Advanced Nurse Practitioners: How and why

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Advanced Nurse Practitioners:

How and why

Philip Moons, PhD, RN

Centre for Health Services and Nursing Research, Katholieke Universiteit Leuven, Belgium

University Hospitals Leuven, Belgium

Providing better care:

Advanced nurse practitioners and the

effects on the clinical results

Philip Moons, PhD, RN

Danish Nurses Organisation, Copenhagen, 2 april 2009 © P. Moons , 2009 Advanced Practice Nursing

(Hamric, Spross, Hanson, 2005)

Clinical Nurse

Specialists Nurse Practitioners Certified

Nurse Midwife Nurse Anesthesist Case manager Advanced Practice Nurses

APN

…………

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© P. Moons , 2009

Nurse Practitioners

„ Dr. Loretta C. Ford „ 1965

„ Public Health Nurse

„ Denver, Colorado

„ Started with the first nurse practitioner,

together with Dr. H. Silver (pediatrician)

©

P. Moons

, 2009

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

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©

P. Moons

, 2009

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 © P. Moons , 2009

Nurse Practitioners

„ Competencies:

„ Strong clinical skills

„ At the tangent of care and cure

„ In some countries: prescription authority „ Under supervision of physician for medical

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P. Moons

, 2009

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)

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P. Moons

, 2009

Nurse Practitioners

Nurse practitioner No nurse practitioner Uncertain

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© P. Moons , 2009 0 2 4 6 8 10 12 14 16 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 4 RN= 1 MD 3 RN= 1 MD 2 RN= 1 MD 1 RN= 1 MD Ireland Iceland The Netherlands Luxembourg Switserland Sweden Norway Denmark Australia Canada Germany Czech Rep Austria Finland UK USA Japan Spain France Slovak Rep Belgium Italy Greece Portugal Hungary Poland Korea Turkey Mexico RN/1000 inhabitants MD/1000 inhabitants

Ratio RN-MD/1000 inhabitants

(By courtesy of W. Sermeus)

©

P. Moons

, 2009

Outcomes

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©

P. Moons

, 2009

Patient outcomes of nurse practitioners

Health Outcomes Institute, 1996

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

©

P. Moons

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©

P. Moons

, 2009

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)

©

P. Moons

, 2009

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

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©

P. Moons

, 2009

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)

©

P. Moons

, 2009

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

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©

P. Moons

, 2009

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 28.14£)

(Hollinghurst et al, Brit J Gen Pract 2006)

©

P. Moons

, 2009

Patient outcomes of nurse practitioners

Health Outcomes Institute, 1996

NP to substitute physicians

Positive effects Negative effects No difference

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

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©

P. Moons

, 2009

„ 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)

©

P. Moons

, 2009

„ 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

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©

P. Moons

, 2009

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

Patient outcomes of nurse practitioners

Health Outcomes Institute, 1996

NP to complement physicians

Positive effects Negative effects No difference © P. Moons , 2009

Patient outcomes of nurse practitioners

„ RCT: 228 patients with hypercholesterolemia „ 115 received case management by a nurse

practitionerin 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

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©

P. Moons

, 2009

Patient outcomes of nurse practitioners

„ RCT: 246 patients with poorly controlled diabetes

„ 123 received case management by a nurse practitionerin 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)

©

P. Moons

, 2009

Patient outcomes of nurse practitioners

„ RCT: 157 patients with hypertension or diabetes „ Chronic disease management by a

physician-nurse 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

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©

P. Moons

, 2009

Patient outcomes of nurse practitioners

Health Outcomes Institute, 1996 Positive effects

Negative effects No difference

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 © P. Moons , 2009 Advanced Practice Nursing

(Hamric, Spross, Hanson, 2005)

Clinical Nurse

Specialists Nurse Practitioners Certified

Nurse Midwife Nurse Anesthesist Case manager Advanced Practice Nurses

APN

…………

(14)

©

P. Moons

, 2009

Patient outcomes of Clinical Nurse Specialists

Health Outcomes Institute, 1996

CNS to complement physicians

Positive effects Negative effects No difference

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 © P. Moons , 2009

Outcomes

„ Patients „ Nurses

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©

P. Moons

, 2009

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

©

P. Moons

, 2009

Outcomes for nurses

Staff nurse Specialist nurse

Advanced Practice Nurse Nurse practitioner Nurse consultant (Academic tour 2006) CNS NP Advanced Practice Nurse Specialised nurse

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©

P. Moons

, 2009

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)

©

P. Moons

, 2009

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

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