Nurses could manage chronic care on doctors’ orders

NEW YORK Tue Jul 15, 2014 4:58pm EDT

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NEW YORK (Reuters Health) - Expanding the role of nurses in managing chronic conditions such as diabetes, high blood pressure and high cholesterol could be an effective way to handle the shortage of primary care physicians, according to a new study.

“The idea was to see if we could have nurses, who are the nation’s largest healthcare workforce, assume additional roles which they already do in hospitals, but they don't necessarily do that much in outpatient settings,” said lead author Ryan Shaw.

A registered nurse and health services researcher at the Veterans Affairs Medical Center in Durham, North Carolina, Shaw told Reuters Health the Affordable Care Act is only worsening the shortage of primary care doctors by increasing demand for health care.

New models for managing chronic disease, which consumes 75 percent of healthcare spending in the U.S., are badly needed, Shaw and his coauthors write in the Annals of Internal Medicine.

He and his colleagues reviewed past research evaluating the effectiveness of registered nurses in leading the management of outpatients with any of several chronic diseases by following protocols set by physicians.

They analyzed 18 studies covering more than 23,000 patients in treatment for diabetes, high blood pressure or high cholesterol. Six of the studies were randomized controlled trials, considered the gold-standard in research.

Nurses in all the studies were able to change the dosages of medications that were originally prescribed by physicians. Nurses in 11 of the studies could also initiate new medications independently.

Shaw and his team found the nurse-managed protocols had a positive effect on chronically ill patients.

The patients who were managed by nurses overall had better blood sugar management, slightly lower blood pressure readings and larger decreases in total and LDL ("bad") cholesterol levels, when compared to patients under usual care.

“The findings were that it was relatively safe. We didn't really find any adverse outcomes, and it did seem to improve patient outcomes,” Shaw said.

He noted that nurses would go through training for this type of care and explained that the nurses would be working as part of a team that includes physicians, pharmacists and other health professionals, and not as individual practitioners.

“They’re not practicing by themselves,” he said. “They're just extending the care that you might get from a physician.”

The study team acknowledges limitations in their analysis. The studies they looked at had limited descriptions of the treatments given and the training levels of the nurses. In addition, 11 of the 18 studies were done in Western Europe, which could limit the applicability of the findings to U.S. health care practices.

Nevertheless, write Drs. Sandeep Jauhar and David Battinelli in an editorial published along with the study, “Like it or not, outpatient medicine has become too complicated for physicians to handle by themselves. We need new models of primary care, and enlisting nurses will be central to this effort.”

Jauhar and Battinelli are both with Hofstra North Shore-LIJ School of Medicine in New York, and were not involved in the new research.

The United States has approximately 200,000 primary care physicians and 2.8 million registered nurses, they note.

Jauhar told Reuters Health that some conditions, such as hypertension and high cholesterol, could be treated with a relatively straightforward approach.

“These are conditions for which there are pretty well-defined flowcharts for how to manage the conditions, so for those relatively straightforward conditions, I think that nurse-managed protocols are perfectly acceptable,” he said.

Jauhar said that a physician’s judgment is required for more complex conditions where there is some degree of judgment or subjectivity in deciding how to treat the patient.

“I think those are conditions where you want to be seen by a doctor,” he said.

Jauhar pointed out that the nurses described in the review paper were conferring and collaborating with doctors and discussing the cases with their supervising physicians.

“There's a dearth of primary care physicians, so for relatively straightforward conditions like hypertension I think it's better to be seen by a nurse following a protocol than it is not to be seen by a physician for several weeks because of availability,” he said.

SOURCE: bit.ly/U7fMd7 Annals of Internal Medicine, online July 14, 2014.

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