Diane Newman: Welcome. I'm Diane Newman. I'm a urology nurse practitioner and a continence and pelvic floor specialist at the University of Pennsylvania. I'm also Editor of UroToday's Bladder Health Center of Excellence. What I want to share with you is the Future of Urology: Nurse Practitioners and Physician's Assistants.

Let's first start with the nurse practitioner. A nurse practitioner's considered an advanced practice provider. She's a registered nurse with a bachelor of science in nursing. Has to have a graduate degree, master's program, and many of them will have a doctorate nursing practice, which is what I have and that means additional training at the doctoral level. All of us nurse practitioners have a national certification examination that we must pass to ensure competencies and then training, which is usually the primary care level where we take courses in practicum, in diagnosis and management of common and complex medical conditions. All nurse practitioners are subject to the specific regulation of their state board of nursing as an independent practitioner.

Now, a physician assistant is also considered an advanced practice provider, but their degree varies. A minimum maybe of two years of college courses. They have to have that as a minimum in the basic sciences or behavioral sciences. They must have graduated from a physician assistant program and they are nationally certified in the state license to work under the supervision of a physician. Their training is based on the medical model as the nurse practitioner's training is based on the nursing model.

Practices that employ nurse practitioners and PAs report higher weekly visit rates, improved efficiency, patient care, and professional satisfaction. And this is a picture of my physician collaborator, Dr. Alan Wein, and this was taken several years ago and surrounding him are nurse practitioners and physician assistants in Penn Urology at the University of Pennsylvania. Now a nurse practitioner was rated number seven of the top 100 best jobs by US News and World Report in 2019 and the Bureau of Labor Statistics predicts that there will be 5,100 new positions for nurse practitioners by the year 2026. By 2030, they're expected to be 397,000 full-time equivalents of nurse practitioners. Now the number of NPs, and this slide is good because it shows you a lot of growth from 1999 to 2019, you can see that every year we've grown quite significantly and those numbers will continue to grow.

This picture of the US is color-coded to show you where we have nurses who are nurse practitioners who do not need to have a collaborating physician. All the solid blue States are where the State Board of Nursing has passed within at the state level regulations that the nurse practitioner can practice independently. That means she does not need to have a collaborating physician and you can see that most of these states are in the West where you have a lot of rural areas and where there's a lack of physicians. The shaded blue areas are where they have, not 100% independent practice, but the orange-red states, you can see where we have not yet passed that and one of them is in Pennsylvania, which I practice and right now, all these states are undergoing some changes as far as the independence of our practice and what is said at the government level, the federal level is that NPs should be able to practice to the full authority of their certification, which means without necessarily a collaborating physician.

And now with COVID-19 with this virus occurring now, because I'm recording this in April of 2020, I think that you're going to see those laws quickly go across all the country because we need more nurse practitioners to be practicing. We need more healthcare providers and one of those healthcare providers is an advanced practice providers, such as a nurse practitioner. Now as far as physician assistants, a PA was rated number three of the top 100 best jobs by the US news and world report in 2019. And the PA is also growing. Those numbers are growing in the US and the Bureau of Labor Statistics predicts 39,600 new positions for PAs by 2026 and by 2030 they're expected to be 184,000 full-time equivalence of the PAs in the United States. So you also see them growing.

This was actually an article that was just published in the Journal Health Affairs, which looked at the historical and projected numbers, physicians, nurse practitioners, and physicians assistants. And around the red box, I want to show you those projections. And as you can see, the growth of nurse practitioners, physician assistants by 2030 will be growing at a greater rate than the growth of physicians. And those numbers really have continued for the past 10 years. That the growth of advanced practice providers, which is NPs and PAs, has been consistently growing. So these will be more of what you're going to find in primary care practices. But what I want to share with you today is really what is the growth in the urology workforce.

The American Urological Association has come out with two documents. The bottom document is the consensus statement on advanced practice providers which was done several years ago. In 2018, they came out with a State of the Urology Workforce and Practice in the United States, and what you're going to see is that they're going to be more urologist retiring, which is opening up the field to advanced practice providers, nurse practitioners and PA's. Now, this is currently the classification of advanced practice providers by the American Urological Association. Nurse practitioners and physician's assistants are considered advanced practice providers, and what that means really is that we have our own licensure and can practice independently if you're a nurse practitioner, but also we have those advanced degrees. They've defined the allied health professional as a registered nurse, a licensed practical nurse, medical assistants, and technicians. So that's where you see the AUA dividing up these groups of professionals. I will stress to you though that the Society of Urologic Nurses and Associates is really the lead educator of that nurse practitioner. Whereas physician assistants also have an association of PA's and they have a section in urology.

Now to give you some statistics, by 2030 the percentage of the US population will be over the age of 65 and actually 20.3% of individuals in the US will be over that age. And as we know, urologic diseases increase with the aging population, we're seeing more BPH, more urinary incontinence, individuals with bladder, kidney, and prostate cancer are living longer into that sixth, seventh and eighth decade. So the implications for the intersection of urology and geriatrics is even greater and will only grow in the future.

So urologists as a group, a subspeciality is older than other surgical specialists, they age and retire at a rate that outpaces the number of urology residents completing training and achieving board certification. Currently, there are 3.9 urologists per 100,000 populations and you're seeing many more urologists retiring in that rural area of the United States, down in rural counties, of which we have many in Pennsylvania. You're seeing less and less urologist to care for that population, which is aging. And when you look at statistics from the American Urological Association surveys, 62.7% of urologist practice was with at least one advanced practice provider.

This graph was in the Journal of Urology and shows that aging workforce of urologists. Nearly 50% of urologists are over the age of 55 and as you can see on this graph is only increasing and it's going to be increasing in the future. When you look at those urologists plus an advanced care provider, you see the need is the blue, but you see the forecast and this is going into 2035. There's a 12% shortage of the need of urologists plus the advanced practice provider or what they call the advanced care provider in this survey. So basically the supply versus demand and the supply is much less than what the demand is going to be. And this is a concern in urology. We're going to need more and more urologists, but that is probably not going to be the case. What you're going to see is that growth of the advanced practice provider, that nurse practitioner or physician assistant will grow in these urology practices.

Now, this was a survey that came in 2017 and basically it was done by the American Urological Association of those advanced practice providers who were members of the AUA. Now, not all nurse practitioners and PAs who practice in urology practices in the United States are members of the AUA. So that's an important point to note. So this was a survey of 1,347 members who were advanced practice providers and members of the AUA, and there was a sponsor response rate of 296 responded. And as you can see, this shows where are they practice, where is their practice focus? And the bulk of these providers are in general urology. And I think that's important to note that they're really seeing probably what we call benign urology, BPH, maybe possibly urinary incontinence, men and women. And that's really the largest group who is and that's the largest group as far as what their practice focus is.

When you looked at the survey as far as when they asked about those who are performing high complexity procedures, you can see that these nurse practitioners and PAs in urology are expanding their role and the green is cystoscopy with stent removal. That has been an increase and again, you can see that increasing with the years. Cystoscopy is actually the red one and that's actually highest and they are also performing transrectal biopsy and this is especially the case within the VA system, urology practice in the VA system. So nurse practitioners and PA's are performing much more complex procedures. When you look at urgent interventions as far as drainages, penile injections, you can see that again, complicated Foley catheter placement. This is also increasing. So these urgent interventions that they may need with someone with acute retention who needs an indwelling catheter placed. The APP is the one who's really performing those. And this survey also looked at voiding dysfunction procedures, urodynamics, posterior tibial nerve stimulation, InterStim™ programming and pelvic floor with biofeedback and again these are also increasing.

So what these last three slides showed you is that the practice provider, that nurse practitioner PA's expanding their role within urology, and this is probably the result of we're seeing increase NPs and PAs being hired to practice in urology specialty. But also there are less urologists practicing because there's more and more retiring, hitting that retirement age. And with the aging population, we're going to see a huge increase need for that urology specialists.

These next few slides I want to show you were actually a survey done by UroToday and this was done fairly recently in March of 2018 at the Society of Urologic Nurses and Associates, the SUNA Advanced Practice Conference, which was in March actually in Philadelphia in 2018. So these were advanced practice providers, mostly nurse practitioners, but also physician assistants. This survey, and you'll see the number on each one of these slides, looked at some basic trying to get demographic data from these attendees and you can see that most of them were women and probably this conference attracted mostly nurse practitioners. And when you look at the breakdown of gender between PAs and NPs within urology practice, is you tend to see more women who are nurse practitioners. Physician assistants, as part of the training, get six months of OR experience. That's not part of the NP educational system and that's why you see a lot of urologists hiring physician assistants to be assistants in the OR for robotic surgery, maybe in the cysto suite, that type of thing. But you tend to see more women who are NPs. When you look at their ages, that is this pie chart down the bottom. As you can see, the largest group is actually near retirement, 55 to 64 is that yellow group and that was 36.23% so I had to tell you that these are these advanced practitioner providers are also aging and we're going to see retirement in the coming years.

And it's not surprising to note that the younger age groups are the smaller piece of the pie because you must remember that when you come out as a nurse practitioner or PA, we are training more at the primary care level. We then need to be educated for whatever specialty, if we want to go into a specialty such as say, oncology, neurology, urology, and I will tell you that the SUNA group has come up with a core curriculum to assist nurse practitioners in achieving those core competencies that are needed to become a urology nurse practitioner advanced practice provider. The other thing in this survey, another question was to describe their practice, and this was 70 individuals answer this question. And not surprising, is that 25% reported large group practices and 25% reported being academic university practices and these large group practices, where you have 10 or more urologists and are multidisciplinary practitioners. They will have urology nurse practitioners, PAs, medical oncologists. They may have radiologists in these practices. They may have gynecologists and this is a growing group.

I know in the South Jersey area we have about one of the largest groups over 125 urologists, multi-specialty group and other physicians and nurse practitioners, a PA. we also have a large portion here are academic and then you can see the breakdown of others and you can see that VA system was around 9%. The main focus of this group that attended and it's not surprising is it was voiding dysfunction and incontinence. That was actually a big focus of this meeting and you can see 71.43% were actually interested in pelvic floor dysfunction. And that is a growing area in urology. We have a lot of pelvic floor reconstructive surgeons who are fellowship-trained and a lot of nurse practitioners and PAs are interested in doing this.

As a pelvic floor specialist in urology, I found the growth in this area to be significant in the past five years. One of the continuing education programs I've been involved in has been a workshop in conjunction with the SUNA spring and fall meeting on pelvic floor with biofeedback training and there has been such a... We limit it to 40 individuals to attend this workshop and every workshop we are at our limit and I've asked to add more on. So there is a big growth and it is nurse practitioners and PAs, so it's an advanced practice type of focus. You can see the next is really general urology, so this is similar to the AUA survey that I just discussed that was done several years before this. So general urology is a big portion. Then we have neurogenic bladder, so a lot of individuals who may have spinal cord injury, MS and that, and then you can see the differences here as far as the different groups of which APPs are practicing within urology.

Now we also asked the question of are they independently managing their patients? To give you an example, I have my own schedule where I see individuals who are referred from within the urology practice, within the University setting from other providers and outside the system also. So I independently manage my patients and I also work in collaboration with my fellow colleagues who are urologists and as you can see most of the individuals who were attending this SUNA meeting in March of 2018 were actually independently managing their patient base. I think that's encouraging to show their independence. We also ask them their prescribing method and most people in most of these practices are doing electronically and I think that probably makes sense because that's where the incentive for reimbursement is. We all have electronic health records and ours is specific to the fact that we do prescribe electronically directly to the pharmacist of the patient and that's really where you see the bulk of their prescribing going in most practices.

We also want to know as far as where the industry is within these practices. And what we've seen in the academic centers of the past really five to 10 years is we no longer take drug samples from representatives and you can see that a little over 50% of the respondents to this UroToday survey stated that they were still taking samples. There's a big debate on that, but you can see that there still is something that's going on within these urology practices.

We wanted to understand as far as those more complex procedures such as what the AUA had asked in their survey. So we asked, we picked Botox, how many performing Botox injections? And 90% stated they were not involved at all, and that was an interesting number because I showed you before that actually voiding dysfunction or incontinence was the top on practice focus of these nurse practitioners, PAs. But what you can see by this, this question resolve is that the bulk are not doing these and of those that are doing them, about 7% are doing under the direction of the urologist's direct supervision and a very small percentage, about 3% are doing them alone, but the doctor's available.

We also asked about InterStim™ stage one which is the stage where you determine whether the patient is going to have a positive response or a negative response to an InterStim™ prior to undergoing the implant. So that would be office testing. And again the bulk, 80%, are not involved in that. And again, this was surprising considering that most of these practitioners are doing voiding dysfunction and incontinence, but 10% do them alone and 10% do under direct supervision. So again, a small portion is actually doing stage one in their office.

Now what I wanted to also share with you is a very recent article that came out in Urology Practice. This was I think last month. It was looking at reaching them and what this article was about was the fact that the AUA is not reaching and the number of individuals who are advanced practice providers in urology practice. I showed you before that about 1300 APPs are members of the AUA and we think on average it's probably about 7,000 nurse practitioners or PAs right now practicing in urology practices in the United States. They're not members of the AUA. Many of them are members of the Society of Urologic Nurses and Associates, they're members of SUNA. And this article tries to explore what's going on, what do they see as benefits for education, and I thought it was an interesting art article to discuss.

What they talked about was that they looked at advanced practice providers and allied health professionals. So remember those would be both nurse practitioners or PAs, but also our RNs, LPNs, medical assistants technicians. And they found out there were only a total of 600 members. In the 217 AUA census that was done in 2017, 42% were PAs, 51% were NPs and then others, so again, the bulk of these advanced practice providers are nurse practitioners.

This is where they said, again, where that the general from this survey was, where practice was again, general urology, then oncology, and here you see pelvic medicine was pretty low and that's interesting because when you saw the SUNA survey, that was actually the number one practice focus of those attendees to the SUNA meeting, which leads me to believe that individuals who are nurse practitioners or PAs who are practicing as probably for specialists treating patients with voiding dysfunction, incontinence, bladder health, are actually really getting their education from SUNA. When you look at what they do primarily, they evaluate office patients. They may do a preoperative evaluation, postoperative evaluation, and then you can see perform procedures in an outpatient setting is also a fairly high percentage. The lowest is doing cystoscopy and prostate biopsy, which actually follows what that recent, the other survey that I showed you.

So I think that this gives us an idea that we do have these providers in urology, they are growing in the urology practice. We are going to need them more and more of them because the urology workforce is aging. They're retiring at a much greater rate than we see residents coming into urology and achieving certification. So what's going to happen here? What's going to happen is we're going to need those advanced practice providers, especially in rural areas where you don't have urologists. We also are going to need them to be able, especially nurse practitioners, to practice to the full of their capabilities. And I think that we're going to see state laws changing rapidly because we need that. But also we need to also educate them.

And as a nurse practitioner for now over 30 years, I learned urology through hands-on. There were no formal programs back in the 80s when I learned urology and I think that we need more mentoring programs. We need maybe fellowships in urology. The SUNA core curriculum is an excellent resource for anyone who's listening to this. It has 21 chapters, 14 chapters were on pediatrics. It has a lot of procedures in their voiding trials, how to do an intravesical instillation. How to do manual irrigation for someone who has who's bleeding and has blood clots. So it's a good resource for advanced practice providers. The AUA also provides a lot of good resources. They have quite a few publications and I find that their two-day course at their meeting in May is actually geared towards the advanced practice provider.

Also, I want to commend SUNA for starting a spring conference for just that advanced practice provider in urology, which is also another source for education for the nurse practitioner or PA. So I hope that you found this presentation helpful. I just want to give you a little picture of where we're going with nurse practitioners and PAs and how urology really is the growing specialty. So if you are a nurse practitioner, and want to get into some specialty, I really encourage you to come into urology. Thank you very much.