Mid-Level Providers Proficient in Rheumatology Practice

VBCR - April 2014, Volume 3, No 2 - The Rheumatology Nurse
Rosemary Frei, MSc

Many nurse practitioners (NPs) and physician assistants (PAs) working in rheumatology clinics appear ready and willing to diagnose and treat rheumatoid arthritis (RA), according to a recently published survey (Solomon DH, et al. Arthritis Care Res [Hoboken]. 2013 Dec 10. Epub ahead of print). The results may pinpoint a key to preventing the projected shortfall in rheumatologists in the near future, the researchers suggest.

“We’re not going to be able to train enough rheumatologists to fill that gap easily—and having mid-level providers like NPs and PAs getting rheumatology training in greater numbers is an obvious potential solution,” lead investigator Daniel H. Solomon, MD, PhD, and Chief of the Section of Clinical Sciences in Rheumatology, Brigham and Women’s Hospital, Boston, told Value-Based Care in Rheumatology. “They’re not a substitute but are an extender for doctors—our study confirmed they can manage a lot of clinical issues quite well.”

Dr Solomon and colleagues conducted the survey in anticipation of the predicted shortages in the rheumatologist workforce. In December 2013, investigators observed there is already a dearth of rheumatologists in many smaller regions of the country (American College of Rheumatology Committee on Rheumatology Training and Workforce Issues, et al. Arthritis Rheum. 2013;65:3017-3025). In addition, a recent proposal in the Affordable Care Act suggests more active roles for mid-level providers in team-based care (Iglehart JK. N Engl J Med. 2013;368:1935-1941). The last survey of mid-level rheumatology providers was published 6 years ago (Hooker RS, Rangan BV. J Clin Rheumatol. 2008;14:202-205).

The investigators created a survey and worked with the Association of Rheumatology Health Professionals and the Society of Physician Assistants in Rheumatology to disseminate it electronically and by mail to mid-level providers working in rheumatology across the United States in 2012. The survey included 51 questions and took approximately 10 minutes to complete. Respondents received an incentive to participate.

There was a 30% response rate; 174 NPs and PAs submitting completed questionnaires of 572 who received the survey. Overall, 82 NPs and 89 PAs responded to the survey (for a total of 171; 4 participants did not identify themselves as an NP or a PA and 1 identified herself as both). Approximately the same percentage practiced fewer than or more than 10 years as a mid-level provider, while 72.8% worked in rheumatology for no more than 10 years. The average age of the respondents was 46 years and 84.2% were women.

The respondents had a range of rheumatology training and duration of training. Overall, 69.5% of NPs and 58.4% of PAs said they had their own panel of patients. More than 75% reported being very confident in diagnosing patients with RA and 21.3% said they were somewhat confident. Similarly, 74.7% said they use RA disease measures such as the Disease Activity Score or the patient global arthritis activity index.

Each NP and PA managed an average of 147 and 151 patients, respectively. Approximately half (47.6%) of the respondents said a rheumatologist assisted in patient visits when needed, while 38.6% said a rheumatologist rarely involved in patient visits. Very few respondents indicated that a rheumatologist was always or never involved in patient visits (5.4% and 8.4%, respectively). Mid-level providers’ level of independence was not statistically significantly related to their age, sex, certification as an NP or PA, number of years in rheumatology practice, or amount of rheumatology training.

Almost all of the mid-level providers said they prescribed both nonbiologic and biologic disease-modifying antirheumatic drugs. The majority perform the entire spectrum of rheumatology-related activities, including intake assessments, physical exams, interpreting bone density test results, giving intra-articular steroid injections, starting and adjusting medications, and patient education. Seventy-eight percent reported being familiar with treat-to-target strategies and 75.4% reported that the clinic they worked in used such strategies.

Significant proportions of respondents reported managing infusion clinics (30.5%, NPs; 14.6%, PAs) and being involved in research (39.0% and 39.3%, respectively).

“In addition to leading this survey I’ve also talked to many rheumatologists, and some say they would welcome mid-level providers and others say they wouldn’t,” noted Dr Solomon. “The trade-off is the volume of patients that can be seen—if the rheumatologist has no one to help with lower complexity visits it’s a less efficient use of his or her time.”

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