‘The writing is on the wall’: The ever expanding, evolving role of APPs in rheumatology

The number, and role, of advanced practice providers in rheumatology care is exploding.

Between 2009 and 2020, the number of APPs in the field increased 141%, while the quantity of rheumatologists increased by a relatively paltry 23%, according to data published by Mannion and colleagues in Arthritis & Rheumatology.

Some experts see this development as a welcome opportunity to not just ameliorate current and projected workforce shortages, but to ultimately grow the specialty.

“We do not have enough rheumatology trainees to replace the numbers that are going to retire over the next 10 years,” Kenneth G. Saag, MD, professor of medicine in the division of clinical immunology and rheumatology at the University of Alabama, Birmingham, told Healio Rheumatology. “We are not cranking them out fast enough. We need to expand our workforce, and one way to do that is by using APPs.”

However, for others, there are concerns. Stepping into rheumatology practice can come with a steep learning curve, and for APPs — which include physician assistants (PAs) and nurse practitioners (NPs) — that can mean learning while on the job.

As such, education and training of PAs and NPs in rheumatology has evolved into a top priority, particularly in light of the continued workforce shortage.

“If I am looking to hire an APP to help with the workload in our practice, I have two questions,” Jeffrey Curtis, MD, MS, MPH, of the University of Alabama at Birmingham, said in an interview. “How much training have you had, and where did you get it?”

Even experienced APPs can find it difficult to step into a busy rheumatology practice, according to Christine Stamatos, DNP, ANP-C, director of the Fibromyalgia Long Covid Clinic in New York, and senior nurse practitioner in the division rheumatology at Northwell Health.

“The training and onboarding is a laborious and time-consuming process,” she said. “These challenges can be compounded because the practices that need an APP the most are often those that are already overwhelmed.”

Meanwhile, not all rheumatologists are willing to take the time and effort to adequately train an APP, according to Stamatos.

“They do not really know what an NP or PA can do for them,” she said. “Others do not provide enough training and throw the APP into a situation where they are overwhelmed by their patient load within a few months.”

In the latter situation, burnout or early departure from the practice is common. Many of these providers never return to rheumatology.

To help address these concerns, the American College of Rheumatology Workforce Committee is working to provide support and training materials for rheumatologists hoping bring APPs into their practice. Other players, like the Rheumatology Nurses Society (RNS) and Rheumatology Advanced Practice Providers (RhAPP), are involved, as well.

However, these organizations can only do so much. According to Saag, a former president of the ACR, individual rheumatologists must be willing to put in the work to prepare APPs for a career in the specialty.

“It is incumbent upon us as a field to figure out ways to train APPs,” he said. “Physicians really need to participate in mentoring, in clinic work, and in the apprenticeship of on-the-job training.”

However, even for those rheumatologists who are willing to train and practice with APPs, billing and reimbursement are ongoing issues. Similar financial issues face providers hoping to deploy APPs in telehealth paradigms in particular. Moreover, not all rheumatology patients are suitable for tele-rheumatology — with or without with an APP.

“Though there are financial challenges, these issues face any provider hoping to deploy telehealth paradigms,” Stamatos said. “There is a time and a place for telehealth. It is not for all patients or all situations.”

It is indisputable that APPs will play a larger role in rheumatology care going forward. It will take all players involved to determine and define what that role will be. This begins with accepting their place in the specialty.

‘The Writing is on the Wall’

The first step in acceptance is defining the term “APP” itself, according to Amanda Mixon, PA-C, a PA with UCHealth North, in Fort Collins, Colorado, and founder of RhAPP.

“This term encompasses a group of highly trained health care professionals who provide a range of care and treatment to patients,” she said.

In addition to NPs and PAs, advance practice providers include certified nurse anesthetists (CRNAs), anesthesiologist assistants (AAs) and certified nurse midwives (CNMs).

“RhAPP also includes PharmDs in this category, as we find tremendous benefits in working with them,” Mixon said. “Although nurses, infusion suite staff and support staff are critical to patient care they are generally not considered APPs and not a driving force in the increase you are seeing.”

Despite this breadth of practitioners, all with varying backgrounds and training, some rheumatologists are still not convinced that an APP can help their practice, according to Stamatos.

“Also, some rheumatologists are unwilling to give up control of their patients or practice,” she said.

However, for Saag, whether a provider wants an APP in their practice is almost beside the point. The stark reality of the field, right now, is that rheumatologists need help, and APPs are offering a much-needed hand.

“The writing is on the wall,” Saag said. “We have a need for more care in our specialty. We all have to get on board and do a better job of training a workforce of people who did not go into rheumatology fellowships. It is all of our responsibility.”

That said, even rheumatologists who accept this message have expressed concerns that the workforce shortage may lead to APPs treating patients without sufficient oversight.

“In the evolving landscape of rheumatology care, although it is accurate that a small percentage of APPs are treating rheumatology patients without direct oversight from a rheumatologist, it is important to contextualize this within the broader health care framework,” Mixon said.

The trend of APPs operating independently is predominantly driven by the acute need in underserved areas, including impoverished or rural locales, according to Mixon.

“The overarching benefit of this model is the critical access it provides to care for patients who might otherwise remain undiagnosed or untreated for their rheumatic conditions,” she said. “The capacity of independently practicing rheumatology APPs to improve patient outcomes and enhance the quality of life for countless individuals cannot be overstated. Their role in these settings is often the difference between suffering in silence and receiving necessary, life-altering treatment.”

Given that APPs are here to stay and can potentially provide “life-altering” care for patients, the next important question to consider is how best to train them.

‘Huge Amount of Training’

In a paper published in ACR Open Rheumatology, Lundon and colleagues assessed the workforce attributes of extended role practitioners (ERPs) in arthritis care in Canada. Results showed “differences in practice patterns” in arthritis care depending on the professional background of the ERP. Importantly, 95% of respondents reported that formal training is necessary to work as an ERP in a rheumatology practice, but only half perceived that they had sufficient training for their position.

“I have had the privilege of interacting and working with many APPs,” Curtis said. “I have seen some who have a lot of training and experience in rheumatology and others who have been trained in as little as 6 to 8 weeks or less. Consequently, some APPs understand the scope of our diseases — particularly if they’ve worked in an internal medicine-type setting — but others have little experience with managing chronic illnesses. The ACR and other groups have devoted substantial efforts to creating and maintaining a training curriculum that may be useful for APPs, but not everyone takes advantage of it or even knows about it.”

Ideally, APPs can and should function similarly as fellows, according to Saag.

“Our mentors dedicated their careers to training us,” he said. “We should be doing the same not just for our fellows, but for the other practitioners who are going to provide care for, and be co-managers of, our patients.”

One issue is that rheumatologists may be more familiar with how to train a fellow with an MD or DO than how to train a provider with an NP or PA.

“Physicians need mentoring on how to bring on an APP,” Stamatos said.

According to Carrie Beach, BSN, RN-BC, past president of the Rheumatology Nurses Society, patience is essential.

“Introducing a nurse or APP to rheumatology takes time, and often, on-the-job training is the most effective way to feel comfortable in the specialty,” she told Healio Rheumatology. “How long that takes is dependent on the nurse or APP and any relevant experience they may have.”

Although Beach noted that training and onboarding typically lasts 2 to 3 months before an APP begins working independently, the reality is that it can — and should — take longer.

“It probably takes 6 months to a year before anyone would feel comfortable and competent in a rheumatology nursing role,” she said.

It can also be problematic when providers put their APPs in charge of an endless run of stable osteoarthritis or fibromyalgia patients, according to Stamatos.

“The work gets tedious because they are not learning or operating at the top of their skill set,” she said. “They get disillusioned and do not want to stay in this situation.”

Conversely, some practices give their APPs too much responsibility before they are prepared.

“We have seen practices bring on a provider and, in less than 6 months, they are seeing upwards of 20 or more patients per day,” Stamatos said. “You just can’t do that to someone who has not had sufficient training. These APPs often end up quitting, as well.”

That said, the data do not lie. As the number of APPs expands in the rheumatology space, their roles are evolving and broadening, according to Mixon.

“While APPs new to rheumatology certainly should not be expected to care for the most complicated of patients, our growing numbers coincide with more experienced APPs staying in the field,” she said. “These APPs are taking on more complex responsibilities, driven by both the growing demand for rheumatologic care and the evolving health care landscape.”

As the responsibilities placed on APPs have increased, a call for standardizing training protocols has emerged.

‘There is Always Something New to Learn’

In an effort to standardize basic information for rheumatology providers, the ACR has created a curriculum for APPs in the field. According to Stamatos, the course helps new APPs in the field “know what to expect and when,” and includes evaluation tools for each stage of training. This curriculum is available free for all Association of Rheumatology Professional (ARP) members.

“The online Advanced Rheumatology Course (ARC) has 19 modules, including labs and how to approach different patients with different diseases,” she said. “It takes a few months to go through the entire course.”

In addition to improving the level of care, standardization could also provide a financial benefit for rheumatology providers whose APPs can demonstrate a certain level of competency.

“For example, certification might allow practices to command higher reimbursement for care delivered by APPs,” Curtis said. “We’ve seen that in other specialties that offer certification as Centers of Excellence.”

The ACR is not the only organization making efforts to recruit and train APPs. The Rheumatology Research Foundation offers a $25,000 training grant for rheumatologists to bring on an APP, according to Stamatos.

“There are certification requirements,” she said, noting that APPs who are part of this grant will be required to take the ARC, attend a certain number of in-person rheumatology events and cross thresholds of proficiency.

In-person events offer more than just education, according to Beach.

“They also offer the opportunity to build a network of peers that you can reach out to with questions, share experiences and offer support for the difficult situations that we grapple with in daily practice,” she said. “It is for this reason that the RNS offers chapters that can help engage nurses new to rheumatology and offer a network of support to help members with the challenges we face every day.”

The organization is also thinking beyond training, according to Beach.

“RNS recently met with members of Congress to advocate for support of the Train More Nurses Act, which would require the departments of Health and Human Services and Labor to jointly report on existing grant programs that support the nursing workforce,” she said. “The anticipated outcome of this report would be to change grant programs to increase nurse faculty, provide more pathways for experienced nurses to become faculty, and support pathways for LPNs to become RNs.”

Meanwhile, Mixon said that RhAPP members have requested shorter, more succinct bites of actionable information from which they can learn in between conferences.

“To that end, we have begun production on 2- to 3-minute videos,” she said. “These will fall into a few categories — FAQs, medication reviews, 3-minute journal clubs, or our podcast, RhAPPcast.”

Prospective APPs are encouraged to visit the ACR, RNS and RhAPP websites or social media platforms for further information. They may also find programs are in place to match APPs who might be a good fit for a rheumatology practice with rheumatologists who are willing to train them.

“We are helping physicians understand the type of training and clinical hours they need for PAs or NPs to reach a level of proficiency,” Stamatos said.

Another model is for rheumatologists to offer their practice as a place for APPs to acquire training hours, which could potentially offer advantages for both the practice and the APP.

“That way, the rheumatologist can pre-evaluate the APP to see if they will be a good fit for their practice,” Stamatos said.

Matching APPs with rheumatologists can also be a two-way street, according to Stamatos.

“If you are a PA or NP who has some interest in rheumatology, reach out and make yourself available to a practice,” she said.

Getting involved in organizations like the ACR, RRF, RNS and RhAPP can also open doors. However, the best advice for APPs seeking to join a rheumatology practice, according to Beach, is to practice patience.

“Be patient,” she said. “It is easy to become overwhelmed. It is a fast-paced specialty that is constantly evolving.”

Like Stamatos, Beach has seen RNs leave a rheumatology practice due to frustration and burnout.

“When I am training a nurse who is new to rheumatology, I tell them to stay with it for 6 months before deciding whether to continue in the field,” she said. “I remind them often that I have been in the practice for more than 20 years and there are still times that I have to ask a colleague for an answer. There is always something new to learn.”

The idea that there are always opportunities to expand one’s knowledge and experience often applies to APPs and rheumatologists alike, particularly when it comes to technologies like telemedicine.

‘A Convenience, If Not a Courtesy’

“If COVID taught us anything, it’s that telehealth is here, and it is not going anywhere,” Mixon said.

Like many in the field, Mixon both expressed a preference in seeing patients in person and acknowledged the critical role telemedicine is likely to play moving forward, particularly for underserved populations.

“More rheumatology providers are still needed to see those patients via telehealth,” she said. “Frankly, we need more people on the other end of that computer.”

APPs can be those people, according to Mixon.

“This approach not only facilitates virtual consultations for diagnosis, monitoring and management, but also enables APPs to deliver care efficiently, ensuring timely and appropriate treatment for patients regardless of their geographic location,” she said.

For Curtis, it is important to factor patient preferences into the equation. He argued that although the use of telemedicine has “definitely diminished” in rheumatology since the height of the pandemic, many patients may still want to use it.

“It is a convenience, if not a courtesy, to allow stable patients that can be safely and effectively managed remotely the opportunity to stay home rather than spend time and money traveling to the clinic,” Curtis said.

However, use of telemedicine has been uneven across the specialty, partly due to patients and providers alike having reservations about its utility in a hands-on field like rheumatology, according to Saag.

“The laying of hands, empathy and face-to-face interaction cannot be substituted by telehealth,” he said.

That said, Saag encouraged the rheumatology community to pay attention to data that attempt to evaluate and define the role telemedicine could play in the field.

In a paper published in ACR Open Rheumatology, Venuturupalli and colleagues systematically evaluated 33 articles on home-based telehealth in rheumatology. Results showed that triage appointments or predictive models were useful in selecting optimal candidates for telehealth interventions. In addition, follow-up of patients with systemic lupus erythematosus or inflammatory arthritis could be conducted using telehealth. Conversely, new patient visits and visits where a physical exam is required were not ideal settings for telemedicine. Although further data demonstrated that patients reported “high satisfaction” with telemedicine visits, more study is required to determine how best to continue that trend.

According to Stamatos, drug monitoring is one way that APPs could deliver telehealth. However, as with other facets of APP care, she stressed that clearly defining how these practitioners will actually practice is critical to improving patient care.

“We also need to develop ways and standards for APPs to conduct joint assessments using telehealth,” Stamatos said.

Saag stated he believes that, despite its limitations, telehealth will be an essential tool for rheumatologists moving forward.

“The thing we have to recognize is that some rheumatology care is likely better than no rheumatology care,” he said. “If you are using telehealth and APPs to deliver a reasonable level of quality in rheumatology care, in an area that previously had none, that is an improvement.”

However, one major limitation of telehealth, at least currently, has less to do with patient health, and more to do with a practice’s financial health, provider convenience or insurance/payer restrictions.

“Some payers will not pay for telehealth visits, or may impose unduly burdensome restrictions that create hardships for patients to use telehealth,” Curtis said. “But we need to make them understand that it makes sense and it can save money.”

Understanding this financial landscape can help practices save money and implement APPs in an effective way.

‘Nimble and Flexible’

“One of the problems that is emerging is that when a rheumatologist and an APP co-manage patients, the insurance company will not allow for billing at the rheumatologist level,” Saag said. “It will be billed the APP rate.”

Understandably, some rheumatologists are reticent to include APPs in patient care for this reason. Perhaps the best way to convince rheumatologists who are skeptical of implementing APPs is to demonstrate that there can be financial benefits to their presence, despite these billing concerns.

In a paper published in Cureus, Kidd and colleagues formed an oversight committee to evaluate APP care models. Outcomes were assessed by APP productivity year-over-year aggregate. According to the researchers, APP productivity yielded a 53% increase in work relative value units (wRVUs), an 84% increase in payments and a 79% increase from the previous year in charges. Regarding clinical outcomes, results showed a 45% increase in APP-completed visits in ambulatory care, 92% of which were return patient visits while 8% were new patient visits.

APP care demonstrated no adverse impact on patient satisfaction, physician-generated wRVUs or efforts to expand the program. Moreover, the majority of NPs and PAs who responded to the survey reported that they worked at the top of their practice most of the time or always.

“This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance,” Kidd and colleagues wrote.

However, even as more rheumatologists bring on APPs for these expected benefits, it is important to remember that rheumatology care — and, as such, the role of APPs — looks different depending on the geographic location and patient population, according to Mixon.

“It is important to recognize that the use of APPs in rheumatology is not a one-size-fits-all situation currently, and it will not be in the future either,” she said.

It is for this reason that Saag encouraged all players to be willing to adapt.

“We should develop training and onboarding programs that are nimble and flexible,” he said. “That way, we will be able to use this growing component of our workforce efficiently and effectively.”

• References:
• Kidd VD, et al. Cureus. 2023;doi:10.7759/cureus.34475.
• Lockwood MM, et al. Arthritis Care Res (Hoboken). 2022;doi:10.1002/acr.24569.
• Lundon K, et al. ACR Open Rheumatol. 2020; doi:10.1002/acr2.11129.
• Mannion ML, et al. Arth & Rheum. 2024; doi:10.1002/art.42833.
• Robinson S, et al. Musculoskeletal Care. 2017;doi: 10.1002/msc.1212.
• Venuturupalli S, et al. ACR Open Rheumatol. 2024;doi:10.1002/acr2.11660.

• For more information:
• Carrie Beach, BSN, RN-BC, can be reached at 1211 Dublin Rd., Columbus, OH 43215; email: carrieeburke@hotmail.com.
• Jeffrey Curtis, MD, MS, MPH, can be reached at 1720 2nd Ave. South, Birmingham, AL 35294; email: jrcurtis@uabmc.edu.
• Amanda Mixon, PA-C, can be reached at 2121 E. Harmony Rd., Suite 230, Fort Collins, CO 80528; email: aozanich@gmail.com.
• Kenneth G. Saag, MD, can be reached at 1720 2nd Ave. South, Birmingham, AL 35294; email: ksaag@uabmc.edu; nmledwon@uabmc.edu.
• Christine Stamatos, DNP, ANP-C, can be reached at 734 Park Ave., Huntington, NY 11743; email: castamatos@gmail.com.