Advanced Practice Providers Research Articles

Cutaneous Toxicities With Amivantamab for Non-Small Cell Lung Cancer: A Practical Guide and Best Practices.

Amivantamab is an epidermal growth factor receptor (EGFR) and MET bispecific antibody approved for certain patients with advanced non-small cell lung cancer with EGFR variant. Cutaneous toxicities are known on-target effects of EGFR inhibition. This article describes the occurrence and management of cutaneous toxicities in patients whose disease progressed on platinum chemotherapy treated with amivantamab. Post hoc analysis evaluated incidence, severity, and time to first onset of rash and paronychia. Five nurses and advanced practice providers were interviewed. Of 380 patients, 296 (78%) experienced treatment-related rash and/or paronychia. Paronychia (43%), rash (36%), and dermatitis acneiform (35%) were most frequent, with scalp rash reported by 17%. Treatment modifications because of rash and paronychia were infrequent. Nurses and advanced practice providers collaborate with physicians to manage cutaneous toxicities by administering comedications, modifying amivantamab dose, and educating patients.

Advanced Practice Providers in Burn Care, 2013-2022.

This study evaluated the prevalence characteristics of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to burns in the United States from 2013 to 2022 using national claims data. Our analysis was a retrospective, large cohort study evaluating debridement, wound care, and office-based services provided by advanced practice providers from 2013 to 2022 using the Medicare Provider Utilization and Payment Data Public Use Files from the CMS. The reported provider type and billing codes were used to identify healthcare professionals providing burn care. Trends over the study period and available data about care provided were analyzed. From 2013 to 2022, burn care providers included 6,918 (43.3%) surgeons, 4,264 (26.7%) other physicians, and 4,783 (30.0%) advanced practice providers. Overall, the number of advanced practice providers who billed for burn care increased by 250.4% from 714 in 2013 to 2,502 in 2022. Compared with physicians, advanced practice providers were more likely to be female and provide care in micropolitan areas with less than 50,000 people. Based on these trends, we project that the number of APPs providing services related to burns will increase by 56.7% from 2,502 in 2022 to 3,921 (95% CI, 3,541-4,303; R2=0.97) in 2030. With a growing need for burn care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Trends in advanced practice providers in plastic and reconstructive surgery, 2013–2021

This restrospective cohort study of Medicare payment data found increases in the number of advanced practice providers who bill for plastic and reconstructive surgery care. The growth in advanced practice providers is expected to continue in plastic surgery, and further investigation is needed to effectively integrate these providers into academic centers.

Optimizing Treatment of BRAF V600E–Mutant Metastatic NSCLC With Encorafenib and Binimetinib: A Practical Resource for Advanced Practice Providers

Optimizing Treatment of BRAF V600E–Mutant Metastatic NSCLC With Encorafenib and Binimetinib: A Practical Resource for Advanced Practice Providers

Recruitment of informal caregivers into community oncology research studies: results from the 2022 Landscape Assessment.

Understanding the experiences of community oncology practices in recruiting informal (unpaid/family) caregivers into research studies can inform strategies to improve caregiver enrollment. We used data from the 2022 National Cancer Institute Community Oncology Research Program (NCORP) Landscape Assessment to describe the experience of recruiting informal caregivers for research studies in community oncology practices. Among 258 practice groups, only one-third (30%, 78/258) reported prior experience recruiting informal caregivers for research studies. In multivariable logistic analyses, having a greater number of oncology providers (increase per 10 providers, adjusted odds ratio [AOR] 1.16, 95% CI 1.03-1.31) and having advanced practice providers (APPs) involved in research (AOR 2.17, 95% CI 1.05-4.48) were significantly associated with prior experience recruiting caregivers. In conclusion, many community oncology practices lack caregiver recruitment experience and may benefit from education, integration of APPs/caregiver stakeholders in research infrastructure, and/or other strategies to improve caregiver recruitment.

Impact of personalized risk scores on shared decision making in left ventricular assist device implantation: Findings from a qualitative study

ObjectiveTo assess stakeholders’ perspectives on integrating personalized risk scores (PRS) into left ventricular assist device (LVAD) implantation decisions and how these perspectives might impact shared decision making (SDM). MethodsWe conducted 40 in-depth interviews with physicians, nurse coordinators, patients, and caregivers about integrating PRS into LVAD implantation decisions. A codebook was developed to identify thematic patterns, and quotations were consolidated for analysis. We used Thematic Content Analysis in MAXQDA software to identify themes by abstracting relevant quotes. ResultsClinicians had varying preferences regarding PRS integration into LVAD decision making, while patients and caregivers preferred real-time discussions about PRS with their physicians. Physicians voiced concerns about time constraints and suggested delegating PRS discussions to advanced practice providers or nurse coordinators. ConclusionsIntegrating PRS information into LVAD decision aids presents both opportunities and challenges for SDM. Given variable preferences among clinicians and patients, clinicians should elicit patients’ desired role in the decision-making process. Addressing time constraints and ensuring patient-centered care will be crucial for optimizing SDM.Practice implicationsClinicians should elicit patient preferences for PRS information disclosure and address challenges, such as time constraints and delegation of PRS discussions to other team members.

Advanced practice providers in the medical genetics workforce: A nationwide survey

PurposeThis study characterizes the current landscape of genetics advanced practice providers (APPs) in the United States. MethodsA 35-question survey was emailed to the Genetics APP Listserv in the fall of 2023. Questions represented 5 domains: demographics, practice, onboarding, compensation, and perceptions. ResultsA total of 105 genetics APPs (93%) completed the survey. Genetics APPs evaluate various patient types and populations in multiple settings, working an average of 41.3 hours and seeing 15 patients weekly. Nearly all see new (96%) and follow-up (98%) patients and utilize telemedicine (93%). Half (51%) have only worked in the genetics specialty during their career. Overall, APPs are generally satisfied with their career as a genetics APP (98%) and work-life balance (86%), and most (86%) feel that they function at the top of their scope. ConclusionStudy findings elucidate the current state of genetics APPs. Results define the characteristics and role of an APP in the genetics specialty and will guide employers and genetics organizations to utilize APPs at the top of their scope and recruit new APPs to this exciting field. A collaborative effort is needed to increase the overall genetics workforce, decrease patient wait times, and increase access to genetics care.

Advanced Practice Providers in Pediatric Surgery: A 10-Year Analysis of Clinical Productivity

Introduction: Advanced practice providers (APPs) are integral to nonsurgical and surgical fields. In surgical settings, APPs work autonomously alongside surgeons to enhance continuity of care. While small-scale studies across various surgical specialties have explored APP utilization, literature specific to the pediatric population is limited. This study assesses the impact of increased APP utilization on productivity within one of the largest pediatric surgery departments in the United States. Methods: Data was sourced from the Surgery Department Executive Committee (SDEC) annual reports. Descriptive analyses were performed to delineate trends in clinical volumes, OR cases, gross charges, work relative value units (wRVUs), and provider full-time equivalents (FTEs) between October 2011 and September 2023. Secondary analyses were performed from 2016 to 2023, after APP roles were refined in each division. Results: Since 2012, an upward trend is observed in total clinic visits, total OR cases, and OR cases per MD. In 2016, APPs saw 1 clinic patient for every 2.2 seen by MDs, decreasing to a 1:1 ratio by 2023. The MD surgical conversion rate has increased by 20.5% since 2016, while the conversion rate per total clinic volume has decreased by 7.3% over the same period. Total wRVUs and gross charges increased across the department and per provider, despite fewer overall providers since 2021. Conclusion: Increased utilization of APPs within the department of surgery may enhance procedural productivity for surgeons while ensuring continued patient access to care. This study highlights the importance of developing care models that optimize the full skillset of APPs.

Innovative training program for advanced practice providers in electrophysiology

Cardiac electrophysiology is a highly specialized field focused on the management of cardiac arrhythmias. Therefore, rigorous training is required for advanced practice providers (APPs) to competently practice independently within the specialty. An in-depth, 12-month training curriculum was created for electrophysiology in conjunction with a previously established APP Fellowship Program for the training of other complex subspecialties at an academic medical center. The Stanford Health Care Electrophysiology APP Fellowship Program is the first in the country to provide in-depth education and training for novice APPs to deliver high level care to patients with cardiac arrhythmias. The training program has proven to be successful in transitioning novice APPs to independent practitioners within the specialty since its inception in2021.

Venous thromboembolism prophylaxis prescribing patterns for patients with orthopedic trauma: a clinical vignette survey

BackgroundA recent clinical trial suggested aspirin is a viable alternative to enoxaparin for venous thromboembolism (VTE) prophylaxis in patients after orthopedic trauma. The initial impact of these findings on VTE...

Patterns of utilization of advanced practice providers in reproductive endocrinology: a 2023 national survey

ObjectiveTo evaluate the current utilization of advanced practice providers (APPs) within the field of reproductive endocrinology and infertility (REI). DesignCross sectional. SubjectsA total of 201 APPs surveyed through the American Society of Reproductive Medicine APP Professional Group. ExposureAnonymized online survey. Main Outcome MeasuresDemographics, scope of practice and responsibilities, and training and onboarding. ResultsRespondents were primarily Family Nurse Practitioners (FNPs, 26.4%), Women’s Health Nurse Practitioners (WHNPs, 33.3%), or Physician Associates (PAs, 29.8%). Two-thirds (67.4%) reported that their scope of practice is limited by their employer or practice, 43.5% by state restrictions, and 25.2% by insurance. Survey respondents reported that 44.4% of their time at work is dedicated to performing procedures and scans and 30.6% to conducting consults and follow-ups. The most commonly reported duties were physical exams (88.6%), intrauterine inseminations (IUI; 86.6%), saline sonohysterograms (79.6%), endometrial biopsies (76.6%), ultrasounds (74.6%), and problem visits such as for pain, cysts, and bleeding (73.1%). The majority of survey respondents (61.7%) reported having autonomy in deciding protocols and treatment options for patients in their practice. Respondents described their onboarding training as including observation/on-the-job training (94.0%), independent reading of texts and journals (66.7%), ASRM online courses (45.3%), formal orientation (34.8%), and practice-organized training programs (29.4%). ConclusionsAPPs are highly trained members of the care team, but continue to be underutilized within the field of REI. Improvements in educational resources and/or use of a formalized program to train APPs to their full scope of practice may help increase clinic efficiency and improve patient access to care.

Sustainability of a PICU Situation Awareness Intervention: A Qualitative Study.

We aimed to investigate facilitators and barriers that impact the sustainability of an interprofessional situation awareness bundle. This is a single-center qualitative study at a tertiary care pediatric center examining the sustainability of an interprofessional situation awareness bundle to reduce in-hospital cardiac arrests. The bundle includes an automated clinical decision support tool, twice-daily safety huddles, and a bedside mitigation plan. A trained research staff member interviewed participants in October 2022. Interviews were audio recorded and transcribed verbatim, and recruitment continued until data saturation. Inductive and deductive analyses were used here. The authors interviewed twelve staff members via individual semistructured interviews: registered nurses (RN, n = 2) and clinicians [(advanced practice providers, n = 2), pediatric critical care fellows, n = 4 and attendings, n = 4)]. Five main themes were identified: (1) the situation awareness bundle is ingrained into daily practice and culture, (2) the bundle has strengthened communication, decision-making, and improved outcomes, (3) standardized processes, stakeholder buy-in, and support of team members are key to adoption and sustainability, (4) variation in processes and fast-changing clinical context remains a challenge for reliable use, and (5) the situation awareness bundle excluded families. The situation awareness bundle has become ingrained, strengthened, and sustained over the last 5 years through integration into daily practice and culture and leveraging standardized processes, tools and technology. It is associated with improved communication and shared decision-making. Understanding the key components for implementation and sustainability is necessary for ongoing spread and improvement in the future.

Prevalence and Practice Characteristics of Advanced Practice Providers in Upper-Extremity Surgery, 2013–2021

This study evaluated the prevalence, characteristics, and reimbursement of advanced practice providers, including nurse practitioners and physician assistants, who provide care related to the diagnosis and treatment of diseases and conditions of the hand, wrist, and upper extremities in the United States from 2013 to2021. Our analysis was a retrospective cohort study evaluating the diagnostic, procedural, and therapeutic services provided by advanced practice providers from 2013 to 2021 using the Medicare Provider Utilization and Payment Data Public Use Files from the Centers for Medicare and Medicare Services. The reported provider type and billing codes were used to identify health care professionals providing upper-extremity care such as ordering radiographs, applying casts and splints, and performing procedures on the hand, wrist, or other anatomic regions of the upper extremity. Trends over the study period and available data about services provided were analyzed. From 2013 to 2021, providers of upper-extremity care included 19,525 (64.7%) doctor of medicine or doctor of osteopathic medicine upper-extremity surgeons, 7,612 (25.2%) physician assistants, and 3,042 (10.1%) nurse practitioners. The nonsurgeon providers were more likely to be women and provide care in micropolitan areas with less than 50,000 people compared with upper-extremity surgeons. Overall, the number of advanced practice providers who billed for upper-extremity care increased by 170.9% from 1,965 in 2013 to 5,324 in 2021. Based on these trends, the growth of APPs providing upper-extremity care is expected to continue. There is a growing prevalence of advanced practice providers in upper-extremity care, and this trend is expected to continue. With a growing need for upper-extremity care and predicted shortages in the surgeon workforce, the scope of practice and integration of advanced practice providers merits further discussion and evaluation.

Fostering Organizational Excellence through Inclusive Leadership: Practical Guide for Radiology Leaders.

Inclusive leadership styles value team members, invite diverse perspectives, and recognize and support the contributions of employees. The authors provide guidance to radiology leaders interested in developing inclusive leadership skills and competencies to improve workforce recruitment and retention and unlock the potential of a rapidly diversifying health care workforce. As health care organizations look to attract the best and brightest talent, they will be increasingly recruiting millennial and Generation Z employees, who belong to the most diverse generations in American history. Additionally, radiology departments currently face critical workforce shortages in radiologists, radiology technicians, staff, and advanced practice providers. In the context of these shortages, the costs of employee turnover have emphasized the need for radiology leaders to develop leadership behaviors that promote recruitment and retention. Radiology department leaders who perceive and treat valued employees as replaceable commodities will be forced to deal with the extremely high costs associated with recruitment and training, decreased morale, and increased burnout. The authors review inclusive versus exclusive leadership styles, describe key attributes and skills of inclusive leaders, provide radiology leaders with concrete methods to make their organizations more inclusive, and outline key steps in change management. By adopting and implementing inclusive leadership strategies, radiology groups can position themselves to succeed in rapidly diversifying health care environments. ©RSNA, 2024 See the invited commentary by Siewert in this issue.

59: Case-Based ECMO Education Sessions for Pediatric Critical Care Fellows and Advance Practice Providers

59: Case-Based ECMO Education Sessions for Pediatric Critical Care Fellows and Advance Practice Providers

Sutimlimab for Cold Agglutinin Disease.

Cold agglutinin disease (CAD) is a rare type of autoimmune hemolytic anemia (AIHA) distinct from warm antibody AIHA. One of the ways it is distinct is that CAD is usually not responsive to corticosteroids compared with warm antibody AIHA. Historically, CAD therapy has been limited to immunotherapy or chemoimmunotherapy with varying responses. Cold agglutinin disease also poses a risk for thrombosis and mortality. For patients, fatigue tends to be a common symptom of CAD. The hallmark of CAD is complement-mediated hemolysis, which makes complement inhibitors a critical therapeutic option for patients. Previously, eculizumab, a C5 inhibitor, had limited therapeutic effect for CAD. More recently, sutimlimab, a C1s inhibitor, was shown in two phase III studies to be an efficacious treatment for CAD, improving hemoglobin, hemolysis, and fatigue. However, there is a paucity of medical literature on CAD and on sutimlimab in particular that is geared toward advanced practice providers (APPs). This article aims to provide APPs with a background in CAD and a focus on sutimlimab, assisting these providers in caring for patients with CAD receiving this therapy.

Outcomes of pediatric-focused advanced practice provider fellowship programs: An integrative review.

An increased demand for pediatric-focused advanced practice providers (APPs) exists to address the health care needs of children with medical complexity. Postlicensure advanced practice fellowship programs have been developed to help improve novice provider transition to practice, reducing attrition. The objectives of this integrative review are to (1) identify outcome measurements of pediatric-focused advanced practice fellowship programs and (2) evaluate the outcome measures to guide future implications for practice. A systematic integrative literature review was conducted in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses. PubMed, CINAHL, Embase, and Google Scholar were searched in August and September 2022. Articles met inclusion criteria if they included new graduate APPs, reported the intervention of a pediatric fellowship program, and shared outcome measurements. Studies were excluded if they did not directly report on fellowship program outcome measures. Thirteen studies met inclusion criteria and were summarized and appraised for quality using the Johns Hopkins Evidence-Based Practice Model. Four themes from the literature included the favorable impact of advanced practice fellowship programs on (a) job satisfaction, (b) retention, (c) clinical and professional performance, and (d) financial outcomes. Variable strategies were used to measure outcomes across programs. Postlicensure pediatric-focused advanced practice fellowship programs seem to improve retention and job satisfaction, increase provider confidence, and bring a favorable return on investment for the organization. Future work should include investment in developing validated, standardized assessment tools to support future development of these programs in the pediatric population.

A pragmatic approach to teaching physician assistant students basic pain management.

Chronic pain is increasing in prevalence, with new cases now outnumbering those of diabetes, depression, or hypertension. Advanced practice providers have reported that their training in pain management inadequately prepared them to care for patients suffering from painful conditions. In response, the authors of this work developed a basic pain management conceptual framework to provide physician assistant (PA) students with the foundational knowledge necessary to manage and treat patients suffering from a wide variety of painful conditions. The devised framework activity includes categories of pain management such as conservative therapies, medications, injections, minimally invasive procedures, and moderately to highly invasive procedures. This framework can be incorporated into the existing PA educational curriculum and presented alongside a realistic pain patient case study. Furthermore, other health science educational programs, such as nurse practitioner or pharmacy programs, could adopt this framework to increase student knowledge in pain management.

Clinician Wellbeing and Mental Health Assessment Across Two Acute Care Hospitals During the COVID-19 Pandemic.

The purposes of this study were to determine whether positive work environments affect clinician wellbeing and mental health, and to identify participants' priority interventions to improve clinician wellbeing. This study was designed to determine the potential benefit of modifying the aforementioned factors for clinicians and hospitals to impact positive patient outcomes. The SARS-CoV-2 virus pandemic has become one of the leading causes of death in the United States and worldwide, and has exacerbated widespread burnout among health care professionals. This has resulted in negative collateral implications for the stability of the clinician workforce. A Clinician Wellbeing study (CWS) was launched in two Magnet®-designated hospitals in the southeast. The CWS was part of a multi-site collaborative research project led by the Center for Health Outcomes and Policy Research (CHOPR) at the University of Pennsylvania School of Nursing. A cross-sectional observational study design was implemented. Data were collected through anonymous surveys of 708 registered nurses (RNs) and advanced practice providers (APPs) working in two Magnet hospitals in the southeastern United States. Each participant completed 8 surveys. Clinicians' self-reported level of burnout was higher for both RNs and APPs at Emory University Hospital than Emory Saint Joseph's Hospital including intent to leave and dissatisfaction with their jobs. RNs and APPs self-reported their overall health to be good or excellent and they reported sleep quality as fair. Both groups in both hospitals indicated that they experienced anxiety, depression, and stress. The APPs reported a higher percent that their work did not leave enough time for personal and family life. Data also indicated that the primary work environment concern was related to inadequate nurse staffing. The data illuminated opportunities for the two hospitals to employ continuous improvement interventions to positively transform the work environment.

The rise of advanced practice provider independence bills: a misguided attempt to address the physician shortage.

In the past decade, the rise of state legislation that allows for advanced practice provider (APP) independence has grown steadily across the country. Most recently, Montana has enacted House Bill 313, which allows for physician assistant independent practice in primary care services. This is a concerning trend because there is a multitude of studies that demonstrate worsened patient outcomes and increased healthcare expenditures for care delivered by nonphysicians. There are also many unintended consequences that are likely to occur due to this inappropriate expansion of scope of practice for APPs. In this commentary, we outline the ramifications that are likely to occur in states such as Montana that enact legislation that expands the scope of practice for nonphysicians.