The number of patients requiring nephrology subspecialty care has grown tremendously. Unfortunately, while fellowship applicants have increased nearly 10% since 2019, nephrology has only had an increase of about 3% (1). This gap between workload and workforce has led to an increase in the use of non-physician practitioners (NPPs), the Centers for Medicare & Medicaid Services’ term that includes nurse practitioners (NPs) and physician assistants (PAs). Within our specialty, however, there has not been adequate discussion regarding proper utilization of NPPs.
While physicians understand their own personal background, they may not understand the wide range of experiences of NPPs.
When discussing the roles of members of the health care team, it is paramount to understand the background and training required for each member's certification (2). While physicians understand their own personal background, they may not understand the wide range of experiences of NPPs. This article will propose some general tenets of practice that will maximize NPP use while ensuring excellent subspecialty care (Figure 1).
In the inpatient environment, NPPs should, under direct supervision, be able to competently see most end stage kidney disease (ESKD) patients. The physician should, at initial consult, assess patients for volume and electrolyte status to ensure the NPP places appropriate dialysis orders. In addition, NPPs should be able to perform an initial chart review and examine consults for non-ESKD patients with the nephrologist personally examining every patient and directing the workup and management of their condition. Additionally, NPPs can help coordinate care including vascular access and communicating recommendations to hospitalists. Because of the complexity of intensive care unit (ICU) patients, NPPs should not be used to see consults there. In all cases, NPPs and physicians should maintain a frequent dialogue about any changes in the clinical status of patients.
In the outpatient clinic, NPPs can assist with administrative and workflow tasks. They should not independently see new consults as they are not trained to evaluate new consults independently. Non-nephrologists refer their patients for specialty advice, and it is imperative that nephrologists use our expertise to provide expert-level diagnoses and detailed management recommendations. NPPs can see stable patients in follow-up with defined guidelines for physician re-evaluation. This may include medication changes, a change in clinical status, every other visit, or patient request. Additionally, NPPs should be encouraged to discuss patients at regular intervals with the nephrologist.
In the dialysis clinic, it is optimal for the physician to see every patient monthly, if not more. An NPP can effectively see dialysis patients two to three times a month to complete short visits. NPPs should be given specific guidelines on when to report issues they are encountering and for referring patients for physician re-evaluation as needed.
NPPs can be incorporated into team-based practice in all areas of nephrology (Table 1). By developing specific guidelines for clinical practice and encouraging open and frequent communication, physicians and NPPs create strong care teams that improve access to subspecialty care.
Specific NPP role suggestions
Halinski C. Nurse practitioners in nephrology: Understanding the educational and career pathway to specialty practice. Kidney News, September 2022; 14(9): 24–25.