Understanding the role of advanced practice providers in oncology in the United States.

PURPOSE: Advanced practice providers (APPs, which include NPs and physician assistants [PAs]) are integral members of oncology teams. This study aims first to identify all APPs in oncology and, second, to understand personal and practice characteristics (including compensation) of those APPs. METHODS: We identified APPs who practice oncology from membership and claims data. We surveyed 3,055 APPs about their roles in clinical care. RESULTS: We identified at least 5,350 APPs in oncology and an additional 5,400 who might practice oncology. Survey respondents totaled 577 out of 3,055, which provided a 19% response rate. Results focused on 540 NPs and PAs. Greater than 90% reported satisfaction with career choice. Respondents identified predominately as white (89%) and female (94%). NPs and PAs spent the majority (80%) of time in direct patient care. The top four patient care activities were patient counseling (NPs, 94%; PAs, 98%), prescribing (NPs, 93%; PAs, 97%), treatment management (NPs, 89%; PAs, 93%), and follow-up visits (NPs, 81%; PAs, 86%). A majority of all APPs reported both independent and shared visits (65% hematology/oncology/survivorship/prevention/pediatric hematology/oncology; 85% surgical/gynecologic oncology; 78% radiation oncology). A minority of APPs reported that they conducted only shared visits. Average annual compensation was between $113,000 and $115,000, which is about $10,000 higher than average pay for APPs not in oncology. CONCLUSION: We identified 5,350 APPs in oncology and conclude that number may be as high as 7,000. Survey results suggest that practices that incorporate APPs routinely rely on them for patient care. Given the increasing number of patients with and survivors of cancer, APPs are important to ensure access to quality cancer care now and in the future.

Understanding the Role of Advanced Practice Providers in Oncology in the United States.

PURPOSE: Advanced practice providers (APPs, which include nurse practitioners [NPs] and physician assistants [PAs]) are integral members of oncology teams. This study aims to identify all oncology APPs and to understand personal and practice characteristics (including compensation) of those APPs. METHODS: We identified APPs who practice oncology from membership and claims data. We surveyed 3,055 APPs about their roles in clinical care. RESULTS: We identified at least 5,350 APPs in oncology and an additional 5,400 who might practice oncology. Survey respondents totaled 577, which provided a 19% response rate. Results focused on 540 NPs and PAs. Greater than 90% reported satisfaction with career choice. Respondents identified predominately as White (89%) and female (94%). NPs and PAs spent the majority (80%) of time in direct patient care. The top four patient care activities were patient counseling (NPs = 94%; PAs = 98%), prescribing (NPs = 93%; PAs = 97%), treatment management (NPs = 89%; PAs = 93%), and follow-up visits (NPs = 81%; PAs = 86%). A majority of all APPs reported both independent and shared visits (65% hematology/oncology/survivorship/prevention/pediatric hematology/oncology; 85% surgical/gynecologic oncology; 78% radiation oncology). A minority of APPs reported that they conducted only shared visits. Average annual compensation was between $113,000 and $115,000, which is approximately $10,000 higher than average pay for nononcology APPs. CONCLUSION: We identified 5,350 oncology APPs and conclude that number may be as high as 7,000. Results suggest that practices that incorporate APPs routinely rely on them for patient care. Given the increasing number of patients with and survivors of cancer, APPs are important to ensure access to quality cancer care.

Understanding the Role of Advanced Practice Providers in Oncology in the United States.

PURPOSE: Advanced practice providers (APPs, which include nurse practitioners [NPs] and physician assistants [PAs]) are integral members of oncology teams. This study aims first to identify all oncology APPs and, second, to understand personal and practice characteristics (including compensation) of those APPs. METHODS: We identified APPs who practice oncology from membership and claims data. We surveyed 3,055 APPs about their roles in clinical care. RESULTS: We identified at least 5,350 APPs in oncology and an additional 5,400 who might practice oncology. Survey respondents totaled 577, which provided a 19% response rate. Results focused on 540 NPs and PAs. Greater than 90% reported satisfaction with career choice. Respondents identified predominately as white (89%) and female (94%). NPs and PAs spent the majority (80%) of time in direct patient care. The top four patient care activities were patient counseling (NPs, 94%; PAs, 98%), prescribing (NPs, 93%; PAs, 97%), treatment management (NPs, 89%; PAs, 93%), and follow-up visits (NPs, 81%; PAs, 86%). A majority of all APPs reported both independent and shared visits (65% hematology/oncology/survivorship/prevention/pediatric hematology/oncology; 85% surgical/gynecologic oncology; 78% radiation oncology). A minority of APPs reported that they conducted only shared visits. Average annual compensation was between $113,000 and $115,000, which is approximately $10,000 higher than average pay for nononcology APPs. CONCLUSION: We identified 5,350 oncology APPs and conclude that number may be as high as 7,000. Survey results suggest that practices that incorporate APPs routinely rely on them for patient care. Given the increasing number of patients with and survivors of cancer, APPs are important to ensure access to quality cancer care now and in the future.

The State of Oncology Practice in America, 2018: Results of the ASCO Practice Census Survey.

PURPOSE: To describe the US hematology and medical oncology practice landscape and to report findings of the sixth annual ASCO Oncology Practice Census survey. PARTICIPANTS AND METHODS: ASCO used Medicare Physician Compare data to characterize oncology practices in the United States. Practice size, number of care sites, and geographic distribution were determined. Trends in the number and size of practices from 2013 to 2017 were examined. All US oncology practices were targeted for the survey; survey responses were linked to the practices identified from Physician Compare to augment results and assess generalizability. RESULTS: More than 2,200 hematology/oncology practices provided care to adult patients in 2017. We observed annual decreases in the number of practices and annual increases in practice size. Of the 2017 practices, 394 (18%) completed the survey and accounted for 58% of the US hematologist/oncologist workforce (n = 7,203). Respondents tended to be larger and encompass more sites of care than nonrespondents. Surveyed practices cited payers (58%), competition (38%), and staffing (37%) as primary sources of strain. Prior authorization was dominant among payer pressures (78%). Electronic health records remained a burden on practices, with only 15% reporting full interoperability. CONCLUSION: The results of ASCO's 2017 survey indicate that oncology practices are challenged by day-to-day operations, often related to payment, reimbursement, and competition. Our findings likely represent conservative estimates of such burdens because they are driven by responses from midsized to large-sized organizations, which have lower relative administrative burden, greater market influence, and potentially better ability to adapt in a changing health care environment.

Understanding the Role of Advanced Practice Providers in Oncology in the United States.

Purpose: Advanced practice providers (APPs, which include nurse practitioners [NPs] and physician assistants [PAs]) are integral members of oncology teams. This study aims first to identify all oncology APPs and, second, to understand personal and practice characteristics (including compensation) of those APPs. Methods: We identified APPs who practice oncology from membership and claims data. We surveyed 3,055 APPs about their roles in clinical care. Results: We identified at least 5,350 APPs in oncology and an additional 5,400 who might practice oncology. Survey respondents totaled 577, which provided a 19% response rate. Results focused on 540 NPs and PAs. Greater than 90% reported satisfaction with career choice. Respondents identified predominately as white (89%) and female (94%). NPs and PAs spent the majority (80%) of time in direct patient care. The top four patient care activities were patient counseling (NPs, 94%; PAs, 98%), prescribing (NPs, 93%; PAs, 97%), treatment management (NPs, 89%; PAs, 93%), and follow-up visits (NPs, 81%; PAs, 86%). A majority of all APPs reported both independent and shared visits (65% hematology/ oncology/survivorship/prevention/pediatric hematology/oncology; 85% surgical/ gynecologic oncology; 78% radiation oncology). A minority of APPs reported that they conducted only shared visits. Average annual compensation was between $113,000 and $115,000, which is approximately $10,000 higher than average pay for nononcology APPs. Conclusion: We identified 5,350 oncology APPs and conclude that number may be as high as 7,000. Survey results suggest that practices that incorporate APPs routinely rely on them for patient care. Given the increasing number of patients with and survivors of cancer, APPs are important to ensure access to quality cancer care now and in the future.

Association Between Geographic Access to Cancer Care and Receipt of Radiation Therapy for Rectal Cancer.

PURPOSE: Trimodality therapy (chemoradiation and surgery) is the standard of care for stage II/III rectal cancer but nearly one third of patients do not receive radiation therapy (RT). We examined the relationship between the density of radiation oncologists and the travel distance to receipt of RT. METHODS AND MATERIALS: A retrospective study based on the National Cancer Data Base identified 26,845 patients aged 18 to 80 years with stage II/III rectal cancer diagnosed from 2007 to 2010. Radiation oncologists were identified through the Physician Compare dataset. Generalized estimating equations clustering by hospital service area was used to examine the association between geographic access and receipt of RT, controlling for patient sociodemographic and clinical characteristics. RESULTS: Of the 26,845 patients, 70% received RT within 180 days of diagnosis or within 90 days of surgery. Compared with a travel distance of <12.5 miles, patients diagnosed at a reporting facility who traveled ≥50 miles had a decreased likelihood of receipt of RT (50-249 miles, adjusted odds ratio 0.75, P<.001; ≥250 miles, adjusted odds ratio 0.46; P=.002), all else being equal. The density level of radiation oncologists was not significantly associated with the receipt of RT. Patients who were female, nonwhite, and aged ≥50 years and had comorbidities were less likely to receive RT (P<.05). Patients who were uninsured but self-paid for their medical services, initially diagnosed elsewhere but treated at a reporting facility, and resided in Midwest had an increased the likelihood of receipt of RT (P<.05). CONCLUSIONS: An increased travel burden was associated with a decreased likelihood of receiving RT for patients with stage II/III rectal cancer, all else being equal; however, radiation oncologist density was not. Further research of geographic access and establishing transportation assistance programs or lodging services for patients with an unmet need might help decrease geographic barriers and improve the quality of rectal cancer care.

Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance.

PURPOSE: Geographic access to care may be associated with receipt of chemotherapy but has not been fully examined. This study sought to evaluate the association between density of oncologists and travel distance and receipt of adjuvant chemotherapy for colon cancer within 90 days of colectomy. PATIENTS AND METHODS: Patients in the National Cancer Data Base with stage III colon cancer, diagnosed between 2007 and 2010, and age 18 to 80 years were selected. Generalized estimating equation clustering by hospital service area was conducted to examine the association between geographic access and receipt of oncology services, controlling for patient sociodemographic and clinical characteristics. RESULTS: Of 34,694 patients in the study cohort, 75.7% received adjuvant chemotherapy within 90 days of colectomy. Compared with travel distance less than 12.5 miles, patients who traveled 50 to 249 miles (odds ratio [OR], 0.87; P=.009) or ≥250 miles (OR, 0.36; P<.001) had decreased likelihood of receiving adjuvant chemotherapy. Density level of oncologists was not statistically associated with receipt of adjuvant chemotherapy (low v high density: OR, 0.98; P=.77). When stratifying analyses by insurance status, non-privately insured patients who resided in areas with low density of oncologists were less likely to receive adjuvant chemotherapy (OR, 0.85; P=.03). CONCLUSION: Increased travel burden was associated with a decreased likelihood of receiving adjuvant chemotherapy, regardless of insurance status. Patients with nonprivate insurance who resided in low-density oncologist areas were less likely to receive adjuvant chemotherapy. If these findings are validated prospectively, interventions to decrease geographic barriers may improve the timeliness and quality of colon cancer treatment.

Results of the 2013 American Society of Clinical Oncology National Oncology Census.

PURPOSE: The American Society of Clinical Oncology (ASCO) National Oncology Census (Census) provides a mechanism for ASCO to systematically gather and analyze information about current practice structures and potential changes at a time when practices are working to adapt to increasing administrative and financial pressures. The Census is conducted annually and reports on new and trending data. METHODS: The 2013 Census was launched on May 30, 2013, as a national survey of oncology practices. The survey required practices to answer 11 questions and provided additional optional questions. RESULTS: The Census collected 530 useable responses in 2013 compared with 632 respondents in 2012. Practices reporting in 2013, however, represented a total of 8,011 physicians compared with only 5,018 in 2012. CONCLUSION: The pace of policy change in oncology practice is changing the landscape of how practices are organized. A greater number of practices with more than seven physicians responded in 2013, which could indicate overall growth in the size of oncology practice. Practices reported increased affiliations with hospitals through a variety of contractual mechanisms. In subsequent census efforts, ASCO will have the capability to match 2013 respondents to future respondents, allowing for increased precision in comparison of longitudinal data.

Satisfaction with work-life balance and the career and retirement plans of US oncologists.

PURPOSE: To evaluate satisfaction with work-life balance (WLB) and career plans of US oncologists. METHODS: The American Society of Clinical Oncology conducted a survey of US oncologists evaluating satisfaction with WLB and career plans between October 2012 and March 2013. The sample included equal numbers of men and women from all career stages. RESULTS: Of 2,998 oncologists contacted, 1,490 (49.7%) returned surveys. From 1,117 oncologists (37.3% of overall sample) completing full-length surveys, we evaluated satisfaction with WLB and career plans among the 1,058 who were not yet retired. The proportion of oncologists satisfied with WLB (n = 345; 33.4%) ranked lower than that reported for all other medical specialties in a recent national study. Regarding career plans, 270 oncologists (26.5%) reported a moderate or higher likelihood of reducing their clinical work hours in the next 12 months, 351 (34.3%) indicated a moderate or higher likelihood of leaving their current position within 24 months, and 273 (28.5%) planned to retire before 65 years of age. Multivariable analyses found women oncologists (odds ratio [OR], 0.458; P < .001) and those who devoted greater time to patient care (OR for each additional hour, 0.977; P < .001) were less likely to be satisfied with WLB. Satisfaction with WLB and burnout were the strongest predictors of intent to reduce clinical work hours and leave current position on multivariable analysis. CONCLUSION: Satisfaction with WLB among US oncologists seems lower than for other medical specialties. Dissatisfaction with WLB shows a strong relationship with plans to reduce hours and leave current practice. Given the pending US oncologist shortage, additional studies exploring interactions among WLB, burnout, and career satisfaction and their impact on career and retirement plans are warranted.

Burnout and career satisfaction among US oncologists.

PURPOSE: To evaluate the personal and professional characteristics associated with career satisfaction and burnout among US oncologists. METHODS: Between October 2012 and March 2013, the American Society of Clinical Oncology conducted a survey of US oncologists evaluating burnout and career satisfaction. The survey sample included equal numbers of men and women and represented all career stages. RESULTS: Of 2,998 oncologists contacted, 1,490 (49.7%) returned surveys (median age of respondents, 52 years; 49.6% women). Among the 1,117 oncologists (37.3% of overall sample) who completed full-length surveys, 377 (33.8%) were in academic practice (AP) and 482 (43.2%) in private practice (PP), with the remainder in other settings. Oncologists worked an average of 57.6 hours per week (AP, 58.6 hours per week; PP, 62.9 hours per week) and saw a mean of 52 outpatients per week. Overall, 484 oncologists (44.7%) were burned out on the emotional exhaustion and/or depersonalization domain of Maslach Burnout Inventory (AP, 45.9%; PP, 50.5%; P = .18). Hours per week devoted to direct patient care was the dominant professional predictor of burnout for both PP and AP oncologists on univariable and multivariable analyses. Although a majority of oncologists were satisfied with their career (82.5%) and specialty (80.4%) choices, both measures of career satisfaction were lower for those in PP relative to AP (all P < .006). CONCLUSION: Overall career satisfaction is high among US oncologists, albeit lower for those in PP relative to AP. Burnout rates among oncologists seem similar to those described in recent studies of US physicians in general. Those oncologists who devote the greatest amount of their professional time to patient care seem to be at greatest risk for burnout.

Where do patients with cancer in Iowa receive radiation therapy?

PURPOSE: Multiple studies have shown survival benefits in patients with cancer treated with radiation therapy, but access to treatment facilities has been found to limit its use. This study was undertaken to examine access issues in Iowa and determine a methodology for conducting a similar national analysis. PATIENTS AND METHODS: All Iowa residents who received radiation therapy regardless of where they were diagnosed or treated were identified through the Iowa Cancer Registry (ICR). Radiation oncologists were identified through the Iowa Physician Information System (IPIS). Radiation facilities were identified through IPIS and classified using the Commission on Cancer accreditation standard. RESULTS: Between 2004 and 2010, 113,885 invasive cancers in 106,603 patients, 28.5% of whom received radiation treatment, were entered in ICR. Mean and median travel times were 25.8 and 20.1 minutes, respectively, to the nearest facility but 42.4 and 29.1 minutes, respectively, to the patient's chosen treatment facility. Multivariable analysis predicting travel time showed significant relationships for disease site, age, residence location, and facility category. Residents of small and isolated rural towns traveled nearly 3× longer than urban residents to receive radiation therapy, as did patients using certain categories of facilities. CONCLUSION: Half of Iowa patients could reach their nearest facility in 20 minutes, but instead, they traveled 30 minutes on average to receive treatment. The findings identified certain groups of patients with cancer who chose more distant facilities. However, other groups of patients with cancer, namely those residing in rural areas, had less choice, and some had to travel considerably farther to radiation facilities than urban patients.

Access to chemotherapy services by availability of local and visiting oncologists.

PURPOSE: Geographic disparities have raised important questions about factors related to treatment choice and travel time, which can affect access to cancer care. PATIENTS AND METHODS: Iowa residents who received chemotherapy regardless of where they were diagnosed or treated were identified through the Iowa Cancer Registry (ICR), a member of the SEER program. Oncologists and their practice locations, including visiting consulting clinics (VCCs), were tracked through the Iowa Physician Information System. Oncologists, VCCs, and patients were mapped to hospital service areas (HSAs). RESULTS: Between 2004 and 2010, 113,885 newly diagnosed invasive cancers were entered into ICR; among patients in whom these cancers were diagnosed, 31.6% received chemotherapy as a first course of treatment. During this period, 106 Iowa oncologists practiced in 14 cities, and 82 engaged in outreach to 85 VCCs in 77 rural communities. Of patients receiving chemotherapy, 63.0% resided in an HSA that had a local oncologist and traveled 21 minutes for treatment on average. In contrast, 29.3% of patients receiving chemotherapy resided in an HSA with a VCC, and 7.7% resided in an HSA with no oncology provider. These latter two groups of patients traveled 58 minutes on average to receive chemotherapy. Availability of oncologists and VCCs affected where patients received chemotherapy. The establishment of VCCs increased access to oncologists in rural communities and increased the rate that chemotherapy was administered in rural communities from 10% to 24%, a notable increase in local access. CONCLUSION: Access to cancer care is dependent on the absolute number of providers, but it is also dependent on their geographic distribution.

Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage.

PURPOSE: The American Society of Clinical Oncology (ASCO) published a study in 2007 that anticipated a shortage of oncologists by 2020. This study aims to update and better assess the market for chemotherapy and radiation therapy and the impact of health reform on capacity of and demand for oncologists and radiation oncologists. METHODS: The supply of oncologists and radiation oncologists, by age, sex, and specialty, was projected through 2025 with an input-output model. The Medical Expenditure Panel Survey, commercial claims, and Medicare claims were analyzed to determine patterns of use by patient characteristics such as age, sex, health insurance coverage, cancer site, physician specialty, and service type. Patterns of use were then applied to the projected prevalence of cancer, using data from the SEER Program of the National Cancer Institute. RESULTS: Beginning in 2012, 16,347 oncologists and radiation oncologists were active and supplying 15,190 full-time equivalents (FTEs) of patient care. Without consideration of the Affordable Care Act (ACA), overall demand for oncologist services is projected to grow 40% (21,255 FTEs), whereas supply may grow only 25% (18,997 FTEs), generating a shortage of 2,258 FTEs in 2025. When fully implemented, the ACA could increase the demand for oncologists and radiation oncologists by 500,000 visits per year, increasing the shortage to 2,393 FTEs in 2025. CONCLUSION: Anticipated shortages are largely consistent with the projections of the ASCO 2007 workforce study but somewhat more delayed. The ACA may modestly exacerbate the shortage. Unless oncologist productivity can be enhanced, the anticipated shortage will strain the ability to provide quality cancer care.

American Society of Clinical Oncology National Census of Oncology Practices: preliminary report.

In response to reports of increasing financial and administrative burdens on oncology practices and a lack of systematic information related to these issues, American Society of Clinical Oncology (ASCO) leadership started an effort to collect key practice-level data from all oncology practices in the United States. The result of the effort is the ASCO National Census of Oncology Practices (Census) launched in June 2012. The initial Census work involved compiling an inventory of oncology practices from existing lists of oncology physicians in the United States. A comprehensive, online data collection instrument was developed, which covered a number of areas, including practice characteristics (staffing configuration, organizational structure, patient mix and volume, types of services offered); organizational, staffing, and service changes over the past 12 months; and an assessment of the likelihood that the practice would experience organizational, staffing, and service changes in the next 12 months. More than 600 practices participated in the Census by providing information. In this article, we present preliminary highlights from the data gathered to date. We found that practice size was related to having experienced practice mergers, hiring additional staff, and increasing staff pay in the past 12 months, that geographic location was related to having experienced hiring additional staff, and that practices in metropolitan areas were more likely to have experienced practice mergers in the past 12 months than those in nonmetropolitan areas. We also found that practice size and geographic location were related to higher likelihoods of anticipating practice mergers, sales, and purchases in the future.

Who does not receive treatment for cancer?

PURPOSE: Little has been published on nontreatment of cancer, yet the National Cancer Data Base (NCDB) indicates that 9.2% of patients receive no first course of treatment. Because the NCDB is limited to accredited cancer programs, there is potential for the actual rate to differ. We sought to understand the rate and characteristics of patients with cancer who receive no first course of treatment in a more population-representative data source. MATERIALS AND METHODS: The Iowa Cancer Registry (ICR) strives to capture 100% of newly diagnosed cancer cases among Iowa residents, regardless of where they are diagnosed or treated. RESULTS: In the ICR from 2004 to 2010, 12.3% of newly diagnosed patients with cancer did not receive a first course of treatment, which is 48% higher than the NCDB data for the state of Iowa (8.3%) during the same time period. Logistic regression indicated that nontreatment was more common in certain cancers (ie, small-cell and non-small-cell lung/bronchial cancers and low-grade non-Hodgkin lymphoma), advanced stages, older patients, those receiving treatment recommendations at nonaccredited cancer programs, and patients who never consulted an oncologist, radiation therapist, or surgeon. Distance to treatment facilities was not related to nontreatment. CONCLUSION: The rate of nontreatment varies by cancer type and stage and is higher in patients receiving initial treatment recommendations in nonaccredited cancer programs than in accredited cancer programs. This pattern seems to be correlated with patient characteristics but also may be related to provider and facility characteristics available to people locally that influence both patient and provider decision making.

Results of the ASCO Study of Collaborative Practice Arrangements.

PURPOSE: ASCO projects a shortfall of oncologists in the next decade. The study was designed to address the workforce shortage by exploring collaborative oncology practice models that include nonphysician practitioners (NPPs). METHODS: ASCO contracted with Oncology Metrics, a division of Altos Solutions, to conduct a national survey of NPP integration and identify collaborative practice models and services provided by NPPs, as the first phase of the ASCO Study of Collaborative Practice Arrangements. Results of the national survey were used to identify practices for the next phase, in which selected practices participated in a more detailed data survey and satisfaction surveys. Focus groups or interviews were conducted with NPPs to collect additional subjective information to inform the project. RESULTS: The incident-to practice model was the predominant model. Satisfaction was universally high for patients and generally high for physicians and NPPs. In virtually all cases (98%), patients recognized they were seeing an NPP rather than a physician. Practices in which the NPP worked with all practice physicians showed significantly higher productivity than those practices in which the NPP worked exclusively with a specific physician or group of physicians. CONCLUSION: The use of NPPs in oncology practices increases productivity for the practice and provides high physician and NPP satisfaction. Patients were aware when care was provided by an NPP and were very satisfied with all aspects of the collaborative care that they received. The integration of nonphysician practitioners into oncology practice offers a reliable means to address increased demand for oncology services without adding physicians.

Oncology Workforce: Results of the ASCO 2007 Program Directors Survey.

The supply of oncologists is projected to increase by 14%, but the demand for oncology visits is projected to increase by 48% because of a growing aging population and an increase in the number of cancer survivors. Multiple strategies must be implemented to ensure continued access to quality cancer care, such as increasing the number of oncology training positions.