Survey looks at relationship between advanced practitioners, nephrologists
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Physician assistants and nurse practitioners, collectively known as advanced practitioners or APs, provide an increasing portion of primary care in the United States and will be the dominant clinicians recognizing and referring patients with chronic kidney disease in the 21st century. In 2016, there were 104,000 APs practicing in primary care, almost half of the number of the 223,000 PCPs.1 The PCP population is declining and aging with greater than 25% of the workforce older than 60 years. In contrast, the AP population is younger; for example, the mean age for a PA is 37 years.1
As the future CKD referral and management base will increasingly include AP representation, we surveyed APs to determine perceived challenges to working with nephrologists. Previous U.S. research on existing barriers to co-management of patients with CKD between PCPs and nephrologists is limited to data generated by a focus group of 32 experienced physicians.2,3 There is a lack of data on the management and referral of patients with CKD by APs and on the dynamics within the AP-nephrology team. We sought to fill gaps in current knowledge of the primary care-nephrology partnership with a broader look on the AP perspective in diverse clinical settings.
Methods
With input from the team who surveyed the PCP groups, we undertook a straw poll survey of the current challenges to nephrology referral and co-management.2,3 Polling occurred May 2019 to June 2019 at national PA and NP conferences, with written feedback submitted from both experienced and new APs in specialty and primary care settings.
This questionnaire-based survey sampled 90 APs asking the following open response questions:
- What challenges, if any, do you have with referring to nephrology practices?
- Are you interested in co-managing patients with nephrology providers?
- What communication issues occur in your area with nephrology providers?
Demographic data were also collected, and the analysis was manually tabulated.
Results
The cohort consisted of 90 participants, 40 in specialties and 50 in primary care. There was roughly equitable representation in terms of provider experience: 31% had been in practice 0 to 3 years; 29% in practice 4 to 10 years; and 40% had more than 11 years in practice (Table).
APs practiced in diverse settings: rural communities, free clinics, the Veterans Affairs system, as well as academic and private practice. The largest geographical region was the Midwest (46%), then the South (31%), Northeast (14%), West (7%) and those with multiregional practices (2%).
Five main themes emerged as barriers to nephrology referral and co-management (Figure).
Access to timely care
Long wait times to see a nephrologist were identified by one-third of all survey participants, with primary care APs more likely to report limited access than specialist APs (50% vs. 12.5%, respectively). Those with less than 3 years of experience reported more barriers accessing nephrology than those with more than 11 years of experience.
Insurance or financial barriers
Insurance and financial restrictions to nephrology care were reported by 11% of all APs, including 7.5% of specialists and 14% of primary care APs. New APs identified insurance and/or cost more often compared with those with 4 to 10 years of experience and those with more than 11 years in practice (21%, 0% and 11%, respectively).
Suboptimal provider-provider communication
The lack of/delay in patient information exchange among APs was cited by 31% of participants: 22.5% of specialists and 38% of PCPs. Length of practice experience showed that mid-career APs had the largest issue with communication in nephrology; those with less than 3 years of experience, 4 to 10 years of experience and more than 11 years of experience reporting communication issues (32%, 46% and 22%, respectively).
Provider knowledge gaps
Lack of AP certainty in referral and co-management was a common issue in all levels of experience in the cohort ranging from 6% (those with less than 3 years and those with more than 11 years of experience) to 12% (4 to 10 years of experience). Knowledge gaps identified by APs included timing of referrals and frequency of CKD laboratory monitoring. None of the specialist APs surveyed reported uncertainty about when to refer and/or check labs.
Nephrologist-AP role conflicts
Lack of agreement about management roles and/or care decisions were reported by 6% of the total cohort; 2.5% of specialist APs and 8% of those in primary care. Conflict was more often reported by APs with more experience: 4% for those with less than 3 years of experience, 0% for those with 4 to 10 years of experience and 8% for those with more than 11 years of experience. Conflicts included stopping NSAIDs or blood pressure and/or diabetes goals.
Sixty percent of specialty APs and 16% of primary care APs identified no barriers to nephrology-AP CKD care. More than 75% of APs were interested in co-managing patients with nephrology, more commonly primary care APs.
Discussion
While the medical community has long acknowledged the risks and costs, both financially and socially, of CKD, the public is comparatively unaware of the threat. The growing prevalence of CKD and the associated threat to long-term cardiovascular and public health outcomes emerged in the national spotlight in July 2019.4 The Executive Order on Advancing American Kidney Health signed by President Donald J. Trump called the state of medical care for patients with CKD and end-stage kidney disease unacceptable and set forth three major policy goals. The primary policy is to focus on prevention of CKD with two secondary goals to improve options for patients with ESKD.5
With 15% of U.S. adults (37 million people) with CKD and 90% of those with CKD unaware of their diagnosis, the challenge to prevent kidney failure whenever possible through better diagnosis, treatment and incentives for preventive care cannot be borne by the nephrology community alone.3 Indeed, PCPs and other non-nephrology specialists often manage conditions such as diabetes, hypertension and obesity that profoundly influence risk for the development of CKD. PCPs and APs are responsible for the majority of care for patients with early CKD disease (stages 1 to 3).6
Focus groups of PCPs have uncovered a lack of comfort with managing specific sequelae of CKD.2 Previous studies have demonstrated suboptimal CKD diagnosis and management in the primary care setting.7,8 These gaps in quality CKD care represent an actionable means by which to achieve the public health goal of the United States of preventing progression to ESKD whenever possible.5
Our survey provides a front-line view of the perceived barriers to nephrology referral and team-based care with APs in diverse clinical settings. APs surveyed, especially those in primary care, are motivated to engage in team-based care of patients with CKD, despite, or perhaps because of, challenges in access to nephrologists and suboptimal communication between nephrology and APs. This primary care-AP interest in team-based care is related to the AP’s central role in managing patient care.
The observation that primary care APs were more likely to report limited access to nephrology care arguably lends further support to the hypothesis that the APs are motivated by the need to fill the gaps in CKD care.
This study reinforced several systems-, provider- and patient-level barriers to nephrology referral/co-management reported in physician-only focus groups.2,3 One communication barrier not previously identified was the exclusion of APs from communications, ie, “nephrologists send reports to my collaborating physician even though I sent the referral, delaying patient care.” Another AP echoed this stating that even though she had sent the referral, the nephrology office would call the physician in the practice for a management discussion. The AP cohort was particularly attuned to insurance and financial barriers their patients face, themes rarely reported in physician-generated responses. The physician focus group reported belief that they are unable to improve CKD was not expressed by any of the APs in the present study. This may be related to differences in methodology (ie, focus-group based vs. questionnaire based).
Limitations of the study include the “snap-shot” view of APs attending a conference. There was a predominance of APs from the Midwest due to conference sites. While the free-response written system allowed more nuanced responses than a checklist method, this method did not lend itself to granular statistical analysis.
Strengths include the diverse nature of the responses; PAs and NPs, specialty and primary care, early, middle and late career APs and nationwide coverage of responses. The volume of the AP cohort was three times that of physician responses in previous publications.2,3
Several APs expressed interest in receiving direct patient-specific recommendations by which they could support their nephrology colleagues in co-management. This appears to be an excellent opportunity for the nephrology community to invest in outreach and education for the AP, recognizing the increasing role APs play in CKD care. Indeed, the presence of APs in nephrology specialty groups was recently recognized as a key quality in delivering high-value care.9
We believe the overall high level of AP interest in collaborating with nephrology lends itself to an optimistic interpretation that APs, representing a growing number of the next generation of primary care practitioners, see these barriers not as insurmountable obstacles, but as opportunities to truly advance American kidney health.
- References:
- www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCare Chartbook.pdf
- Sperati CJ, et al. PLOS ONE, 2019;doi:10.1371/journal.pone.0221325.
- Greer RC, et al. J Gen Internal Med. 2019;doi:10.1007/s11606-019-04975-y.
- Hoerger TJ, et al. Am J Kidney Dis. 2015;doi:10.1053/j.ajkd.2014.09.023.
- Executive Order on Advancing American Kidney Health, Exec. Order No. 13879, fed. reg. doc. 2019-15159. (July 10, 2019). Federal Register: The Daily Journal of the United States.
- Shahinian VB, et al. Adv Chronic Kidney Dis. 2010;doi:10.1053/j.ackd.2010.02.003.
- Boulware LE, et al. Am J Kidney Dis. 2006;doi:10.1053/j.ajkd.2006.04.073.
- Allen AS, et al. J Gen Intern Med. 2011;doi:10.1007/s11606-010-1523-6.
- Brady BM, et al. JASN. 2019; doi:10.1681/ASN.2019030219.
- For more information:
- Rebecca Boyle, PA-C, is with the Stanford Hypertension Center, Stanford Healthcare Division of Nephrology in Palo Alto, California, and can be reached at rboyle@stanfordhealthcare.org.
- Jane S. Davis, DNP, is with the University of Alabama at Birmingham in the division of nephrology in Birmingham, Alabama, and can be reached at jsdavis@uabmc.edu. Davis is also a Nephrology News & Issues Editorial Advisory Board Member.
- Kim Zuber, PA-C, is the executive director of the American Academy of Nephrology PAs in St. Petersburg, Florida, and can be reached at zuberkim@yahoo.com.
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