In recent years, advanced practitioners have emerged as an important workforce in nephrology and urology. Advanced practitioners include, but are not limited to, nurse practitioners and physician assistants. Their traditional function was thought to be limited to extending the role of physicians in mostly ambulatory settings, hence the misnomers of “physician extender” and “mid-levels.” But today, advanced practitioners play an increasingly important role in direct patient care in nearly all areas of health services, including ambulatory and inpatient sectors as well as critical care and surgical and procedural operations. In nephrology, an increased need for advanced practitioners appeared in the early 2000’s, when the Medicare ESRD program’s Conditions for Coverage started requiring at least 4 visits per month to be eligible for full dialysis physician fee payments. Many nephrology groups arrange several monthly dialysis rounds by advanced practitioners under the short-visit billing code in addition to a monthly comprehensive dialysis visit by the nephrologist of record to ensure regulatory compliance. Non-dialysis ambulatory clinics use APPs to provide care to less complicated cases of CKD progression. This care can encompass preparation of transition to dialysis therapy. As a result of increasing nephrology inpatient volumes and a shortage of recently trained nephrologists, inpatient advanced practitioners have emerged as important members of the nephrology consult service in both academic and community practices. They ensure adequate documentation of the quality of care that hospitalized patients receive as well as their safety. Whereas some consult groups may prefer to assign advanced practitioners to more stable cases, there are highly capable advanced practice providers who can provide more sophisticated and critical care nephrology consults with minimal oversight by a nephrologist.
In the field of renal transplantation, advanced practitioners have exhibited a wide ranging function across all practice areas, including kidney transplant eligibility work ups, sensitive communications among family members and interdisciplinary team members and other providers, and after-hours and weekend calls for deceased-donor kidney offers. Advanced practice providers are also an important workforce in the post-transplant outpatient setting and ensure excellent care to renal transplant recipients. More and more advanced practitioners who specialize in kidney transplantation are making multidisciplinary inpatient rounds along with transplant surgeons—and often in place of the transplant nephrologist. These providers perform focused workups for acute rejection, suspected infections, and urologic complications of renal transplantation. Urologists, too, work not infrequently with advanced practitioners, although questions remain about the most efficient ways to integrate them from a regulatory and practice management approach, according to an American Urological Association position paper published in January 2022.
With the rise of advanced practitioners in nephrology and urology, national experts and opinion leaders, including Vasco Deon Kidd, PA-C, DHSc, MPH, of the University of California Irvine, have highlighted renewed focus on several areas related to the education and integration of these providers, such as inclusivity within organized medicine to reduce health disparities and achieve health equity by addressing the deleterious effects of implicit bias in health care and clinical outcomes.
The need for expanded multidisciplinary teams in nephrology and urology in contemporary practice should be recognized and advocated, with the inclusion of dedicated advanced practitioners to ensure a more effective and efficient kidney health team. As American Society of Nephrology President Susan Quaggin, MD, might phrase it, the goal should be to put “patients first—always.”
Kam Kalantar-Zadeh, MD, PhD, MPH
Professor & Chief, Division of Nephrology, Hypertension & Kidney Transplantation
UC Irvine School of Medicine, Orange, CA