Nurse practitioners, physician assistants, and pharmacists are the greatest. As members of teams, they actually provide the best chronic cardiovascular disease management. In every trial involving optimal medical treatment (OMT), nurses delivered most of the clinical care using carefully designed protocols. In patients who had had a heart attack or a stent, OMT reduced death by 90% and per patient per year cost by $21,900 compared with usual care—the care that most people receive. A similar trial for type 2 diabetes produced equally impressive results. Patients that received OMT had one fourth as many heart attacks, one fifth as many strokes, and one sixth as many progressed to dialysis compared with usual care. OMT patients lived 8 years longer than usual care patients. Nurses delivered most of the treatment. There are 15 trials that prove that OMT alone prevents heart attack and sudden death just as well as OMT plus a stent. Nurses provided most of the care in those trials. Teams combining nurses and pharmacists control blood pressure to goal in 90% of the patients. In usual care across the country, hypertension control is only 44%. The nurses providing this care were members of a team that included physicians and carefully designed protocols combining best practice medications and lifestyle management. Nurse practitioners are critically important members of these teams.
That said, recent changes in their status are a great example of one of the most pressing problems in American medicine. Nurse practitioners can practice totally independently in almost half of the states. If they provide usual care that just means more people will have access to substandard care for chronic diseases. That is a great example of how medical care is arranged around the needs of providers and institutions. Care for these conditions that disable and kill most Americans is not patient-centered.
Eighty-five percent of health care costs come from chronic disease. Just 5% of the patients generate half the cost. These conditions also cause most disability and death. Teams provide best practice chronic disease management. Many organizations have quality improvement teams, and they believe they are doing the work, but most are not using OMT protocols, and they are not achieving the best results. Changes that make perfect sense often do not work. They have no impact. If they do not improve clinical outcomes and or reduce costs, they are of limited value. Nurses and pharmacists on these chronic disease teams provide most of the direct care. They spend enough time with the patients to establish trust and a higher level of understanding of their disease. They use protocols that are very carefully designed to provide more benefit than simply lowering risk factors while minimizing side effects and drug interactions. These teams achieve much better patient acceptance of evidence-based treatments than providers in usual care. For example, only about half of patients with a high risk of cardiovascular disease take a statin in usual care. In the program for patients who had a history of a heart attack or a stent 91% were on a statin. Making certain that every patient receives every evidence-based treatment every time makes a huge difference is patient health outcomes and costs.
Truly patient-centered care for the most pressing problems in American medicine today does not exist in most places. The evidence is clear. Teams combining a physician, nurses, and pharmacists who can make independent treatment decisions based on carefully designed protocols provide the best OMT care for chronic cardiovascular and related diseases. Success requires a comprehensive solution combining new science, new systems, and new payment models. OMT care is dramatically superior to usual care. The protocols are essential, but they only address eighty or ninety percent of patients. A medical professional can become a nurse practitioner with a bachelor’s degree RN and a master’s degree that can be achieved online through a prestigious institution like Georgetown in as little as 27 months. After college, a physician goes to medical school 4 years and that is followed by 3 years of residency training. That is 7 years of post-graduate training vs a little more than two years. The physician is part of the team to address patients who are in trouble or who don’t fit the protocol. That is where his additional training is valuable. But doctors look down on protocols as “cookbook” medicine and that is a tremendous barrier to improved chronic condition management. Nurses are used to care pathways and teamwork. All members of the professional team should be regarded as peers, and they should feel free to contribute to team design, protocol design and leadership.
Each team member makes an equally valuable contribution to patient-centered care. We can have better health at lower cost today, but to achieve that, we must have care that is truly patient centered. Allowing nurse practitioners to provide more access to usual care outside of teams is a step backwards. Optimal medical therapy should be a universal standard of care. Until we have teams focused on a set of related chronic diseases from Sarasota to Seattle, we will not have truly patient-centered care. If I had to choose between an OMT team for cardiovascular and related disease that was made up solely of nurse practitioners vs usual care delivered by a physician, I would choose the OMT team every time. The most effective teams will include both nurse practitioners and physicians. Some nurse practitioners will understand the value of OMT and teams. If you want to be part of part of moving in that direction, please join me at Slowing Aging and Delaying Chronic Disease Development with a free subscription. Like you, l want to be a part of better care for our patients. A highly collaborative effective team with mutual respect and support is a most satisfying place to work.
Much depends on the level of training and skill of nurse practitioners. At least one of mine has a doctorate, and that is becoming much more common among nurse practitioners. I also like that they tend to spend more time with patients than most physicians I have seen. I'm glad you highlighted them, as well as physician assistants and pharmacists, as important team members.