Patients with autoimmune disease rated care from APPs similarly to that of rheumatologists
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Patients who received rheumatology care from nurse practitioners or physician assistants rated their overall experience similarly to those who saw a rheumatologist, according to survey data published in Arthritis Care & Research.
The researchers additionally concluded that nurse practitioners and physician assistants may also improve access to care for patients who reside in areas with few or no rheumatologists available.
“Some rural residents travel 200 miles or more for an appointment with a rheumatology specialist,” Karen Frazier, PhD, of the American Institutes for Research in Chapel Hill, North Carolina, and colleagues wrote. “To improve access to care in the face of this shortfall, the 2015 American College of Rheumatology Workforce Study recommended the ACR and the Association of Rheumatology Professionals (ARP) adopt strategies to increase the inclusion of nurse practitioners (NPs) and physician assistants (PAs) in rheumatology care and provide appropriate training to prepare them.”
“Advanced practice providers (APPs) — which comprise NPs and PAs — specializing in rheumatology work independently to evaluate and treat patients, interpret and deliver test results, perform procedures, and prescribe medications,” they added. “Despite studies showing equivalence in quality of care provided by APPs and physicians, only about a quarter of rheumatologists employed APPs in their practices in 2015, with APPs making up just 7.5% of the adult and 8% of the pediatric rheumatology workforce. In addition, the research is silent on the extent to which rheumatology patients accept APPs for their care.”
To determine whether patients would accept advanced practice providers as an alternative in lieu of available rheumatologists, Frazier and colleagues conducted a cross-sectional survey of 500 individuals — or, in the case of juvenile patients, their parents — diagnosed with an autoimmune condition. Inclusion criteria required participants to have seen their primary rheumatology provider within the past 6 months.
For adults, qualifying diseases included rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, juvenile arthritis persistent to adulthood and lupus. Included conditions for children were juvenile idiopathic arthritis, juvenile myositis, juvenile lupus, juvenile scleroderma, vasculitis and fibromyalgia.
The survey, conducted in English and Spanish from March 24, 2020, through April 16, 2020, by the research firm SSRS, asked respondents to self-report whether their primary providers were rheumatologists, nurse practitioners or physician assistants, as well as their attitudes on their overall care experience.
To ensure that the survey included an adequate number of respondents with nurse practitioners or physician assistants as their primary rheumatology providers, the firm oversampled in metropolitan areas known by the Arthritis Foundation to have advanced practice providers employed in rheumatology practices, as well as in more than 250 areas with large-to mid-size nursing and assistant credentialing programs.
According to the researchers, 36.8% of the 500 respondents reported having nurse practitioners or physician assistants as primary rheumatology providers. Notably, these patients were significantly more likely to arrive at their provider’s office in 15 minutes or less (P < .01), and to be able to schedule routine (P = .02) and urgent (P = .05) appointments sooner, compared with those who reported having a rheumatologist as a primary provider.
Regarding patients’ overall patient experience of care, there were no significant differences between provider types, the researchers wrote. However, although most patients rated their providers highly regardless of type, those who saw rheumatologists rated their providers significantly higher (P < .01). Patients who saw nurse practitioners or physician assistants were significantly more likely to prefer them over rheumatologists (P < .01), and to recommend advanced practice providers to others (P < .01), compared to those who visited a rheumatologist.
“Because a substantial portion of people with autoimmune conditions seem receptive to APPs, increasing the supply of APPs could improve access to care and help ameliorate the current and projected workforce shortages,” Frazier and colleagues wrote. “This is particularly promising because previous research on APPs in rheumatology practice found that APPs functioned independently, with nearly two-thirds (61%) of patient visits covered by APPs alone.”
They added: “With patients receptive to APPs and these providers able to shoulder a significant proportion of patient care responsibilities, providing APPs with specialty training and incorporating them into rheumatology practice could improve access to care for people with rheumatologic conditions, particularly those in areas of the country where rheumatology care is difficult to schedule or unavailable.”
Perspective
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April Johnson, APRN, CNP
As autoimmune diseases continue to become more prevalent, the shortage of rheumatologists continues to become more problematic. Addressing the shortage of rheumatologists has been a hot topic for the past 5-10 years. Advanced practice providers (APPs) are in a valuable position to fill in the gap and provide care for patients struggling with chronic autoimmune diseases and more and more APPs are taking on this challenging but critical role.
In the right setting with the right training and support, APPs have been shown to provide quality standard of care with their assessments, clinical skills, medication management and evaluations compared to a board-certified rheumatologist. As an APP myself, I stay up to date on the latest treatments, trends and evidence-based practice while utilizing my teaching and listening skills learned while in nursing to evaluate and treat the needs of the patient.
I believe in treating the whole person spiritually, physically and mentally while formulating an individual treatment plan for each patient and utilizing the shared decision-making model to allow patients to be involved with their care. I find that developing your own style of treatment, different from the rheumatologist, is valued and welcomed with most patients. Patients also express how nice it is to have both a rheumatologist and an APP to formulate a treatment plan together to treat and monitor their chronic disease.
The future of rheumatology looks vastly different than it did 20 years ago, and I believe the patient’s approval of the APP’s rheumatologic care will be the key to solving the shortage of rheumatology providers.
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