ARTICLE IN BRIEF
The inclusion of nurse practitioners (NPs) and physician assistants (PAs) in neurology practices has greatly changed the delivery of neurologic care over the last 20 years. NPs and PAs who are AAN members discuss how they train and their growing role in neurology at a time when neurologist shortfalls are projected.
The 32-year old mother returned to the headache clinic at Emory University in Atlanta, GA, tired and depressed. Since her 2-year old's birth her migraines had become so frequent and debilitating that many days she was unable to care for her child. She had failed trials of topiramate, nortriptyline, amitriptyline, metoprolol, and propranolol. But during that visit, after a thorough discussion of the procedure and risks, she was ready to try botulinum toxin injections. Six weeks later, she logged in to her patient portal happy to report that her headache frequency had been reduced to one to two headache days per week.
In Springfield, MA, the pager alerted the stroke team that an acute stroke was en route to Baystate Medical Center. Within minutes, emergency medical services brought in a 72-year old woman with a history of atrial fibrillation who had developed a left hemiplegia and homonymous hemianopsia an hour earlier. Imaging revealed a right middle cerebral artery occlusion and the decision was made to administer tissue plasmiogen activator. Within 90 minutes from presenting to the hospital the patient regained vision and motor function.
This isn't a story about the strides that neurologic therapeutics have made in the last two decades, but rather about how the delivery of neurologic care has changed. The primary caregiver in each case was an advanced practice provider (APP), part of a rapidly growing sector of health care providers who are specialized in neurologic care. In fact, their numbers have risen so greatly in the US that in 2014 the AAN created a two-tiered membership category just for them, and on August 3, it welcomed its one-thousandth member.
APPs include physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists. According to the 2017 annual report of the National Commission on Certification of Physician Assistants, there are more than 115,500 certified PAs working in every state throughout the country. Their numbers increased 44 percent in the last six years alone, and the Bureau of Labor Statistics estimates that the PA profession will grow 30 percent by 2024.
Almost 28 percent of certified PAs work in primary care: family medicine/general practice, general internal medicine, and general pediatrics. Currently, less than 1 percent (0.8 percent) of certified PAs cite neurology as their principal clinical focus, according to the 2016 Statistical Profile of Certified Physician Assistants, an Annual Report of the National Commission on Certification of Physician Assistants. But according to a March 2017 National Center for Health Workforce Analysis report, between 2013 and 2025, the supply of neurologists will likely only grow by 11 percent, while demand is projected to grow by 16 percent, resulting in a shortfall of 820 physician full-time employees. For PAs working in neurology, the supply is expected to increase by 87 percent, and demand is expected to increase by 16 percent.
Also filling that gap in care will be nurse practitioners (NPs). There are more than 234,000 NPs currently licensed in the US, according to the 2017 AANP National Database. NPs are registered nurses (RNs) with advanced training in diagnosing and treating illness. Likewise, the majority have a primary care focus: 89.2 percent of NPs are certified in an area of primary care, and around 1.67 percent work in neurology, according to the American Association of Nurse Practitioners.
Calli Cook, FNP-C, who treated the mother at Emory's outpatient neurology clinic, is one of them. When she started to work at Emory in 2014, there was a 90-day waiting list in patient access at the outpatient neurology clinic. Within one year of her seeing new patients, Emory decreased their wait-time to 30 days for new patient visits.
Passionate about neurology, Cook, who has her master's degree in nursing from Emory, intends to begin her doctoral studies at Ohio State University (OSU) this fall. While at OSU she plans to study neuroimaging in primary headache syndromes. She became an AAN member in 2015, and earlier this year, she became chair of the Consortium of Neurology Advanced Practice Providers, created in 2017.
“Many of the Consortium's APP members are leaders in other neurology organizations and within their own health care systems,” she said. “Many also have research interests and work with local colleges and universities to help in the education of APPs in neurology.”
One of the benefits of the Consortium is being able to compare notes with colleagues and discuss challenges specific to APPs across the country, she pointed out. Its focus is to create best practices for APPs in neurology, promoting patient satisfaction, quality, and cost effectiveness.
Dennis O'Brien, PA-C, MMSc, a PA and vice chair of the APP Work Group, oversaw the care of the stroke patient and works in the Baystate inpatient neurology service, along with eight other APPs. They provide 24/7 coverage for neurology consultations and work with a team of neurologists who rotate on staff consultations that cover telestroke and telemedicine consultations at their four campuses. “In the setting of acute stroke, we are the first call from the emergency department,” he said. “We see the patients, coordinate their diagnostics, and collaborate with a neurologist and neuro-endovascular specialist to implement a treatment plan.”
Lucretia Long, CNP, has been a member of the American Epilepsy Society for more than 20 years and joined the AAN two years ago. She has been working as an epilepsy NP at OSU for 28 years. Her current role involves diagnosing and managing adult patients with epilepsy, participating in industry and self-initiated research studies, precepting NP students and training neurology residents and others health care professionals on vagus nerve stimulation. She also serves as an ad-hoc reviewer for Epilepsy and Behavior and has been published in nursing and medical journals.
“APPs are not interested in replacing neurologists,” she said, “but instead seek to provide a collaboration that can be beneficial to patients and families in terms of overall outcomes and patient access.”
SUPPORT FROM NEUROLOGY
In 2002, when Neurology Today first wrote about APPs, a number of neurologists feared that APPs would threaten our profession. Back then, the subject was controversial and an entire section of the story was devoted to apprehensions and reservations by our physician members. But we predicted that cultural acceptance in the medical community was likely to rise as more PAs and NPs with specialized neurological training entered the market and busy neurologists pressed for time looked for ways to enhance the quality of care their practices provide. And indeed, there now not only appears to be acceptance of APPs, but neurologist AAN members now champion their success.
Cook, O'Brien, and Long had strong mentors who supported and advocated for them. At Emory, Gregory J. Esper, MD, MBA, FAAN, current chair of the Health Services Research Subcommittee, encouraged Cook to join the AAN and facilitated her goal to see patients independently at Emory's neurology clinic. William H. Likosky, MD, FAAN, former member of the AAN Therapeutics and Technology Assessment Subcommittee, taught APPs to be experts in neurology at Swedish Medical Center in Seattle, where O'Brien spent seven years as the program evolved into a neurohospitalist service. Long was invited to participate in an APP Work Group by one of her collaborating physicians, Miriam Freimer, MD, who was chair of the APP Work Group that developed an AAN position paper on neurology APPs in 2014; Long became an AAN member as a result of her invitation.
AAN President Ralph Sacco, MD, FAHA, FAAN, fully endorses the partnership. He is concerned about how Academy members will address the aging population's neurologic needs with already long waiting times, and even greater shortages predicted. He told Neurology Today he hopes the APP Consortium can help fill that demand. “We need to get more APPs trained in neurology and help expand their educational opportunities,” he said.
“APPs are among the fastest growing segment of AAN members. I hope to see more APPs engaged in our task forces, committees and in future leadership roles within the AAN, standing shoulder to shoulder with other AAN members.”