65,000 surgeons and other specialists.
By 2020, 250,000 physicians will likely retire, according to the AAMC.
The pipeline isn’t generating enough doctors. Residency training programs continue to be in short supply. One reason, according to the AAMC, is the number of federally funded residency training positions was capped by Congress by the Balanced Budget Act of 1997. The 26,000 residency positions available for first-year trainees will not be enough to provide training for the students graduating from medical school as early as 2016.
All the while, statistics point to a growing demand for health care, with an aging baby boomer population and the newly insured under the Affordable Care Act. The Congressional Budget Office estimated in 2013 that 32 million more Americans would get insurance because of the health care law by 2017.
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