Nurse practitioners can help boost quality of care for older patients with chronic conditions
|Dr. David Reuben|
U.S. residents today are living longer than previous generations, thanks to improved public health and medical treatment. But they're also living longer with chronic geriatric health conditions like dementia, urinary incontinence, depression and debilitating falls, which often require complex medical care.
Doctors spend significant time and resources treating individuals with chronic conditions, and the average family physician can become severely overtaxed managing care for such patients. The picture becomes even worse with chronic geriatric conditions.
Several heath care treatment models have been designed over the years to improve medical care for chronic geriatric ailments. One model, for instance, helped improve patient care by teaming geriatricians in an academic medical center setting with nurse practitioners to co-manage care. But can the same model work in community-based primary care settings?
The answer is yes, according to a UCLA-led study published in the June issue of the Journal of the American Geriatrics Society. The study's findings highlight the crucial role nurse practitioners can play in treating chronic geriatric conditions.
"It is becoming increasingly clear that care of chronic geriatric conditions is better when it's done in teams," said the study's lead author, Dr. David Reuben, chief of the geriatrics division in the department of medicine at the David Geffen School of Medicine at UCLA. "There are some things that nurse practitioners do better than doctors and some things that doctors do better than nurse practitioners."
Reuben noted that while doctors are generally good at treating acute medical conditions and those requiring highly complex decision-making, some chronic conditions tend to be "swept by the wayside" because physicians either don't have the time or are simply not as skilled in dealing with them.
In addition, doctors often can't make the time to deal with both patient symptoms and the management of chronic illnesses that may not have acute symptoms. "There just isn't enough time in the office to do both," Reuben said.
For the current study, researchers screened 1,084 patients at two primary care facilities in Southern California for four chronic geriatric conditions: falls, urinary incontinence, dementia/Alzheimer's disease, and depression. Of those patients, 658 had at least one condition; 485 of the 658 patients were then randomly selected for medical review.
Of those 485 patients, 237 (49 percent) were seen by a nurse practitioner, for co-management with a primary care physician of at least one condition. The rest were seen only by a primary care physician.
The researchers examined whether a set of measures known as "quality indicators" were performed for each condition. For example, if a patient had a history of falls, did the care provider assess whether the patient might be taking medications that increase the risk of falls and assist the patient in reducing or stopping the use of that drug?
The study authors found that the percentage of quality indicators that were satisfied for patients whose cases were co-managed by a nurse practitioner and a physician was higher than for those seen only by a physician.
For falls, 80 percent of quality indicators were satisfied for co-managed cases, compared with 34 percent for physicians alone; for urinary incontinence, 66 percent of indicators were satisfied, compared with 19 percent; for dementia, 59 percent were satisfied, compared with 38 percent; and for depression, 63 percent were satisfied, compared with 60 percent.
Much of the difference was due to the fact that the nurses were likely to take far more detailed patient histories and to perform other assessments. For instance, the pass rates — that is, whether the measure was performed — for taking a patient's history of falls was 91 percent for co-managed cases, versus 47 percent; vision testing was 87 percent, versus 36 percent; and discussion of treatment options for urinary incontinence was 79 percent, versus 28 percent.
The findings were limited by several facts, the researchers said. Some cases that primary care physicians considered "mild" were not referred for co-management, the study was conducted in only two facilities within a single geographic area, and it was a one-time intervention with minor revisions as the study went along rather than a longer, continuous learning process.
Grants from the UniHealth Foundation; a Career Development Award from the Health Services Research and Development Service of the Veterans Affairs Health Administration (U.S. Department of Veterans Affairs) through the VA Greater Los Angeles Health Services Research and Development Center of Excellence (Project # VA CD2 08-012-1); and the National Institute on Aging (5P30AG028748) funded this study.
Other researchers on this study included David A. Ganz, Heather E. McCreath, Karina D. Ramirez and Neil S. Wenger of UCLA, and Carol P. Roth of the RAND Corp. Ganz and Wenger are also associated with RAND, and Ganz is associated with Veterans Affairs Greater Los Angeles Healthcare System.
The UCLA Division of Geriatrics within the department of medicine at the David Geffen School of Medicine at UCLA offers comprehensive outpatient and inpatient services at several convenient locations and works closely with other UCLA programs that strive to improve and maintain the quality of life of seniors. UCLA geriatricians are specialists in managing the overall health of people age 65 and older and treating medical disorders that frequently affect the elderly, including memory loss and dementia, falls and immobility, urinary incontinence, arthritis, arthritis, high blood pressure, heart disease, osteoporosis and diabetes. As a result of their specialized training, UCLA geriatricians can knowledgably consider and address a broad spectrum of health-related factors — including medical, psychological and social — when treating patients.