Non-physician practitioners (NPPs) are good for oncology practices in terms of both efficiency and overall satisfaction. That is the conclusion of the new ASCO study of “collaborative practice arrangements,” which assessed 226 practices in 43 states.
Patients surveyed for the study, published in the September issue of the Journal of Oncology Practice (2011;7:278-282), reported being extremely satisfied with the service they received, while physicians also expressed a high level of satisfaction with having nurse practitioners and physician assistants as part of the practice. Furthermore, practices in which NPPs worked with all physicians and saw a wide variety of patients were found to be 19% more productive than practices in which NPPs play a more restricted role.
The study was done, the authors noted, because of the projection of a significant shortfall of oncologists by 2020 (OT, 4/10/07).
“This paper is right in synch with the Institute of Medicine report released in October 2010 on the future of nursing” (OT, 10/25/10) commented Jan Towers, PhD, NP-C, CRNP, Director of Health Policy/Federal Government & Professional Affairs for the American Academy of Nurse Practitioners.
“We should be able to practice at our full scope of education and training. This is another study that shows that we can make a significant contribution, and that barriers need to be pulled down to allow us to do that.”
Oncology Nursing Society President Carlton G. Brown, RN, PhD, AOCN, wrote an accompanying commentary in the journal, saying that the study “may help to change some minds” about the role NPPs can play in oncology practice. He said, though, that he also believes that more research is needed, particularly since collaborative practice cannot completely compensate for the projected oncology-provider shortfall.
“The study was beautifully done,” he said in an interview. “It has shown what I've already seen, including in my own practice—that if you have a team working well together, including nurse practitioners, that it's an incredible experience for the patient and it's also an incredible working experience. But even when we're all working together, with the shortage of both nurses and physicians in the future, it's going to be difficult to get done what needs to be done.”
226 Oncology Practices in 43 States
The researchers, led by Elaine L. Towle, CMPE, Director of Consulting Services for a company called Oncology Metrics, a division of Altos Solutions in California, began the study in March 2009, with funding from the Susan G. Komen for the Cure Foundation.
Thirty-one of the 226 practices were selected by the researchers for a more in-depth analysis, based on their practice size, geographic location, and collaborative practice model, in order to have a sample that was representative of oncology practices across the nation. Twenty-seven of these were then studied for an additional six months beyond that.
Of the total 226 practices surveyed, 73% were physician-owned private practices, 12% were hospital-owned, 8% were academic, and 7% were other forms of practices. Fifty-eight percent of the practices included NPPs. Among the remaining practices, the main reason given for not including NPPs was that “physicians are not interested in working with NPPs.” The other two most common explanations were, “we do not have the patient volume to support an NPP” and “we have worked with NPPs in the past and it didn't work out.”
“This implies that if these attitudes could be changed, more patients could be seen,” wrote the researchers, who also included Thomas R. Barr, MBA; Amy Hanley; Michael Kosty, MD; Stephanie Williams, MD; and Michael A. Goldstein, MD.
Eighty-four percent of the practices studied in depth were physician-owned private practices; and the rest were hospital-owned (academic practices were excluded from this part of the study).
The most common practice arrangement in both the survey and study groups is the “incident-to-practice” model, where the physician or physicians are generally present in the office suite, but NPPs usually see patients without physicians being present. This allows both NPPs and physicians to see more patients, and practices to bill Medicare for NPP services as “incident to” the physician or as though they were delivered by the physicians, Ms. Towle explained.
“This model not only provides access by patients to both the NPP and the physician at alternating visits, but also maximizes reimbursement — an important consideration for today's oncology practices.”
The average ratio of NPPs to physicians in the practices studied was one to two. Almost all patients—98%—were aware that clinical services were being provided to them by NPPs. The average rate of overall patient satisfaction was 92.5%.
“This is evidence that such collaborative practice arrangements are well accepted by patients, and we believe there should be no lingering concerns that patients will react negatively to oncology care provided by non-physician practitioners in a collaborative practice model,” the researchers concluded.
Physician and NPP satisfaction ratings were also high, at 79.8% and 78.2%, respectively. The key drivers for NPP satisfaction included whether there was “respect for clinical decision-making” and that “the physician treats me as an equal,” as well as feelings of “making a difference” for patients and being able to “grow as a professional.”
When Ms. Towle and her colleagues asked clinicians about their workloads, 58% of physicians said they were too busy, while only 18% of NPPs felt that way. Surprisingly however, both physicians and NPPs who felt they “could be busier” were seeing larger numbers of patients and were therefore more productive than those who said they were too busy.
Fifteen of the 27 study-group practices analyzed for productivity used a model in which NPPs worked with all practice physicians and saw a wide variety of patients. In another 11, NPPs worked with specific physicians.
The average number of patient encounters per full-time-equivalent provider in the six-month observation period was 1,066 in the exclusive group compared with 897 in the non-exclusive set of practices—a 19% difference.
The team also conducted both one-on-one and group interviews with 47 NPPs from 27 of the study practices. The main theme in their comments was, “how can I better support patients?”
This shows a need for formal continuing education for NPPs, the researchers said.
Other recommendations include possibly creating a new track at ASCO's Annual Meeting focusing on practice management and the practical aspects of creating collaborative care. Also suggested was that ASCO work to increase physician awareness and acceptance of NPPs' important role in oncology practice.
Asked for her opinion for this article, OT Editorial Board member Carolyn Weaver RN, MSN, AOCN, Clinical Nurse Specialist and Patient Education Coordinator at Fox Chase Cancer Center, noted that collaborative practice arrangements have been used increasingly at her institution and that they make it possible for oncologists to see new patients in a more timely manner. “This study should help to convince others considering this type of practice that it can be successful,” she said.
“If there are skeptics out there, this should help prove that collaborative practice arrangements can work. In fact I think they were more successful than expected.”
Formal Oncology Training
Dean Bajorin, MD, Co-chair of ASCO's Workforce Advisory Group, which provided guidance for the study, said in a statement that the combination of patients' high degree of satisfaction with the care they received and professionals' satisfaction with the delivery of cancer services shows that coordinated and integrated cancer care provided by both oncologists and non-physician providers is a very successful model.
“Additional measures,” he continued, “such as establishing formal oncology training for nurse practitioners and physicians' assistants will help us enhance efficiency and patient experience as oncology practices address the increased demand for cancer services nationwide.”
The full 97-page study (with information beyond the Journal of Oncology Practice article) can be found at http://bit.ly/oIWcIq
ASCO President Michael Link: Nurse Practitioners Already Integrated in Pediatric Oncology
“In anticipation of the projected shortage, ASCO continues to seek solutions that will not only transform oncology care, but continue to ensure a sustained high level of excellence,” ASCO President Michael P. Link, MD, said in a statement. “This study shows that practices are extending oncology services by promoting a collaborative practice with nurse practitioners and physicians' assistants. In pediatric oncology, nurse practitioners are already an integral part of our practice and are indispensable.”