Journal Briefs: Urology Practice: Advanced Practice Provider-Led Active Surveillance Clinic for Men with Prostate Cancer
By: Behfar Ehdaie, MD, MPH; Xin Lin, MSN, AGNP-BC; Natalie Wolchasty, MSN, AGACNP-BC | Posted on: 03 Sep 2021
Clements MB, Lin X, Gmelich C et al: Assessing quality and safety of an advanced practice provider-led active surveillance clinic for men with prostate cancer. Urol Pract 2021; 8: 535.
With the workforce of urologists projected to decrease over the next 20 years, the addition of advanced practice providers (APPs), including nurse practitioners and physician assistants, is vital to meet urological care needs.1 As of 2019, 93% of academic urologists and 63% of private practice urologists were estimated to work alongside APPs.2 The majority of APPs practice within ambulatory urology clinic settings, but there has been a large increase in their performance of office procedures; based on Medicare claims, APPs perform up to 0.57% of all transrectal ultrasound (TRUS)-guided biopsies.3,4 Recognizing that APPs can acquire the skill set to manage urology patients and perform prostate biopsies, implementation of APP-led active surveillance (AS) clinics is a key priority for private practice groups and academic centers. However, it is important to establish that APP-led AS care meets appropriate quality standards in clinical practice.
In 2016, we established an AS clinic managed by APPs to extend our ability to deliver quality care to an increasing population of patients meeting AS criteria. After an initial comprehensive evaluation by the attending physician, patients with Grade Group 1 or 2 disease and no other high-risk features are offered enrollment into the APP AS program. They then follow an institutional AS protocol, which includes prostate specific antigen (PSA) testing and digital rectal examination (DRE) every 6 months, multiparametric magnetic resonance imaging (MRI) of the prostate every 18 months and a prostate biopsy every 3 years.5 Changes in PSA or prostate MRI findings can prompt biopsy earlier than scheduled within the protocol.
Our APPs undergo a structured training program taught by the leader of the program (BE). In addition to precepting clinical visits, learning to implement the institutional AS protocol and instruction on communication skills to discuss disease risk, procedural training is also required. A minimum of 10 supervised template TRUS-guided biopsies must be satisfactorily performed before the APP concludes his or her training. To acquire the skills to perform independent MRI-targeted prostate biopsies, additional direct supervision is needed, and this specific training is typically accomplished within 6 months. Once APP training is completed, APPs provide independent care for their patients, including standard systematic and MRI-targeted prostate biopsies. Cases are reviewed as needed with the physician supervising the program (BE).
In order to evaluate the quality standards of an APP-led clinic, we sought to compare adherence to scheduled appointments and rate of prostate biopsy complications between APPs and urologists.6 We hypothesized that if patients were uncomfortable with an APP visit or dissatisfied with their prior visit, they were less likely to adhere to appointments scheduled with an APP. Furthermore, we evaluated the safety of prostate biopsy by evaluating prostate biopsy complications. Our second aim was to determine whether biopsy complications while on AS differed based on the type of provider performing the biopsy (APP or urologist). We defined complications associated with prostate biopsy as any infectious complication (including any visit to the urgent care center or admission to the hospital that had an associated urine culture taken), bleeding or urinary retention within 30 days of biopsy.
Our first analysis included 10,350 visits from 2,341 patients; of these visits, 8,537 were with an attending urologist and 1,813 were with an APP. There was a total of 721 canceled or no-show visits, 159 (8.8%) with an APP and 562 (6.6%) with an attending urologist. While these results were statistically significant, the effect was small; for every 41 patients seen by an APP rather than an attending urologist, 1 patient would cancel as a result. Our second analysis assessed biopsy complications, comprising 1,578 biopsies performed in 1,333 patients. Among those biopsies, there were 29 complications: 23 infections, 3 urinary retention complications and 3 bleeding complications. Only 1 patient treated by an APP had a complication.
As health care delivery evolves, there is increasing emphasis on a shared delivery model that efficiently uses all members of the health care team. Within urology, this includes integrating APPs into AS management, an important urological care need. While there was a small but statistically significant increase in no-show appointments for APP visits, this was estimated to be a difference of only approximately 1 patient every 2 clinic days. We found no evidence of increased complication rates in prostate biopsies performed by APPs. These data are especially important, given the substantial increase in APPs performing prostate biopsies in the last decade.3 We have demonstrated acceptable real-world performance in 2 important areas to support adoption of APPs managing active surveillance.
- McKibben MJ, Kirby EW, Langston J et al: Projecting the urology workforce over the next 20 years. Urology 2016; 98: 21.
- The State of the Urology Workforce and Practice in the United States 2019. Linthicum, Maryland: American Urological Association 2020.
- Langston JP, Duszak R Jr, Orcutt VL et al: The expanding role of advanced practice providers in urologic procedural care. Urology 2017; 106: 70.
- Langston JP, Orcutt VL, Smith AB et al: Advanced practice providers in U.S. urology: a national survey of demographics and clinical roles. Urol Pract 2017; 4: 418.
- Carlsson S, Benfante N, Alvim R et al: Long-term outcomes of active surveillance for prostate cancer: the Memorial Sloan Kettering Cancer Center experience. J Urol 2020; 203: 1122.
- Clements MB, Lin X, Gmelich C et al: Assessing quality and safety of an advanced practice provider-led active surveillance clinic for men with prostate cancer. Urol Pract 2021; 8: 535.