Survey on Referring Clinician Perspectives of Nurse Practitioners in Pediatric Cardiology Clinic

Background: In the setting of physician shortages, nurse practitioners (NPs) have become a vital part of healthcare. Their roles have evolved with increasing independence across all healthcare settings, including pediatric subspecialties. We sought to characterize referring clinicians’ acceptance of consultations performed by NPs in pediatric cardiology clinics.

Methods: We electronically surveyed pediatricians, pediatric subspecialists, family medicine physicians, pediatric and family medicine physician trainees (residents/fellows), and pediatric NPs in Arkansas between May 2021 and June 2021. The survey was distributed via email through the Arkansas chapters of the American Academy of Pediatrics and American Academy of Family Physicians, as well as the referring-physician liaison team at Arkansas Children’s Hospital. We developed and employed an 11-item survey using a Likert scale to assess the acceptability of new pediatric cardiology consultations being completed by a NP under varying circumstances, including the seven most common reasons for referral. The scale offered five choices ranging from ‘definitely unacceptable’ to ‘definitely acceptable.’ Findings were reported as descriptive statistics, with Kruskal-Wallis and Wilcoxon rank-sum (Mann-Whitney) tests of equality among and between sub-groups, respectively. Two-tailed significance was defined at p < 0.05.

Results: A total of 292 referring clinicians responded to the survey, for a response rate of 16.6% of the 1756 clinicians who received emails. The respondents included 95 pediatricians (33%), 57 family medicine physicians (20%), 63 pediatric subspecialists (22%), 52 residents or fellows (18%), 24 NPs (8%), and 1 who identified as “other” ( <1%). Overall, 57% of respondents considered NP-completed pediatric cardiology evaluations of the seven scenarios either definitely or probably unacceptable, although the acceptability of NP consultations varied by referral reason and referring clinician characteristics (Figures 1 and 2). The referral reasons deemed most unacceptable for evaluation by a NP were “abnormal EKG,” “VSD,” and “bicuspid aortic valve.” Family medicine physicians, pediatricians, clinicians working in solo or two physician practices, and clinicians working in community hospitals or clinics considered NP-completed pediatric cardiology evaluations unacceptable at the highest rates, whereas 93% of referring NPs found pediatric cardiology consultations by a NP acceptable. When presented with a hypothetical situation in which NP evaluation of a murmur would include required review with a cardiologist, the unacceptability rate dropped from 50% to 24%. Physicians who work with a NP have a slightly more favorable view of NP-completed pediatric cardiology evaluations, but 60% of physicians who work with NPs still consider NP completed evaluations unacceptable.

Conclusion: Most referring physicians find pediatric cardiology evaluations performed by NPs to be unacceptable. Requisite review of each case with a cardiologist improved acceptance of NP evaluations.