Nurse Practitioners Can Lead the Way to Better Cardiovascular Disease Management
New guidelines call for optimal medical therapy (OMT) first for patients with coronary artery disease. Patients with stable heart artery disease should only move on a heart catheterization and stent if they fail OMT. A program for heart artery disease patients in Colorado reduces mortality by up to 90% while lowering per patient per year costs by $21,900. Nurses and pharmacists provided the care in this controlled study. The program has been expanded to serve 12,000 patients. It is magnificent. It works.
There is a mountain of evidence to support this model. Most medical groups and institutions in America have quality improvement teams, but they almost universally fail to reduce mortality, hospitalization, and costs. That seems crazy, but it is the truth. They develop plans to improve that make sense, but they almost universally fail. There is powerful evidence to support success. “The one approach that has proven to be effective is using specially trained nurses or pharmacists, under appropriate supervision, with authority to make medication changes without consulting the physician as long as the changes fell within approved treatment algorithms.”
This critically important article also points to the interventions that don’t work. “Many approaches have been tried to improve diabetes care but, with one exception, have been mostly ineffective. These include simply reminding patients about appointments; providing laboratory information on the patient to the physician, even when specific treatment recommendations for the individual patient were included; case management when the case manager could not make independent treatment decisions; education of physicians; and multifaceted quality improvement interventions in the practice setting” Because we have not followed the systems evidence in treating cardiovascular disease, only 44% of Americans have their blood pressure controlled to 140/90 or less. A smaller number would achieve 130/80. The nurse teams in Colorado dramatically improved risk factor management and outcomes as would be expected based on the evidence.
Americans could have much better care for cardiovascular and related diseases like hypertension and diabetes quickly. This is the low-hanging fruit to improve healthcare in this country. Nurse practitioners can practice completely independently in a majority of states. (See the green states in the map) They are accustomed to case management and care pathways. They understand the need for systems and protocols. The model has been developed: the advanced medical home focused on the needs of patients with cardiovascular disease and related conditions. Nurse practitioners in advanced medical homes can provide excellent optimal medical therapy whether you live in Seattle or Savannah.
But there is a deep structural problem that keeps this from happening. Most nurse practitioners are trained in family practice but surviving in independent primary care is financially very hard no matter where you are. The big gains in chronic disease management will come from outpatient primary care practices, but these practices are on the ropes. Very few remain. They have almost all been bought by very large health systems and corporate entities. The last thing they have on their mind is optimal medical therapy. Primary care in that setting is present to send patients to specialists and expensive procedures late in disease. They are there to keep “heads in beds”.
The AMA is dominated by specialists. They have no interest in change that reduces referrals or their share of the money. The AMA advises Medicare on physician compensation in a clear conflict of interest. The proportion of total spending devoted to primary care has dropped from 7% to 5% at a time when a substantial shift in spending should occur to support their efforts to produce optimal medical therapy. We must change the way we pay for these services. We should pay a fixed rate annually for each patient with heart artery disease, diabetes, and related conditions. Advocates for optimal medical therapy and independent advanced nurse practice face the same barriers to progress.
You can have advanced medical home teams manned by nurse practitioners and pharmacists in your community now. You could lower health care costs and your people could have longer healthier lives now. It does not require fancy, expensive buildings or medical equipment. You don’t need a heart cath lab. A medium sized town in a rural area could support this model. Great health care supports your ability to attract business. The citizens could own it. A board of citizens could govern it. I work with a group that has the systems and protocols to support these clinics very inexpensively with population health tools and data management. If you have interest or want more information, please contact me. wbestermann@congruityhealth. com