May 2025
EAST Monthly Literature Review
"Keeping You Up-to-Date with Current Literature"
Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Quality, Safety and Outcomes Committee Members Andrew Medvecz, MD, MPH, Christopher Dente, MD, William Brigode, MD, and A.J. Bethurum, MD, MPH.
Thank you to Haemonetics for supporting the EAST Monthly Literature Review.
In This Issue: Quality, Safety and Outcomes
Scroll down to see summaries of these articles Article 1 reviewed by Andrew Medvecz, MD, MPHEffects of advanced practice providers on single specialty surgical practice. Hollenbeck BK, Kaufman SR, Oerline M. et al. Ann Surg. 2023 Jan 1;277(1):e40-e45. Article 2 reviewed by Christopher Dente, MDInvisible Work: Advanced Practice Providers’ Role in the Education of Surgeons. Rosenblatt A, Ballard HA, Amortegui D, et al. J Surg Educ. 2022 Nov-Dec;79(6):1353-1362. Article 3 reviewed by William Brigode, MDTrauma advanced practice provider education: the current state of trauma advanced practice provider postgraduate education in the United States. Lasinski A, Shaughnessy A, Claridge. J Trauma Surg Acute Care Open. 2024 Aug 21;9(1):e001423. Article 4 reviewed A.J. Bethurum, MD, MPHAdvanced Practice Providers in Burn Care, 2013-2022. Das RK, Jagasia PM, Bailey AE, Mubang R, Drolet BC. Journal of Burn Care Research. 2025 Jan 24;46(1):166-170.
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Article 1
Effects of advanced practice providers on single specialty surgical practice. Hollenbeck BK, Kaufman SR, Oerline M. et al. Ann Surg. 2023 Jan 1;277(1):e40-e45.
Advanced practice providers (APPs) have been integrated into surgical practices for many years, but their impact on improving access, coordinating care, and improving outcomes was not previously quantified. The authors used Medicare national data to evaluate the impact of adding an APP to a surgical practice. Four common procedures for the elderly (coronary artery bypass graft, colectomy, major joint replacement, and cystectomy) were evaluated from 2010 to 2016. They assessed practices that incorporated an APP, comparing the outcomes in the one year before and the year after the addition of the APP. The authors noted an increase in APP incorporation by 46.9% in general surgery group practices over the study period. The authors identified 6,282 patients meeting inclusion criteria. Patients were less likely to have a complication (OR 0.84, 95% CI 0.73-0.97) and readmission (OR 0.82, 95% CI 0.70-0.95) 90-days post-procedure after incorporation of an APP into practice. Length of stay was reduced by 0.33 days (95% CI -0.49 to -0.17). General, orthopedic, and urologic practices were able to increase their annual Medicare visit volume by 42 to 205 visits per surgeon.
The implications of this study are far reaching as it demonstrates some of the quantifiable advantages of adding APPs into surgical practice. While not identifying the specific manners in which APPs improve outcomes, the ability for APPs to have roles both inpatient and outpatient may assist in alleviating the potential shortfall in surgeons in the future. The authors posit that APPs may improve continuity of care, identify complications earlier, or arrange discharge plans more efficiently so that patients can be discharged sooner. While the authors note the limitation that they only valuated the impact of APP integration on Medicare claims, the implication can therefore follow that the effect of APP integration may be even greater when applied to entire populations of surgical practices.
Article 2
Invisible Work: Advanced Practice Providers’ Role in the Education of Surgeons. Rosenblatt A, Ballard HA, Amortegui D, et al. J Surg Educ. 2022 Nov-Dec;79(6):1353-1362.
The authors present the results of a series of semi-structured individual and small group interviews of a wide variety of providers from American general surgery residency programs. The interviews presented in this manuscript, which were part of a larger inquiry into the culture of surgical education, revolve around the roles of Advanced Practice Providers (APPs) in surgical teams at teaching institutions. The authors identified 40 transcripts from 51 total interviewees that dealt specifically with the role of APPs within the teams. This represented 6-11 residency programs and a total of 13 faculty, 17 residents and 10 APPs. Using a method to deductively code qualitative data, they were able to identify four central themes regarding APPs within a surgical team. The first theme, “APP as educator”, revealed that APPs tend to provide a fair bit of printed resources for residents rotating on services (in the form of guidelines and service expectation documents) and also do a fair bit of bedside teaching, especially with junior residents for minor procedures. They were nearly universally considered integral to overall resident education. The second theme, “Canary in the Coal Mine”, noted that APPs tended to be the first to notice alterations in resident behavior, often indicative of burnout and were often willing to cover for them in order to allow them mental health breaks. This demonstrated more of a protective role rather than a peer role. Third, APPs allowed a division of labor, letting residents concentrate on higher level tasks with more educational value, most notably in the operating room. This led to the fourth theme of “second class citizen” whereupon APPs described the feeling of being de-prioritized in favor of resident wellness and education. This was especially true when their efforts were not recognized.
Over recent decades, APPs have become an integral part of most surgical teams. Their interactions with residents are generally positive and in high-performing teams, an APP can take on the role of facilitator, educator and even protector of surgical trainees. Given that they are also highly trained professionals, however, there are instances where they feel their efforts are underappreciated and de-emphasized. As such, it behooves faculty and residents in teaching services to both set expectations for the relationships between APPs and trainees and also to ensure APPs’ efforts are recognized and rewarded. While this study does offer the standard limitations of qualitative research (recall bias, limited sample size), it does provide important insight into the developing role of APPs in the education of surgical trainees.
Article 3
Trauma advanced practice provider education: the current state of trauma advanced practice provider postgraduate education in the United States. Lasinski A, Shaughnessy A, Claridge, JA. J Trauma Surg Acute Care Open. 2024 Aug 21;9(1):e001423.
This manuscript aimed to study characteristics of APP postgraduate programs in trauma training. The authors highlight the background of increased prevalence of physician assistants (PAs) and nurse practitioners (NPs), in trauma services. They describe a heterogeneity of onboarding processes, including a traditional transition to practice model, followed by PA fellowships (1971), and NP fellowships (2007). There is no universal administrative body overseeing these programs. The authors cite a multitude of national organizations that may provide oversight to subsets of the postgraduate training. The authors aimed to identify and characterize programs specific to trauma training; they performed a cross-sectional study of the eight programs they identified through June 2022 with a survey to understand the curricula.
Of seven participating programs, six included PA and NP, while one was isolated to PA. One each were accredited by the ANCC, while five were unaccredited. The main reasons for unaccredited status included no unifying body or a costly process. The main offerings of programs included rotations on trauma floor, trauma ICU, nights, trauma/surgical step-down units in five of seven programs. Four included emergency general surgery and surgical ICU. The content of the seven programs was heterogeneous with six including ATLS and five including FCCS (Fundamental Critical Care Support). Most programs included arterial line placement and central venous cannulation, while other procedures such as intubation, thoracostomy, and operative first assist training was more variable.
The authors note that other specialties such as hospital medicine also had highly variable curricula and certification, while trauma programs in general had more frequent expectations of presentations, formal procedural skills, and research/scholarly activity. The authors conclude that while the trauma community is increasingly adopting APPs, implementation is heterogeneous secondary to program specific needs. They noted an enthusiasm and benefit among programs and providers (trainees) for ongoing standardization and accreditation.
Article 4
Advanced Practice Providers in Burn Care, 2013-2022. Das RK, Jagasia PM, Bailey AE, Mubang R, Drolet BC. Journal of Burn Care Research. 2025 Jan 24;46(1):166-170.
The growing demand for burn care in the context of a shrinking surgical workforce has elevated the role of advanced practice providers (APPs) in caring for patients with burn injury. To better characterize this changing landscape, Das and colleagues use national CMS data from 2013–2022 to quantify the prevalence of nurse practitioners and physician assistants who provide burn-related care. Over the study period, the number of APPs billing for burn services rose by 250%, in contrast to a 23% decrease in surgeons and physicians of other specialties who provide burn care. To illustrate this shift further, the authors add that APPs accounted for just 12.7% of burn care providers billing CMS in 2013, but by 2022, this proportion had risen to 40%. APPs were more likely to work in micropolitan or rural areas, suggesting their growing importance in filling workforce gaps and providing frontline care in underserved settings. The authors project that APPs could represent over half of CMS-billing burn care providers by 2030 (95% CI, 3541–4303; R2 = 0.97).
The implications for surgeons providing burn care or involved in institutional leadership are multifold. As burn centers identify avenues optimizing operational workflow, the integration of APPs has been associated with improved patient throughput, reduced ICU length of stay, and enhanced continuity of care. The study also surfaces key administrative challenges, including the need for clearer guidelines on team roles for APPs and their impact on resident education. While this study is limited to CMS data, only drawn from Medicare Part B beneficiaries, the robust nature of this nationwide cohort adds to the study’s generalizability. In all, this retrospective review is the first to illustrate the changing composition of burn care providers, identifies the growing role for APPs in rural burn care, and calls for thoughtful implementation strategies that enhance patient safety, support academic missions, and sustain high-quality burn care delivery.
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