Landscape of Advanced Practice Provider Responsibilities in Pediatric Neurology

ABSTRACT

Introduction

A worldwide shortage of pediatric neurologists, combined with increased demand, increased wait times, and clinician burnout, have led to substantial access limitations. Given these challenges, we need to ensure advanced practice providers (APPs) in pediatric neurology are utilized effectively. Our results provide a framework for optimizing modern pediatric neurology practice through a thoughtful consideration of APP integration.

Methods

A survey was sent through two large neurology academic organizations. Emails were also sent to known professional contacts across 59 practice sites. An electronic survey in REDCap with 31 open‐ended or multiple‐choice questions about demographics, supervision, inpatient and outpatient clinical processes, procedures, and scholarly activities was sent.

Results

Surveys were completed from 29 sites. Sixteen of these sites (55%) reported APPs do not have demographic restrictions in their outpatient practice. At many practice sites APPs perform inpatient consultations, with variable models for independence and partnership with attending neurologists. APPs subspecialize frequently and perform a variety of procedures including lumbar punctures and headache treatment injections.

Conclusion

Most US‐based APPs in outpatient pediatric neurology practice autonomously and also frequently perform procedures. APP independence in the inpatient setting should be expanded. As pediatric neurology practices evolve, information regarding the landscape of APP clinical responsibilities will aid in increasing access to care.

1. Introduction

Nurse practitioner (NP) and physician associate (PA) programs originated in the 1960s with a goal of improving access to primary care. A prior definition of PA has been “physician assistant,” but since 2021 the American Academy of Physician Associates changed the name to reflect the PA's broader role in medicine. NPs and PAs are often collectively referred to as advanced practice providers (APPs). Training pathways of NPs and PAs are distinct, with NPs being trained in an advanced nursing model and usually requiring prior RN experience, while PA training programs are focused on a broad medical model. NPs are further diverse with training and accreditation pathways encompassing primary care NPs, acute care NPs, and family NPs. As health care has evolved dramatically over the past 60 years, APP practice has also changed to meet the needs of patients, caregivers, and health care systems [1, 2]. APPs continue to fill crucial gaps and improve access to care, but their roles are no longer limited to primary care settings. Rapidly increasing knowledge and technologies, increased acuity and complexity, increasing wait times [3], and rising costs [4] have all changed the landscape of health care in the United States. APPs are now integrated within all aspects of health care delivery, including subspecialty and population‐specific care. Employment organizations such as hospitals and academic health care systems determine provider privileges, while the scope of practice for NPs and PAs is determined by state laws and regulations [5]. Thus, significant differences in practice parameters exist between different states as well as organizations, especially in specialty and subspeciality practice. APPs have been shown to deliver cost‐effective care with high patient satisfaction and excellent patient outcomes [6, 7, 8, 9]. In 2020, the American Academy of Neurology updated their position statement on APPs to include the following: “The integration of APPs into the field of neurology to form care teams and create models of care is crucial to improving access, quality, and continuity of care of people with neurologic disease. It is necessary to recognize the accepted scope(s) of practice and allow each member of the neurology care team to practice to the full extent of their professional license, training, and abilities” [10].

It is evident that there is a shortage of pediatric neurologists in the United States, and this shortage is predicted to grow even larger in the next 10 years [11]. According to the Child Neurology Foundation, the number of pediatric neurologists in the United States is estimated to be at least 20% below national needs [12]. Increasing specialization within pediatric neurology [13], hiring changes as a result of the COVID pandemic [14], and increasing demand [15] have also hampered access to pediatric neurology care. Following the recommendations of the American Academy of Neurology, pediatric neurology practices can help fill this gap using APPs. Currently, there are no formalized guidelines regarding the use of APPs in pediatric neurology practices. In an attempt to better understand the current state of APP practice in pediatric neurology within the United States, 59 academic pediatric institutions were surveyed. The goal of this survey was to determine current APP roles in US‐based pediatric neurology practices. Health care organizations can use this information to integrate APPs into pediatric neurology practices, improve access to care, optimize physician workload, and reduce burnout [16]. It will also help ensure that all pediatric neurology providers are using their skills, knowledge, and experience at top of scope to realize their full potential.

2. Methods

2.1. Survey Development

IRB approval was obtained from the Colorado Multiple Institutional Review Board (#24‐0362). We created a 31‐question survey in REDCap [17] that was piloted to APP clinicians within our institution and adjusted based on their feedback. Survey domains included demographic information, clinician staffing numbers, outpatient (OP) clinical structure and staffing models, inpatient (IP) clinical structure, clinical procedures performed, and scholarly activities. The questions were either open‐ended or multiple choice. The survey is provided as Figure S1.

2.2. Study Sample and Recruitment

We engaged the American Epilepsy Society (AES) to distribute a survey link in their regular AES Connections email on April 24, 2024. Despite a national email, no responses were returned. Updates to the IRB protocol were then adjusted to include professional networking with Association of Child Neurology Nurses (ACNN) and AES leadership. Using US News & World Report (USNWR) as a guide to identify established pediatric academic neurology centers [18], personalized emails with REDCap surveys were sent to 59 individual clinician contacts at each practice site. Efforts were made to identify neurology clinicians with leadership titles in their section/division who we thought could best accurately describe staffing and clinical scope for APPs. Emails were sent a second time to those who did not respond to the survey after 2 weeks. For each site of practice, a request was sent to a single potential respondent.

3. Results

3.1. Section 1: Demographic

The response rate was 29/59 sites (49%) with data returned between August and November 2024. Responders' backgrounds were 11 pediatric nurse practitioners (PNPs) 19%, 4 family nurse practitioners (FNPs) 7%, 6 physician associates (PAs) 10%, 6 medical doctors (MD), doctors of osteopathy (DO), or bachelor of medicine, bachelor of surgery (MBBS), and the remaining 2 respondents had a mixture of other titles.

Seventeen of the 29 sites carried a 2024 USNWR top 50 children's hospital ranking in neurology and neurosurgery [18]. The respondents had many leadership roles (Figure 1), though “APP lead” was the most represented.

Figure 1.

Site respondent titles. APP lead was the most common response, though others in leadership positions were represented as well. Total number of respondents = 29. Each respondent came from a unique site. APP, advanced practice provider; APRN, advanced practice registered nurse.

3.2. Section 2: Clinical Practice Design

Survey respondents reported a large variation in the number of neurology clinicians within their practice (Figure 2). Twenty (69%) responded that APPs were employed by the hospital while five (17%) were employed by an affiliated university. One responder reported that APPs were employed by the school of nursing, and the three remaining (11%) replied that employment was mixed or that they were uncertain.

Figure 2.

Marked variability in group size of neurologist providers and APPs among respondents. The vertical y axis indicates the number of neurology practices that have the indicated number of neurologists (above) or APPs (lower). Total number of respondents = 29.

3.3. Section 3. Clinical Practice in Scope

APPs reported practicing in more than 13 pediatric neurology subspecialty care roles. The most common specializations were in epilepsy and headache (Figure 3). APPs reported a variety of clinical procedures performed, including adjustments to vagus nerve stimulators, lumbar punctures, headache‐related treatments such as botulinum toxin injections, and nerve block injections) (Figure 4).

Figure 3.

APP reported specialties and subspecialties. Other subspecializations included neurorehabilitation, traumatic brain injury, and concussion. Total number of respondents = 29.

Figure 4.

Specific procedures and number of sites performed by APPs. Total number of respondents = 29.

3.4. Section 4: Outpatient Care Models

Sixteen sites (55%) reported that APPs did not have section or hospital‐imposed restrictions on OP chief complaints or demographics seen by APPs in the OP clinic (Figure 5). Almost all sites (93%) reported APPs saw a mixture of new and follow‐up patients. One responder reported that their APPs only see follow‐up patients, and another single responder reported that their APPs see new seizure and headache patients only.

Figure 5.

Number of sites reporting section or hospital‐imposed restrictions on patients seen in clinic by advanced practice providers. Other included: probation period for the first.

APPs independently see patients in clinic in 23 of 28 respondents (82%), partially staffed in 11 of 28 (38%), and fully staffed by a neurologist in only 4 of 28 respondents (14%).

3.5. Section 5: Inpatient Care Models

APPs also perform a variety of IP roles. Epilepsy monitoring unit (EMU) and IP consulting services were the most common (Figure 6). Nineteen sites (65%) reported that their institution has APPs whose majority of clinical work is IP (excluding EMU). For APPs involved in neurocritical care, 13 sites (45%) report that the neurocritical care APPs are part of the neurology service team; 3 (10%) reported they are part of their intensive care unit team. Approximately a third responded that APPs are not a part of any neurocritical care team. Three selected “other” and answers included “I am not sure” and “APPs do not work in the critical care unit.”

Figure 6.

IP advanced practice roles. Non‐acute subspecialties include IP ketogenic diet, headache, and neuromuscular care. Total number of respondents = 29. APPs, advanced practice providers; CICU, cardiac intensive care unit; EMU, epilepsy monitoring unit; IP, inpatient.

When responding to IP consultations, 19 sites reported specific aspects of their staffing model. In 10 of these 19 sites (53%), the attending neurologist always sees and examines the patient. Seven of 19 sites (37%) report the attending physician sees the patient approximately 75% of each encounter, and two sites (11%) reported the attending sees the patient approximately 25% of the time.

3.6. Section 6: Scholarly Activities

Academic and scholarly activity varied across institutions, with the majority reporting involvement in quality improvement projects, clinical research, and abstract/posters (Figure 7).

Figure 7.

Advanced practice provider (APP) scholarly work. Total number of respondents = 29.

4. Discussion

4.1. Summary and Clinical Implications

We found that APPs perform a variety of clinical care in pediatric neurology with significant depth and breadth of activities. The APP role originated to improve access to care. As the relative availability of pediatric neurology care may decrease, patient care and families' experiences may be negatively impacted. This will be further exacerbated by reduced emphasis on IP care for future pediatric and child neurology residents during their training [12]. Employing pediatric APPs is a viable solution to improve access to pediatric neurology care. We described the current landscape in 2024 by highlighting actual responsibilities in multiple institutions and opportunities for the future.

APPs specializing in pediatric neurology are an essential part of the care team across a wide range of US‐based academic pediatric neurology practices. APP and attending level numbers at different practices varied greatly. Additionally, most institutions surveyed report that APPs were involved not only in the OP general neurology clinic, but also part of subspecialty care, performed procedures, and were part of diverse IP roles, including neurocritical care.

4.2. Roles and Staffing Models

APPs largely practice without restrictions in OP clinical settings. The majority also reported that APPs practice independently in this setting. While neurology APPs were utilized in many different IP roles, independence in the IP setting was more limited, though a small number did IP consultations with minimal physician oversight. These differences in APP restrictions in the IP versus OP setting should be further explored but are likely due to state laws governing medical practice, local institutional policy, training, and the customs and culture of their local neurology practice. We intend to explore this further in larger follow‐up studies as IP clinical areas outside of pediatric neurology, including adult neurology, pediatric hospital medicine, and pediatric critical care, have demonstrated successful independent and co‐management practice for APPs [19, 20, 21].

4.3. Procedures

APPs perform many different neurological procedures, with approximately half adjusting vagus nerve stimulator devices as well as other procedures, including lumbar punctures. In efforts to have attending physicians working at the top of their scope of practice, institutions should consider increasing the frequency of APPs performing routine procedures to allow physician providers more time to participate in complex neurological care. APPs performing procedures may have a cost‐effective component as well, though this will require further study.

4.4. Academic Pursuits

Our findings suggest that APPs are actively involved in academic work, including scholarly work and clinical research. Most institutions reported having active APPs engage in scholarly work in addition to their clinical duties. However, the survey did not ask if that effort or time was supported or protected as part of their employment or completed during “off” hours. The expectations, work hours, promotions, or incentives for APP academic work at each institution are likely to vary. It will be very important to understand how such efforts are supported and what resources are available, including mentorship, research training, statistics, and data support. Increasing involvement of APPs in scholarly activities could extend academic productivity at many institutions. This could aid in improving care and enhance retention at a pivotal time in pediatric neurology.

4.5. Next Steps

As practices continue to evolve, our data may provide a better understanding of the current scope of responsibilities and roles that pediatric neurology APPs are performing in the United States. Sections/divisions of pediatric neurology may be able to use this survey to advocate for expanding the roles or opportunities for APPs beyond their current practice, especially in the IP setting. In addition to improved access to care, pediatric neurology APPs have the potential to improve clinician satisfaction for all team members [19], contributing to retention through reduced turnover and burnout. Further opportunities to explore include best practices in APP neurology education, onboarding new hires, professional development, patient load metrics, and better defining and measuring quality and value of care. We plan to repeat surveys over time to better understand how the landscape of APP practice in pediatric neurology evolves in future years.

4.6. Limitations

While we had a very good overall response, incomplete responses to our survey may bias the results. We sent our survey to institutions where we did not have a personal connection with any providers but also to institutions where colleagues and personal acquaintances worked. While this was a practical measure and likely led to the relatively high response rate of 49%, it is a source of bias. We plan to mitigate this with follow‐up studies by sending to all institutions with pediatric neurology groups and not just those ranked by USNWR. Further potential bias is from targeting potential respondents who held leadership positions (Figure 1). While we maintain they are in the best position to address our request, results may have been different for a group mainly consisting of non‐leadership respondents.

Clinical responsibilities are impacted by state governing laws that govern responsibilities and independence and may not reflect restrictions by the institution. Only one respondent from each institution was surveyed, and many of them were in fact APPs themselves. As such, the data provided may be impacted by the respondent's role and awareness of all APP‐related activities and care. The role of APPs in private practice models was not explored.

5. Conclusion

This is the first report of the contemporary workforce and scope of practice for APPs practicing in pediatric neurology. Further work will be needed to evaluate the perceived benefit from APPs by their teams/colleagues [19], differences between NPs versus PAs [6], APP job and salary satisfaction metrics [22, 23], and academic and scholarly pursuits. Other outstanding questions include the comparative role of APPs in small, medium, or large programs as well as APP roles in programs with different USNWR rankings. While prior research done on APPs in other subspecialties shows favorable satisfaction by APPs and their team members [20, 21, 22, 23], future studies should explore perceptions by team members, as well as professional and salary satisfaction for academic pediatric neurology APPs.

Author Contributions

Chelsey F. Stillman: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing–review and editing, data curation, resources. Mona P. Jacobson: conceptualization, investigation, writing ‐ original draft, methodology, writing – review and editing, project administration, resources. Jill M. Marks: writing – original draft, methodology, writing – review and editing, resources. Craig A. Press: conceptualization, investigation, writing – original draft, writing – review and editing, supervision. Kelly G Knupp: conceptualization, investigation, methodology, validation, writing – review and editing, writing – original draft, project administration, supervision. Kevin C. Ess: supervision, funding acquisition, writing – original draft, writing – review and editing, validation, methodology, conceptualization.

Ethics Statement

This study was approved by the Colorado Multiple Institution Review Board (IRB #24‐0362).

Conflicts of Interest

Dr. Kevin Ess is a member of the editorial board for Annals of the Child Neurology Society. The other authors declare no conflicts of interest.

Supporting information

Supporting‐Figure‐Stillman‐et‐al‐2025.

Data Availability Statement

The primary data are not openly available due to confidentiality but are available from the corresponding author upon reasonable request. Data are securely stored within REDCap (Research Electronic Data Capture).