Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics
REVIEW
An overview of clinical associate roles in the neurointerventional specialty Melissa D Chittle,1 Teresa Vanderboom,2 Judith Borsody-Lotti,1 Suvranu Ganguli,1 Patricia Hanley,1 JoAnne Martino,1 Peter Mueller,1 Alexandra Penzias,1 Catherine Saltalamacchia,1 Robert M Sheridan,1 Joshua A Hirsch2 1
Department of Radiology, Division of Interventional Radiology, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA 2 Department of Radiology, Division of Neurointerventional Radiology, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA Correspondence to Melissa D Chittle, Massachusetts General Hospital, Interventional Radiology, 55 Fruit St Blake 298, Boston, MA 02114, USA; [email protected] Received 12 December 2014 Accepted 13 December 2014
To cite: Chittle MD, Vanderboom T, BorsodyLotti J, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2014-011576
ABSTRACT Neurointerventionalists have long partnered with certain types of clinical associates to provide longitudinal care. This overview summarizes differences in education, background, roles, and scopes of practice of the various clinical associates ( physician assistants, nurse practitioners, clinical nurse specialists, radiology practitioner assistants, radiologist assistants, and nursing care coordinators). Key differences and similarities are highlighted to alleviate confusion about the roles clinical associates can assume on a neurointerventional service. This overview is intended to guide practices as they consider broadening their clinical support teams.
guide for NI practices. We will also discuss how clinical associates in our NI practice help enhance value across the trajectory of patient care. One way to compare clinical associates is through expanding the chart created by Rosenberg et al1 in their position statement on the role of physician assistants in interventional radiology (table 1). The following text supplements the chart by providing a brief history of each clinical associate, reviewing a history of the profession, education, scope of practice, and potential roles as reported in the literature.
Physician assistant (PA) INTRODUCTION The neurointerventional (NI) specialty is one that has multidisciplinary collaboration in its DNA. NI radiologists were exposed to the benefits of working with clinical associates relatively early in the radiology life cycle. The ever-changing and increasingly complex regulatory environment suggests a clear benefit of broadening NI teams with further inclusion of clinical associates. ‘Clinical associate’ is a term used to encompass nonphysician clinical support staff and includes physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), radiology practitioner assistants (RPAs), radiologist assistants (RAs), and nursing care coordinators. In providing neurovascular comprehensive care, NI specialists frequently assume the role of primary providers of that care. Clinical associates can help NI practices to adapt to these increasing demands. However, understanding the diverse backgrounds and scopes of practice of clinical associates can be challenging. The role of NPs and PAs in interventional radiology, commonly referred to as ‘midlevel providers’ or ‘advanced practice clinicians’, has been highlighted previously in publications by the Society for Interventional Radiology.1–5 Advanced practice clinicians are defined as healthcare providers with less training and a more restricted scope of practice than physicians, but who are formally certified and accredited in their jurisdictions to practice medicine. However, such publications are not focused on NI practices and, furthermore, not all clinical associate team members have been represented in the literature. Our aim is to provide a concise overview of clinical associates, summarizing the pertinent differences in education, backgrounds, roles, and scopes of practice which may serve as a useful
According to the American Academy of PAs, a PA is a medical professional who works as part of a team to practice medicine with the supervision of a physician.6 Supervision does not mean that the physician must always be present or direct every aspect of PA-provided care.
History The profession dates back to 1965 during a shortage of primary care physicians (PCPs). To meet the healthcare needs of the population, Dr Eugene A Stead Jr of Duke University Medical Center selected medically trained Navy corpsman and taught them through a fast track medical education program, and his first class graduated on 6 December 1967.
Education Most PA programs require 2–4 years of prior healthcare experience in a range of backgrounds including respiratory therapy, physical therapy, paramedical training, and an applicant must complete at least 2 years of college courses in basic science and behavioral science, analogous to premedical studies required of medical students. PA programs are modeled on the medical school curriculum, average 27 months, most award a Masters degree and promote clinical problem-solving and decision-making, emphasizing a team approach to care. PA education includes didactic work and more than 2000 h of clinical rotations in many settings.
Scope of practice A PA graduates as a medical generalist but can work in any specialty. A PA can practice in almost all the same settings as physicians since the passage of the Balanced Budget Act in 1997, but must be
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
1
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics Table 1 Comparison of clinical associates Radiology practitioner assistant (RPA)
Radiologist assistant (RA)
Clinical nurse specialist (CNS)
Nursing care coordinator (NCC)
Radiology Department MS/BS/Certificate
Nursing model
Nursing model
MS/DNP
Radiology Department BS
MS/DNP
NCCPA q10 year, state license
ANCC/AANP q 5 year, state license
CBRPA q 10 year, state license
ARRT, state license
ANCC q5 year, state license
BS/Associate/ Certificate/RN ANCC
100 h q 2 year (including 20 h process improvement/ self-assessment)
24 h q 2 year
50 h q 2 year
75 h q 5 year (6 h pharmacology)
75 h q 5 year
Scope of physician
75 h q 5 year (25 h pharmacology q 5 year and professional development (research, publication, mentoring) Scope of physician
Extend ability of radiologist
Extend ability of radiologist
Consent
Yes
Yes
Yes
Care coordination/ patient education/ communication No
Perform procedures Prescriptive authority/write prescriptions (DEA/ NPI number) Billable providers/ services reimbursed Order labs/imaging tests Write notes (consult, clinic, admission, discharge)
Yes Yes*
Yes Yes*
Yes No
Yes (best practice includes radiologist meeting patient) Yes No
Patient care/ nursing practice/ systems/process Yes*
No Yes*
No No
Yes
Yes
No
No
Yes*
No
Yes
Yes
Yes
No
Yes*
No
Yes
Yes
No
No
Yes*
No
Clinical associate
Physician assistant (PA)
Nurse practitioner (NP)
Education
Medical model
Nursing model
Degree
MS
Licensure/ certification and interval to recertification CME for national certification (state CME varies)
Scope (regulated by state boards)
Adapted from chart created by Rosenberg et al1 in their position statement on the role of physician assistants in interventional radiology. *Varies by state. AANP, American Association of Nurse Practitioners; ANCC, American Nurses Credentialing Center; ARRT, American Registry of Radiologic Technologist; BS, Bachelors of Science; CBRPA, Certification Board for Radiology Practitioner Assistants; CME, continuing medical education; DEA, Drug Enforcement Administration; MS, Masters of Science; DNP, Doctorate of Nursing Practice; NCCPA, National Commission on Certification of Physician Assistants; NPI, National Provider Identification.
employed within a physician practice. Their scope is limited to the scope of practice of the supervising physician. Hospitals will grant only privileges that the supervising physician holds through a credentialing process, wherein the PA applies for privileges and must document competency before performing without a physician present. Scope of practice varies from state to state, but most states leave determination of specific procedures deemed within the PA scope of practice to the supervising physician and the credentialing committees of individual hospitals. This encompasses first assist in procedures, performing procedures independently, evaluation and management services in inpatient and outpatient settings, performing physical examinations, diagnosing and treating illness, providing initial interpretation of imaging studies, ordering and interpreting laboratory tests, administering procedural sedation, prescribing medication, billing for their services, patient education and counseling, making rounds in acute and long-term facilities, conducting research, and participating in health policy.6–8
Nurse practitioner (NP) According to the American College of NPs, an NP is a clinician who blends clinical expertise in diagnosis and treating health conditions with an added emphasis on disease prevention and health management.9 2
History The NP profession started in the 1950s when an increase in specialization in medicine led a large number of physicians out of the primary care setting, thus creating a shortage of PCPs. Dr Loretta Ford and Dr Henry Silver developed the first NP program at the University of Colorado in 1965. The first students were public healthcare nurses who became pediatric NPs focusing on health promotion, disease prevention, and the health of children and families.
Education An NP is a registered nurse who has advanced clinical training beyond initial nurse preparation and is educated in the nursing model. Their focus is on promoting wellness and quality outcomes rather than focusing only on illness and disease. An NP must first obtain a registered nursing licence prior to entering an advanced practice program; however, many programs offer both components. Traditionally, programs have been at the Masters level but many programs now offer the Doctorate of Nursing Practice as the terminal degree for the NP. The American Association of Colleges of Nursing has recommended moving the current level of preparation necessary for advanced nursing practice from the Master’s degree to the Doctorate level by the year 2015. On average, education varies from 2–3 years of
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics advanced training with a minimum of 500 clinical hours in a focus area.
Scope of practice An NP can practice in all the same settings as physicians (and in which they hold certification) since the Balanced Budget Act of 1997. NPs are practitioners who do not necessarily require a supervising physician unless required by state regulations. They often work with a physician within a collaborative agreement outlining the scope of practice, method of consultation, and referral to the physician. Their scope of practice is essentially identical to that of PAs detailed above.10
Radiology practitioner assistant (RPA) According to the American Society of Radiologic Technologists (ASRT), an RPA is a health professional certified and registered as a radiographer and is credentialed to provide primary radiology healthcare service with physician supervision.11
History The RPA concept emerged in 1970 at a time when there was a shortage of radiologists in armed forces medical programs, problems with patient access, and the roles and responsibilities of radiologic technologists were becoming more complex due to technological innovations and medical imaging. In 1993, the Department of Defense asked Weber State University to design the first RPA program in an attempt to address these issues, and in 1996 it created the first program which focused on training radiologic technologists to become specialized physician extenders to increase the accessibility of quality radiologic services while reducing the time required of the radiologist.
Education An RPA must have completed a BA in radiology, be a licensed radiologic technologist, and have 3–5 years of clinical experience in radiologic sciences. They complete a 21 month distance learning program and graduate with a Bachelor in Science. Under the supervision of a radiologist in a healthcare facility radiology department, they complete their clinical requirements and competency assessments including learning to perform a variety of imaging procedures, evaluation of images to determine normal from abnormal pathology, anatomy and physiology, proper patient placement, and radiological patient management.
Radiologist assistant (RA) According to the ASRT, an RA is an advanced-level radiographer who enhances patient care by extending the capacity of the radiologist.16
History In 2002 there was a shortage of radiologists and a growing demand for imaging services that motivated the American College of Radiology to look for alternative ways of continuing to provide high quality patient care. At the same time the ASRT was looking for ways to extend the career path of radiologic technology in order to support recruiting and retention efforts. The two initiatives found a common solution in the RA concept, and the first program was developed through their collaboration.17
Education An RA is a radiographer with a Bachelor’s degree, registered in radiography, and has at least 1 year of clinical experience. The RA completes an advanced academic program, approximately 2 years in length, with a nationally recognized RA curriculum, and is awarded a certificate, Bachelor or Masters degree. Following didactic courses, the RA completes a radiologistdirected clinical preceptorship with specified mandatory and elective procedures.
Scope of practice Under the supervision of a radiologist, the RA extends the radiologist’s ability to provide patient care. This does not require the radiologist to be present in the same room, although the radiologist does need to be in the facility and immediately available for assistance. An RA can conduct selected examinations, fluoroscopy, and other radiology procedures using contrast, create images needed for diagnosis, act as a liaison between the patient and radiologist, take responsibility for patient assessment, education and management and make initial image observation. RAs do not perform interpretations ( preliminary, final, or otherwise) of any radiologic examination, nor do they transmit observations other than to supervising radiologists. They cannot diagnose or treat medical problems, do not bill for their services, and do not prescribe medication.
Clinical nurse specialist (CNS) According to the National Association of CNSs, a CNS is a license registered nurse who has graduate preparation (Masters or Doctorate) in nursing focused practice.18
Scope of practice
History
The RPA must work in a radiology department or imaging center and their scope is defined by the supervising radiologist. Within this relationship they can exercise autonomy in decisionmaking to participate more fully in patient care and management. They conduct radiologic patient assessments, participate in patient management, evaluate images, review and create preliminary reports, separate normal from abnormal imaging examinations, and determine whether immediate radiologist interpretation is needed. They protocol patients to determine clinical pathways, perform procedures in which competency has been demonstrated, administer contrast media and some intravenous medications and, following review with a radiologist, may order additional imaging studies. They do not diagnose or treat medical problems, do not bill for their services, and do not prescribe medication.12–15
In the mid-1800s the CNS was focused on the care and management of the psychiatric patient to provide moral treatment. In the 1960s, in response to the increasing complexity of healthcare delivery, the role took a modern turn with emphasis on ensuring that nursing practice is evidenced-based and nursing training and education remain in touch with the latest trends and technology.
Education A CNS obtains a nursing degree and then completes a Masters or Doctorate program that can take 2–5 years. A core curriculum including research, ethics, and health policy, and 600 h of clinical practice in an area of focus is required. The CNS is credentialed in a specialty area and must practice in the population of certification.
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
3
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics Scope of practice A CNS is an advanced practice nurse whose focus is the structure, process, and outcome of nursing care and practice. The CNS is often described as having three spheres of influence: (1) client-directed care, in which they provide expert consultation and independent nursing care; (2) nurses and nursing practice, in which the CNS is an expert consultant for nurses, leads quality improvement projects, and designs innovative evidencebased nursing care standards; and (3) impacting organizations and systems, in which the CNS is a leader in transforming healthcare agencies, political systems, public and professional organizations.18–22
Nursing care coordinator The American Nurses Association (ANA) defines a nursing care coordinator as a professional nurse who ensures that patients’ needs are met across settings and providers and facilitates the delivery of quality care.
History Our fragmented healthcare system is often characterized by communication failures and there is evidence to indicate that uncoordinated care has a negative impact. The Patient Protection and Affordable Care Act invokes care coordination throughout its provision to improve quality and control costs, and it is also a key feature for accountable care organizations. In 2011 the ANA advocated in a statement to the Centers for Medicare and Medicaid Services (CMS) that a nursing care coordinator was a possible solution to help fix the broken system, increase efficiency, and make the process of care delivery smoother while enhancing patient satisfaction.
Education A nursing care coordinator completes a nursing degree, which ranges from a 4-year Baccalaureate degree to a 2–3-year Associate degree, a 3-year diploma offered by a limited number of hospitals, or an accelerated 12-month Bachelor’s degree.
Scope of practice The scope of a nursing care coordinator varies depending upon the workplace, but frequently their role is ensuring adequate patient care through assisting patients as they navigate the healthcare system. Responsibilities include patient education, communicating with different departments and providers about care plans, and coordinating the scheduling of visits, imaging, and procedures. They triage patient telephone calls and communicate with patients after discharge to ensure they understand and are adherent to the care plan. They assess the financial, social, and emotional needs of patients and assist in obtaining resources needed by patients to manage their care. They are often involved in care coordination projects that seek to improve patient outcomes, decrease costs, and enhance patient satisfaction.23–25
DISCUSSION In practice, there are areas where the roles of clinical associates overlap and areas where their roles differ. PAs and NPs— referred to as advanced practitioners (APs)—are often interchangeable in their function on an NI inpatient service and in the outpatient clinic. This is both a function of state laws and institutional credentialing, which typically grants them essentially identical privileges. In addition, they are both classified as non-physician providers (NPPs) by the CMS and are thus billable providers whose services are recognized and reimbursed at 4
85–100% of the physician fee schedule. The revenue they generate can offset the cost of employment. In addition, they do not require personal supervision and can care for and bill for patients seen outside the procedural area. This can free the NI specialist to do other tasks, maximizing the number of patients seen and the revenue generated.26 APs have a strong presence in our NI outpatient clinic. They consult on new patients, see follow-up patients independently, perform history and physical examinations, write notes in the chart with assessments and recommendations, order additional laboratory and imaging tests, prescribe medications, triage acute issues, obtain informed consent, provide support and education to patient and families and link them to community resources. APs are used in the NI inpatient setting and interface with providers including those in neurocritical care, neurosurgery, neurology and medicine. The AP can be the first point of contact with the service and at times carries the service pager, triaging incoming pages pertaining to new consults, acute emergencies, incoming transfers, and new admissions. The AP remains a consistent presence working closely with in-house CNS and nursing leadership to act as a liaison to the NI practice. For patients admitted for elective NI procedures, the AP is the responding clinician, manages first-line clinical care for the patient, and provides support and education to families. Duties include daily rounding, sheath removal, writing orders, and discharge planning including case management, linking patients to community resources, and setting up follow-up care in the NI outpatient clinic. The role of the NI CNS is distinctly different from the AP as our state licensing board does not grant the CNS prescriptive or procedural privileges. The CNS thus focuses on the process of care delivery and has a critical role in educating staff and developing high performing teams. This is done in many ways, including sitting on institutional committees to develop treatment algorithms and policies, developing, reviewing and ensuring employe compliance with mandates and guidelines, educating staff through simulation, teaching Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and developing learner-focused evidenced-based orientation and annual competency programs. The CNS also educates patients and referring providers through talks, writing position statements, and creating standard discharge materials and management algorithms. The NI nursing care coordinator ensures patient follow-up with interval imaging and clinical evaluations over the trajectory of their care by overseeing a tracking database and scheduling patient visits. RAs and RPAs are not used in our NI outpatient clinic or inpatient settings as they are not recognized as NPPs by the CMS. As a result, services they perform on the floor or in the clinic cannot be billed for unless the supervising physician (typically a radiologist) is present. Their focus is much more geared to a traditional radiology department. They are used solely in the procedural area and under the supervision of a physician assist in conducting selected examinations and procedures by creating images needed for diagnosis.
CONCLUSION NI is a specialty rooted in innovation which must continue to adapt to increasing clinical and economic demands. Clinical associates can play a vital role in enabling NI specialists to meet these ever increasing demands—clinical, regulatory, and administrative. Since there is great variation in the backgrounds and scopes of practice among clinical associate team members, this concise review can guide NI practices in their hiring process.
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics Some of the differences in the way clinical associates can practice are determined by various third-party payers, regulatory agencies, jurisdictions, and healthcare centers, and therefore NI practices are always advised to consult with local experts regarding modes of practice that are acceptable in their regions. Since often more than one role group can fulfill the same need, a good personality fit, critical thinking skills, motivation, and flexibility will remain the qualities of utmost importance when selecting a clinical associate and building a successful NI team. Contributors MDC, TP and JAH drafted the preliminary manuscript. SG, JB-L, AP, CS, RMS, JM and PM critically reviewed the manuscript and provided meaningful editorial suggestions. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
10 11 12 13 14 15 16 17 18 19
REFERENCES 1 2 3 4
5 6 7 8 9
Rosenberg SM, Rosenthal DA, Rajan DK, et al. Position statement: the role of physician assistants in interventional radiology. J Vasc Interv Radiol 2008;19(12):1685–9. Taylor K, Sansivero GE, Ray CE Jr. The role of the nurse practitioner in interventional radiology. J Vasc Interv Radiol 2012;23:347–50. Stecker MS, Armenoff D, Johnson MS. Physician assistants in interventional radiology practice. J Vasc Interv Radiol 2004;15:221–7. Hong K, Georgiades CS, Hebert J, et al. Incorporating physician assistants and physician extenders in the contemporary interventional oncology practice. Tech Vasc Interv Radiol 2006;9:96–100. Davies L, Laasch HU, Wilbraham L, et al. The consent process in interventional radiology: the role of specialist nurses. Clin Radiol 2004;59:246–52. American Academy of Physician Assistants. What is a PA? http://www.aapa.org/ landingquestion.aspx?id=290 (accessed 2 Jun 2014). American Academy of Physician Assistants. Certification maintenance. http://www. aapa.org/twocolumn.aspx?id=984 (accessed 2 Jun 2014). American Academy of Physician Assistants. Becoming a PA. http://www.aapa.org/ twocolumn.aspx?id=984 (accessed 2 Jun 2014). American Association of Nurse Practitioners. Education (Continuing Education, CE Accreditation, Certification). http://www.aanp.org/education (accessed 2 Jun 2014).
20
21 22
23 24 25
26
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
American Association of Nurse Practitioners. Legislation/Regulation. http://www. aanp.org/legislation-regulation (accessed 2 Jun 2014). Certification Board for Radiology Practitioner Assistants. Professionals. http://cbrpa. org/professionals/ (accessed 2 Jun 2014). Certification Board for Radiology Practitioner Assistants. Accreditation. http://cbrpa. org/professionals/ (accessed 2 Jun 2014). American Registry of Radiologic Technologists. Employers and regulators. https:// www.arrt.org/Employers-Regulators (accessed 2 Jun 2014). American Registry of Radiologic Technologists. Patients and public. https://www.arrt. org/Employers-Regulators (accessed 2 Jun 2014). American Registry of Radiologic Technologists. Radiologic technologists. https:// www.arrt.org/Employers-Regulators (accessed 2 Jun 2014). American Society of Radiologic Technologists. Standards and regulations. http:// www.asrt.org/main/standards-regulations (accessed 2 Jun 2014). American Society of Radiologic Technologists. About ASRT. http://www.asrt.org/ main/standards-regulations (accessed 2 Jun 2014). National Association of Clinical Nurse Specialists. History and mission. http://www. nacns.org/html/history.php (accessed 2 Jun 2014). National Council for the State Boards of Nursing. Role delineation study of nurse practitioners and clinical nurse specialists. 2007. https://www.ncsbn.org/06_LPN_ RoleDelStudy_NCLEX_30_Web.pdf (accessed 1 Jun 2014). National Association of Clinical Nurse Specialists. Prescriptive authority of clinical nurse specialists. http://www.nacns.org/html/advocacy-policy.php (accessed 2 Jun 2014). National Association of Clinical Nurse Specialists. Advocacy and policy. http://www. nacns.org/html/advocacy-policy.php (accessed 2 Jun 2014). Clark A, Davidson S, Baldwin K. Statement on clinical nurse specialist practice and education. National Association of Clinical Nurse Specialists Statement on Clinical Nurse Specialist practice and education. www.nacns.org/docs/NACNS-statement.PDF Harrisburg, PA, 2004:1–57. American Nurses Association. Career and credentialing. http://www.nursingworld. org (accessed 2 Jun 2014). American Nurses Association. Practice. http://www.nursingworld.org (accessed 2 Jun 2014). American Nurses Association. The value of nursing care coordination: a White Paper of the American Nurses Association. http://www.nursingworld.org/carecoordination whitepaper (accessed 2 Jun 2014). Mulaik MW. Role of radiology extenders-dos and don’ts of proper billing. Radiology Today 2012;13(5–12). http://www.radiologytoday.net/archive/rt0512p12.shtml (accessed 2 Jun 2014).
5
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
An overview of clinical associate roles in the neurointerventional specialty Melissa D Chittle, Teresa Vanderboom, Judith Borsody-Lotti, Suvranu Ganguli, Patricia Hanley, JoAnne Martino, Peter Mueller, Alexandra Penzias, Catherine Saltalamacchia, Robert M Sheridan and Joshua A Hirsch J NeuroIntervent Surg published online January 5, 2015
Updated information and services can be found at: http://jnis.bmj.com/content/early/2015/01/05/neurintsurg-2014-01157 6
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 0 of which you can access for free at: http://jnis.bmj.com/content/early/2015/01/05/neurintsurg-2014-01157 6#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Socioeconomics (55)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Socioeconomics
REVIEW
An overview of clinical associate roles in the neurointerventional specialty Melissa D Chittle,1 Teresa Vanderboom,2 Judith Borsody-Lotti,1 Suvranu Ganguli,1 Patricia Hanley,1 JoAnne Martino,1 Peter Mueller,1 Alexandra Penzias,1 Catherine Saltalamacchia,1 Robert M Sheridan,1 Joshua A Hirsch2 1
Department of Radiology, Division of Interventional Radiology, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA 2 Department of Radiology, Division of Neurointerventional Radiology, Massachusetts General Hospital & Harvard Medical School, Boston, Massachusetts, USA Correspondence to Melissa D Chittle, Massachusetts General Hospital, Interventional Radiology, 55 Fruit St Blake 298, Boston, MA 02114, USA; [email protected] Received 12 December 2014 Accepted 13 December 2014
To cite: Chittle MD, Vanderboom T, BorsodyLotti J, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2014-011576
ABSTRACT Neurointerventionalists have long partnered with certain types of clinical associates to provide longitudinal care. This overview summarizes differences in education, background, roles, and scopes of practice of the various clinical associates ( physician assistants, nurse practitioners, clinical nurse specialists, radiology practitioner assistants, radiologist assistants, and nursing care coordinators). Key differences and similarities are highlighted to alleviate confusion about the roles clinical associates can assume on a neurointerventional service. This overview is intended to guide practices as they consider broadening their clinical support teams.
guide for NI practices. We will also discuss how clinical associates in our NI practice help enhance value across the trajectory of patient care. One way to compare clinical associates is through expanding the chart created by Rosenberg et al1 in their position statement on the role of physician assistants in interventional radiology (table 1). The following text supplements the chart by providing a brief history of each clinical associate, reviewing a history of the profession, education, scope of practice, and potential roles as reported in the literature.
Physician assistant (PA) INTRODUCTION The neurointerventional (NI) specialty is one that has multidisciplinary collaboration in its DNA. NI radiologists were exposed to the benefits of working with clinical associates relatively early in the radiology life cycle. The ever-changing and increasingly complex regulatory environment suggests a clear benefit of broadening NI teams with further inclusion of clinical associates. ‘Clinical associate’ is a term used to encompass nonphysician clinical support staff and includes physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), radiology practitioner assistants (RPAs), radiologist assistants (RAs), and nursing care coordinators. In providing neurovascular comprehensive care, NI specialists frequently assume the role of primary providers of that care. Clinical associates can help NI practices to adapt to these increasing demands. However, understanding the diverse backgrounds and scopes of practice of clinical associates can be challenging. The role of NPs and PAs in interventional radiology, commonly referred to as ‘midlevel providers’ or ‘advanced practice clinicians’, has been highlighted previously in publications by the Society for Interventional Radiology.1–5 Advanced practice clinicians are defined as healthcare providers with less training and a more restricted scope of practice than physicians, but who are formally certified and accredited in their jurisdictions to practice medicine. However, such publications are not focused on NI practices and, furthermore, not all clinical associate team members have been represented in the literature. Our aim is to provide a concise overview of clinical associates, summarizing the pertinent differences in education, backgrounds, roles, and scopes of practice which may serve as a useful
According to the American Academy of PAs, a PA is a medical professional who works as part of a team to practice medicine with the supervision of a physician.6 Supervision does not mean that the physician must always be present or direct every aspect of PA-provided care.
History The profession dates back to 1965 during a shortage of primary care physicians (PCPs). To meet the healthcare needs of the population, Dr Eugene A Stead Jr of Duke University Medical Center selected medically trained Navy corpsman and taught them through a fast track medical education program, and his first class graduated on 6 December 1967.
Education Most PA programs require 2–4 years of prior healthcare experience in a range of backgrounds including respiratory therapy, physical therapy, paramedical training, and an applicant must complete at least 2 years of college courses in basic science and behavioral science, analogous to premedical studies required of medical students. PA programs are modeled on the medical school curriculum, average 27 months, most award a Masters degree and promote clinical problem-solving and decision-making, emphasizing a team approach to care. PA education includes didactic work and more than 2000 h of clinical rotations in many settings.
Scope of practice A PA graduates as a medical generalist but can work in any specialty. A PA can practice in almost all the same settings as physicians since the passage of the Balanced Budget Act in 1997, but must be
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
1
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics Table 1 Comparison of clinical associates Radiology practitioner assistant (RPA)
Radiologist assistant (RA)
Clinical nurse specialist (CNS)
Nursing care coordinator (NCC)
Radiology Department MS/BS/Certificate
Nursing model
Nursing model
MS/DNP
Radiology Department BS
MS/DNP
NCCPA q10 year, state license
ANCC/AANP q 5 year, state license
CBRPA q 10 year, state license
ARRT, state license
ANCC q5 year, state license
BS/Associate/ Certificate/RN ANCC
100 h q 2 year (including 20 h process improvement/ self-assessment)
24 h q 2 year
50 h q 2 year
75 h q 5 year (6 h pharmacology)
75 h q 5 year
Scope of physician
75 h q 5 year (25 h pharmacology q 5 year and professional development (research, publication, mentoring) Scope of physician
Extend ability of radiologist
Extend ability of radiologist
Consent
Yes
Yes
Yes
Care coordination/ patient education/ communication No
Perform procedures Prescriptive authority/write prescriptions (DEA/ NPI number) Billable providers/ services reimbursed Order labs/imaging tests Write notes (consult, clinic, admission, discharge)
Yes Yes*
Yes Yes*
Yes No
Yes (best practice includes radiologist meeting patient) Yes No
Patient care/ nursing practice/ systems/process Yes*
No Yes*
No No
Yes
Yes
No
No
Yes*
No
Yes
Yes
Yes
No
Yes*
No
Yes
Yes
No
No
Yes*
No
Clinical associate
Physician assistant (PA)
Nurse practitioner (NP)
Education
Medical model
Nursing model
Degree
MS
Licensure/ certification and interval to recertification CME for national certification (state CME varies)
Scope (regulated by state boards)
Adapted from chart created by Rosenberg et al1 in their position statement on the role of physician assistants in interventional radiology. *Varies by state. AANP, American Association of Nurse Practitioners; ANCC, American Nurses Credentialing Center; ARRT, American Registry of Radiologic Technologist; BS, Bachelors of Science; CBRPA, Certification Board for Radiology Practitioner Assistants; CME, continuing medical education; DEA, Drug Enforcement Administration; MS, Masters of Science; DNP, Doctorate of Nursing Practice; NCCPA, National Commission on Certification of Physician Assistants; NPI, National Provider Identification.
employed within a physician practice. Their scope is limited to the scope of practice of the supervising physician. Hospitals will grant only privileges that the supervising physician holds through a credentialing process, wherein the PA applies for privileges and must document competency before performing without a physician present. Scope of practice varies from state to state, but most states leave determination of specific procedures deemed within the PA scope of practice to the supervising physician and the credentialing committees of individual hospitals. This encompasses first assist in procedures, performing procedures independently, evaluation and management services in inpatient and outpatient settings, performing physical examinations, diagnosing and treating illness, providing initial interpretation of imaging studies, ordering and interpreting laboratory tests, administering procedural sedation, prescribing medication, billing for their services, patient education and counseling, making rounds in acute and long-term facilities, conducting research, and participating in health policy.6–8
Nurse practitioner (NP) According to the American College of NPs, an NP is a clinician who blends clinical expertise in diagnosis and treating health conditions with an added emphasis on disease prevention and health management.9 2
History The NP profession started in the 1950s when an increase in specialization in medicine led a large number of physicians out of the primary care setting, thus creating a shortage of PCPs. Dr Loretta Ford and Dr Henry Silver developed the first NP program at the University of Colorado in 1965. The first students were public healthcare nurses who became pediatric NPs focusing on health promotion, disease prevention, and the health of children and families.
Education An NP is a registered nurse who has advanced clinical training beyond initial nurse preparation and is educated in the nursing model. Their focus is on promoting wellness and quality outcomes rather than focusing only on illness and disease. An NP must first obtain a registered nursing licence prior to entering an advanced practice program; however, many programs offer both components. Traditionally, programs have been at the Masters level but many programs now offer the Doctorate of Nursing Practice as the terminal degree for the NP. The American Association of Colleges of Nursing has recommended moving the current level of preparation necessary for advanced nursing practice from the Master’s degree to the Doctorate level by the year 2015. On average, education varies from 2–3 years of
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics advanced training with a minimum of 500 clinical hours in a focus area.
Scope of practice An NP can practice in all the same settings as physicians (and in which they hold certification) since the Balanced Budget Act of 1997. NPs are practitioners who do not necessarily require a supervising physician unless required by state regulations. They often work with a physician within a collaborative agreement outlining the scope of practice, method of consultation, and referral to the physician. Their scope of practice is essentially identical to that of PAs detailed above.10
Radiology practitioner assistant (RPA) According to the American Society of Radiologic Technologists (ASRT), an RPA is a health professional certified and registered as a radiographer and is credentialed to provide primary radiology healthcare service with physician supervision.11
History The RPA concept emerged in 1970 at a time when there was a shortage of radiologists in armed forces medical programs, problems with patient access, and the roles and responsibilities of radiologic technologists were becoming more complex due to technological innovations and medical imaging. In 1993, the Department of Defense asked Weber State University to design the first RPA program in an attempt to address these issues, and in 1996 it created the first program which focused on training radiologic technologists to become specialized physician extenders to increase the accessibility of quality radiologic services while reducing the time required of the radiologist.
Education An RPA must have completed a BA in radiology, be a licensed radiologic technologist, and have 3–5 years of clinical experience in radiologic sciences. They complete a 21 month distance learning program and graduate with a Bachelor in Science. Under the supervision of a radiologist in a healthcare facility radiology department, they complete their clinical requirements and competency assessments including learning to perform a variety of imaging procedures, evaluation of images to determine normal from abnormal pathology, anatomy and physiology, proper patient placement, and radiological patient management.
Radiologist assistant (RA) According to the ASRT, an RA is an advanced-level radiographer who enhances patient care by extending the capacity of the radiologist.16
History In 2002 there was a shortage of radiologists and a growing demand for imaging services that motivated the American College of Radiology to look for alternative ways of continuing to provide high quality patient care. At the same time the ASRT was looking for ways to extend the career path of radiologic technology in order to support recruiting and retention efforts. The two initiatives found a common solution in the RA concept, and the first program was developed through their collaboration.17
Education An RA is a radiographer with a Bachelor’s degree, registered in radiography, and has at least 1 year of clinical experience. The RA completes an advanced academic program, approximately 2 years in length, with a nationally recognized RA curriculum, and is awarded a certificate, Bachelor or Masters degree. Following didactic courses, the RA completes a radiologistdirected clinical preceptorship with specified mandatory and elective procedures.
Scope of practice Under the supervision of a radiologist, the RA extends the radiologist’s ability to provide patient care. This does not require the radiologist to be present in the same room, although the radiologist does need to be in the facility and immediately available for assistance. An RA can conduct selected examinations, fluoroscopy, and other radiology procedures using contrast, create images needed for diagnosis, act as a liaison between the patient and radiologist, take responsibility for patient assessment, education and management and make initial image observation. RAs do not perform interpretations ( preliminary, final, or otherwise) of any radiologic examination, nor do they transmit observations other than to supervising radiologists. They cannot diagnose or treat medical problems, do not bill for their services, and do not prescribe medication.
Clinical nurse specialist (CNS) According to the National Association of CNSs, a CNS is a license registered nurse who has graduate preparation (Masters or Doctorate) in nursing focused practice.18
Scope of practice
History
The RPA must work in a radiology department or imaging center and their scope is defined by the supervising radiologist. Within this relationship they can exercise autonomy in decisionmaking to participate more fully in patient care and management. They conduct radiologic patient assessments, participate in patient management, evaluate images, review and create preliminary reports, separate normal from abnormal imaging examinations, and determine whether immediate radiologist interpretation is needed. They protocol patients to determine clinical pathways, perform procedures in which competency has been demonstrated, administer contrast media and some intravenous medications and, following review with a radiologist, may order additional imaging studies. They do not diagnose or treat medical problems, do not bill for their services, and do not prescribe medication.12–15
In the mid-1800s the CNS was focused on the care and management of the psychiatric patient to provide moral treatment. In the 1960s, in response to the increasing complexity of healthcare delivery, the role took a modern turn with emphasis on ensuring that nursing practice is evidenced-based and nursing training and education remain in touch with the latest trends and technology.
Education A CNS obtains a nursing degree and then completes a Masters or Doctorate program that can take 2–5 years. A core curriculum including research, ethics, and health policy, and 600 h of clinical practice in an area of focus is required. The CNS is credentialed in a specialty area and must practice in the population of certification.
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
3
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics Scope of practice A CNS is an advanced practice nurse whose focus is the structure, process, and outcome of nursing care and practice. The CNS is often described as having three spheres of influence: (1) client-directed care, in which they provide expert consultation and independent nursing care; (2) nurses and nursing practice, in which the CNS is an expert consultant for nurses, leads quality improvement projects, and designs innovative evidencebased nursing care standards; and (3) impacting organizations and systems, in which the CNS is a leader in transforming healthcare agencies, political systems, public and professional organizations.18–22
Nursing care coordinator The American Nurses Association (ANA) defines a nursing care coordinator as a professional nurse who ensures that patients’ needs are met across settings and providers and facilitates the delivery of quality care.
History Our fragmented healthcare system is often characterized by communication failures and there is evidence to indicate that uncoordinated care has a negative impact. The Patient Protection and Affordable Care Act invokes care coordination throughout its provision to improve quality and control costs, and it is also a key feature for accountable care organizations. In 2011 the ANA advocated in a statement to the Centers for Medicare and Medicaid Services (CMS) that a nursing care coordinator was a possible solution to help fix the broken system, increase efficiency, and make the process of care delivery smoother while enhancing patient satisfaction.
Education A nursing care coordinator completes a nursing degree, which ranges from a 4-year Baccalaureate degree to a 2–3-year Associate degree, a 3-year diploma offered by a limited number of hospitals, or an accelerated 12-month Bachelor’s degree.
Scope of practice The scope of a nursing care coordinator varies depending upon the workplace, but frequently their role is ensuring adequate patient care through assisting patients as they navigate the healthcare system. Responsibilities include patient education, communicating with different departments and providers about care plans, and coordinating the scheduling of visits, imaging, and procedures. They triage patient telephone calls and communicate with patients after discharge to ensure they understand and are adherent to the care plan. They assess the financial, social, and emotional needs of patients and assist in obtaining resources needed by patients to manage their care. They are often involved in care coordination projects that seek to improve patient outcomes, decrease costs, and enhance patient satisfaction.23–25
DISCUSSION In practice, there are areas where the roles of clinical associates overlap and areas where their roles differ. PAs and NPs— referred to as advanced practitioners (APs)—are often interchangeable in their function on an NI inpatient service and in the outpatient clinic. This is both a function of state laws and institutional credentialing, which typically grants them essentially identical privileges. In addition, they are both classified as non-physician providers (NPPs) by the CMS and are thus billable providers whose services are recognized and reimbursed at 4
85–100% of the physician fee schedule. The revenue they generate can offset the cost of employment. In addition, they do not require personal supervision and can care for and bill for patients seen outside the procedural area. This can free the NI specialist to do other tasks, maximizing the number of patients seen and the revenue generated.26 APs have a strong presence in our NI outpatient clinic. They consult on new patients, see follow-up patients independently, perform history and physical examinations, write notes in the chart with assessments and recommendations, order additional laboratory and imaging tests, prescribe medications, triage acute issues, obtain informed consent, provide support and education to patient and families and link them to community resources. APs are used in the NI inpatient setting and interface with providers including those in neurocritical care, neurosurgery, neurology and medicine. The AP can be the first point of contact with the service and at times carries the service pager, triaging incoming pages pertaining to new consults, acute emergencies, incoming transfers, and new admissions. The AP remains a consistent presence working closely with in-house CNS and nursing leadership to act as a liaison to the NI practice. For patients admitted for elective NI procedures, the AP is the responding clinician, manages first-line clinical care for the patient, and provides support and education to families. Duties include daily rounding, sheath removal, writing orders, and discharge planning including case management, linking patients to community resources, and setting up follow-up care in the NI outpatient clinic. The role of the NI CNS is distinctly different from the AP as our state licensing board does not grant the CNS prescriptive or procedural privileges. The CNS thus focuses on the process of care delivery and has a critical role in educating staff and developing high performing teams. This is done in many ways, including sitting on institutional committees to develop treatment algorithms and policies, developing, reviewing and ensuring employe compliance with mandates and guidelines, educating staff through simulation, teaching Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), and developing learner-focused evidenced-based orientation and annual competency programs. The CNS also educates patients and referring providers through talks, writing position statements, and creating standard discharge materials and management algorithms. The NI nursing care coordinator ensures patient follow-up with interval imaging and clinical evaluations over the trajectory of their care by overseeing a tracking database and scheduling patient visits. RAs and RPAs are not used in our NI outpatient clinic or inpatient settings as they are not recognized as NPPs by the CMS. As a result, services they perform on the floor or in the clinic cannot be billed for unless the supervising physician (typically a radiologist) is present. Their focus is much more geared to a traditional radiology department. They are used solely in the procedural area and under the supervision of a physician assist in conducting selected examinations and procedures by creating images needed for diagnosis.
CONCLUSION NI is a specialty rooted in innovation which must continue to adapt to increasing clinical and economic demands. Clinical associates can play a vital role in enabling NI specialists to meet these ever increasing demands—clinical, regulatory, and administrative. Since there is great variation in the backgrounds and scopes of practice among clinical associate team members, this concise review can guide NI practices in their hiring process.
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
Socioeconomics Some of the differences in the way clinical associates can practice are determined by various third-party payers, regulatory agencies, jurisdictions, and healthcare centers, and therefore NI practices are always advised to consult with local experts regarding modes of practice that are acceptable in their regions. Since often more than one role group can fulfill the same need, a good personality fit, critical thinking skills, motivation, and flexibility will remain the qualities of utmost importance when selecting a clinical associate and building a successful NI team. Contributors MDC, TP and JAH drafted the preliminary manuscript. SG, JB-L, AP, CS, RMS, JM and PM critically reviewed the manuscript and provided meaningful editorial suggestions. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
10 11 12 13 14 15 16 17 18 19
REFERENCES 1 2 3 4
5 6 7 8 9
Rosenberg SM, Rosenthal DA, Rajan DK, et al. Position statement: the role of physician assistants in interventional radiology. J Vasc Interv Radiol 2008;19(12):1685–9. Taylor K, Sansivero GE, Ray CE Jr. The role of the nurse practitioner in interventional radiology. J Vasc Interv Radiol 2012;23:347–50. Stecker MS, Armenoff D, Johnson MS. Physician assistants in interventional radiology practice. J Vasc Interv Radiol 2004;15:221–7. Hong K, Georgiades CS, Hebert J, et al. Incorporating physician assistants and physician extenders in the contemporary interventional oncology practice. Tech Vasc Interv Radiol 2006;9:96–100. Davies L, Laasch HU, Wilbraham L, et al. The consent process in interventional radiology: the role of specialist nurses. Clin Radiol 2004;59:246–52. American Academy of Physician Assistants. What is a PA? http://www.aapa.org/ landingquestion.aspx?id=290 (accessed 2 Jun 2014). American Academy of Physician Assistants. Certification maintenance. http://www. aapa.org/twocolumn.aspx?id=984 (accessed 2 Jun 2014). American Academy of Physician Assistants. Becoming a PA. http://www.aapa.org/ twocolumn.aspx?id=984 (accessed 2 Jun 2014). American Association of Nurse Practitioners. Education (Continuing Education, CE Accreditation, Certification). http://www.aanp.org/education (accessed 2 Jun 2014).
20
21 22
23 24 25
26
Chittle MD, et al. J NeuroIntervent Surg 2015;0:1–5. doi:10.1136/neurintsurg-2014-011576
American Association of Nurse Practitioners. Legislation/Regulation. http://www. aanp.org/legislation-regulation (accessed 2 Jun 2014). Certification Board for Radiology Practitioner Assistants. Professionals. http://cbrpa. org/professionals/ (accessed 2 Jun 2014). Certification Board for Radiology Practitioner Assistants. Accreditation. http://cbrpa. org/professionals/ (accessed 2 Jun 2014). American Registry of Radiologic Technologists. Employers and regulators. https:// www.arrt.org/Employers-Regulators (accessed 2 Jun 2014). American Registry of Radiologic Technologists. Patients and public. https://www.arrt. org/Employers-Regulators (accessed 2 Jun 2014). American Registry of Radiologic Technologists. Radiologic technologists. https:// www.arrt.org/Employers-Regulators (accessed 2 Jun 2014). American Society of Radiologic Technologists. Standards and regulations. http:// www.asrt.org/main/standards-regulations (accessed 2 Jun 2014). American Society of Radiologic Technologists. About ASRT. http://www.asrt.org/ main/standards-regulations (accessed 2 Jun 2014). National Association of Clinical Nurse Specialists. History and mission. http://www. nacns.org/html/history.php (accessed 2 Jun 2014). National Council for the State Boards of Nursing. Role delineation study of nurse practitioners and clinical nurse specialists. 2007. https://www.ncsbn.org/06_LPN_ RoleDelStudy_NCLEX_30_Web.pdf (accessed 1 Jun 2014). National Association of Clinical Nurse Specialists. Prescriptive authority of clinical nurse specialists. http://www.nacns.org/html/advocacy-policy.php (accessed 2 Jun 2014). National Association of Clinical Nurse Specialists. Advocacy and policy. http://www. nacns.org/html/advocacy-policy.php (accessed 2 Jun 2014). Clark A, Davidson S, Baldwin K. Statement on clinical nurse specialist practice and education. National Association of Clinical Nurse Specialists Statement on Clinical Nurse Specialist practice and education. www.nacns.org/docs/NACNS-statement.PDF Harrisburg, PA, 2004:1–57. American Nurses Association. Career and credentialing. http://www.nursingworld. org (accessed 2 Jun 2014). American Nurses Association. Practice. http://www.nursingworld.org (accessed 2 Jun 2014). American Nurses Association. The value of nursing care coordination: a White Paper of the American Nurses Association. http://www.nursingworld.org/carecoordination whitepaper (accessed 2 Jun 2014). Mulaik MW. Role of radiology extenders-dos and don’ts of proper billing. Radiology Today 2012;13(5–12). http://www.radiologytoday.net/archive/rt0512p12.shtml (accessed 2 Jun 2014).
5
Downloaded from http://jnis.bmj.com/ on November 15, 2015 - Published by group.bmj.com
An overview of clinical associate roles in the neurointerventional specialty Melissa D Chittle, Teresa Vanderboom, Judith Borsody-Lotti, Suvranu Ganguli, Patricia Hanley, JoAnne Martino, Peter Mueller, Alexandra Penzias, Catherine Saltalamacchia, Robert M Sheridan and Joshua A Hirsch J NeuroIntervent Surg published online January 5, 2015
Updated information and services can be found at: http://jnis.bmj.com/content/early/2015/01/05/neurintsurg-2014-01157 6
These include:
References Email alerting service
Topic Collections
This article cites 5 articles, 0 of which you can access for free at: http://jnis.bmj.com/content/early/2015/01/05/neurintsurg-2014-01157 6#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Socioeconomics (55)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
