Abstract: In the era of value-based care and constrained resources, oncology practices are increasingly employing advanced practice providers (APPs) to improve practice workflow, increase efficiency, and enable physicians to focus on complex patient care. The role of APPs is expanding in oncology for myriad reasons including improving access to care by closing the gap between demand for services and physician availability. This is especially pertinent in oncology, where the shortage of oncologists and physician burnout is creating challenges for many practices and communities. In light of these factors, Cardinal Health conducted a survey of community oncologists to assess oncologists’ views of the scope of practice of APPs, the role of APPs in patient treatment and support, and their impact on practice workflow. Understanding potential variations in the scope of practice for APPs may help establish a benchmark against which future changes are measured. It is likely that the number of APPs employed by community oncology practices as well as the scope of their practice will continue to expand. Optimal integration of APPs into oncology practices is critical moving forward; this analysis offers current insights and proposed strategies for a path forward. These steps can potentially have a larger impact on quality of patient care and mitigate physician burnout.
In 1917 a landmark legal decision, Frank v South, laid the legal precedent for advanced practice providers (APPs) in the United States1 by allowing nurses in the field to administer anesthesia and other medications under the orders and supervision of a licensed physician. Soon thereafter, a physician led-council created a manual for field nurses that would allow them to administer many medications in the absence of a physician as long as they followed the guidance laid out in the manual, thereby paving the way to the practice of medicine by nurses. Over the ensuing century, the titles of these nonphysician health care professionals have been myriad, from frontier nurses to mid-level providers to physician extenders. In the more recent past, the roles and training of these APPs have been codified into two professions: nurse practitioners (NPs) and physician assistants (PAs). Based on data from the American Community Survey and the National Sample Survey of Registered Nurses, the numbers of full-time equivalent PAs and NPs have increased by 16% and 70%, respectively, from 2010 to 2016.2 Moreover, employment of APPs has increased not only in primary care practices but also in multispecialty practices.3
One medical specialty that stands out for its embrace of APPs is that of hematology/oncology as was predicted by a 2007 American Society of Clinical Oncology (ASCO) Workforce Study that projected a shortage of oncologists by 2020.4 Indeed, an updated report in 2014 concluded that these earlier projections were accurate. Moreover, the recent analysis cautioned that the Affordable Care Act might exacerbate these shortages due to increased demand for oncology services and higher expectation for quality of care.5 The authors of the 2007 report proposed that increased usage of APPs might help narrow the gap between workforce supply and demand.4
According to the ASCO Practice Census Reports, employment of APPs in oncology practices has increased from 52% in 2014 to 81% in 2017.6-8 Additionally, to accommodate the increase in patient volume, expand oncology services, and decrease workload burden, 36% of practices who responded to the ASCO Trends Survey reported that they employed more APPs than in the year preceding the survey.8 A recent study estimated that over 5300 APPs are engaged in the practice of oncology with an additional 5400 APPs who might practice oncology.9 To better understand the roles of APPs in oncology practices, several studies have focused on identifying the total number of oncology APPs and their scope of work.9,10 In oncology, the practice for APPs is largely conducted via collaborative work with physicians on complex cases.11 Such team-based care delivery is distinct from the APP clinical model for independent practice in primary care settings. Another recent survey of over 3000 oncology APPs accrued a 19% response rate and revealed that patient counseling, prescribing, treatment management, and follow-up visits are the top four patient care activities for APPs in oncology.9
We conducted the present study of community-based medical oncologists to better understand their practices’ use of APPs, the APP’s role in patient treatment and support, as well as their impact on practice workflow.12,13
Methods
Between September 2018 and November 2018, a total of 163 US-based community medical oncologists were surveyed using a web-based instrument. This 22-question survey was created de novo by the authors and captured participants’ demographics, practice characteristics, clinical tasks performed by APPs; perceived benefits of APPs to their practices; and their view of future trends in APP utilization. Physicians were also asked how frequently their APPs performed certain tasks on a 5-point scale (ie, never, occasionally, sometimes, frequently, and always).
The participants were medical oncologists and/or hematologists in the US community setting from the Cardinal Health Oncology Provider Extended Network (OPEN™). The OPEN network is composed of US-based community and hospital-employed oncologists who have participated in previous surveys and real-world evidence studies.
Responses were summarized using descriptive statistics.
Results
In this survey, a total of 163 oncologists who were geographically dispersed throughout the United States completed the online survey: 42% (n = 68) practiced in urban areas and 58% (n = 95) in suburban and rural areas (Table 1). A minority (9.2%) saw an average of 10 patients or less per working day, while the majority (66%) saw 16 patients or more per day. Among the physicians surveyed, 81% (n = 132) employed APPs in their practice, 74.2% employed NPs, 39.9% employed PAs, and 33.1% employed both.
APP Scope of Work
As shown in Figure 1, the majority (62.1%) of physicians stated that APPs only evaluated and saw returning patients, whereas 35.6% of physicians used APPs to evaluate and see both new and returning patients; a small minority (2.3%) utilized APPs to see and evaluate new patients only.
We investigated APPs’ scope of work that is directly related to patient care (Figure 2). Most physicians stated that APPs were frequently/always involved in providing patient education (84.1%), ordering imaging and laboratory studies (68.9%), and/or making supportive care decisions (62.1%). Most (87.9%) physicians agreed that APPs can discuss imaging reports with patients, and 59.8% reported that APPs sometimes or occasionally perform this task. A majority (86.4%) of physicians agreed that APPs discussed end-of-life (EOL) care with patients, and 57.6% reported that APPs sometimes or occasionally perform this task. Regarding invasive procedures, half of the physicians (51.9%) agreed that APPs performed bone marrow biopsies and intrathecal chemotherapy, and APPs are less frequently involved in performing invasive procedures compared with other tasks. More physicians agreed that APPs are involved in modifying existing treatment regimens (eg, chemotherapy dose/schedule changes) than those who allowed APPs to make decisions about new therapies (68.2% vs 39.4%). The majority (58.3%) reported that APPs are sometimes or occasionally involved in modifying existing chemotherapy regimens, while only 37.9% reported that APPs are sometimes or occasionally involved in making new treatment decisions.
Practice Efficiency and Future Trends
As shown in Figure 3, more than 60% of physicians stated that APPs enhanced their practice efficiency, enabled physicians to focus more on complex patient cases, and made their workload manageable. Half of respondents (52.3%) stated that APPs allowed their practice to see more new patients. Less than one-third of respondents (29.5%) stated that APPs helped increased their practice revenue.
The majority (57.6%) of physicians reported that they would employ more APPs in the next 3 years, with 38.6% would employ the same number of APPs (Figure 4). Additionally, 41.7% of physicians reported that APPs would likely take on additional responsibilities in the next 3 years, 56.8% think they would keep the same responsibilities, and 1.5% think they would take less responsibilities (Figure 5).
Among practices that employed at least one APP (n = 132), 43% (n = 57) of physicians reported a 1:3 APP to physician ratio, 31% reported a 1:2 ratio, 18% reported a 1:1 ratio, and the rest (8%) reported other ratios from 2:1, 3:1, to 2:3. Overall, within 74% of the practices that employ APPs, we observed 1:2 to 1:3 APP to physician ratios.
Discussion
In this era of value-based care, our research and that of others confirm that most community oncology practices in the United States have employed APPs and are finding significant value in the APP roles by delegating various aspects of patient care to them. Our survey reveals that, despite 82% APP penetration,12,13 community practices are considering increasing the number of employed APPs while expanding the scope of their responsibilities. Almost three-quarters of the physicians reported an APP to physician ratio of 1:2 to 1:3, which is consistent with a previous report from ASCO that reported an average of 0.44 APPs per oncologist.7 However, this ratio may change in the future if more APPs are recruited to oncology practices.
Based on our findings, APPs currently appear to be more frequently involved in patient education, ordering laboratory and imaging studies, and discussing EOL care. Fewer are involved in performing procedures or selecting systemic therapies. In a recent national survey of over 5000 oncology APPs, similar trends were noted with oncology practices relying on APPs routinely for direct patient care.9 This survey found that APPs spend the bulk of their time (an average of 85%) in prescribing and managing treatments, conducting follow-up patient visits, and counseling patients. A majority of APPs in oncology (90%) reported being satisfied or very satisfied with their position and their collaborative practice with oncologists and it was noted that on an average APPs in oncology earn approximately 10% more than APPs in non-oncology fields.9
While less than one-third of the physicians (30%) in our study reported that APPs helped increase their practice revenue, over twice that reported that APPs improved their practice efficiency, made their workload more manageable, and allowed them to focus on more complex patients. Additionally, over half reported that APPs allowed them to see more new patients. Improving operational efficiency and allowing for additional new patients are obvious surrogates for improved revenue but may be difficult to assess in terms of ascribing a dollar value to the APP function. Thus, the perception regarding revenue contribution may underestimate the actual financial contribution of APPs since physicians from medium or large practices may not be aware of precise practice financials. Further studies on APPs and their impact on practice revenue are warranted but adjusting for the dollar value of improved physician quality of life may complicate the exercise.
As the US health system moves toward more value-based care, APPs also play a vital role in improving quality of care. To align with value-based care principles, many oncology practices have implemented changes to their operations, such as providing 24/7 care access and care plan documentation.14 Understanding the tasks and capabilities of APPs from physicians’ perspective may help practices reorganize an oncology care team that operates efficiently in the value-based care era. With the growing demand in oncology workforce, expanding roles and more responsibilities of APPs are expected in the future (eg, survivorship clinics, supportive care, and care quality improvement).15 Future research should continue investigating how APPs and physicians could work more effectively and collaboratively in improving quality of care, enhancing practice efficiency, and reducing provider burnout.
While our survey highlighted various aspects of APP involvement in oncology practices, it is not without limitations. The survey was limited to physicians, and APPs were not surveyed. It is equally important to understand the APPs’ perceptions of their own practices and how they envision the ongoing process. Also, there were no uniform definitions of some terminologies used in the survey questions such as “practice efficiency” and “burnout”.
Conclusion
With more understanding regarding APPs’ involvement in advanced roles (eg, ordering/adjusting chemotherapy and performing invasive procedures), we believe this study offers insights as to how APPs bring value to oncology practices and their physicians, serving as a potential solution to alleviating physician burnout.
References
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