Daniel Geersen, MPAP, PA-C From Foams to Filters 2010

Daniel Geersen, MPAP, PA-C From Foams to Filters 2010

Topics 1. Nurse Practitioners / Physician Assistants 1. Demographics 2. Professional governance and regulations 3. Education 2. History of the Mid-level provider 3. Supportive evidence and research 4. Use of the physician extender at Duke 5. The PA/MD relationship; a personal perspective

NPs and PAs

The PA and NP Professions Physician Assistant In 2009 72,433 PAs eligible to practice, with a new graduation rate of 5,800 annually 154 Programs 50% practice in Primary Care More likely to work in surgery Fully Physician Dependant Nurse Practitioner As of 2010, there are 140,000 practicing NPs and 8,000 graduate each year 325 programs 85% practice in Primary Care More Likely to work in pediatrics and women s health Depending on State regulations may be solo practitioner or incorporate with a physician practice www.aapa.com, www.aanp.org, Hooker RS. MJA 2006; 185 (1): 4-7

Demographics Physician Assistant Mean age: 41 years 60% Women Work Full Time: 90% >32 Hrs Median Salary: $87,828 Degree Level: Most currently hold a Bachelors, with most programs awarding Masters today Nurse Practitioners Mean age: 46 years 90% Women Work Full Time: 50% >32Hrs. Median Salary: $87,831 Degree Level: Most hold a Masters, with a new shift toward a Doctorate by 2015 to all new graduates AAPA Census 2009, Salary.com, Hooker RS., MJA 2006; 185 (1): 4-7

PA/NP Regulations Must graduate from a nationally accredited program Pass a national certification medical board examination administered by their administrative body Obtain State License to Practice Apply for own DEA License Submit for National Provider Identification number Hospital Privileges are granted after similar review as MDs Responsibilities must conform with individual state regulations and institutional policy North Carolina Medical Board

NP and PA Education NPs: Must complete a 2 year RN program and have practiced for at least one year before applying to a NP program. The NP programs are 2-3 years full or part time. A masters or doctoral degree is then awarded in the perspective field or focused specialty. PAs: Must have a BA or be admitted to a BS program. Prerequisites similar to premed are required. GRE or MCAT score must be competitive for Masters programs. Programs are 2-3 years full time. Upon completion the PA can practice in any field their supervising MD has privileges. Post-graduate/Residency programs are growing for both fields. Surgery OB/GYN Pediatrics Orthopedics Geriatrics Anesthesiology Oncology

Regulatory Bodies NPs are often regulated by the Board of Nursing. There is current debate whether the Medical Board or Nursing should regulate the practitioners since in the majority of states they can practice as independent practitioners. PAs are regulated through the perspective state Medical Boards.

History of the Mid-Level Provider First PA Class of Duke 4 to 1 Student Teacher Ratio

History of the Mid-Level Provider 1942: Dr. Stead is forced to develop a 3 year medical curriculum for WW II, and run Emory University and Grady hospitals with residents and medicine students at the time. 1959: US Surgeon General announces a shortage of medical practitioners. 1961: Dr. Hudson in the Journal of the American Medical Association suggests a corpsman can be trained for a midlevel provider position. 1964: Dr. Stead moves forward with a 2 year experimental program using former military corpsmen. 1965: Dr. Silver and Loretta Ford establish the pediatric nurse practitioner program at the University of Colorado. 1967:First Master s Program for NPs is established at Boston College. http://www.pahx.org/timeline.html http://www.worldofnursepractitioners.com/nurse-practitioner-history.html DUMC Archives

History of the Mid-Level Provider 1970: AMA recognizes PAs 1971: Comprehensive Health Manpower Training Act (PL92-157) contracts PA education 1973: More than 65 NP programs are in practice. 1974: American Nurses Association develops the Council of Primary Care NPs 1977: Rural Health Clinic Services Act (PL95-210) provides Medicare reimbursement of PA and NP services in rural clinics.

Evidence and Research

PA and NP Utilization Impact on rural or solo practices demonstrate increase in productivity. Increase numbers of patients seen Improve the workload for the MD Increase revenues (Hooker RS, Phys Assist 2000; 24: 51-71)

The Economics Comparison productivity of PAs and NPs to MD counterpart demonstrate they saw 10% more patients in the ambulatory setting annually. Secondary to the MDs hospital responsibilities and other roles institutionally. Patients seen per hour were the same for all three providers. Hooker RS. Assoc. of Acad. Health, 1993: 51-68

Cost Effectiveness PAs and NPs have lower salaries, and see a comparable number of patients. Compensation-to-production ratios examined of group medical practices found 0.38 for PAs, 0.41 for NPs, 0.49 for family physicians. MGMA, 2006 report. Hooker, RS. MJA 2006; 185 (1):4-7

Looking at Procedural Practices Society of Interventional Radiology supports utilization of PAs. Proven quality cost effective care Enhances patient satisfaction Increase productivity Ability to perform numerous procedures Allow MDs to concentrate on major complex cases Are first contact consultants (Rosenberg SM. Et. Al. J Vasc Radiol 2008; 19:1685-1689)

How We do it at Duke

Team Approach Three MD two PA practice. Patients are seen in conjunction with the MD, or individually We are reliant upon each other PAs see: New consults Returns Scheduled or emergent visits PAs do not perform EVLA or RFA, but do perform sclerotherapy On average see 15 to 20 patients per clinical day for each practitioner, when seeing patients in a joint clinic ~40 patients scheduled. ½ new, ½ returns and sclerotherapys Take care of the patient.

Patients by Diagnosis Venous insufficiency Perform venous sclerotherapy Pelvic congestion syndrome Arterial venous malformations Arterial disease Wound care, venous ulcerations Thoracic outlet IVC stenosis or occlusions DVT Superficial venous thrombosis Consult for IVC filter Consult anticoagulation

Administrative PAs are responsible for and participate in: Patient phone calls FMLA papers Prescription refills Letters of Medical necessity Clinical Research Teaching Preceptors Post-graduate Training

Patient Encounters The Venous practice is ideal for the MD/PA or NP partnership. All patients are seen by the supervising MD. 3 month follow-ups have an opportunity to be scheduled with the MD or PA/NP provider depending upon who was seen for initial consultation. Either provider can order the labs or studies necessary for diagnosis and treatment planning prior to return follow-up. Once surgical planning has been scheduled the MD will perform EVLA, RFA or sclerotherapy ablation. Either provider will see the patient in follow-up and perform post operative sclerotherapy where appropriate.

Orientation Assume you need 2-3 months to orient the new practitioner to the venous practice. Shadow Solo encounters with presentations Introduce complex cases and discuss areas of potential complications Create a dictation template/ discuss venous disease documentation After that period start joint or separate clinics Attempt to maximize efficiency of the two providers PA see all returns?, New consults?, Pre-op patients discussing the risks and benefits of procedures?

Procedures It is reliant upon the supervising physician that the PA is capable of performing the procedures within their scope of practice effectively and safely. See one, do one, teach one. Discuss each sclerosing agent, the risks and benefits of each, and concentrations that should be used in a particular patient. PAs in our practice were taught like residents and fellows. Once competency is reached, individual decision making can be made, and procedures are performed individually.

Quality Assurance Whether new or practiced the PA or NP should have monitoring of their outcomes and complications. Using a program like HI-IQ or documentation in the chart needs to be maintained. Many institutions require a performance review prior to renewal of privileges. NCMB requires once a month documented meetings between the supervising MD and the PA in the first 6 months and biannually after that. Supervising physicians must be either directly available on site or by phone.

Potential Conflicts Patient requests to see only the MD. Often the patient just wants to know the MD is available and can see them any time. This should not discourage the PA or NP from seeing the patient and can often work to develop a strong relationship. The MD is suddenly unavailable to cover clinic. Staff can call the patients and notify them that the PA/NP is available to see them and they can keep their appointment.

Added Perspective The PA and NP come from different backgrounds as the MD. Primary Care Nursing Surgery Post-graduate training When seeing a complicated patient or handling an obstacle they can provide perspective to the team and decision making. They are an extension of you. You have the full fund of knowledge and resources of that provider at your disposal. Reminder: PA/NPs must take board exams to retain their license and certification. These are primary and internal medicine based. They may have a position in a sub-specialty but are responsible for continuing to maintain a fund of knowledge of a generalist.

MD/PA Partnership

Partnership Philosophy The PA profession is born of the team approach to practice. As a PA you are a coordinator for quality care and a strong patient advocate while supporting the supervising physician. Physicians and PAs are trained in the same medical model and there is continuous communication between the partners. This strengthens the PAs practice through reviews and beneficial adjustment Builds a strong foundation of trust, necessary to the team approach and critical for quality care

The Clinical Practice The relationship supports efficient care. As a PA you are moving patients forward through the treatment plan, maximizing the time of the Physician. While the supervising physician is performing procedures you are seeing follow-ups, consults, and discussing operative planning with patients so they can get the necessary treatment. This is capable by the trust each places on the other, which was built through strong communication. The PA above anyone else; understands the practice, and is familiar with the supervising physician s desires and how to get things done.

I am driving the speed boat with the pedal to the floor, while my PA is standing over the engine poring in another gallon of gas. An anonymous attending s description of their MD/PA partnership.

Personal Daily Objectives Provide competent care for each patient with reliable service. Minimize surprises to my supervising physician whenever possible. I am always available to see a patient. Seek advice when in doubt. Never, practice out of bounds of your scope of practice.

How to hire a PA or NP Contact the local PA or NP program Look on line to list a job on the AANP or AAPA web addresses Best way, preceptor students >1/3 of all PAs met their first employer through clinical rotations while is school

Reminder to PAs and NPs We are the direct representative of our supervising physicians. It is our responsibility to provide excellent customer service and provide increased access to care. Never betray the trust that has been placed in you.