Mr. David Mick, PHD, LVN

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Optimizing urology group partnerships: Collaboration and compensation best practices

Overall Cohort

Among the entire cohort of interest the inclusion of an APP as part of a write my essay team resulted in an overall decreased LOS . Median LOS decreased from 3.00 days (IQR 2.00–6.00) to 3.00 (IQR 2.00–5.00) thereafter (p <0.042). There was an increase in the number of discharges before 11 a.m. (p <0.001) with 21/553 discharges (3.8%) before APP inclusion and 57/633 discharges (9.0%) before 11 a.m. after APP inclusion. There was no statistically significant change in total direct cost for all 3 groups combined (p=0.893). Total direct median cost prior to APP inclusion was $11,511.13 (IQR 9,959.69–16,254.20), and $11,907.49 (IQR 9,999.81–15,074.63) after APP inclusion.


Cystectomy with Ileal Conduit

Among patients undergoing cystectomies with ileal conduit the inclusion of APP resulted in no significant changes to LOS with median LOS prior to APP 7.00 days (IQR 6.00–10.00) as compared to 6.00 (IQR 5.00–9.00) thereafter  There was no statistically significant change in the number of discharges before 11 a.m. (p=0.112). There were 2/87 discharges (2.3%) before APP inclusion and 8/90 discharges (8.9%) before 11 a.m. after APP inclusion. There was a statistically significant decrease in total direct cost for cystectomies after APP inclusion (p=0.048) with a total direct median cost prior to APP inclusion for cystectomies of $19,173.69 (IQR 16,214.70–23.946.46) and $16,794.72 (IQR 14,406.47–22,152.78) after with a net median decrease of $2,378.97 .



Among patients undergoing nephrectomies the inclusion of an APP resulted in no significant changes to LOS (p=0.682) without change in LOS 3.00 days (IQR 2.00–5.00) . Additionally, there was a statistically significant increase in the number of discharges before 11 a.m. with 16 (5.0%) after APP as compared to 32 (9.4%) (p=0.032) before. In fact, initiation of an APP increased early discharges prior to 11 a.m. by almost 200%. While there was a significant reduction in cost within the cystectomy cohort this was not observed in procedures with a typically shorter postoperative course. There was no statistically significant change in total direct cost for nephrectomies before and after APP inclusion 



Among patients undergoing prostatectomies the inclusion of an APP resulted in a statistically significant write my essay for me with a median of 2.00 days (IQR 1.00–4.25]) before APP inclusion and 2.00 (IQR 1.00–3.00) after APP inclusion. Of note, there was a statistically significant increase in the number of discharges before 11 a.m. (p=0.02). There were 3/150 discharges (2.0%) before APP inclusion and 17/200 discharges (8.5%) before 11 a.m. after APP inclusion. There was no statistically significant change in total direct cost for prostatectomies before and after APP inclusion (p=0.456). Total direct median cost before APP inclusion for prostatectomies was $11,359.56 (IQR 10,044.19–13,636.75) and after APP inclusion it was $11,590.83 .



The advanced practice provider model since the birth of the profession in the 1960s has extended worldwide into more than 70 countries including the United Kingdom, Australia and New Zealand among others, all employing NPs and PAs. The profession aims to improve access to treatment, provide cost-effective care and provide services in remote communities. The expansion of the APP role into urology comes primarily out of need with an alarming shortage of physicians and especially urologists in the current health care system. While the number of NPs and PAs has increased annually, projected number of APPs delivered would equal about 25,000 physicians with a deficit twice that number. Projections estimate a 37.5% increase in urological services during the next 2 decades, and the number of urologists per capita is expected to decline during that time. The need to provide urological services coupled with an evolving shortage became an impetus for incorporation of an APP into urological outpatient and inpatient settings. While their credibility, efficacy and use have been widely researched in primary medicine and pediatric literature  few studies have focused on cost efficacy within the urological realm. This study represents the first cost and benefit analysis of an inpatient APP within a urological setting.

Our study was able to show a decrease in LOS in the overall cohort with the introduction of an APP that is clinically and statistically significant. The decrease in LOS after NP addition has been relatively well characterized and studies have cited improved overall coordination of care especially regarding plans surrounding discharge as a dominant factor. Specifically, NPs can contact the appropriate interprofessional staff in a timely manner when the patient nears discharge and allow patients the ability to call with concerns during office hours.

The observed overall lack of statistically significant change in direct cost after APP inclusion is surprising, especially when compared to studies that have paper writing service online NPs as cost-effective in many areas of medicine including primary care, inpatient cardiology, neonatology and emergency medicine.  However, our study was limited in sample size and we did observe a decrease in total direct cost for the cystectomy group, a procedure with a notably longer postoperative course.  In current literature the common theme among the effects of NPs on direct cost savings appears to be their ability to streamline coordination of care with other departments resulting in decreased LOS and readmission rates all while maintaining strong patient satisfaction levels and clinical outcomes. To our knowledge there have been no studies that have examined the cost-effectiveness of NPs within surgical specialties.

There were several limitations to our study. Although our initial sample size was large and included 1,100 urological procedures over a 3.5 year span, after subdividing by procedure and by APP status it was difficult to establish statistical significance for some procedures. We did not adjust for specific patient factors including comorbidities and postoperative complications in our study. In addition, the generalizability of the study has not been established as the data were gathered from a single tertiary care referral center and compared data before and after a single APP hire. There are numerous intangible benefits of inpatient APP not measured in this study including patient satisfaction, transition of care and availability of care. In addition, there was not a way to definitely prove a causal relationship between APP hiring and subsequent changes in LOS, discharge rates or other dependent variables by controlling for other potentially significant events that occurred during the timespan of interest, which included a switch in custom essay writer rates with a change in several insurance payers.

Nevertheless, as a whole our findings provide evidence supporting the inclusion of advanced practice providers within inpatient settings. The statistically significant decreased length of stay and earlier discharges for major urological cases after APP inclusion are largely consistent with the roles APPs were designed to play within a urological health care team. A survey of 53 NPs designed to evaluate the role of the nurse practitioner in urology revealed that for the vast majority of NPs (78%) over 75% of their time was spent as a clinician and managing urological diagnoses. Further work is required to more fully elucidate the direct cost savings benefits APPs provide within inpatient urological health care teams using larger sample sizes from multiple centers across an extended period of time. In addition, apart from cost savings future work should be geared toward further clarifying the clinical benefits of APP hiring for urological teams, analyzing outcomes standpoint and patient satisfaction.



The inclusion of an advanced practice provider within the inpatient urological setting has been shown to consistently improve length of stay and direct cost for cystectomy care. Further work is required to more fully characterize the clinical and financial benefits of APP hiring.