APPs: Urology’s new normal

For U.S. urologists, working with nurse practitioners and physician assistants has become more the norm than the exception.

More than 70% of practicing urologists work with one or more nurse practitioners and physician assistants, collectively called advanced practice providers (APPs), according to 2017 AUA Census data. By comparison, 62.7% of urologists worked with an APP in 2015.

“A decade ago it was rare to have advanced practice providers as part of routine urologic care. Now they’re integral and a necessary part of any active urologic practice,” said Bradley A. Erickson, MD, MS, associate professor of urology and surgery, University of Iowa, Iowa City.

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Urology isn’t the only specialty with a growing APP work force. About 28% of all specialty practices employed APPs in 2016, according to a recent research letter published in JAMA Internal Medicine (2018; 178:988-90). That’s a 22% jump from the percentage of specialty practices employing APPs in 2008.

APPs’ expanding roles

The AUA’s position is that APPs should practice as a team with a board-certified urologist as the head of that team, according to Christopher Gonzalez, MD, MBA, professor and chair of urology at Loyola University School of Medicine, Chicago. Dr. Gonzalez led an AUA working group, including APPs, to develop the AUA Consensus Statement on Advanced Practice Providers, published in 2013.

That position hasn’t changed since 2013, but the roles that APPs have within those teams appear to be expanding. One example: surgery. Urologists are increasingly using APPs as assistants in surgery, particularly in robotic and laparoscopic operations, Dr. Erickson and colleagues reported in a 2017 study (Urology 2017; 106:76-81).

The most common way in which APPs assist urologists in clinical procedures is in the operating room (30%), according to the 2017 AUA Census. APPs also assist with cystoscopy for difficult catheter placement, cystoscopy for diagnostic or cancer surveillance, urodynamics interpretation, cystoscopy for stent removal, cystoscopy for botulinum injections, cystoscopy for bladder biopsy, circumcision, vasectomy, and priapism injection treatment, according to AUA data, which was presented in part by Raymond Fang et al at the AUA annual meeting in San Francisco.

Next:APPs increasingly performing some procedures independentlyMore controversial is the fact that APPs increasingly perform some urologic procedures independently. The AUA reports that the most common clinical procedures APPs performed independently in 2017 were bladder instillation (56.3%) and intracavernosal injections for erectile dysfunction (55%). About 40% of APPs perform urodynamics interpretation independently, 39% do percutaneous tibial nerve stimulation, and 33.8% do chemotherapy injections. More than one-fourth of APPs administer luteinizing hormone-releasing hormone antagonists and conduct urodynamics.

Approximately one-fourth of APPs independently perform cystoscopy for stent removal, neuromodulation with InterStim programming, and priapism injection treatments.

Dr. Erickson and colleagues authored a study published March 2017 in Urology Practice that found APPs independently performed 54,549 simple procedures in urologic practice in 2003 versus 230,683 such procedures, including post-void residual, insertion of catheter and interpretation of uroflowmetry, in 2014. APPs independently billed for 328 cystoscopies in 2003 compared to 2,284 in 2014 (Urol Pract 2017; 4:169–75).

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Research looking at whether APPs perform urologic procedures like these as safely and effectively as urologists is lacking, according to Dr. Gonzalez. “We just know that the trends show a small number of more complex procedures are being done by advanced practice providers and that number of procedures is starting to grow,” he said.

While most procedures that APPs are performing are relatively straightforward, some are complex with notable technique-based side effect profiles, according to urologist J. Stuart Wolf, Jr., MD, professor in the department of surgery and perioperative care, Dell Medical School, University of Texas at Austin.

“The important issue when you’re having an advanced practice provider do a procedure is not only making sure they have the technical skills to do the procedure but also that they know when something’s wrong, when something’s different and out of the ordinary, and when to involve the supervising physician,” Dr. Wolf said. “I think cystoscopy for bladder tumor surveillance is a great example. Sure, technically it’s not a whole lot different than doing cystoscopy for stent removal. But cognitively, it’s significantly different. It entails a lot more knowledge to do well.

“I think that’s a good example of a procedure that perhaps a well-trained APP could do under supervision with the attending looking at the monitor, although frankly, I would argue at that point you’re better off just having the physician doing the procedure.”

Dr. Wolf, who works with a physician assistant in his practice, said it’s important to teach APPs the cognitive aspect of procedures-knowing when to do something, when not to do something, and when to change course. He said urologists’ concerns about working with APPs are less about turf and more about patient safety and outcomes.

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“It really gets down to a quality of care issue,” he said. “If an APP can do tasks to free me to do more complex tasks, that’s good for quality of care. The only time I get worried is if the practice of the APP creeps into those more complex areas where more subject matter expertise is required. Then quality might suffer.”

Next:Improving accessImproving access

APPs can increase patient access, and that’s a big deal and real need in urology, experts in the field say.

Barry Kogan, MD, chief of urology at Albany Medical College, Albany, NY, said having an APP in his pediatric urology practice helps him accomplish things he might not have the time or patience for.

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“We treat bedwetting, and that’s a problem that takes a lot of time and effort. As someone who is more focused on surgery, maybe I have less time to take with families, whereas my nurse practitioner is more able to discuss the issues in more depth with families,” Dr. Kogan said. “I can only see so many patients. APPs help with access.”

APPs might be a solution for increasing access problems due to an aging urologist work force. Twenty-seven percent of practicing urologists plan to retire in the next 5 years. Compared to non-retiring urologists, those near retirement are more likely to practice outside metropolitan areas, a study based on AUA Census data found (Urology 2016; 94:85-9).

“There’s a concern that we won’t have enough providers or we’ll have a geographic maldistribution of providers, where younger urologists and large groups will be concentrated in urban areas and rural areas will be underserved,” Dr. Gonzalez said. “This is where we really think there’s an opportunity with advanced practice providers.”

The number of urologic providers probably will be adequate if some of the nonsurgical care is directed elsewhere, according to Dr. Erickson. 

“I think that we’ll probably be OK with the current work force if we’re just concerned about the surgical needs of our patients. However, to manage all their medical needs, especially the chronic diseases, we’ll need to continue to see evolution in the urologist/APP partnership,” Dr. Erickson said.

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There’s a natural tendency for urologists to treat APPs as second-class citizens, Dr. Kogan said.

“I think treating them with courtesy and respect and understanding that they bring something to the table is really important,” he said. “Once they’re up to speed and educated, then I think you want to treat them as a full partner on the team and let them know that.”

Next: An APP shares what has helped her in practiceKarla Giramonti, MS, FNP-BC, of Albany Medical Center’s division of urology, works with Dr. Kogan. She said the two things that have most helped her in practice have been the practice’s team approach to patient care and Dr. Kogan’s continuous teaching. Today, Giramonti performs circumcisions in the operating room and in the office. 

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“That’s something many surgeons consider a fairly minor procedure, but in New York it’s a very much needed procedure. It saves the operating room time for Dr. Kogan to do cases that are much more serious and need to be done in a timely manner,” Giramonti said. “Dr. Kogan is constantly training me and I’m constantly learning. We did the circumcisions together. We confirmed that I had my knowledge base that was well documented. He makes himself available if there’s a concern. He makes sure that I’m comfortable.”

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To optimize their relationships with APPs in practice, urologists should allow APPs to perform to their full scope of practice within the confines of state and institutional policies, according to Heather Schultz, NP, of the department of urology, University of North Carolina at Chapel Hill and chair of the AUA’s APP Education Committee. They should also include APPs in practice decisions, she said.

Next:APP training 101

APP training in urology can come from within the practice. There are also some programs around the U.S. that train nurse practitioners, physician assistants, or both in urology practice, including those at Mayo Clinic, UT Southwestern, Rosalind Franklin University, University of Southern California, Vanderbilt, and the Carolina Medical Centers in Charlotte, NC. 

The AUA also offers programs that are helpful to APPs in urologic practice, according to Heather Schultz, NP, chair of the AUA’s APP Education Committee. Education opportunities for APPs include:

• At the annual AUA meeting, free with registration, there is a two-day program for APPs on a variety of topics based on past years evaluations and education needs assessment surveys. 
• A part of AUA member benefits, APPs and allied health professionals have access to Urology Place, which is a platform for those working in urology to connect, discuss and share information.
• The Urology Care Foundation offers free, printable patient education materials.
• The AUA offers online education modules for APPs, where they can obtain continuing education credit through AUA University. 
• The Society of Urologic Nurse and Associates offers regional and national meetings, online education, publications and urology certification through the Certification Board for Urology Nurses and Associates.
• The Urological Association of Physician Assistants offers national meetings, online education, and publications.
• The AUA also offers guidelines, white papers, and best practice statements, which can help APPs in practice.