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2017 ACS Governors Survey: The increasing role of APPs in providing surgical care

The results of a survey of ACS Board of Governors are summarized, including surgeon viewpoints on the increasing role of APPs.

David W. Butsch, MD, FACS, Juan C. Paramo, MD, FACS, John Kirby, MD, FACS, Peter Andreone, MD, FACS

July 1, 2018

Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the College leadership. The 2017 ACS Governors Survey, conducted in August 2017 by the B/G Survey Workgroup, had an 88 percent (241/274) response rate.

The following article focuses on Governors’ concerns regarding the use of advanced practice providers (APPs) in surgical practices.

APPs consist primarily of physician assistants (PAs) and nurse practitioners (NPs). Interestingly, each profession started in the U.S. in 1965. That year at Duke University School of Medicine, Durham, NC, Eugene A. Steed, Jr., MD, started the first class of PAs; and at the University of Colorado, Denver, Loretta Ford, RN, and Henry Silver, MD, introduced the first NP program. Since then, the number of schools and training programs has increased dramatically.

Today, APPs play an important role in surgical care in the U.S. and throughout the world. It is anticipated that APPs will continue to expand their roles and increase in number. They are well-trained, reliable, and have become an integral part of the health care delivery system in many surgical practices. Surgeons and APPs each contribute to the delivery of high-quality, value-based patient care.

The 2017 B/G survey

To better understand the role of APPs in surgery, the 2017 B/G survey included a series of questions related to how ACS Governors use APPs in their practices. The results of the survey are discussed in this article.

A total of 77 percent of U.S. ACS Governors said they use at least one APP in their practices, whereas only 40 percent of Canadian Governors and 37 percent of International Governors employ APPs. A comparison of U.S. use of APPs with international use in this survey may be affected by the smaller number of international surgeons respondents (see Figure 1).

Figure 1. Do you use PAs and/or NPs in your practice?

Figure 1. Do you use PAs and/or NPs in your practice?
Figure 1. Do you use PAs and/or NPs in your practice?

Practice setting

Most (79 percent) APPs work with surgeons in an academic, tertiary, or quaternary care institution. However, APPs also work in smaller hospitals, community hospitals, and rural hospitals (see Figure 2).

Figure 2. Utilization of APPs by practice setting

Figure 2. Utilization of APPs by practice setting
Figure 2. Utilization of APPs by practice setting

Specialty utilization

Most surgical specialties use APPs to provide some care, but the four that account for more than half of all employed APPs are as follows: general surgery (23 percent); acute care surgery (12.7 percent); surgical oncology (10.4 percent); and trauma (10 percent).

Interestingly, the specialties with the highest percentage of surgeons employing APPs are orthopaedic (100 percent), trauma (81 percent), critical care (80 percent), acute care (73 percent), vascular (68 percent), and breast (68 percent) (see Table 1).

Of the Governors who make use of APP services, 66 percent said that they have one to three APPs in their practices. Overall, Governors employ 30 percent more NPs than PAs. Nearly half of all the practices that employ PAs (45 percent) and NPs (51 percent) have had APPs on staff for 10 years or longer. Moreover, the practices that have had APPs for more than 10 years are more than twice as likely to employ NPs rather than PAs.

Table 1. Utilization of APPs by specialty

Table 1. Utilization of APPs by specialty
Table 1. Utilization of APPs by specialty

Responsibilities of APPs within surgical practices

APPs fulfill a variety of responsibilities in surgical practices. Most PAs work in the operating room (OR) (42 percent) and the office (48 percent). However, NPs are almost three times more likely to work in a surgeon’s office than in the OR (see Figure 3).

Figure 3. How are APPs used in your practice?

Figure 3. How are APPs used in your practice?
Figure 3. How are APPs used in your practice?

APPs have earned the respect and confidence of physicians. A notable change in recent years is the inclusion of APPs on medical staffs and the added level of responsibility held by these individuals. According to the survey, 35 percent of PAs and 46 percent of NPs are on medical staffs (see Figure 3); 10 percent of PAs and 13 percent of NPs are voting members. Furthermore, 9 percent and 13 percent, respectively, are allowed to hold medical staff office.

According to the survey, less than a quarter of APPs take night call—22 percent of PAs and 20 percent of NPs. In a small percentage (8 percent) of practices, an APP is sometimes the only provider to see a patient in a 24-hour period. This is more likely to occur in an academic setting than in a private practice (see Table 2).

Table 2. Is an APP the only provider to see a patient during a 24-hour period?

Table 2. Is an APP the only provider to see a patient during a 24-hour period?
Table 2. Is an APP the only provider to see a patient during a 24-hour period?

Future plans

The usefulness of APPs is readily apparent through an analysis of the survey results. Almost 40 percent of the Governors already employing APPs indicated future plans to hire more PAs and NPs (see Figure 4).

Furthermore, when the Governors who do not use APPs were asked about their future hiring plans, 67 percent indicated they would hire APPs if finances were not an issue.

Figure 4. What are your future plans for APPs in your practice?

Figure 4. What are your future plans for APPs in your practice?
Figure 4. What are your future plans for APPs in your practice?

Conclusion

Although the results of the B/G survey reveal widespread use of APPs and satisfaction with their work, many questions remain. For example, even though APPs have enriched the surgical care and the experience of our patients and are an integral and important part of the surgical team, to what degree should they be supervised, and how much independence should they have? Should their hours be regulated? What is the effect of APPs on residents, and how do you integrate APPs into residency training programs and staff? How should APPs be integrated in the formal organized medical staff framework, such as peer reviews and medical staff voting rights? The answers to these questions may vary significantly depending on the respondent’s practice setting, specialty, and so on. Next steps should include answering these questions to gain a better understanding and appreciation for the work of APPs, now and in the future.

Acknowledgment

The B/G Survey Workgroup members who compiled this survey are grateful to and deeply appreciative of the patience and thoroughness of the Governors who responded. The Workgroup also wishes to thank the College and, in particular, Emily Kalata, Manager, Board of Governors, and Connie Bura, Member Services Associate Director, Division of Member Services, for the amount of work they put into this survey.