The National Kidney Foundation’s Council of Advanced Practice Providers issues a biennial online survey to assess roles, compensation, benefits, trends in job description, payment models and benefits among advanced practitioners.

The 15-minute online survey was conducted utilizing Survey Monkey and was open to all advanced practice providers (APPs) working in nephrology, regardless of their NKF membership. The link to the online survey was shared to theNKF’s Council of Advanced Practice Providers (NKF/CAPP) and American Academy of Nephrology Physician Assistants (AANPA) listservs. Data were collected between Jan. 1, 2022, and March 15, 2022.

An outbreak of COVID-19 spread rapidly across the globe, with the first confirmed case in the United States in January 2020. As a result, additional questions were added to the survey regarding the COVID-19 pandemic to assess its impact on practice for the nephrology APP workforce.

Even though NKF/CAPP membership has increased since 2020, there was a 9% reduction in the number of responses compared with the 2020 survey. Responses were reported from 47 states, three territories and three international sites.

Most nephrology APPs (91%) responding to the survey were employed full time. Although about 50% of APPs reported to be new to nephrology, most have a minimum of 5 years of experience as an APP.

However, APPs are aging out of their careers, similar to the trends seen with nephrologists. Nephrology APPs who are in their 30s and 40s each comprise 27% of the APP taskforce (compared with 29% and 25% in 2018). However, APPs who are 50 years or older make up 35% of the workforce (compared with 24% in 2018). This may also explain reported data that one-fourth of APPs are at the top of their pay scale.

Nurse practitioners (NPs) still make up most of the workforce (67%), with 80% of all APPs reporting that their highest degree obtained was a master’s degree.

Trends from the profile information provided in the survey indicate that the workforce has become more diverse. Eleven percent of the surveys were completed by those who self-identify as Asian American, 7% as African American and 5% as Hispanic. Female respondents comprise 87% of the nephrology APP workforce; however, there is an appreciable increase in men (13%), particularly male NPs.

APPs perform a wealth of clinical and non-clinical duties across a variety of domains. However, hemodialysis center duties continue to dominate for most APPs. Eighty-two percent of survey respondents uphold hemodialysis center duties compared with office practice duties (72%), education (52%), hospital coverage (51%), peritoneal dialysis duties (37%), administrative/ supervisory (23%) and research (11%).

Pediatric nephrology duties remain at 4% of survey respondents compared to 2020. The top three hemodialysis center duties identified were weekly rounds (96%), protocol management of ESAs or vitamin D (69%) and taking calls Monday through Friday during business hours (66%). Twenty-nine percent of APPs report managing 51 to 99 patients on dialysis weekly while 27% report 101-150 patients. Twenty-one percent of survey respondents report managing 50 or fewer dialysis patients per week. Patient numbers are spread across 2 to 3 hemodialysis units for a little more tha a one-third (36%) of APPs, with weekly commute times varying significantly from 1 hour to more than 4 hours.

Interestingly, although many APP survey respondents continue to fulfill hemodialysis center duties, 82% is the lowest seen since the inception of this survey.

More APPs (51% compared with 31% in 2016) are providing hospital coverage as a significant part of their responsibilities. Data published from 2010 through 2020, prior to the acute increase in hospitalizations secondary to the COVID-19 public health emergency, demonstrate the acuity of patients seen by APPs has increased along with their responsibility to manage them. Top hospital duties reported in the 2022 NKF/CAP survey included patient rounds (94%), hospital consults (90%) and history and physicals/discharge dictations (39%).

Other hospital duties included taking calls during business hours Monday through Friday, serving as a medical staff member, performing minor nephrology-related procedures, and serving on hospital committees, including peer reviews and for quality improvement.

Time spent related to duties involving peritoneal dialysis increased marginally since 2020 (37% in 2022 vs. 35% in 2020), however, the percentage of time APPs spent on hospital-only PD responsibilities grew from 40% in 2020 to 50% in 2022. It would be interesting to know if the rise in hospital-only PD is attributed to ongoing conversations promoting the use of that modality for urgent-start dialysis during hospitalization.

Office practice duties remain centered around chronic kidney disease management (86%) and hospital follow-ups (72%), though both are decreased from 2020 survey findings. New patient office consults expanded from 41% to 49%, while transplant management in the office practice setting (23%) stayed the same compared with 2020 survey findings.

Survey results indicated work responsibilities decreased for 5% of respondents due to patients’ fear of coming to the office and fewer transplants being performed due to the COVID-19 pandemic. Conversely, almost 40% reported a significant increase in patient numbers and workload.

Sadly, increased numbers of both staff and patient deaths were reported among 10% of respondents, which was thought by respondents to be a direct result of the pandemic. There has been an increase in the number of APPs who cover home dialysis patients with 39% stating there was an increase in workload, while 37% said they did more telehealth.

Educational (52% of survey respondents), administrative/supervisory (23%) and research (11%) duties account for some of the non-clinical responsibilities fulfilled by APPs. Within educational duties, much of the APP’s time is allocated to mentorship of APP students during clinical rotations (58%), orienting and training new APPs (54%) and teaching kidney disease education classes (41%).

Many APPs reported an increase in administrative duties, such as prior authorizations, billing and filing, due to staffing shortages associated with the pandemic. Research accounts for the smallest segment of APP time and most survey respondents indicate data collection (78%) and monitoring patients (62%) as top research duties. Research participation among APPs has continued to trend downward since at least 2018. Of note, 9% of respondents indicated they serve as primary investigators, 76% serve as sub-investigators (SI), while 30% of study respondents indicated they uphold SI and study coordinator duties. This is surprising because the duties of a study coordinator are not typical for APPs. This may also reflect a redistribution of responsibilities secondary to the disruptive nature of the COVID-19 pandemic.

Salaries for APPs continue to increase overall, with trends of six figures for both NPs and PAs continuing since 2016.

For 2022, an 8.4% increase in overall salary was seen compared with the 2020 salary report, with 25% of respondents reporting being at the top of their pay scale. While salaries have been comparable between nephrology NPs and PAs during the years, in 2022 NP salaries slightly exceeded PA salaries for the first time ($119,580 vs. $118,200 respectively).

NPs also reported their greatest increase in annual salary between 2020 and 2022, jumping from an average of $109,200 to $119,580. Pay determined by merit was reported by 42% of respondents. Almost two-thirds (64%) of APPs received a raise, with half of those getting a 1% to 3% salary increase.

Bonuses were given to more than half of respondents (57%) although of that group, most stated the bonus was not pandemic-related. One-third of bonuses were based on the overall practice productivity and about one-fourth of bonuses given were based on individual provider productivity.

Data regarding the differences in salary between male and female APPs is limited. Only 33 of the 293 respondents were men, but data indicated that salaries were lower for men compared with women. A subanalysis of the potential impact of geographic location, education and experience was not performed due to the small sample size. The effects of the COVID-19 pandemic on salary are difficult to fully appreciate. Approximately half of nephrology APPs reported an initial decrease in income, but half of those reporting a decrease saw their income rebound. Explanations for the rebound were not provided.

In terms of benefits, the most common benefits offered by employers are malpractice insurance (94%), retirement (91%) and CME( 88%). Employer-offered health insurance has seen a steady decline since 2016, although it remains the fourth most common benefit APPs report. Reimbursement for organizational fees fell significantly from 2020 to 2022, while cell phone benefits had the most significant increase from 2020 to 2022.

Extra benefits included flexible hours, extra computer monitors and office supplies. Despite the hemodialysis unit responsibilities, mileage reimbursement returned to 2018 levels. While it could be presumed, it is unclear if these were related to the COVID-19 pandemic.

Most APPs (60%) have written contracts in place with their employers, and of those with a contract in place, a non-compete clause is included in just less than half of respondents (49%). APPs reported having paid time off (PTO) and CME days, which are typically bundled together. Approximately two-thirds of APPs have 21 or more days of PTO available, and two-thirds also reported receiving holiday pay. For those who receive specific CME days, almost half (48%) get 4 to 5 days/year with many employers compensating APPs for CME.

Anecdotally, this was not always because of a contractual obligation. As mentioned previously, many APPs take call Monday to Friday during business hours. For those who take call after hours, 20% are compensated and 17% receive comp time instead.

This survey reflected a crucial period that was impacted by the COVID-19 global pandemic. While every attempt was made to measure the impact of the pandemic on nephrology APP practice, salary and benefits, there are areas that simply require speculation. Increased care of hospitalized patients, often with higher acuity levels, as well as more responsibility in caring for patients on home dialysis and increased telehealth visits, may be direct results of the COVID-19 pandemic.

Additionally, certain benefits related to work from home requirements, such as more flexible work schedules and technology resources, seem to reflect the impact of the pandemic on practices. Indeed, the 2024 survey results will be interesting to see. Only with time and robust participation in surveys like this one, can one identify how lasting effects of the pandemic will create opportunities for APPs to have roles in which APPs work to the fullest extent of their respective scopes of practice, hone our skills, and expand education and expertise.

The authors thank the NKF/CAPP for its assistance with the survey and Kim Zuber, PA-C, for assistance in data analysis.

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