Advanced Practice Providers Research Articles

Changes in outpatient antibiotic prescriptions by U.S. physicians and advanced practice providers, 2011 and 2022

Background: The number of advanced practice providers (APPs)—nurse practitioners (NPs) and physician assistants (PAs)—continues to expand across the United States. Several studies suggest differences in antibiotic prescribing rates and appropriateness by APPs compared to physicians. The objective of this analysis is to characterize population- and provider-specific outpatient antibiotic prescribing rates among physicians and APPs nationally, by state, and within urban versus rural counties. Methods: We estimated outpatient oral antibiotic prescription rates for 2011 and 2022 using county-level prescription dispensing data from IQVIA Xponent® (numerator) and population census estimates (denominator). Provider specialty denominators were provided by IQVIA, based on data from the American Medical Association. Counties were classified as urban or rural per the 2013 National Center for Health Statistics classification. National and state-level prescription volume, rates per 1000 population, and average number of prescriptions per provider were calculated for physicians, NPs, and PAs. We assessed the degree to which provider-specific rates explained the variance of the overall rate by state, using the coefficient of determination (r2) from Pearson’s correlation. Results: Between 2011 and 2022, overall U.S. antibiotic prescribing declined from 877 to 709 per 1000 population, a 19.2% relative reduction. The provider-specific proportion of the overall prescribing rate relatively decreased by 32% for physicians but increased by 157% for APPs (NPs 229%, PAs 86%; Figure 1). State-level antibiotic prescribing rates varied by provider type for both years, shifting towards proportionally greater APP prescribing in 2022 (Figure 2). For 2011 and 2022, physician prescribing rate strongly correlated with the overall state rate (r2 = 0.83 in 2011 versus 0.80 in 2022), whereas the correlation of the NP prescribing rate increased (r2 = 0.20 in 2011 versus 0.76 in 2022). A total of 60,327 (7.2%) physicians practiced in rural settings in contrast to 42,876 (12%) NPs and 14,495 (9.4%) PAs in 2022. Providers in rural counties prescribed more antibiotics per provider on average compared to urban counties; rural physicians prescribed 57% more antibiotics per provider (207 vs 132 antibiotics per provider), rural NPs prescribed 115% more (284 vs 132), and rural PAs prescribed 53% more (289 vs 189). Conclusions: The relative contribution of APPs to outpatient antibiotic prescriptions more than doubled over the past decade, accounting for 1 in 3 prescriptions in 2022. This contribution was especially prominent among NPs in rural counties. Further evaluation of antibiotic prescribing appropriateness among APPs and integration of APPs into antibiotic stewardship efforts in various settings.

Advanced practice providers: An evolution of scope of practice and clinical integration across the surgical healthcare landscape

Advanced practice providers (APPs) have become an integral part of surgical practice over the past 50 years. Understanding the clinical roles of Physician Assistants (PAs) and Nurse Practitioners (NPs) provides insight into practice norms, collaborative opportunities, the nuances of APP independent practice trends, billing practices, and current practice challenges.Exploring the history, education, and current practice environment of APPs allows a sophisticated understanding of their roles in the inpatient/facility and outpatient/office settings. This article explores the impact of APPs on access to care, and their role across the overall healthcare landscape in the United States particularly as government and healthcare continue to intersect.The aim of this work is to provide the reader with a nuanced understanding of the factors influencing the current practice of APPs working in surgical fields in the United States and to foster an authentic appreciation of the existing complexities of APPs practicing in the field of surgery in the context of the current evolving national healthcare landscape.

The Uncharted Patterns of Antibiotic Prescribing in Urology Ambulatory Practices: A Four-Year Analysis

Background: Urinary tract infections (UTIs) represent a prevalent indication for outpatient antibiotic usage, yet limited data exist regarding antibiotic prescriptions within urology specialties. This study aimed to assess antibiotic prescribing patterns in urology offices over a four-year period, providing insights for potential stewardship interventions. Methods: The analysis focused on antibiotic prescribing trends in adults between 2018 and 2021 during both visit and non-visit (e.g. telephone and chart messages) encounters across 15 ambulatory Urology clinics in an academic medical center in Western New York. Exclusions were made for antivirals, antiparasitics, antifungals, oral suspensions, selected non-UTI antibiotics, duplicate orders on the same day or week, and prescriptions exceeding 28 days. Prescriptions were categorized into single doses administered in the clinic and those prescribed for 2-28 days, with descriptive statistics and trend analyses conducted using SAS v9.14. Results: Over the four-year period, 54,282 prescriptions were analyzed. Of these, 26,944 (49.7%) were single doses administered in the clinic, predominantly for pre-procedure prophylaxis. The most commonly prescribed antibiotics for prophylaxis were fluoroquinolones (FQ) (47.5%), followed by ceftriaxone (19.2%), nitrofurantoin (13.2%), trimethoprim/sulfamethoxazole (8.6%), and gentamicin (4.2%). Among the 27,288 prescriptions for 2-28 days, 72.3% were from non-visit encounters, with 61.6% prescribed by advanced practice providers (APPs) (Figure 1). The mean number of prescriptions per patient was 2.07, with women receiving more prescriptions than men (2.39 vs. 1.88, P < 0.001). FQ remained the most commonly prescribed antibiotics during all encounters (23.7%), followed by nitrofurantoin (23.0%) (Figure 2). The antibiotic duration was longer for visit-based compared to non-visit-based prescriptions (mean 10 vs. 7 days, P < 0.001). Notably, there was a significant decrease in fluoroquinolone use between Q1 2018 and Q4 2019 for both male and female patients, followed by insignificant changes thereafter. Conclusions: Antibiotic use in urology outpatient settings is substantially underestimated if only prescriptions made during visit encounters are considered. More than two-thirds of prescriptions for 2-28 days were from non-visit encounters, with the majority originating from APPs. The average therapy duration exceeded guideline recommendations. Moreover, approximately half of the antibiotics were administered in the office for pre-procedure prophylaxis. To enhance antibiotic prescribing in these specialized clinics, interventions should focus on non-visit prescriptions and provide education for APPs, alongside adjustments to default durations in electronic orders. Further evaluation is essential to assess the appropriateness of single doses for pre-procedure prophylaxis.

What Is the Medical and Legal Risk of Physicians Supervising Advanced Practice Providers?

Physicians would be prudent to carefully evaluate their legal duties when supervising advanced practice providers. There are real legal risks inherent in the supervisory role physicians assume in today’s medical practice models. This article highlights the legal risks and the due diligence necessary when considering how to manage the agency relationship between physicians and advanced practice providers. The understanding of respondeat superior doctrine and vicarious liability will facilitate physician understanding of how to manage these relationships and mitigate legal risk.

Barriers and Facilitators to Optimal Antibiotic Prescribing on Discharge from the Hospital to Nursing Homes

Background: Up to half of antibiotics used in nursing homes (NHs) are initiated in acute care hospitals prior to nursing home admission. Optimizing antibiotic prescribing on hospital discharge presents an opportunity to improve NH antibiotic use. We aimed to identify barriers and facilitators to optimal antibiotic prescribing on discharge from the hospital to NHs. Methods: This was a qualitative thread of a convergent parallel mixed methods study to identify high-value targets to optimize antibiotic prescribing on discharge from the hospital to NHs. We conducted 32 qualitative interviews: 16 with prescribers (9), pharmacists (6), and a care manager (1) from 3 acute care hospitals and 16 with advanced practice providers (12) and registered nurses/nurse managers (4) from 7 NHs in Oregon and Wisconsin. Interview participants were asked to describe their typical practice for prescribing antibiotics on discharge to NHs or admitting patients with antibiotic prescriptions from hospitals, and about barriers and facilitators for optimal antibiotic prescribing during these transitions. Interviews were audio recorded, transcribed verbatim, and analyzed by 3 investigators using the qualitative descriptive analysis Results: Hospital healthcare workers described that there are different practice flows for oral and intravenous (IV) antibiotic prescribing. IV antibiotic orders are typically routed to the infectious diseases (ID) specialists and ID pharmacists to review and verify appropriateness. There were minimal established workflows to review and verify oral antibiotic orders. Pharmacists appeared integral to optimal antibiotic prescribin; however, the high frequency of oral prescriptions and short turnaround times from discharge orders to transportation limited pharmacists’ abilities to review these orders. With limited pharmacist involvement, the quality of oral antibiotic prescription relied on the prescribers’ knowledge, and there was no systematic oversight for inexperienced prescribers or specialists who may not be familiar with the adequacy of antibiotic use for NH residents. NH participants perceived that most antibiotics prescribed from hospitals were appropriate. Yet, some commented that they occasionally observe inadequate or unusual prescriptions from newer prescribers or specialists. NH participants most common concern related to antibiotic prescriptions was missing information including unclear or lack of antibiotic indications or stop dates. NH participants also stated that the frequent need to contact the hospital to obtain missing information is challenging and burdensome. Conclusions: Qualitative interviews identified several barriers and facilitators to optimal antibiotic prescribing on discharge to NHs. These results will be used to develop an intervention to improve antibiotic prescribing during these transitions.

Innovation adoption, use and implementation in emergency departments during the COVID-19 pandemic

IntroductionDuring a public health emergency like the COVID-19 pandemic, emergency department (ED) clinicians may be able to save more lives if they rapidly identify and implement innovations that are safe...

A Real-World Evidence Primer for Advanced Practice Providers: Integrating P-Reality X Into Shared Decision-Making for People With HR+/HER2− Metastatic Breast Cancer

Advanced practice providers in oncology are now likely to encounter real-world data (RWD) studies in addition to data from randomized controlled trials (RCTs) in their practice. Real-world evidence derived from RWD can provide important information about a therapeutic agent’s effectiveness outside of the confines of RCTs. It is important to understand how these studies are conducted and how data from these two types of studies can be interpreted and integrated for practical clinical use and shared decision-making. The goal of this manuscript is to provide an overview of the fundamental aspects of RWD studies and what is required to conduct a robust RWD study. Recently published studies are cited to demonstrate how RWD studies complement RCTs.

A survey of current specialty palliative care education in the United States.

Palliative care (PC) is a health care specialty that is focused on the holistic care of individuals with serious illness. It requires interprofessional collaboration and expertise to meet the physical, psychosocial, social, cultural, and spiritual needs of patients experiencing serious illness and their families. The interprofessional team (IPT) is most often composed of Advanced Practice Providers (APPs) [including Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Associates/Assistants (PAs)], Chaplains, Registered Nurses (RNs), Doctors of Medicine and Doctors of Osteopathic Medicine (MDs/DOs), Registered Pharmacists (RPhs), Social Workers (SWs) and other professions depending on site of care, the age of the patient, and the illness. The United States has specialty palliative care (SPC) IPT members who have completed advanced education and training and obtained specialty certification. However, there is currently no interprofessional consensus education and training resulting in interprofessional variability of definitions of education and requirements for academic preparation into the specialty. This article offers the results of an online review and survey of the current availability of SPC education in the United States which includes certificate programs, residencies, fellowships, and immersion programs available to each profession. The purpose of this review is to unify the available information regarding SPC programs, providing a succinct, yet thorough, overview of the SPC educational landscape. It emphasizes the length of time, cost, and delivery method for IPT members in choosing programs.

An Analysis of Trainee Salaries Offered in Nurse Practitioner and Physician Assistant/Associate Postgraduate Residency and Fellowship Programs in the United States.

Background Although there has been steady growth in the number of postgraduate nurse practitioner (NP) and physician assistant/associate (PA) residency and fellowship programs in the United States, little is known about annual salaries paid to trainees across a national sample of postgraduate programs and specialties. We describe postgraduate program NP and PA trainee salaries and the relationship to specific variables. Methodology An electronic survey was distributed via email to 336 postgraduate NP, PA, and joint NP/PAresidency/fellowship programs between November 2023 and December 2023.Frequency tables (for categorical variables) and descriptive statistics (for continuous variables) were used to summarize the data. Chi-square tests of independence were used to determine the relationship between trainee salary and program type, geographical location, and clinical setting. Results There was a statistically significant association between trainee salary for primary care and clinical profession (χ2(6) = 13.993, p = 0.022). Over half of NP respondents(52.1%) reported that their trainees had an annual salary between $76000 and $86000. The majority of PA respondents (57.1%) reported that their trainees had an annual salary below $75000. Respondents who were non-clinical professionals(50.0%) reported that their trainees had an annual salary of over $86000. The single physician respondent also reported that their trainees' had an annual salary of over $86000.It appears that PA respondentswere more likely to report lower trainee salaries than respondents who were NPsand non-clinical professionals. Additionally, respondents associated with primary carejoint NP/PA cohorts were more likely to report higher trainee salaries than participants having NP-only cohorts. Lastly, there was a statistically significantly positive relationship between trainee salary and the number of postgraduate advanced practice provider (APP) trainees in psychiatric mental health (τb= 0.451, p = 0.006). Conclusion To the best of our knowledge, this national study is the first of its kind to examine and summarize APP postgraduate trainee annual salaries across multiple specialties. Additional studies are needed to clarify the relationships between trainee salaries and other variables.

Key factors for establishing and sustaining a successful palliative radiation oncology program: a survey of the Society for Palliative Radiation Oncology.

Dedicated palliative radiation oncology programs (PROPs) within radiation oncology (RO) practices have been shown to improve quality and decrease costs of radiation therapy (RT) in advanced cancer patients. Despite this, relatively few PROPs currently exist, highlighting an unmet need to understand characteristics of the few existing PROPs and the potential barriers and facilitators that exist in starting and maintaining a successful PROP. We sought to assess the attributes of existing PROPs, the facilitators and barriers to establishing these programs, and the resources needed to create and maintain a successful program. A 15-item online survey was sent to 157 members of the Society of Palliative Radiation Oncology (SPRO) in July 2019. Of the 157 members, 48 (31%) responded. Most practiced in an academic center (71% at main center and 15% at satellite) and 75% were from a larger group practice (≥6 physicians). Most (89%) believed the development and growth of a dedicated PROPs was either important (50%) or most important (39%) to the field of RO. Only 36% of respondents had a PROP, 38% wanted to establish one, and 13% were currently developing one. Of those with PROPs (N=16), 75% perceived an increase in the number of referrals for palliative RT since starting the program. A majority had an ability to refer to an outside palliative care specialist (64%), an outpatient RO service (53%), and specialized clinical processes for managing palliative radiotherapy patients (53%), with 41% having an inpatient RO consult service. Resources considered most essential were access to specialist-level palliative care, advanced practice provider support, a radiation oncologist with an interest in palliative care, having an outpatient palliative RO clinic, an emphasis on administering short radiation courses, and opportunities for educational development. Of those with a PROP or those who have tried to start one, the greatest perceived barriers to initiating a PROP were committed resources (83%), blocked out clinical time (61%), challenges coordinating management of patients (61%), and support from leaders/colleagues (61%). Perceived barriers to sustaining a PROP were similar. For those without a PROP, the perceived most important resources for starting one included access to palliative care specialist by referral (83%), published guidelines with best practices (80%), educational materials for referring physicians and patients (80%), educational sessions for clinical staff (83%), and standardized clinical pathways (80%). PROPs are not widespread, exist mainly within academic centers, are outpatient, have access to palliative care specialists by referral, and have specialized clinical processes for palliative radiation patients. Lack of committed resources was the single most important perceived barrier for initiating or maintaining a PROP. Best practice guidelines, educational resources, access to palliative care specialists and standardized pathways are most important for those who wish to develop a PROP. These insights can inform discussions and help align resources to develop, grow, and maintain a successful PROP.

Advanced Practice Provider Procedures Commonly Performed in Interventional Radiology: Medicare Volume Trends From 2010 to 2021

Advanced Practice Provider Procedures Commonly Performed in Interventional Radiology: Medicare Volume Trends From 2010 to 2021

Preventing Infection in Pediatric Patients Receiving Chemotherapy: A Survey of Provider Recommendations.

Sepsis is the leading cause of mortality in patients with childhood cancer receiving cytotoxic chemotherapy. Pediatric hematology/oncology and transplant (PHOT) providers must counsel their patients on the safety of public activities and weigh the risk of infection exposure with the social and developmental benefits of in-person school and social outings. We hypothesize that there is significant variability in recommendations given by PHOT providers. An electronic anonymous survey was developed and piloted by a group of PHOT providers to assess current methods for educating patients and families on limiting infectious exposures. Five clinical vignettes were created by the study team to explore how providers balance the competing priorities of safety and health-related quality of life (HRQoL). The electronic survey was institutional review board-approved and disseminated via email to all PHOT providers affiliated with the Children's Oncology Group across the United States. In total, 545 clinicians completed the survey. Most respondents were attending physicians (393, 72%), followed by fellows (61, 11%), advanced practice providers (APPs; 38, 7%), and nurses (37, 7%). On average, nurses and fellows made more conservative recommendations for avoiding infectious exposures compared with the recommendations from attending physicians and APPs (P < .0001). On average, providers with more years of clinical experience expressed less cautious recommendations, whereas those with less years of experience provided more cautious recommendations for avoiding infectious exposures (P = .0072). This survey demonstrates the importance of collaboration between all members of the care team in defining priorities for balancing safety risk and HRQoL to provide consistent messaging to patients. The variations in survey responses highlight the need for universal guidelines to standardize physician recommendations for limiting infectious exposures in pediatric patients on chemotherapy.

Written communication and the ICU team experience (WRITE): A pre-post intervention study

ObjectiveFamilies of critically ill patients may benefit from receiving a written update of patient care each day. Our objective was to develop a system to facilitate care provider creation of written updates and to determine the effect of implementing this process on the care provider experience. DesignThe experiences of ICU care providers (nurses, advanced practice providers, and physicians) were measured monthly during a 3-month pre-intervention and a 3-month intervention period. During the intervention period, written updates were sent to families each day and posted in the electronic medical record. Study investigators assisted by editing and distributing the written communication to families. SettingAn urban academic medical center in the United States. Main outcome measuresNurse-Physician Collaboration Scale (NPCS) and Maslach Burnout Inventory (MBI). ResultsOver the 3-month intervention period, care providers created written communication for families of 152 patients (average 5 ICU days per family). NPCS scores among the 65 participating care providers were significantly lower, indicating greater collaboration during the intervention vs. pre-intervention period: 49.9 (95 % CI 46.4–53.6) vs. 55.4 (95 % CI 51.5–59.3), p = 0.002. MBI scores were similar during the intervention vs. pre-intervention periods. A subset of care providers participated in individual interviews. Care providers reported that the process of creating written communication was acceptable and had clear benefits for both families and the medical team. ConclusionsUse of written communication as a supplement to verbal communication improves collaboration among ICU care providers without affecting symptoms of burnout. Implications for practiceWe created a system to facilitate written communication with ICU families that was acceptable to care providers and improved aspects of their experience. In the future, use of written communication can be enhanced with refinements to the process that reduce the time spent creating written updates while highlighting the benefits to families and care providers.

Perceptions of families and healthcare providers about feeding preterm infants in the neonatal intensive care unit: protocol for a qualitative systematic review

IntroductionThe underdevelopment of preterm infants can lead to delayed progression through key early milestones. Demonstration of safe oral feeding skills, constituting proper suck-swallow reflex are requirements for discharge from the...

NURS-19. IMPLEMENTING A NURSING LED WORKING GROUP WITHIN THE PEDIATRIC NEURO-ONCOLOGY CONSORTIUM (PNOC), A TWO-YEAR EXPERIENCE AND EVALUATION

Abstract BACKGROUND Incorporation of nurses and advanced practice providers (APPs) creates an opportunity to enhance the work of clinical trial consortia in providing care to children and young adults with central nervous system tumors enrolled on clinical trials. Within PNOC, a formalized APP and nursing working group (“APPNIC”) was established in 2021. Since inception, APPNIC has assigned members to each clinical trial committee, developed support documents to partner with protocols, highlighted supportive care measures, and provided nursing education across all PNOC sites. METHODS A de-identified, electronic Qualtrics survey was distributed to PNOC members in Fall 2023 to evaluate the 2-year impact of APPNIC. Physicians, nurses or APPs, and CRCs were eligible to participate. RESULTS Thirty-six surveys were completed in total from physicians or principal investigators (n=15; PIs), nurses/APPS (n=18), and clinical research coordinators (n=3; CRCs) representing multiple institutions. PI satisfaction with APPNIC was high with all reporting APPNIC to be “somewhat helpful” (40%) or “very helpful” (60%) and most PIs (53%) working directly with APPNIC members. Nurses confirmed they use the protocol roadmaps (87%) and education sheets (80%) generated by APPNIC. Barriers to APPNIC participation continue to indicate scarce resources allowing time for APPs and nurses to participate in hybrid meetings and limited travel funds to attend meetings and conferences. Identified education needs of APPs and nurses include identifying supportive care for novel treatments, understanding developmental therapy strategies, and receiving routine study updates. CONCLUSIONS With high overall satisfaction of PIs and utilization of study deliverables by consortium site members, we plan to continue APPNIC as currently structured. Ongoing efforts to integrate APPNIC members early in protocol development will increase PI and APPNIC member collaboration. Education for APPs and nursing will continue to be a priority, along with investigating mechanisms to increase funding to attend meetings and conferences.

NURS-23. THE ROLE OF THE ADVANCED PRACTICE PROVIDER IN THE PAIRED NORMAL SPECIMEN PROCESS AT A TERTIARY CARE CENTER

Abstract BACKGROUND Paired tumor - normal specimen testing is standard of care to improve the timing and knowledge of genetic variations present in the brain tumor cell and germline. A new process was developed to ensure the paired normal specimen (PNS) testing was completed. METHODS The Neuro-Oncology Advanced Practice Provider (APP) is integral in the process of ordering and obtaining the PNS. RESULTS In the last 15 months, this tertiary care center has performed more than 90 pediatric brain tumor biopsies and/or resections. APPs identify patient surgery dates via the neurosurgery calendar. On the day of surgery a PNS is ordered for the Solid Tumor panel (predetermined by pathology and neuro-oncology) and “Include germline variant resolution information if applicable?” is answered as “No”. The laboratory runs the next generation sequencing (NGS) on PNS and tumor but the findings remain blinded until a second order is placed to “unblind” the specimen. By doing so, the treating physician collaborates with a genetics counselor prior to discussing with the family. Initial difficulty included patient identification, ordering, and collecting PNS. The APPs developed a shared list with patient identifiers, surgery date, order and collection date of PNS which has ensured less than 5% of PNS have been missed. Challenges include weekend surgeries, APPs out of office, and communication to nursing to collect PNS. Updated protocol includes ordering PNS, messaging shift nurse with order explanation and request to collect. Additionally, the pathology team now messages the APPs if a PNS is not submitted and the tumor is undergoing NGS. CONCLUSIONS Comprehensive processes ensure that paired normal – tumor testing is completed in a timely manner and during the same admission with surgery to ensure better insurance coverage and less cost to families, as well as earlier results of somatic and germline variants.

NURS-15. THE ROLE OF THE ADVANCED PRACTICE PROVIDER AND NURSES IN CLINICAL TRIALS

Abstract BACKGROUND For many years clinical trials fell under the umbrella of medicine without much acknowledgement to the role of the nurse, both as advanced practice provider (APP) and staff nurse. Oncology continues to rank as one of the highest subspecialties when it comes to availability and participation in clinical trials. There remain multiple barriers to involvement including availability, lack of education, and medical mistrust. The specialized role and skill set of the APP and RN as part of the clinical trial team is important in overcoming these barriers. METHODS We distributed a survey to members of the Advanced Practice Provider and Nurse Investigator Committee (APPNIC), a group within the Pediatric Neuro-Oncology Consortium (PNOC), in order to identify themes, barriers to care, and opportunities for both the APP and RN within clinical trials. The use of a survey and interviews within our APPNIC cohort allowed us to collaborate on the nursing role, prioritize care in new and amended trials, and share unanticipated adverse effects and effective management. RESULTS APPs are actively involved with clinical trial enrollment, performance of diagnostic exams and procedures, education, and early recognition/management of adverse effects. There is also a growing theme of the APP as sub-investigator which provides value in facilitating consent, impacting accrual, determining eligibility, managing anticipated side effects. The role of the staff nurse in clinical trials is found to be vital in providing consistent communication/support, educating patients and families, and alleviating adherence and medical mistrust. CONCLUSION The APP and nurse have a specialized, relevant skill set, which when included as part of the multi-disciplinary team, has the ability to decrease barriers and increase overall delivery and safety of clinical trials. Our goal is to outline specific roles we feel should be standardized in the international arena for nursing involvement within clinical trials.

NURS-21. EXPLORATION OF CORRELATIVE STUDIES IN EARLY PHASE TRIALS FOR PEDIATRIC AND YOUNG ADULT CENTRAL NERVOUS SYSTEM (CNS) TUMORS AND THE POTENTIAL TRANSLATION TO CLINICAL CARE

Abstract BACKGROUND Correlative studies are common in early phase clinical trials. In addition to primary aims establishing maximum tolerated dose or efficacy, supplementary information from biospecimens is frequently collected with patient consent. The Pediatric Neuro-Oncology Consortium (PNOC) has included several correlative studies with implications for understanding patterns in the development of tumors, response to treatment, and prognosis. A needs assessment survey of PNOC institutions by the Advanced Practice Provider and Investigational Nurse Committee (APPNIC) highlighted that nurses and advanced practice providers (APPs) desire further education regarding correlative studies. METHODS Blood, stool, cerebrospinal fluid (CSF) and hair strands are examples of correlative biospecimens incorporated in PNOC protocols. We will share a review of the literature and implications for practice. RESULTS Blood, drawn in conjunction with clinical labs, is commonly analyzed for circulating tumor DNA to conduct molecular profiling in blood compared to tissue, explore less invasive means of molecular evolution of tumor somatic mutations, and identify early markers of tumor response or resistance. Stool is collected to utilize the gut microbiome as a lens into treatment response in CNS tumors via the gut-brain axis. Stool samples are compared to normal controls and longitudinally within patients during treatment. CSF sampling provides less invasive disease monitoring, tumor molecular characterization, markers of tumor response or resistance, and drug pharmacokinetics. Hair sampling can be used to further quantify drug levels for pharmacokinetics and assess treatment compliance. The robustness of these correlative samples collected at various timepoints (diagnosis, pre-surgery and post-surgery, post-radiation and/or with recurrence) informs on prognosis, response to treatment; and ultimately, interventions to improve outcomes for pediatric and young adult CNS tumors. CONCLUSION Our assessment identified a need for APP and nursing-focused education on biospecimen collection to inform on emerging clinical and research advances while improving protocol compliance.

New insights into physician burnout and turnover intent: a validated measure of physician fortitude

BackgroundGiven the increasing prevalence of the physician burnout, this study provides new insights into the antecedents driving burnout and turnover intent. By introducing the concept of physician fortitude, we develop a valid and statistically-reliable measure that increases our understanding of these issues.MethodsA two-sample design was employed. Using a sample of 909 physicians, Advanced Practice Providers (APPs) and healthcare leaders, exploratory factor analysis was employed to create a 12-item fortitude scale. In the second study, using a sample of 212 of practicing physicians, APPs and healthcare leaders, bivariate and tetrachoric correlations, and ordinary least square regression modeling were able to establish reliability and validity.ResultsThe fortitude scale shows sufficient reliability. Moreover, we found significant support for convergent and criterion-related validity. Fortitude was significantly related to all three subdimensions of burnout, including emotional exhaustion (r = -.62, p < .01), depersonalization (r = -.70, p < .01) and personal accomplishment (r = .65, p < .01), and turnover intent (r = -.55, p < .01). Moreover, the fortitude measure explained more variance in all three subdimensions of burnout and turnover intent compared to common measures, including grit, hardiness, mental toughness and resilience (p < .01).ConclusionsResults from this study empirically demonstrate that fortitude is significantly related to burnout, and turnover intent. This new fortitude measure adds a new perspective to assist in the development of more effective interventions. Opportunities for future research are discussed.

Urologists and Advanced Practice Providers Evaluating Hematuria.

Urologists and Advanced Practice Providers Evaluating Hematuria.