Advanced Nurse Practitioners: How and why

Transcription

1 Providing better care: Advanced nurse practitioners and the effects on the clinical results Advanced Nurse Practitioners: How and why Philip Moons, PhD, RN Philip Moons, PhD, RN Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Belgium University Hospitals Leuven, Belgium Danish Nurses Organisation, Copenhagen, 2 april 2009 Advanced Practice Nursing APN Advanced Practice Nurses Clinical Nurse Specialists Certified Nurse Midwife Case manager Nurse Practitioners Nurse Anesthesist (Hamric, Spross, Hanson, 2005) 1

2 Nurse Practitioners Dr. Loretta C. Ford 1965 Public Health Nurse Denver, Colorado Started with the first nurse practitioner, together with Dr. H. Silver (pediatrician) Nurse Practitioners USA in the mid 1960s: Unserved groups Nurses frustrated about the traditional role Shortage of physicians is an opportunity Social, political chaos is good environment for drastic changes Start with Primary Care Nurse Practitioner Focus on direct patient care Substitution of physicians 2

3 Nurse Practitioners USA in the 1970s: End of Vietnam war: many nurses returned from the battle field with extensive medical knowledge and experience Start with Acute Care Nurse Practitioner Drivers: Shortage of physicians Access to health care Costs Nurse Practitioners Competencies: Strong clinical skills At the tangent of care and cure In some countries: prescription authority Under supervision of physician for medical activities, autonomous for other activities 3

4 Nurse Practitioners: Examples of practice environments Primary care (in practice of GP) Primary care in remote areas In Minute Clinic (primary care in supermarket) In acute care hospitals Nurse practitioner at emergency department (minor trauma) Nurse practitioner at ward Nurse practitioner at ward (out of hours service) Nurse practitioner at outpatient clinic Nurse practitioner in transmural care (seamless care) Nurse Practitioners By courtesy of P. Roodbol, 2005 Nurse practitioner No nurse practitioner Uncertain 4

5 Ratio RN-MD/1000 inhabitants 16 RN/1000 inhabitants Ireland 4 RN= 1 MD 14 The Netherlands Iceland 3 RN= 1 MD Turkey Mexico Korea Luxembourg Switserland NorwaySweden Australia Canada Denmark Germany UK Finland Czech Rep Austria USA Spain France Japan Slovak Rep Belgium Hungary Italy Poland Portugal Greece 2 RN= 1 MD 1 RN= 1 MD MD/1000 inhabitants 0 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 (By courtesy of W. Sermeus) Outcomes Patients Nurses 5

6 Patient outcomes of nurse practitioners Outcomes Death Disease Disability Discomfort Dissatisfaction Dollars Epidemiological Quality of life Consumer Costs paradigm perspective Clinical outcomes Patient-oriented outcomes Consumer-related Economical outcomes outcomes Health Outcomes Institute,

7 Patient outcomes of nurse practitioners RCT: 406 patients in primary care followed-up for 2 years 222 by nurse practitioner (NP) 184 by physician (MD) Results Blood pressure (in hypertension): NP = MD Peak flow (in asthma): NP = MD Glycosylated hemoglobin (in diabetes): NP = MD Perceived health status: NP = MD Satisfaction with care: NP = MD Health care utilisation: NP = MD (Lenz et al, Med Care Res Rev 2004) Patient outcomes of nurse practitioners RCT: 339 patients who are prepared for diagnostic cardiac catheterisation (attrition n=3) 175 by nurse practitioner (NP) 161 by junior medical staff (JMS) Results Quality of preparation: NP = JMS Patient satisfaction: NP > JMS Duration of preparation: NP < JMS (Stables et al, Eur J Cardiovasc Nurs 2004) 7

8 Patient outcomes of nurse practitioners RCT: 80 patients who are followed-up for bronchiectasis: cross-over design 39 nurse practitioner-led care (NP) 41 doctor-led care (D) Results Exacerbation: NP = D Patient satisfaction: NP > D Cost of care: NP > D (equal in second year of project) (Caine et al, Health Technol Assess 2002) Patient outcomes of nurse practitioners RCT: 1368 patients who asked for a same-day visit with GP: 652 with nurse practitioners (NP) 716 with general practitioners (GP) Results Improvement of symptoms: NP = GP Patient satisfaction: NP > GP Duration of consultation: NP > GP (Kinnersley et al, BMJ 2000) 8

9 Patient outcomes of nurse practitioners Systematic literature review: Comparing cost of NPs and GPs in primary care in UK 2 articles fulfilled the inclusion criteria Results Cost per minute: NP < GP (0.6 vs 1.4 ) Time spent: NP > GP Cost per consultation: NP > GP (30.35 vs ) (Hollinghurst et al, Brit J Gen Pract 2006) Patient outcomes of nurse practitioners NP to substitute physicians Outcomes Death Disease Disability Discomfort Dissatisfaction Dollars Epidemiological Quality of life Consumer Costs paradigm perspective Clinical outcomes Patient-oriented outcomes Consumer-related Economical outcomes outcomes Positive effects Negative effects No difference Health Outcomes Institute,

10 Higher satisfaction Better communication More advice on self care and self management Longer consultations Same health status More investigations Identify physical abnormalities more often More complete records (Horrocks et al, BMJ 2002) Quality of care is as good as in MD Health outcomes are as good as in MD Caveat: Doctor s workload remained unchanged More unmet needs are identified NP generate demand for care In general no cost savings Lower salary for NP Lower productivity by NP (Laurant et al, Cochrane Database Syst Rev 2004) 10

11 Patient outcomes of nurse practitioners NP to complement physicians Outcomes Death Disease Disability Discomfort Dissatisfaction Dollars Epidemiological Quality of life Consumer Costs paradigm perspective Clinical outcomes Patient-oriented outcomes Consumer-related Economical outcomes outcomes Positive effects Negative effects No difference Health Outcomes Institute, 1996 Patient outcomes of nurse practitioners RCT: 228 patients with hypercholesterolemia 115 received case management by a nurse practitioner in partnership with a GP and/or cardiologist (NURS) 113 usual care enhanced with feedback on lipids to GP and/or cardiologist (EUC) Results Lipid lowering: NURS > EUC (-64 vs -49 mg/dl) Cost of care: NURS > EUC (1573 vs 1183 US$) Cost-effectiveness: 26 US$ per mg/dl reduction (Paez & Allen, J Am Acad Nurse Pract 2006) 11

12 Patient outcomes of nurse practitioners RCT: 246 patients with poorly controlled diabetes 123 received case management by a nurse practitioner in collaboration with primary care provider (MD+NP) 123 usual care by primary care provider (MD) Results Hyperglycemia: MD+NP = MD Hyperlipidemia: MD+NP = MD Hypertension: MD+NP = MD Satisfaction with care: MD+NP > MD Health care utilisation: MD+NP = MD (Krein et al., Am J Med 2004) Patient outcomes of nurse practitioners RCT: 157 patients with hypertension or diabetes Chronic disease management by a physiciannurse practitioner team (MD+NP) Usual care by physician alone (MD) Results Glycemic control ( HbA1c): MD+NP > MD HDL cholesterol: MD+NP > MD Quality of life: MD+NP = MD Satisfaction with care: MD+NP > MD Cost for personnel: MD+NP > MD (Litaker et al., J Interprof Care 2003) 12

13 Patient outcomes of nurse practitioners NP to complement physicians Outcomes Death Disease Disability Discomfort Dissatisfaction Dollars Epidemiological Quality of life Consumer Costs paradigm perspective Clinical outcomes Patient-oriented outcomes Consumer-related Economical outcomes outcomes Positive effects Negative effects No difference Health Outcomes Institute, 1996 Advanced Practice Nursing APN Advanced Practice Nurses Clinical Nurse Specialists Certified Nurse Midwife Case manager Nurse Practitioners Nurse Anesthesist (Hamric, Spross, Hanson, 2005) 13

14 Patient outcomes of Clinical Nurse Specialists CNS to complement physicians Outcomes Death Disease Disability Discomfort Dissatisfaction Dollars Epidemiological Quality of life Consumer Costs paradigm perspective Clinical outcomes Patient-oriented outcomes Consumer-related Economical outcomes outcomes Positive effects Negative effects No difference Health Outcomes Institute, 1996 Outcomes Patients Nurses 14

15 Outcomes for nurses Traditional career of nurses:. in order to move up the career ladder, nurses need to move away from the bedside Interesting clinical career opportunities for nurses Outcomes for nurses Nurse consultant Nurse practitioner CNS NP Advanced Practice Nurse Advanced Practice Nurse Specialist nurse Specialised nurse Staff nurse (Academic tour 2006) (Hamric, Spross, Hanson, 2005) 15

16 Outcomes for nurses: Caveat Potential/observed side effects Migrates to medicine: Abandons nursing Difficult acceptance by nurses Does not work with nursing teams Dependent from physicians (Roodbol, Doctoral dissertation 2005) Conclusions - Advice Nurse practitioners can contribute to better patient outcomes Complementing doctors result in better outcomes than substitution Cost reduction must not be the main driver Key question: Do you want equal quality or better quality? Be aware of potential side effects Do not abandon nursing: NP = care + cure Can offer interesting career paths to nurses, however Make sure that they do not fall between two stools Think about blended roles: CNS-NP 16