The role of advanced nurse practitioners in nephrology

Nephrology advanced practitioners are involved in every aspect of renal medicine, and what they do is as unique as they are. Advanced practitioners (AP) include nurse practitioners (NP), physician assistants (PA), and clinical nurse specialists (CNS). Surveys by the National Kidney Foundation (NKF), the Renal Physicians Association (RPA), and the Academy of Nephrology Physicians Association that looked at AP job descriptions revealed the diverse scope of their practice. While all participate in caring for renal patients, their individual duties cover the entire spectrum of nephrology. Depending on the practice needs, an AP may perform history and physicals, dictate discharge summaries, make hospital rounds, and take after-hours calls. Many APs are providers in chronic kidney disease (CKD) clinics and in nephrology clinics. In addition, they round in hemodialysis and peritoneal dialysis clinics. Their duties here include writing and modifying dialysis prescriptions and providing for patient needs. They are also involved in transplantation, often seeing patients and potential donors in transplant evaluation and following the patient after transplant in the hospital and clinic. In addition, some APs are utilized as surgical first assistants. Advanced practitioners are actively involved in research and often direct research studies.1 Patient education is one of their strengths. Advanced practitioners provide educational programs for patients and their families and loved ones. Many APs in teaching institutions are also involved in educating house staff as well.2 Often, APs deliver primary care for CKD stage 3, 4, and 5 patients. These patients often require frequent visits, and the AP can provide the needed follow-up care. Nurse practitioners and PAs have prescriptive privileges with the individual states mandating any restrictions. Early intervention is essential to delay or prevent the progression of kidney disease. Advanced practitioners are ideally suited to provide this. According to the Association of American Medical Colleges 2008 Physician Specialty Data report, there were approximately 7,550 active nephrologists in 2007 with more than 6,000 involved in patient care.4 In 2004, the RPA noted more than 472,000 patients in the United States needed renal replacement either through dialysis or transplantation, according to the latest reports from the United States Renal Data System. It is estimated that approximately 26 million Americans have decreased kidney function. In addition, the number of end-stage renal disease patients is increasing at 9% to 12% annually and has been doing so for approximately 40 years.5 Although efforts have been made to increase the number of practicing nephrologists, it is clear that demand is outpacing supply.2 The inclusion of APs on the renal care team helps close the gap. The RPA Position on Collaborative Practice5 highlights the advantages of using APs in nephrology practices. Patient compliance is essential in the treatment of renal disease; patients are often asked to adhere to rigid dietary and fluid restrictions, as well as treatment schedules. The APs play a central role in increasing patient compliance and managing comorbidities for better outcomes. Because of their frequent contact with the patients, they understand and recognize patient needs and are in an excellent position to influence behavior, which can positively affect outcomes.5 Patient surveys have demonstrated the high level of satisfaction with the care delivered by APs.6 End-stage renal disease is often the result of poorly controlled comorbidities such as hypertension and diabetes. Early intervention is essential to delay or prevent the progression of kidney disease. Advanced practitioners are ideally suited to provide this. Many practices have CKD clinics which are often staffed by APs. These clinics address many aspects of care including management of diabetes, hypertension, anemia, bone disease, cholesterol, and access planning and management. In addition, pre-dialysis education often occurs in these clinic settings. Thus, the patient receives continuity of care from professionals who are knowledgeable regarding renal disease. In recognition of the vital role the AP plays in patient education, the recent Medicare Improvement for Patients and Provider's Act (MIPPA) provided for CKD stage 4 patients to receive six educational visits—which can be provided by the AP. Advanced practitioners provide practices with a financial benefit. Not only do they provide timely intervention that often can prevent more serious complications, their contribution allows nephrologists to expand their practices and manage more patients (Michael Allon, MD, personal communication, May, 2009). A recent RPA Benchmarking survey showed that the average physician reimbursement increased with the addition of APs to a practice.7 An equally important benefit is potentially reducing the costs to third party payers (Steven Rostand, MD, personal communication, July, 2009). Nephrology offers APs the opportunities to use their knowledge and skills in a variety of settings. In this field, where the demand is great and the number of providers small, APs provide an answer to a growing need. These highly motivated and educated practitioners are filling a void to the benefit of physicians and patients alike. As their involvement in nephrology has evolved, APs have also formed professional organizations relating to their field. Ten nephrology PAs formed the American Academy of Nephrology Physician Assistants (AANPA) in 1996. In that short time, they have become a highly visible and active group with more than 200 members. In 2008, five APs met at the National Kidney Foundation annual clinical meeting to form the Council of Advanced Practitioners. In less than six months, there were more than 100 members. Since CAP has become a full-fledged council in September, 2008, it has established two annual awards and developed a program for research grants. In addition, CAP has an active member listserv that receives more than 50 queries and responses monthly from the more than 200 members. While much has changed for APs in nephrology, much as stayed the same. Lynn Poole, a practicing NP since 1973, has been involved in all aspects of renal management. “I've seen many changes in nephrology,” she says, “but the fundamentals have not [changed]. We are seeing a movement back toward patient-centered care and APs are an integral part of that” (personal communication, July 2009).