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    Duties performed by nephrology Advanced Practitioners at different sites of practice

Nephrology Advanced Practitioners: National Kidney Foundation Survey Data

  • 1 Jane Davis, DNP, is with the Division of Nephrology, University of Alabama at Birmingham. Kim Zuber, MSPS, PAC, is Executive Director of the American Academy of Nephrology PAs, St. Petersburg, FL.
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In 1965, on opposite sides of the country, two revolutions in health care took place. In North Carolina, corpsmen returning from the Vietnam conflict put their skills and training to use in the newly formed profession: physician assistant (PA) (1, 2). In Colorado, registered nurses received postgraduate education, enabling them to provide health care in rural communities as nurse practitioners (NPs) (3). Both professions were formed to fill the need created simultaneously by a physician shortage and the increased numbers of patients eligible for health care under Medicare legislation (4). In 2021,

In 1965, on opposite sides of the country, two revolutions in health care took place. In North Carolina, corpsmen returning from the Vietnam conflict put their skills and training to use in the newly formed profession: physician assistant (PA) (1, 2). In Colorado, registered nurses received postgraduate education, enabling them to provide health care in rural communities as nurse practitioners (NPs) (3). Both professions were formed to fill the need created simultaneously by a physician shortage and the increased numbers of patients eligible for health care under Medicare legislation (4). In 2021, there were approximately 325,000 licensed NPs in the United States and 150,000 certified PAs (5, 6). Nephrology PAs/NPs, often referred to as advanced practitioners (APs), represent a small percentage of practicing PAs/NPs. Determining the exact number of nephrology APs is difficult because there is no federal designation; however, nephrology APs are estimated to represent less than 1% of either PAs or NPs.

With the shortage of nephrology fellowship applicants, practices have used APs for years, but a large influx of APs occurred in 2004 when the Centers for Medicare & Medicaid Services billing rules for hemodialysis were implemented (7). As PAs/NPs moved into nephrology, the National Kidney Foundation developed a biannual online survey of the roles, compensation, trends in job description, payment models, and benefits for the workforce. The survey is published biannually in Nephrology News & Issues with the decade of data co-published in the Journal of the American Association of Nurse Practitioners, the Journal of the American Academy of Physician Assistants, and CJASN (811).

Survey findings

Sites of practice for APs have been and are predominantly dialysis units and the office or clinic (Figure 1). However, hospital coverage and high-acuity patient management have increased over the last dozen years.

Figure 1
Figure 1

Duties performed by nephrology Advanced Practitioners at different sites of practice

Citation: Kidney News 14, 9

In the dialysis unit, weekly rounds are the most common duty of the AP, but in 2020, the monthly capitated payment (or monthly) visit was more frequently completed by the AP (Figure 1). It is possible that this change may have been a result of the influx of COVID-19-related acute kidney injury consultations and the need for nephrologists to be in the hospital setting. This is also seen in the increase in “taking call” for the hemodialysis units as the nephologist was less available to the outpatient sites. Although many nephrologists consider themselves primary care providers, there has been a decrease in management of this aspect over the last decade.

Use of APs in hospitals has increased over the last dozen years, with hospital rounds and consults being managed by nephrology APs (Figure 1). Often, this allows the nephrologist to manage the less stable intensive care unit-level patient while still accommodating for inpatients or referring providers.

The statistical analysis of the job descriptions within the office or clinic has been stable over the last dozen years (Figure 1), but many qualitative statements from the survey participants noted changes from 2020 to 2022. Many offices were closed, including referral offices; staff were working from home; and patients were monitored with telehealth. Often, the AP reported being the only person in the office and thus handled many secretarial and nursing chores, such as obtaining prior authorizations for medications, refilling primary care medications, and paperwork for disability or long-term care.

During the COVID-19 pandemic, the number of rounds for inpatient peritoneal dialysis (PD) patients also increased (Figure 1), whereas monthly PD clinic rounds decreased. However, fewer than 40% of all nephrology APs see any PD patients, corresponding to a lack of PD patients managed by all nephrology groups.

Pay and benefits for the nephrology AP have increased as the complexity of the job has increased. The average annual income for the nephrology AP was $84,000 in 2010, increasing, on average, 5% with each survey cycle. This year, the average salary is $119,000. Because of the survey's design and the loss of statistical significance, annual salary cannot be broken down further by state, gender, or years in practice. Benefits for the nephrology AP mirror those of the nephrologist, such as malpractice insurance, 401/403 retirement plans, continuing medical education, paid time off (an average of 4 weeks each year), licensing, and professional dues.

The patient pool is increasing, whereas the physician provider pool is not keeping up.

The patient pool is increasing, whereas the physician provider pool is not keeping up. To provide quality, timely care to this fragile population, APs stand with their physician colleagues to treat, educate, and support patients with kidney diseases. APs have a unique set of qualifications that make them ideally suited for nephrology.

References

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