Survey: Majority of APPs perform advanced procedures

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As the United States faces a urologist shortage, physician assistants and nurse practitioners will likely play an increasingly important role in the field of urology. Now, a new survey-the first of its kind-suggests that many of those in these positions are performing advanced procedures despite lacking postgraduate urologic training.

Lead author Joshua P. Langston, MD, told Urology Times that the findings raise important questions about the care given by these providers.

"We have no guidelines about how many procedures they should do before they do them on their own. People are performing these procedures in a very haphazard way, being trained individually by the physicians supervising them. That leads to a lot of variety, and that's not the best way forward,” Dr. Langston said.

Dr. Langston, instructor of urology at Eastern Virginia Medical School, Norfolk, launched the survey with colleagues at the University of North Carolina, Chapel Hill. The impetus for the study was the 2013 AUA Workforce Survey, which suggested that almost two-thirds of urologists have advanced practice providers (APPs) on staff, Dr. Langston said.

"We realized we were lacking understanding about what they do and the role they do play. We needed to go straight to the source and ask them: What do you do, how many hours do you work, what settings are you in?” Dr. Langston said.

Dr. Langston and colleagues asked 1,347 nurse practitioners and physician assistants-as identified by the AUA, Urological Association of Physician Assistants, and Society of Urologic Nurses and Associates-to answer questions in a 29-item web survey. A total of 296 people responded to the survey.

The findings were presented at the 2016 American College of Surgeons Clinical Congress in Washington. According to Dr. Langston, the study has been accepted by Urology Practice and will appear in a future issue.

Next: 81% perform procedures

81% perform procedures

Of the 296 respondents, the authors found that:

62% were nurse practitioners and 38% were physician assistants.

81% were women, including 96% of nurse practitioners. The median age was 46 years.

6% reported formal postgraduate urologic training.

81% reported performing procedures on the job, and 63% performed procedures of moderate or high complexity. A sampling of various procedures and the percentage of APPs who reported performing them included bladder instillations (56%), chemotherapy injections (29%), percutaneous tibial nerve stimulation (31%), luteinizing hormone-releasing hormone antagonist insertion (28%), aspirate hydrocele (13%), circumcision (2%), and vasectomy (1%).

"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," the study notes. "Whether these consequential procedures should be performed by APPs continues to present a degree of debate within American urology."

What's next? Dr. Langston said APPs could take some of the load off urologists by performing certain procedures at the same level of quality.

"Obviously, the cost to employ and train them is much less,” Dr. Langston said.

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But questions remain.

"We need to start thinking about whether we want to set up guidelines, training, and courses to sanction them doing it," he said.

In a consensus statement on APPs-defined as physician assistants and advanced practice registered nurses such as nurse practitioners-the AUA announced in 2015 that, "It is a goal of the AUA and of practicing urologists to develop a process by which a newly graduated APP would undergo a period of mentorship and training in order to cultivate a practitioner who is capable and willing to independently manage a wide variety of urologic conditions" (http://bit.ly/AUAonAPPs).

“The scenario is not dissimilar to the training and mentorship that goes into training a junior urology resident, who is groomed to be capable of indirect supervision for most encounters in the area of urologic health,” according to the consensus statement.