title: Implementation of an Advanced Practice Provider Service on an Allogeneic Stem Cell Transplant Unit: Impact on Patient Outcomes.
abstract: Allogeneic stem cell transplantation (ASCT) is a complex medical procedure for some patients with hematologic malignancies. Most ASCTs occur at academic centers where either medical residents (house staff [HS]) or advanced practice providers (APPs) provide daily care. As a result of increasing work-hour regulations, APPs have assumed greater responsibilities, including those traditionally held by HS. In this study we evaluate ASCT patient outcomes by inpatient provider service. A retrospective, single-center chart review of ASCT patients was performed. ASCT patients admitted to an HS service from May 2011 to May 2012 (N = 86) were compared with ASCT patients admitted to a newly formed APP service from October 2012 to October 2013 (N = 81). As part of a secondary sensitivity analysis, we compared ASCT patients on the APP service to a subset of ASCT patients admitted to the HS service also from October 2012 to October 2013 (n = 27). Our primary outcomes were 100-day survival and relapse-free survival rates. Additional outcomes included length of stay (LOS), inpatient complications, and ordering behavior. Our primary pre- and post-analyses found no differences in 100-day overall survival and 100-day relapse-free survival rate between the services. The rate of pneumonia was lower on the APP service (15% versus 28%, P = .04), with no significant differences in other infectious complications. HS ordered more blood cultures (6.7 versus 4.2, P = .03) per patient than the APP service. There was no difference in LOS, readmission rates, or inpatient mortality. With regards to our secondary sensitivity analysis, no differences were found in 100-day overall survival and 100-day relapse-free survival rates between the services. There was a decreased LOS on the APP service (29.4 versus 37.2 days, P = .01). HS ordered more blood cultures (9.3 versus 4.2, P < .01) and more radiological films (8.1 versus 5.2, P = .05) per patient than the APP service. This increased ordering and LOS was associated with an increase in mean hospital charges on the HS service (P = .04). ASCT patients on an APP service had similar 100-day outcomes as those on the HS service. In the setting of limited resources, APPs are potential alternative providers for complex transplant inpatients.
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: nirav.shah@uphs.upenn.edu.
authors.forename: Nirav N
authors.initials: NN
authors.lastname: Shah
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Colleen R
authors.initials: CR
authors.lastname: Kucharczuk
authors.affiliation: Department of Biostatistics & Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Nandita
authors.initials: N
authors.lastname: Mitra
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Hirsh
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Jakub
authors.initials: J
authors.lastname: Svoboda
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: David
authors.initials: D
authors.lastname: Porter
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Alison
authors.initials: A
authors.lastname: Loren
authors.affiliation: Abramson Cancer Center, University of Pennsylvania and Division of Hematology/Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Noelle
authors.initials: N
authors.lastname: Frey
authors.affiliation: Division of General Internal Medicine, University of Pennsylvania and Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Division of General Internal Medicine, Philadelphia, Pennsylvania.
authors.forename: Marilyn M
authors.initials: MM
authors.lastname: Schapira
mesh_terms: D000368:Aged; D064591:Allografts; D003695:Delivery of Health Care; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006282:Health Personnel; D019337:Hematologic Neoplasms / Q000401:mortality / Q000628:therapy; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D033581:Stem Cell Transplantation; D015996:Survival Rate
keywords: APPs; Allogeneic transplant; Outcomes