Population growth and aging are driving a growing demand for health care, leading to an increasingly significant shortage of physicians. Recognizing the need for additional health care providers, the National Academy of Medicine and other organizations have recommended increasing the number and capacities of nurses with advanced training (nurse practitioners)and physician assistants(i.e. advanced practice providers). In the last decade,the size of the advanced practice provider workforce has grown considerably faster than the increase in physician supply. A growing body of evidence demonstrates that care provided by advanced practice provider is of similar quality and costs to that provided by physicians. However, this research has typically focused on the delivery of primary care services, which is historically the focus of nurse practitioner training. Surgical care, which is a significant portion of medical care for older adults, has also seen a drastic growth in advanced practice providers. However, the specific tasks performed by advanced practice providers, their quality, and costs in the context of surgical care are largely unknown.There is a critical need to understand how best to allocate the labor of advanced practice providers in the provision of surgical care.

These providers may be utilized in a variety of work involved in surgical care including such disparate tasks as initial consultations, preoperative counseling, outpatient surgical procedures, inpatient perioperative care, assisting major surgical procedures, or care coordination and follow-up. As they have shorter and less surgically-focused training than surgeons, advanced practice providers may be better suited to some of these duties than others.However, the frequency with which these tasks are performed by advanced practice providers and the associated impact on quality of care is unknown. Our preliminary analyses have demonstrated that the addition of advanced practice providers to surgical practices is associated with improved access to care and reduced rates of complications and readmissions, but the mechanisms by which these quality improvements might be realized remains to be elucidated. A better understanding of the current distribution of advanced practice provider work and the impacts of this work on the quality of surgical care is essential to more optimally integrating these providers into surgical care teams.

Aim 1. To develop a taxonomy of advanced practice provider labor in surgical care. Using administrative claims we will identify domains of work in the delivery of surgical care and characterize the degree to which advanced practice providers participate in various aspects of that care.

Aim 2. To understand the association between quality of surgical care and the services delivered by advanced practice providers. Using claims to identify APP services, we will characterize characterize the type of work advanced practice providers perform and identify variations in costs and quality

Aim 3. To evaluate the impact of alternative payment models on the distribution of advanced practice provider work and outcomes

1. Administrative claims based analysis (MarketScan database)

2. Publicly available policy data (Open Payments, Medicare procedure data, etc)

3. Original data collection methods (survey, audit, others)

Retrospective methods of data analysis including regression-based analysis

American Urological Association national conference

AUA-North Central Section

American College of surgeons

Society of urologic oncology

AcademyHealth

Academic Surgical Congress