Advance Practice Providers Drive Practice Efficiency in Oncology

Advanced practice providers (APPs) bring tremendous value to an oncology practice, physician leaders report, but there could be room for expanding scope of practice going forward, according to a new study published in the Journal of Clinical Pathways.

APPs, which primarily include nurse practitioners and physician assistants, have been a key part of the medical field for over a century, the report authors noted. Since they were first tapped to administer anesthesia without a physician in 1917, APPs have been instrumental in extending patient access to care.

This has been notable in the hematology and oncology space, as the nation stares down a particularly pressing oncology physician shortage, the research team pointed out. Between 2014 and 2017, the number of oncology practices employing APPs jumped from 52 percent to 81 percent, the team said citing numbers from the ASCO Practice Census Reports.

But considering the differences in practice models for APPs in oncology care versus primary care, little is known about their job functions and how APPs complement an oncology clinic.

From surveying 163 oncologists across the country, the research team concluded that APPs currently bring notable value to the oncology clinic, although there is room for expanded scope of practice.

Eighty-one percent of the respondents said they employed APPs in their practice, with 74 saying they employed nurse practitioners, 40 percent employing physician assistants, and 33 employing both.

Sixty-two percent said APPs only evaluated or saw returning patients, while 36 percent tapped APPs to see both new and returning patients. Only 2 percent used APPs to see new patients, exclusively.

In as much as what APPs do in oncology practice, most physicians said they relegate less invasive or intensive tasks to their NPs or PAs.

“APPs currently appear to be more frequently involved in patient education, ordering laboratory and imaging studies, and discussing [end-of-life] care,” the researchers found. “Fewer are involved in performing procedures or selecting systemic therapies.”

For example, 84 percent of APPs conducted patient education, 69 percent ordered imaging and lab testing, and 62 percent supported care decisions.

Far fewer (51 percent) conducted invasive procedures, like bone marrow biopsies.

There was some discordance between what physicians said APPs were capable of doing versus the tasks for which APPs were currently responsible.

For example, 87 percent of oncologists agreed that APPs can discuss imaging test results with patients, but only 60 percent said their APPs currently do so. Another 86 percent of physicians said APPs can discuss end-of-life care with patients, but only 58 percent do.

Those practice regulations and discordances notwithstanding, APPs are bringing tremendous value to the oncology clinic, the researchers reported.

Although only 29 percent of physician respondents said APPs increased practice revenue, 60 percent said APPs enhanced practice efficiency and 52 percent said APPs helped practices admit more patients.

These differences may have arisen because of the difficulty in quantifying expanded patient panels, the team said.

“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,” the researchers explained.

“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.”

And because of those benefits, more than half (58 percent) of physician respondents said they would employ more APPs moving into the next three years. Thirty-nine percent said they would maintain the same APP workforce into the near future.

That said, only a minority of physician respondents predicted they would expand APP scope of practice. Forty-one percent said they may expand APP responsibilities, while 59 percent predicted their APPs would maintain the same responsibilities into the future.

This window into APP responsibilities and impacts may help providers augment their care teams moving forward, the researchers said. Understanding how APPs practice in the oncology setting and how that improves the practice may be beneficial to others working with APPs.

“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,” the research team stated. “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).”

“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,” the team added.

Future research may also consult APPs to determine how they perceive their scope of practice and responsibilities within the oncology setting.