2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

NPS AND PAS IN SURVIVORSHIP CARE
Sidebar 1. Essential Components of Survivorship Care
● Surveillance for recurrence
● Screening for new cancers
● Identification and management of the consequences
of the cancer and its treatment
● Health promotion strategies
● Coordination/communication between oncology specialists
and primary care providers
for oncology services up and will continue to do so for the
foreseeable future. 12
The number of physicians entering the field of oncology
has decreased, and the supply of oncologists will not be able
to meet the demand for oncology services by 2020. In fact,
there is a predicted shortage of more than 4,000 physicians
to provide oncology services. Several factors for this gap
have been identified and include fewer residents entering
oncology training programs, a growing population of
retirement-age oncologists, a shift in the health care system
to a focus on primary care, and decreasing reimbursement
for chemotherapy infusion and other services that oncology
practices require to remain fiscally sound. The American
Society of Clinical Oncology (ASCO) Workforce Study completed
in 2007 identified the gap between supply of oncology
physicians and demand for oncology services. There will be
an estimated demand of 57.2 to 60.7 million visits per year
by 2020 and only an estimated supply of 45.6 to 47.8 million
visits per year. Thus, there is a gap of 11.6 to 12.9 million
visits per year by 2020 (Fig. 1). This study highlighted the
fact that the increasing gap in supply and demand requires
new ways of providing oncology services such as increasing
oncology training programs to produce more oncologists and
shifting services traditionally provided by oncologists, such
as survivorship, to the primary care setting. 13
Nurse practitioners (NPs) and physician assistants (PAs)
have been identified as members of the health care team
who can help reduce the oncology supply and demand gap in
a number of ways. 14 Fortunately, there is already a significant
number of NPs and PAs practicing in oncology settings
working with physicians to provide diagnostic evaluation,
patient education, infusion services, treatment monitoring,
KEY POINTS
● There is an increasing number of survivors who have
been successfully treated for cancer.
● The number of oncologists will not be able to meet the
demand for oncology services by 2020.
● Nurse practitioners (NP) and physician assistants
(PA) are professionally prepared to help reduce the
gap in care.
● Innovative care models are being implemented internationally
using NPs and PAs as important colleagues
in the care of cancer survivors.
● Additional research is needed to evaluate the most
efficient, highest quality care models in a variety of
settings and health systems.
surveillance, and symptom management. 15-20 The ASCO
Workforce Study identified that NPs and PAs can extend the
services that oncology physicians provide and allow physicians
to focus on evaluating new patients, creating treatment
plans, and addressing changes in patient condition.
NPs and PAs can free up oncologists from the more routine
needs of patients with cancer so that they can focus on more
complex care. 21 The Workforce Study also identified transitioning
survivorship care from oncology physicians to the
primary care setting as a means to close the gap in supply
and demand. It was estimated that a reduction of 10% to
20% in the number of patients being seen by an oncologist
during the monitoring phase could be achieved. 13 Although
the Workforce Study focused on transitioning survivorship
care from oncologists to primary care physicians, it can be
argued that NPs and PAs can also provide this care. Many
cancer centers and oncology practices have established survivorship
programs that utilize NPs and PAs. These programs
have enabled oncologists to shift post-treatment care
to other members of the team while keeping the patients
within the institution or practice. 22
Drivers of Collaborative Practice
After the ASCO Workforce Study was completed, it was
apparent that NPs and PAs would be an important part of
the solution to close the gap in supply and demand. However,
there has been a limited understanding of the NP and
PA workforce in oncology as well as the scope of services they
provide, their effect on productivity, patient satisfaction,
and physician satisfaction in the utilization of NPs and PAs.
To address these issues, ASCO released the results for a
Study of Collaborative Practice Arrangements (SCPA) in
2011. The study had five main conclusions: oncology patients
were aware and satisfied when the care they received was
provided by NPs and PAs; there was an increase in productivity
in practices that utilized NPs and PAs; utilizing the
full scope of practice of NPs and PAs was financially advantageous
and was a main driver of the model of collaborative
practice chosen; perceptions of workload for oncologists,
NPs, and PAs did not correlate to objective measures of work
production; and physicians, NPs, and PAs are highly satisfied
with their collaborative practices.
Another interesting result of the SCPA was the list of
services provided by NPs and PAs in oncology practices. The
top three services as identified by more than 80% of the
practices surveyed were assessing patients during treatment
visits, pain and symptom management, and follow-up
care for patients in remission. The bottom three services
with 20% or less of practices indicating these services were
NPs and PAs providing night or weekend call, survivorship
clinics, and “other” services. What is striking about these
results is that NPs and PAs provided a large portion of
follow-up care for patients in remission, but this was not
within a formal survivorship program. This seems to indicate
that NPs and PAs have the skills needed to take care of
cancer survivors but that they are not yet doing so within
structured programs.
There have been three main collaborative practice models
described between oncology physicians, NPs, and PAs. Each
model has a different level of physician interaction with the
patient and has a different effect on productivity and patient
volume. The first model, incident-to-practice, is defined as
autonomous practice of an NP/PA while the physician is
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