Optimizing Colorectal Surgery Outcomes: The Role of the Advanced Practice Provider (APP) in Developing a Center for Pelvic Floor Disorders and Maximizing Scope of Practice for APPs

Abstract

Many patients with pelvic floor disorders who are referred to colorectal surgery do not actually need surgery. The Massachusetts General Hospital (MGH) Center for Pelvic Floor Disorders (PFDC) was established in 2008 out of a recognition of the need for a specialized comprehensive treatment for patients living with a pelvic floor disorder. To describe the model that we have created utilizing advanced practice providers (APPs) within the PFDC at the MGH as an example of a model of care for patients who historically may have been managed by colorectal surgeons. The utilization of APPs in surgery has increased, which in turn has had positive effects on patient care and can help reduce the demands put on surgeons to see patients who ultimately do not end up having surgery. There is also a potential for both direct and indirect revenue production through the utilization of APPs at the top of their scope of practice as well as increased access to care for these patients. Training APPs to work at the top of their scope within a surgical practice increases patient's access to care, allows surgeons to focus on those who ultimately require surgery, and can lead to better patient outcomes at a reduced healthcare cost. In order for this symbiotic relationship between APPs and surgeons to be successful, it is essential that there is mutual collaboration and trust between providers. It requires commitment from surgeons to appropriately train their APPs.

With the increasing prevalence of pelvic floor disorders due to the aging population, ¹ there is an increased need for healthcare providers who care for and manage these patients. Complaints of pelvic floor disorders are often evaluated by urology, gynecology, urogynecology, gastroenterology, and colorectal surgery. As the incidence of pelvic floor complaints grows in number and results in more referrals to specialized providers, there has been a recognition for a need for more interdisciplinary care. ² Although the majority of patients with pelvic floor disorders do not need nor benefit from surgical intervention, patients are often sent to surgical specialties for management. Due to the increasing burden on surgeons and lack of surgical need, these patients are often unable to get satisfying resolution of symptoms when seen in the surgical setting. ^{2 3} Thus, they continue to seek alternative care options adding additional burdens to the system. ⁴ The increasing need for patients to receive care has led to the significant growth in the role of the advanced practice provider (APP). The role of APP was initially established and defined in the 1960s. The APP can be defined as a nonphysician provider “who operates in collaboration with a physician to provide a deeper level of access, education, and clinical care to patients.” ⁵

APPs are inclusive of the positions of nurse practitioner (NP), physician assistant/associate (PA), certified nurse midwife (CNM), and nurse anesthetist (CRNA). This article will focus on the utilization of NPs and PAs in the outpatient setting for management of pelvic floor disorders. Currently, more than 355,000 NPs are licensed in the United States ⁶ with more than 36,000 new NPs who completed their academic programs in 2020–2021. ⁷ There are more than 150,000 PAs in the workforce in the US. ⁸ Historically, the role of NP was mainly found in the primary care and pediatric outpatient setting, and the role of PA was focused on inpatient care, assisting in the operating room, and working in the ED. However, as the need for additional providers in the specialty settings increased, so has the utilization of APPs in these settings. ⁹

The utilization of APPs in surgery has increased, which in turn has had positive impacts on patient care and can help reduce the demands put on surgeons to see patients who ultimately do not end up having surgery. APPs have historically been used in surgeons' offices to assist with preoperative and postoperative visits. ¹⁰ However, over time the role has evolved and in some surgical settings the APP may act as the provider completing the initial consultation as well as managing longer term nonsurgical care. In a more recent study by Beaulieu-Jones et al ¹¹ of pediatric surgery practices, greater than 90% of the practices had an APP, with APPs in both the inpatient and outpatient areas. In this study, >90% of surgeons reported a very positive or positive impact on their clinical practice with no negative impacts. They also found a high impact (>90%) of perceived patient satisfaction. Specific areas of significant positive impact include continuity of care, efficiency or service, and education of parents and patients. In addition to positive impact on the surgeons' clinical practice and patient satisfaction, there is the potential for both direct and indirect revenue production through the utilization of APPs at the top of their scope of practice. In the primary care setting, data show that when APPs are practicing at the top of their scope, it has increased both healthcare utilization and quality of care given. Additionally, there is improvement in patients' self-reported health status and reduction in emergency room care use which may help with cost-saving measures in the health system. ¹²

Similarly, when APPs are able to work at the top of their scope within surgical fields and specifically in pelvic floor disorders, there is a potential to have an increase in patient care access. In filling this gap, APPs act as a gatekeeper which creates an opportunity for surgeons to manage more patients who will ultimately undergo surgery. This system also decreases surgeons' burden of seeing and needing to manage the larger portion of patients seeking care for pelvic floor complaints who do not need surgical care. Caldwell et al proposed an integrated practice unit (IPU) model for care with a bundled payment model for patients with vaginal complaints including urinary incontinence and pelvic organ prolapse. ¹⁴ In this model, the APPs perform the initial evaluation including assessing patient-reported outcome measures as well as completing a thorough history and then necessary examinations. The APPs are then able to counsel the patients with surgical and nonsurgical treatment options utilizing a shared decision-making process. Patients who elect to undergo nonsurgical management may continue to follow with the APP instead of seeing a surgeon and those who elect to undergo surgical management are then seen by a urogynecologist for surgical consultation.

This model allows the urogynecologists to primarily see patients who will undergo surgery or require more complex care. The integration of APPs into surgical practices clearly improves access as well as the ability for surgeons to primarily manage patients needing surgical intervention in a timelier fashion. We will be describing the model that we have created utilizing APPs within the Center for Pelvic Floor Disorders at the Massachusetts General Hospital as an example of a model of care for patients who historically may have been managed by colorectal surgeons.

History of the Center

The Massachusetts General Hospital (MGH) Center for Pelvic Floor Disorders (PFDC) was established in 2008 out of recognition of the need for a specialized comprehensive treatment for patients living with a pelvic floor disorder. The recognition of the complex and interconnected problems that are best managed by a team of providers across different specialties led to the hiring and training of an APP to work as an integral part of this collaboration. The need for an understanding of the different components of pelvic floor dysfunction led to a training program that gives all APPs specialized training in urogynecologic assessments, gastroenterology with a specific focus on motility, and colorectal surgery. The colorectal surgeons were an integral part of the initiation of the program as well as creating a structured training program including clinic support, training in testing, and observation of surgery. Additionally, all APPs observe patients undergoing pelvic physical therapy to have a better understanding of this component of treatment. The APPs create strong relationships with the providers in neuro-intestinal gastroenterology, urogynecology, urology, pelvic floor physical therapy, and psychiatry to help ensure effective communication and timely collaboration. The goal in developing our center was to return every patient to health and well-being by taking a holistic, multimodal approach in his or her care. Effective communication and collaboration between specialties and providers is an essential part of our model to ensure that each patient's treatment journey is efficient and successful. A priority of the collaboration at the center was ongoing oversight by the surgeons and physicians with clinical presence and expertise in partnership with the APPs.

The primary center started at the main campus of the MGH in Boston, MA was initially staffed by one colorectal surgeon, three urogynecologists, one gastroenterologist along with one APP (a nurse practitioner). It has since grown to two additional satellite sites, namely, Danvers, MA in 2009 and Waltham, MA in 2022, with four dedicated APPs who provide thorough workups via examinations and in-office testing, create comprehensive care plans, and act as a liaison to bridge the different clinical areas within the center. Currently the multidisciplinary team includes eight urogynecologists and two urogynecology APPs along with a robust urogynecology fellowship, two urologists with training in urogynecology, five colorectal surgeons and four colorectal/access APPs, five gastroenterologists and two GI APPs, and four physical therapists. We also work closely with radiology, GI psychiatry, and pain management on specific patient populations.

All incoming referrals to the PFDC are scheduled based on their diagnosis, which helps to assign them to a particular pathway. Patients who have a single specific diagnosis (only stress urinary incontinence, only constipation etc.) will be seen directly in the appropriate specialty. Patients who have multiple complaints (i.e., fecal and urinary incontinence, rectocele and constipation) are seen by the colorectal/access APPs who provide first-line access to patients. Patients who only have colorectal pelvic floor complaints (fecal incontinence lower anterior resection syndrome [LARS] etc.) are also seen by the colorectal APPs. If patients are accidentally referred to a single department, the APPs then help to facilitate expedited access to the appropriate specialties. Our administrative assistants work with our APPs to make sure appropriate records are brought to the clinic to help facilitate a smoother visit.

When the PFDC was first established, we not only recognized the need to improve access and provide quality care, but also realized the importance of providing innovative and evidence-based care for this patient population. To do this, we understood that we needed to study our patients and promote research in this field. To do so, we created a comprehensive intake questionnaire which is given to all patients prospectively when they are first evaluated along with screens for urinary, prolapse, pain, and bowel symptoms as well as quality of life metrics by incorporating validated QoL questionnaires. The questionnaire also screens for history of trauma to help us provide the best trauma-informed care possible. This form has been modified over time and aligns with the IMPACT form ( I nitial M easurement of Pa tient-Reported Pelvic Floor C omplaints T ool). The IMPACT form incorporates the final recommended list of previously validated instruments which was voted on by more than 100 international experts at the annual Pelvic Floor Consortium Expert Meeting. ¹³

All new pelvic floor patients in colorectal surgery, urogynecology, and urology are mailed and sent a link through their online portal. Online questionnaires are completed in a REDCAP database. Those who complete the questionnaires by hand get uploaded to the REDCAP database at a later time. This allows for prospective data collection and helps to inform the visit and patient care. The APPs are an integral part of the research process. In addition to ensuring collection of initial data from patients, they manage the ongoing utilization of the database, ensure that patient data that have been completed with paper forms are transferred accurately into the larger REDCAP database, and work actively on PFDC research projects.

Clinical Pathway

There is a specific pathway for patients seen by the multidisciplinary group, starting with the colorectal/access pelvic floor APPs. In a similar pathway to that described by Caldwell et al, ¹⁴ an initial consultation is allotted a 1-hour timeframe to facilitate the capture of a detailed medical history as well as history of presenting illness. Additionally, a pelvic/vaginal examination, digital rectal examination, anoscopic examination, and high-resolution anorectal manometry testing are performed for the majority of patients with multicompartment symptoms (this may be deferred if the patient is unable to tolerate due to diminished mental capacity or other concerns). Anorectal manometry testing is interpreted in real time, and results are discussed with the patients during their initial visit. Due to the length of this visit, the APPs see three new pelvic floor patients per day. The clinic visits are completed by the APPs who see the patients independently and manage them autonomously unless/until surgery is needed. As discussed above, this allows patients who are seen for pelvic floor complaints who ultimately do not need surgery to have comprehensive management enabling improved patient outcomes. This allows the surgeons to filter out and only see patients who are appropriate surgical candidates. Despite these defined roles, the interdisciplinary goal of the center necessitates regular collaboration between the APPs and surgeons to ensure there is agreement on ongoing planning even if the outcome doesn't necessarily lead to surgery. The ongoing communication and mutual trust are foundational to the success of this model.

After the consultation, examination, and testing, the APP also determines whether additional studies are warranted (sitz mark study, defecography, colonoscopy, blood and/or stool studies) and helps to facilitate referrals to other specialists within and outside of our facility as appropriate. We have created specific pathways for management of different disease processes. Patients with fecal incontinence and a history of obstetric trauma will often get an anal ultrasound. Patients with constipation, rectal prolapse, and rectoceles with bowel dysfunction undergo fluoroscopic defecography. Patients with slow-transit constipation and abdominal pain may be sent to our neuro-intestinal gastroenterology group, and patients with pelvic pain may be sent to our pain management group for additional evaluation including evaluation for pudendal neuropathy.

Once necessary testing and consultations are completed and diagnoses are attained, patients who may be appropriate for surgery are presented in the multidisciplinary conference (as described below) and are scheduled to see the appropriate surgeons. In an effort to help with ease of coordination and timely scheduling, we have dedicated built-in OR time for combined surgical cases. If the APP determines at the initial visit that a combined surgery may be warranted, they are able to initiate the scheduling of surgery while having the patient complete any additional testing. When the patient then sees the surgeon, there is often a surgical date scheduled and the discussion with the surgeon can focus on the surgical plan. Patients who are not appropriate surgical candidates are followed by the APPs who may make additional referrals and adjust their treatment plan based on their symptoms and progress.

An integral part of our pathway is the utilization of pelvic floor physical therapy. We rely on our specially trained physical therapists in the MGH system and have formed close relationships with other pelvic physical therapists in the community. Patients may be referred directly after the initial consultation for management, and sometimes also for presurgical optimization. Our PT team has built close relationships with our APP team to help facilitate expedited referrals to each other as needed as well as allow the PTs to get assistance with medical management from the APPs and the APPs to get additional recommendations for pelvic floor management for patients.

Care Pathways

Through years of feedback from providers from multiple specialties, we have created pathways to evaluate and treat patients with specific conditions. Some examples of this are discussed below and the pathways are constantly evolving based on new research and evidence as well as discussions between providers. These pathways help to guide our recommendations for surgery and help to optimize care. Some examples include:

Slow-transit constipation : All patients with diagnosed slow-transit constipation who are looking for or are referred for surgery go through a specific pathway ( Fig. 1 ) which is guided by the APPs. This includes evaluation by our neuro-intestinal gastroenterology team to make sure that laxative management has been optimized and there are no additional medication possibilities that would help to avoid surgery. They are also assessed for pan-motility disorders which may impact the outcomes of surgery. This medication management is sometimes done by the access APPs in consultation with the neuro-intestinal GI team to expedite care. Additionally, patients are evaluated by our GI psychiatry team. Those patients who are seen through the entire pathway are then discussed at the multidisciplinary conference and if it seems appropriate, may be offered surgery. Surgeries may include subtotal colectomies, loop or end ileostomies, cecostomy etc.

Fig. 1.

Pathway for patients with slow-transit constipation. APP, advanced practice provider; ACE, antegrade continence enema. (Adapted with permission from Kyle Staller, MD. ¹⁵ )

Rectal and vaginal prolapse : All patients with combined rectal and vaginal prolapse undergo anorectal manometry, POP-Q examination, cough stress test or urodynamic testing, and defecography. Those with underlying constipation work with the APPs and GI to optimize bowel function prior to surgery. Once they are evaluated as described, they are reviewed in the multidisciplinary conference and surgery is offered as appropriate. This may include either combined surgery or single surgery as appropriate.

Patients with psychiatric concerns which may impact care : Although our entire team practices trauma-informed care, many patients with pelvic floor disorders may have a history of trauma which can become a barrier to care. For these patients, we have a specialized therapist who works with these patients. The therapist may help patients initially undergo examinations as well as prepare for any invasive procedures and pelvic physical therapies to help patients achieve the most success in treatment. Patients with eating disorders may be sent to our disordered eating clinic to help with nutrition support during treatment.

Multidisciplinary Conference

As alluded to above, once a month we hold an hour-long multidisciplinary meeting where providers from colorectal surgery, neuro-gastroenterology, uroGYN, urology, radiology, physical therapy, and psychiatry are present. This meeting is used to discuss patients who are candidates for combined surgeries, to discuss medical management of complex patients, or to review interesting imaging findings. All providers at the pelvic floor center can have patients presented at their request. Often those that have been seen by the APPs who are likely surgical candidates are presented for a discussion of surgery before seeing the surgeons. All patients are presented by the urogynecology fellow and appropriate imaging is presented and reviewed by radiology. For every patient who is presented the group comes up with individualized recommendations which are then communicated to the patient by a member of the care team (often the APP). These recommendations are also documented in their chart, so they are easily accessible by all.

Patient Education

Patient education is an integral part of the care our pelvic floor patients receive. Part of the reason for the lengthy initial visit with the APPs is to allow for this education to start from the first visit. This education includes a thoughtful discussion about lifestyle modifications such as proper posturing and breathing, reducing preoccupation with the bathroom, avoidance of intense straining and prolonged sitting, stress management, and relaxation. Our practice is to provide patients with an “after visit summary” which outlines their treatment plan in writing and may also include visual images to help improve patient's understanding and compliance.

APP education includes better understanding of defecatory patterns that exist and how to improve them, as well as education about bladder retraining when appropriate, and education about the role that other testing and consultations may play in their care.

Specific education from APPs about bowel habits are described below:

Prior to going to the bathroom to attempt defecation it can be helpful to help patients differentiate between a rectal urge versus an abdominal urge. A rectal urge is described as the feeling one gets when they know they had better start looking for a bathroom, with pressure being very low in the pelvis. This is opposed to an abdominal urge, where one might feel peristalsis or cramping in the abdomen or hear borborygmi. By waiting until a rectal urge is felt, the patient is more likely to have a complete, satisfying bowel movement. Patients who struggle with outlet obstruction constipation or dyssynergia are then instructed to elevate their feet so that their knees are slightly higher than their umbilicus, with their knees hip distance apart. They can rest their forearms on their thighs/knees or can try leaning back. This positioning helps to straighten the anorectal angle, which at rest maintains a 90-degree angle. By straightening this angle, it allows a straighter path for the stool to empty the rectum. To help reduce straining, patients are then taught to engage in diaphragmatic breathing to assist in relaxation of their pelvic floor muscles. Slow, deep breathing allows the pelvic floor to rest periodically so the muscles remain strong and flexible. For example, when one inhales, the diaphragm moves down, and the pelvic floor lowers and gets a nice stretch. When one exhales, the diaphragm rises, and the pelvic floor moves upward and gets a gentle contraction.

Another important lifestyle piece to consider is the patient's diet and fluid intake. The most common dietary GI triggers include fat, lactose, gluten (non-celiac gluten sensitivity), and high fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) foods. Fat can increase visceral hypersensitivity and can slow intestinal gas transport. Lactose can provoke GI symptoms in a person with lactose intolerance. Non-celiac gluten sensitivity can overflow with other functional GI disorders. High FODMAP foods are poorly absorbed which can bring water into the small intestine causing fermentation in the large intestine and ultimately unwanted GI symptoms. We also discuss foods and beverages which can be bowel irritants such as caffeine, alcohol, and carbonated drinks. It can also be helpful to have patients complete a 2-week bowel diary to look for trends in their bowel pattern or accidents, especially if the patient is not a great historian or is not progressing as hoped.

Conclusion

As previously discussed, the utilization of APPs within the surgical practice can significantly improve patients' access to care as well as improve quality of life for surgeons and patients. The model we have described recognizes the ability for APPs to work at the top of their scope of practice. The establishment and maintenance of this model require a commitment from surgeons to appropriately train their APPs and continually support them via collaboration of care. By utilizing APPs in this manner, and giving them increased autonomy within a surgical practice, this also leads to better job satisfaction for APPs and leads to retention of these APPs.

Having APPs involved in all aspects of care including initial evaluations, ongoing management, multidisciplinary discussions, and research also leads to a more holistic manner of treating patients. Often patients with pelvic floor disorders need significant amounts of time to be counseled and fully understand their complaints and how to manage them. Because the APPs are immersed in the care and management of these patients, they are equipped with the knowledge, tools, and supports from surgeons to fully treat these patients and ultimately allow for patients to be discharged from the practice with a feeling that their complaints have been addressed to their satisfaction, and that they do not need to seek out additional care providers.

Within our practice, the symbiotic relationship between APPs and surgeons has created a robust program for patients with pelvic floor disorders. The commitment to collaboration and ongoing oversight from surgeons is essential to the success of this program, and without this participation and mutual trust between providers the model would not work. In addition to clinical care, the opportunity to be involved in research including writing papers and presenting at conferences has helped to make our APP team feel respected and integrated into the larger field of pelvic floor disorders. The support of the colorectal surgeons by supporting the full engagement in the American Society of Colorectal Surgery (ASCRS) including encouraging ASCRS membership, ongoing participation in the annual meeting, and working on committees has allowed the team of APPs to become experts not only in the management of patients with pelvic floor disorders, but also to have a greater understanding of the entire colorectal field. This has led to additional innovations in the colorectal practice including APP's management of benign anorectal complaints (similar to pelvic floor disorders often not needing surgical intervention), management of patients with anal dysplasia, assistance with management of urgent complaints while surgeons are in the office (acute management of thrombosed hemorrhoids and abscesses), and help with supporting all postsurgical patients. We feel that ultimately the increased utilization of APPs as part of the colorectal teams can help to improve the surgeon's quality of life, create a clinical home for APPs, and ultimately lead to better patient outcomes at a reduced healthcare cost.