UK experience with NPs may be harbinger for U.S. urology

Norwich, UK-If the urologist shortage reaches a critical stage in the United States as many predict, the United Kingdom may offer a glimpse of what the future holds. Urologists in that country rely heavily on nurse practitioners to shoulder the workload, including performing the UK’s most commonly performed urologic procedure, flexible cystoscopy.

Nearly half of the UK’s hospitals use nurse practitioners (NPs or nurse specialists) to perform cystoscopy, according to a 2012 work force survey conducted by the British Association of Urological Surgeons (BAUS). Indeed, “nurse cystoscopists” are well established in many centers across the country.

While published data on the outcomes of NP-performed cystoscopy are lacking, extensive training and careful supervision have helped ensure the procedure’s safety and efficacy in the hands of these practitioners, says Neil Burgess, MCh, consultant urologist at Norfolk and Norwich University Hospital in Norwich, UK.

“Where I’ve seen nurses do things in place of the doctor, they do it better, in my opinion, because they stick to protocol and they don’t take shortcuts,” Dr. Burgess said in a telephone interview with Urology Times. “And they’re not afraid to ask [for help]; they don’t assume a competence that’s beyond them.”

Wait times drive expansion

The use of NPs in the UK expanded in the late 1990s simply out of necessity, says Dr. Burgess, who held the role of work force lead at BAUS for 5 years until stepping down in June. Under the country’s publicly funded National Health Service (NHS), wait times for elective surgical procedures ballooned to 2 years. The urologist-to-population ratio was 1:119,000 in 2000 (vs. 1:33,000 in the U.S.), according to a BAUS work force report co-authored by Dr. Burgess.

“[The wait time is] now 18 weeks from referral from your community physician to your operation, which still sounds like a long time, but that’s available to every individual citizen in the UK as part of the commitment to the NHS,” he said.

With nearly 341,000 cystoscopies performed in the UK annually, the procedure was a logical choice to involve NPs in lightening the workload.

“It’s a big part of our practice,” Dr. Burgess said. “And if you could train a specialist nurse to do it, it frees up the consultant or physician to do something else. That was the argument really for teaching them in the first place.”

Aside from cystoscopy, NPs take an active role in preoperative assessments, assessment of men with lower urinary tract symptoms, urodynamic studies, administration of intravesical treatments, and supervision of lithotripsy treatments, among other responsibilities. Prostate biopsies are performed less commonly by these practitioners, with Dr. Burgess estimating that 10% or fewer hospitals use them in this role.

An evolving role

Initially, in the early 2000s, NPs’ involvement in flexible cystoscopy was primarily focused on the surveillance of superficial bladder cancer-so-called “check cystoscopies.” Their role has evolved to encompass diagnostic cystoscopy, including bladder biopsy, cystodiathermy, and the removal of ureteral stents, a practice that “has evolved without any formal regulation or nationally agreed standard of training or assessment of knowledge or skills,” BAUS and the British Association of Urological Nurses pointed out in a formal guideline that was released in November 2012.

The guideline is designed to provide standardized training and assessment of nurse-based flexible cystoscopy skills. It covers prerequisite skills and knowledge requirements for nurses performing flexible cystoscopy and use of a cystoscope for removal of stents, cystodiathermy, and performing biopsies. The guideline divides the skill of flexible cystoscopy into five stages: observation of the procedure, withdrawal of the cystoscope, examination of the bladder urothelium, insertion of the scope, and performance of the full procedure.

To achieve competence, trainees are required to maintain a portfolio of evidence of training, and formative assessments occur during training in the form of case-based discussions and mini clinical examinations.

Assessment, which is performed by the hospital’s urology clinical director, a consultant urologist who provides training/supervision in flexible cystoscopy to physicians in training, or an experienced nurse cystoscopist, is conducted with the assessor directly observing the trainee for a minimum of five assessed procedures.

Nurse specialists who gain extensive experience in cystoscopy often outperform junior physicians, who have a tendency to over-recommend formal cystoscopy under general anesthesia when a lesion is found, according to Dr. Burgess.

“But if you have a nurse who’s been with you for years, not just 6 months, then you can see how they settle in and gain a lot of experience,” he said.

NPs are required to work within the structure of a urology department and under the supervision of a consultant urologic surgeon. In the event of negligence, the department of urology’s clinical director is ultimately responsible.

Would the UK experience translate to the U.S.? Perhaps, but another factor must be considered: fee for service does not exist in the UK’s publicly funded health system. U.S. urologists may not be ready to part with the income they earn from performing cystoscopy.

“If I do five cystoscopies or 25 cystoscopies on a list, I don’t get paid any differently,” Dr. Burgess said. “It’s quite lucrative to do cystoscopies in the private sector.”

Peter Fabri, MD, PhD, professor of surgery and industrial engineering and senior advisor in graduate medical education at the University of South Florida College of Medicine in Tampa, says U.S. physicians need to consider the successful “business plan” used in dentistry, in which a dental hygienist does a large percentage of the work while the dentist assures that the level of care is appropriate for the patient.

“If the urology patient never saw the urologist in the U.S., that wouldn’t work,” Dr. Fabri said. “But if a urologist could spend the last 5 minutes with the patient after the mid-level provider spent 30 or 45, the quality would be every bit as good (better?), and the patients would be happy.

“Procedural work by mid-level providers is complicated, to be sure,” he added. “But I don’t see why it takes 4 years of medical school and 5 years of residency to learn how to safely do cystoscopy with modern equipment in healthy patients.”UT

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