Utilization Of Advanced Practice Providers Research Articles

1090 Utilization of Advanced Practice Providers in a Pediatric Sleep Program: A Strategy for Expansion and Outcomes

1090 Utilization of Advanced Practice Providers in a Pediatric Sleep Program: A Strategy for Expansion and Outcomes

Defining the Role of the Advanced Practice Provider Within the National Cancer Institute Community Oncology Research Program.

Oncology advanced practice providers (APPs), including nurse practitioners, clinical nurse specialists, physician assistants, and clinical pharmacists, contribute significantly to quality cancer care. Understanding the research-related roles of APPs in the National Cancer Institute's (NCI) Community Oncology Research Program (NCORP) could lead to enhanced protocol development, trial conduct, and accrual. The 2022 NCORP Landscape Assessment Survey asked two questions about the utilization and roles of APPs in the NCORP. A total of 271 practice groups completed the 2022 survey, with a response rate of 90%. Of the 259 nonpediatric exclusive practice groups analyzed in this study, 92% used APPs for clinical care activities and 73% used APPs for research activities. APPs most often provided clinical care for patients enrolled in trials (97%), followed by assistance with coordination (65%), presenting/explaining clinical trials (59%), screening patients (49%), ordering investigational drugs (37%), and consenting participants (24%). Some groups reported APPs as an enrolling investigator (18%) and/or participating in institutional oversight/selection of trials (15%). Only 5% of NCORP sites reported APPs as a site primary investigator for trials, and very few (3%) reported APPs participating in protocol development. Practice groups report involving APPs in clinical research within the NCORP network; however, opportunities for growth exists. As team-based care has enhanced clinical practice in oncology, this same approach can be used to enhance successful research. Suggested strategies include supporting APP research-related time, recognition, and education. The findings of this survey and subsequent recommendations may be applied to all adult oncology practices that participate in clinical research.

Availability of palliative specialty care for adults in community oncology: Results from the 2022 NCORP landscape assessment.

e24125 Background: Palliative care promotes timely symptom management, and care planning and improves quality of life in oncology patients. About 60% of community oncology practices sampled in 2015 had outpatient palliative care. This study updates estimates of palliative care resources in community oncology. Methods: Questions from the 2022 Landscape Assessment of National Cancer Institute Community Oncology Research Program (NCORP) (funding provided by 2UG1CA189824) assessed the availability of specialist palliative care providers and ancillary care services, including utilization of advanced practice providers (APPs). Descriptive statistics describe availability of providers and services. Multivariable logistic regression was used to identify practice characteristics associated with palliative care specialist availability in 2022. Differences in rates of palliative care specialists, outpatient palliative care, APPs and patient portal use between 2015 and 2022 assessment results were assessed using Chi-Square tests, assuming independent time snapshots of general population characteristics. Results: Most community oncology practices sampled in 2015 had palliative care specialists (76%) and 62% of practices reported having outpatient palliative care. Of the 259 non-pediatric exclusive NCORP practice groups included in the 2022 analyses (Table 1), significantly more had palliative care specialists (86%; p = 0.003) and offered palliative care in the outpatient setting (76%; p = 0.001). Most practices utilized APPs (92%) and had a patient portal (95%), while only 41% had a survivorship clinic. Multivariable analyses demonstrated practices with more adult oncology providers (OR = 1.03, p = 0.039) and those with a designated survivorship clinic (OR = 3.16, p = 0.001), were significantly more likely to have specialty palliative care in the outpatient setting. Conclusions: More practices reported availability of palliative care specialists and outpatient services in community oncology practices in 2022 compared to 2015, with more oncology providers being associated with increased odds of having outpatient specialty palliative care in 2022. Smaller community oncology practices with fewer providers may need support to expand their capacity to provide palliative care. [Table: see text]

(325) The Role of Advanced Practice Providers Who Treat Men’s Health Urologic Conditions: An Analysis of Medicare and Commercial Claims in the United States

Abstract Introduction The role of advanced practice providers (APPs) had expanded in the recent years according to the AUA. This increase of APPs had been endorsed by AUA to offset the increasing burden on the urologist workforce. Moreover, contemporary literature on the involvement of APPs in men’s-specific disease conditions is lacking. Objective We aim to clarify the role of APPs for publicly and privately insured patients in the treatment of mens’ urologic conditions commonly encountered in Men’s Health Clinics. Methods Medicare and commercial insurance claims from the Physician/Supplier Procedure Summary and IBM® MarketScan® Commercial Database, were queried for procedures submitted by APPs between 2010 and 2020. Common urologic conditions were identified using Current Procedural Terminology codes and grouped into six categories: overactive bladder (OAB), testicular hypofunction, erectile dysfunction (ED) and Peyronie’s disease (PD), benign prostatic hyperplasia (BPH), genital warts, and scrotal pain. The proportion of procedures submitted by APPs was calculated for each year and category. Results The proportion of claims submitted by APPs treating OAB, genital warts, and testicular hypofunction rose steadily from 2010 to 2020. Proportion of submitted service counts under OAB, genital warts and testicular hypofunction increased approximately 5, 8, and 4-fold among the privately insured compared to 3, 6, and 10-fold among the publicly insured (Figures 1 and 2). For BPH, ED and PD, and scrotal pain the proportion of APPs in both the MarketScan and Medicare groups was higher in 2020 than 2010, but with less dramatic and stable growth rates compared to other procedures. The proportions of APPs for all conditions were higher in the Medicare group compared to the MarketScan group. The Medicare data captured more year to year fluctuations in the proportion of claims submitted by APPs per condition than that of the MarketScan data. Conclusions APPs play a critical role in urologic care and can help address impending physician workforce shortages in urology, specifically in men’s health. The role of APPs in men’s urologic health, particularly OAB, testicular hypofunction, and genital warts, is increasing for both privately and publicly insured patient populations. Further research on implementation and utilization of APPs, as well as the health outcomes of such workforce modifications, is warranted. Disclosure No

Barriers to rural health care from the provider perspective.

Rural populations routinely rank poorly on common health indicators. While it is understood that rural residents face barriers to health care, the exact nature of these barriers remains unclear. To further define these barriers, a qualitative study of primary care physicians practicing in rural communities was performed. Semistructured interviews were conducted with primary care physicians practicing in rural areas within western Pennsylvania, the third largest rural population within the USA, using purposively sampling. Data were then transcribed, coded, and analyzed by thematic analysis. Three key themes emerged from the analysis addressing barriers to rural health care: (1) cost and insurance, (2) geographic dispersion, and (3) provider shortage and burnout. Providers mentioned strategies that they either employed or thought would be beneficial for their rural communities: (1) subsidize services, (2) establish mobile and satellite clinics (particularly for specialty care), (3) increase utilization of telehealth, (4) improve infrastructure for ancillary patient support (ie social work services), and (5) increase utilization of advanced practice providers. There are numerous barriers to providing rural communities with quality health care. Barriers that are encountered are multidimensional. Patients are unable to obtain the care they need because of cost-related barriers. More providers need to be recruited to rural areas to combat the shortage and burnout. Advanced care-delivery methods such as telehealth, satellite clinics, or advanced practice providers can help bridge the gaps caused by geographic dispersion. Policy efforts should target all these aspects in order to appropriately address rural healthcare needs.

107: CURRENT LANDSCAPE OF ADVANCED PRACTICE PROVIDERS IN CRITICAL CARE

Introduction: Advanced Practice Providers (APPs) are a well-established part of the multidisciplinary critical care team, but the scope and utilization of APPs vary dramatically between hospitals. This survey captures current demographic, workflow, and utilization trends in the Society of Critical Care (SCCM) APP community. Methods: This was a cross sectional REDCap survey emailed to 2775 SCCM physician assistant or nurse practitioner members in April 2021. There were 578 responses (20.8%) with 60 non-APP respondents excluded for a sample size of 518. Statistical analysis was performed via SPSS. Results: Of the 518 respondents, there were 149 (28.8%) physician assistants and 327 (63.1%) nurse practitioners. Most respondents (n=371, 72%) were female. 248 APPs (48.1%) worked for large hospitals (>500 beds) and most (n=343, 66.2%) worked in an academic setting. Of the surveyed, 447 (86.3%) reported greater than 2 years of ICU experience. Formal onboarding was common (n=354, 68.6%) and was most likely to occur in academic medical centers (n=233 of 354, p< 0.001). Onboarding was usually completed in under 6 months (n=310, 87.8%). Most APPs (n=409, 79.3%) did not pursue post-graduate fellowships. Most units had full time APP coverage (n=361, 70.1%) including weekends and holidays (n=427, 82.8%). Daytime APP to patient ratios were less than 1:10 (n=377, 75.7%); nighttime ratios were 1:11 or greater (n=328, 72.9%). The majority of APPs performed arterial lines (n=425, 82%), central venous catheters (n=410, 79.2%), temporary dialysis catheters (n=318, 62.4%), and point-of-care ultrasound (n=295, 56.9%). APPs most frequently billed critical care time (n=314, 60.6%) and procedures (n 333, 64.3%). A quarter of respondents (n=137, 26.4%) reported that they did not bill. APPs did not routinely have their billing measured (n=212, 41.5%) and many (n=106, 20.7%) did not know if productivity measures were utilized in their group. Conclusions: APPs are experienced members of the critical care team heavily utilized in large academic hospitals. Current APP roles are mostly clinical and unit-based, with emphasis on procedures and episodic care. Additional research will better quantify APP productivity and value since metrics are inconsistent and many APPs do not currently participate in billing.

Measuring Advanced Practice Provider Productivity at the National Comprehensive Cancer Network's Member Institutions.

Introduction:The utilization of advanced practice providers (APPs) in oncology has been growing over the last decade; however, there is no standard method for assessing an APP's contributions to oncology care.Methods:The NCCN Best Practices Committee (BPC) created an APP Workgroup to develop recommendations to support the roles of APPs at NCCN Member Institutions. The Workgroup conducted surveys to understand how NCCN centers measure productivity. This article will review the survey results and provide recommendations for measuring APP productivity.Results:Although 54% of responding centers indicated they utilize relative value units (RVU) targets for independent APP visits, 88% of APPs are either unsure or do not believe RVUs are an effective measurement of overall productivity. Relative value units do not reflect non-billable hours, and APPs perform a significant number of non-billable tasks that are important to oncology practices. Sixty-six percent of APPs believe that measuring disease-based team productivity is a more reasonable assessment of APP productivity than measuring productivity at the individual level.Conclusion:Our recommendation for cancer centers is to focus on the value that APPs provide to overall care delivery. Advanced practice provider productivity metrics should consider not only the number of patients seen by APPs, but also the high quality and thorough care delivered that contributes to the overall care of the patient and practice. Advanced practice providers can help improve access to care, deliver improved outcomes, and increase patient and provider satisfaction. Reducing the focus on RVUs, accounting for important non-RVU–generating activities, and incorporating quality and team metrics will provide a better overall picture of APP productivity.

Examining the critical role of advanced practice providers on a multidisciplinary transplant team

It is well documented that Physician Assistants (PAs) and Nurse Practitioners (NPs), collectively known as Advanced Practice Providers (APPs), have a beneficial role beyond the field of primary care. APPs broad spectrum of knowledge make them particularly well suited for specializing in complex fields such as transplant. Variations in practice across transplant centers lead to questions regarding optimal use of APPs. Using job descriptions from transplant centers currently employing APPs, we sought to examine the critical role of transplant APPs beyond clinical care alone. In this review, we explore not only the general training of APPs and current utilization of APPs in transplant, but also safety, cost effectiveness, and comparison of APPs to other transplant providers. We aimed to highlight the importance of recruitment and retention of transplant specific trained APPs to provide continuity in transplant programs. Additionally, APPs expansion into transplant research, quality improvement, leadership, and management must be considered. We challenge transplant centers utilizing APPs to consider these important aspects when seeking ways to expand and optimize the critical role APPs provide on the transplant team.

Advanced practice providers in the infectious disease workforce: A nationwide utilization survey.

Shortages of infectious disease (ID) physicians is an identified workforce problem. The COVID-19 pandemic has exacerbated this care gap, leaving many communities without access to an ID physician. More advanced practice providers (APPs), specifically nurse practitioners and physician assistants, work as healthcare extenders, yet are not well described in ID. Evaluate collaboration between ID physicians and APPs, and potential barriers to utilization of APPs. Anonymous and voluntary surveys; one for physicians, another for APPs. We collected experience, practice setting, familiarity regarding APPs in ID, use of APPs, and perceived barriers/concerns for utilization of APPs. Nationwide, 218 ID physicians and 93 APPs in ID responded. 71% (155) of ID physicians use APPs. Of APPs, 53% (49) had>5 years ID experience. Responses highlighted opportunities for dedicated ID education, collaboration, and clarification of practice scope. APPs are an experienced group who provide ID care, working alongside physicians to meet ID workforce needs.

The evolving role of advanced practice providers in transplantation: a literature review.

Solid organ transplantation is a life-saving procedure, often performed in critically ill patients, and advanced practice providers (APPs) have increasingly been incorporated into the multidisciplinary transplant team. A literature review was performed and reinforces the value of transplant APPs, details their evolving roles and responsibilities, and highlights innovative solutions created to address complex problems. The literature review revealed a deficit of quality quantitative data supporting the utilization of APPs in transplantation. Thus, data regarding the value of APPs in critical care was also analyzed. The limited data despite decades long integration of transplant APPs into the multidisciplinary team, suggests there are likely positive outcomes and innovations that go undocumented. Thus, there are missed opportunities for learning and improvement. Transplant programs investing time and mentorship to support APP research will identify strengths and weaknesses within our existing care models, discover cost saving innovations, and continue to optimize the role of APPs in delivering high quality care that is efficient and evidence based.

Utilization of Advanced Practice Providers in Advanced Practice Provider-Led Stroke Clinic to Expand Outpatient Stroke Follow-up Care.

Stroke follow-up care with neurology specialty advanced practice providers is critical to focus on stroke prevention. The need for which is underscored by results of a recent study noting that many stroke survivors of first-ever strokes were not receiving stroke standard-of-care prevention measures including consistent antiplatelet therapies and regular exercise. Study findings further note the rates of usage for stroke prevention interventions (daily anti-platelet therapy, smoking cessation, regular exercise, hypertension control) were between 50% and 70%. Clinical nurse specialists along with nurse practitioner and physician assistant advanced practice providers are uniquely suited to manage outpatient ischemic stroke care to reduce the recurrence of stroke and improve patient outcomes.

617. Physician Perspective: Utilization of Advanced Practice Providers (APPs) in the ID Workforce

BackgroundApplicants entering Infectious Disease (ID) fellowships are declining and shortages of ID physicians is a challenge recognized by the clinical workforce and Infectious Diseases Society of America (IDSA). There is increased awareness of more Advanced Practice Providers (APPs) being used within ID to expand and extend existing practices. However, little is known about APP utilization, APP clinical scope of practice, specific roles, and opportunities for education.MethodsTo evaluate physician perspectives on APP utilization in ID, we created an anonymous and voluntary survey using the REDCap data tool that was distributed by social media, key stakeholder emails, and IDSA online community forum between 12/1/2019-1/31/2020. In addition to collecting geographic information and the type of ID practice, participants were also surveyed about the use of APPs and any perceived barriers that may limit their use.Results218 practicing ID physicians responded to the survey (Figure 1). 155 (71%) physicians work with APPs in their current practice (Figure 2); specifically, 56 (27%) with 1 APP, 62 (30%) with 2-4 APPs, 28 (13%) with 5-9 APPs, and 11 (5%) with > 10 APPs. Of respondents, 104 (48%) practiced at University/Medical schools, 80 (37%) in hospitals/clinics, and 28 (13%) in private practice (Table 1); most work in adult inpatient/outpatient ID. The main reasons selected by respondents for not using APPs in their practice included concerns around a lack of formal ID training 22 (15%), lack of time/lack of ability to assist with APP training 29 (20%), practice is already sufficiently staffed 19 (13%), and concern for physician revenue loss 16 (11%) (Table 1).Figure 1. Physician Responses by Region, n = 218 Figure 2. Physicians Utilizing APPs in Practice, n = 210 (*no response, 8) Table 1. Physician ID Practice Type, Setting, and Concerns ConclusionResults suggest that while collaboration between ID physicians and APPs exists to meet current needs, a lack of ID training is a limiting factor. Our findings demonstrate there is an opportunity for formal ID education and resource development both to enhance APPs clinical skills and address perceived knowledge gaps. Inclusion of APPs in the ID workforce may allow physicians to expand ID care into more resource limited areas to continue to provide high quality patient care.Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)

Patient Acceptability of the Use of Advanced Practice Providers in an Outpatient Neurosurgery Clinic.

IntroductionIncreasing demands for healthcare manpower has necessitated the utilization of advanced practice providers (APPs). The effect of APPs in primary care has been well-characterized but is less studied in surgical subspecialties. The objective of this study is to assess the patient acceptability of APPs in an outpatient neurosurgery setting.MethodsWe conducted a prospective, survey-based study among 78 adult patients in the neurosurgical outpatient clinic. The survey consisted of 10 questions assessing the hypothetical acceptability of care provided by neurosurgeons and APPs. These were compared as pre-specified dyads, with patients blinded to dyad composition. The data were analyzed with Chi-square tests.ResultsPatients preferred to see their neurosurgeon for their first clinic visit even with a longer lag time (29% acceptability difference, p = 0.012). Patients also preferred to see the neurosurgeon for their first postoperative visit (20% difference, p = 0.009). For all visits, patients preferred to see an APP if the clinic visit would be on time, rather than see the surgeon with a significant delay (30% difference, p = 0.0002). If their visit was scheduled with an APP, patients preferred that the neurosurgeon review their treatment plan before they left the clinic (15% difference, p = 0.04). Overall, seeing an APP was acceptable if patients were informed ahead of time (37% difference, p < 0.0001).ConclusionsTeam-based care utilizing APPs is acceptable to patients. Patients had strong preferences for seeing their surgeon for the first neurosurgical clinic visit and first post-operative visit. Patients were satisfied with seeing an APP if they could be seen more expeditiously. Patients also preferred to know ahead of time if they were going to see an APP.

A Review of Interprofessional Variation in Education: Challenges and Considerations in the Growth of Advanced Practice Providers in Emergency Medicine.

The employment and utilization of advanced practice providers (APPs) in the emergency department has been steadily increasing. Physicians, physician assistants (PAs), and nurse practitioners (NPs) have vastly different requirements for admission to graduate programs, clinical exposure, and postgraduate training. It is important that as supervisory physicians, patients, hospital administrators, and lawmakers, we understand the differences to best create a collaborative, supportive, and educational framework within which PAs/NPs can work effectively as part of a care team. This paper reviews the trends, considerations, and challenges of an evolving clinician workforce in the specialty of emergency medicine (EM). Subsequently, the following parameters of APP training are examined and discussed: the divergence in physician, PA, and NP education and training; requirements of PA and NP degree programs; variation in clinical contact hours; degree-specific licensing and postgraduate EM certification; opportunities for specialty training; and the evolution and availability of residency programs for APPs. The descriptive review is followed by a discussion of contemporary and timely issues that impact EM and considerations brought forth by the expansion of APPs in EM such as the current drive to independent practice and the push for reimbursement parity. We review current position statements from pertinent professional organizations regarding PA and NP capabilities, responsibilities, and physician oversight as well as billing implications, care outcomes and medicolegal implications.

Lessons Learned Over A Twenty Year Experience in the Utilization of Advanced Practice Providers in a Large Academic Pediatric Critical Care Medical Setting

Lessons Learned Over A Twenty Year Experience in the Utilization of Advanced Practice Providers in a Large Academic Pediatric Critical Care Medical Setting

Advanced Practice Providers in Radiation Oncology

PurposeThe report highlights utilization of advanced practice providers (APPs) in an academic radiation oncology center and how their role benefits patient care and departmental workflow. Methods and MaterialsA self-reported workflow analysis of department APPs was conducted across 5 disease sites. A review of electronic medical records was performed to determine the percent of APP follow-ups completed independently versus in a shared capacity with the radiation oncologist. A review of the APP’s didactic and clinical training program was performed. ResultsAcross all disease sites, approximately 40% of the APP’s time was spent on direct patient care, predominantly composed of independent follow-up visits (9%-35%) and telehealth (2%-30%). The breast malignancies group was an outlier with a higher focus on consults or shared visits (25%). Indirect patient care accounts for 30% to 50% of workflow with the focus on visit preparation or care coordination (13%-35%) and dictation (8%-13%). Administrative responsibilities including process improvement, research, education, and leadership account for the remainder (5%-26%) and are varied across disease sites. The central nervous system malignancies group and genitourinary malignancies group reported a greater percentage of their time (23%-26%) on administration compared with other groups (5%-9%). On average APPs see most of their visits independently from the physicians (86.41%) with 13.59% of visits being seen in a shared capacity. ConclusionsAPPs can positively affect the field of radiation oncology by augmenting clinical capacity, optimizing workflow and increasing department efficiency via both direct and indirect patient care and through involvement in administrative and leadership duties. By implementing an independent-to practice model, simultaneous APP and physician clinics run parallel to each other, limiting shared visits for complex cases. This promotes APP job satisfaction and provides greater access to patient care without compromising quality. This article highlights a model for the utilization of APPs, which can be implemented by other radiation oncology departments or practices.

Advanced Practice Provider Burnout in a Large Urban Medical Center.

Burnout is characterized by 3 facets: the presence of emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment. It arises when stress becomes so severe relative to a person's own resources that he or she loses motivation to perform, and it is associated with many negative outcomes. Emergency medicine (EM) physicians ranked highest in a study of burnout rates among physician subspecialties. However, there is an overall lack of robust research examining the work-related psychological states in advanced practice providers (APPs). Because the utilization of APPs in emergency departments (EDs) is steadily increasing, we aimed to describe burnout in this understudied group. A sample of APPs employed in a large urban academic hospital was surveyed using 3 well-established questionnaires measuring burnout, resilience, and mindfulness. Responses were compared with a normative group of health care workers (HCWs). The respondents reported a significantly greater sense of personal accomplishment than other HCWs. This was greater with a perceived control over their work environment and if they self-identified as being nonjudgmental. The sense of accomplishment was less in the respondents of older age and for those with children. This group also reported an increased sense of depersonalization. Mindfulness traits of acting with awareness and having trust in their instincts were identified as potential protective factors against depersonalization. Although the respondents were not more emotionally exhausted than other HCWs, being more emotionally "reactive" did predict greater emotional exhaustion. This is an important finding for APPs working in affect-laden work environments such as EDs. These findings suggest that increasing control over the work environment, fostering trust of instincts, and reducing emotional reactiveness are prudent interventional targets for EM-APP leaders to prevent and reduce burnout in the workforce.

A Direct Comparison of the Clinical Practice Patterns of Advanced Practice Providers and Doctors

BackgroundRising health care costs, physician shortages, and an aging patient population have increased the demand and utilization of advanced practice providers (APPs). Despite their expanding role in care delivery, little research has evaluated the care delivered by APPs compared with physicians. MethodsWe used clinical patient simulations to measure and compare the clinical care offered by APPs and physicians, collecting data from 4 distinct health care systems/hospitals in the United States between 2013 and 2017. Specialties ranged from primary care to hospital medicine and oncology. Primary study outcomes were to 1) measure any differences in practice patterns between APPs and physicians, and 2) determine whether the use of serial measurement and feedback could mitigate any such differences. ResultsAt baseline, we found no major differences in overall performance of APPs compared with physicians (P = .337). APPs performed 3.2% better in history taking (P = .013) and made 10.5% fewer unnecessary referrals (P = .025), whereas physicians ordered 17.6% fewer low-value tests per case (P = .042). Regardless of specialty or site, after 4 rounds of serial measurement and provider-specific feedback, APPs and physicians had similar increases in average overall scores—7.4% and 7.6%, respectively (P < .001 for both). Not only did both groups improve, but practice differences between the groups disappeared, leading to a 9.1% decrease in overall practice variation. ConclusionsWe found only modest differences in quality of care provided by APPs and physicians. Importantly, both groups improved their performance with serial measurement and feedback so that after 4 rounds, the original differences were mitigated entirely and overall variation significantly reduced. Our data suggest that APPs can provide high quality care in multiple clinical settings.

An Advanced Practice Provider Clinical Fellowship as a Pipeline to Staffing a Hospitalist Program.

Approximately 83% of hospitalist groups around the country utilize advanced practice providers; however, the demand for hospitalists continues to exceed the supply, and this has led to increased utilization of advanced practice providers in hospital medicine. Advanced practice providers receive very limited inpatient training, and there is wide variation in their clinical abilities after graduation. To determine if an advanced practice provider fellowship is a cost-effective pipeline for filling vacancies within a hospitalist program. In 2014, a one-year advanced practice providers clinical fellowship in hospital medicine was established. Working one-on-one with an experienced hospitalist faculty member, the fellows evaluate and manage patients. The program consists of 80% clinical experience, in the inpatient setting, and 20% didactic instruction. Up to four fellows are accepted each year and are eligible for hire, after training, if there are vacancies. The duration of onboarding and cost to the division were significantly reduced after implementation of the program (25.4 vs 11.0 weeks, P = .017 and $361,714 vs $66,000, P = .004). The advanced practice provider fellowship has proven beneficial for the hospitalist division by (1) reducing costs associated with having unfilled vacancies, (2) improving capacity on the hospitalist service, and (3) providing a pipeline for filling nurse practitioners (NP) and physician assistant (PA) vacancies on the hospitalist service.

Integration of Advanced Practice Providers in Academic Emergency Departments: Best Practices and Considerations.

As emergency department (ED) visits continue to increase nationwide, the utilization of advanced practice providers (APPs) has been steadily increasing. Academic centers face unique challenges in the inclusion of APP staff into the educational and teaching environment. Effort should be made to both take advantage of and support the educational mission of academic centers while bolstering clinical care provided by APP staff. This paper highlights some of the considerations and challenges in incorporating APPs into academic EDs as discussed at the Society for Academic Emergency Medicine Annual Meeting in Indianapolis, Indiana, in May 2018. The panel included representation from Massachusetts General Hospital, Yale New Haven Hospital, Warren Alpert Medical School of Brown University, and University of Massachusetts Medical School-Baystate. Distillation of our common experience shows that best practices in supervision favor uniformity between resident and APP staff except with low-acuity patients. Likewise, professional development takes advantage of the educational environment to provide feedback and identify areas for improvement as well as development of formal clinical and educational curricula for APPs working in academic institutions. Already established medical doctor residencies can be leveraged to provide postgraduate education for APPs in either formal or informal training programs.