Nurses as leaders in chronic care
http://www.100md.com
《英国医生杂志》
Their role is pivotal in improving care for chronic diseases
The chronic care model is widely accepted as a standard for improving care for people with chronic conditions.1 In the United States, projects to put the chronic care model into practice often centre around doctors. Yet the healthcare literature and the experience of many efforts to improve chronic care indicate that nurses, not doctors, are the key to implementing the chronic care model in a patient centred care team. By nature of their education and role, nurses are in a position to champion transformation of chronic care. In many nations, but not in the United States, nurses have been taking this central role for decades.w1
The essence of the chronic care model is the interaction between an informed, activated patient and a prepared, proactive practice team.w2 Indeed, such a team is nearly always needed to enable patients to become adequately informed and activated. What is the record of doctors in informing and activating patients?
A study of family physicians in the United States found that patients making an initial statement of their problem were interrupted by the doctor after an average of 23 seconds.2 Half of patients finish an office visit not understanding what they were told by the doctor.3 The commonest reason for patients not taking their medicines as prescribed is poor communication from doctor to patient.w3 In a study of treatment decisions in over 1000 audiotaped outpatient visits to doctors, the patient was not involved in the decisions 91% of the time.4 Poorly informed passive patients are less likely to adopt healthy behaviours, and they have poorer clinical outcomes than informed, activated patients.5
These failures are often due to the interaction between individual doctors and a dysfunctional system. Some doctors may simply be uncaring and paternalistic. Almost all become less collaborative when they are running two hours behind schedule. Given multiple competing demands, providing care that is consistent and compliant with guidelines in a 15 minute visit is beyond the reach of most primary care doctors, however well trained and well intentioned they may be.6 w4 Lack of time is a considerable barrier, preventing doctors from providing sufficient information to their patients and blocking their ability to share decisions in practice.7 w5-w7
Numerous studies show the central role of nurses in implementing components of the chronic care model, most importantly planned chronic care visits. In Kaiser Permanente's trial of planned visits by groups of people with diabetes led by a nurse educator, participants had significantly lower glycated haemoglobin levels and lower use of hospitals than controls.8 Other work has shown that patients attending a clinic for planned visits led by nurses had improved glycated haemoglobin levels that were also lower than those of patients who got the usual care.9 10 In yet another study, patients attending a diabetes clinic with a nurse, compared with those getting the usual care, had lower mortality and a lower incidence of adverse clinical events (myocardial infarction, angina, revascularisation procedures, end stage renal disease) after a median follow up of seven years.11 A Cochrane review found that planned nursing visits can improve healthy behaviours and patients' outcomes in diabetes; it concluded that nurses "can even replace physicians in delivering many aspects of diabetes care, if detailed management protocols are available, or if they receive training."12
Many of the positive outcomes seen in planned care visits with nurses may be due to better communication between nurse and patient. In a randomised controlled trial of people with diabetes in general practice, analysis of taped discussions showed that nurses covered more topics in the consultations, and more often mentioned diet, alcohol use, smoking, and weight, than did the doctors. Patients were more likely to take the lead in discussing behaviour change with nurses than with doctors.w8 In focus groups, patients preferred nurse led shared care for managing diabetes over doctor led care by a ratio of nearly 6 to 1.w9 w10
Even though evidence and examples show the pivotal role played by nurses in improving chronic care, several barriers inhibit the spread of nurse led programmes in the United States (see bmj.com). The nursing shortage has made nurses difficult to recruit; few insurance plans pay for care provided by nurses; and nursing education in the United States does not emphasise the role that nurses can play in chronic illness care. In some health systems, nurses are under-used, taking blood pressures and putting patients into rooms rather than providing education for and encouraging self management by chronically ill patients. Until these barriers are overcome, the potential for nurses to lead a national effort in the United States to improve chronic illness care may be thwarted.
Thomas Bodenheimer, adjunct professor
Department of Family and Community Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA (Tbodenheimer@medsch.ucsf.edu)
Kate MacGregor, research director
Department of Family and Community Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA
Nancy Stothart, clinical care specialist
Whatcom County Pursuing Perfection Project, Bellingham, WA 98225, USA
References w1-w10 and details of nurse led projects are on bmj.com
Competing interests: None declared.
References
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affairs 2001;20(6): 64-78.
Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda. JAMA 1999;281: 283-7.
Roter DL, Hall JA. Studies of doctor-patient interaction. Annual Rev Public Health 1989;10: 163-80.
Braddock CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice. JAMA 1999;282: 2313-20.
Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med 2002;17: 243-52.
Yarnell KSH, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93: 635-41.
Kaplan SH, Gandek B, Greenfield S, Rogers WH, Ware JE. Patient and visit characteristics related to physicians' participatory decision-making style. Med Care 1995;33: 1176-87.
Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care 1999;22: 2011-7.
Peters AL, Davidson MB. Application of a diabetes managed care program. Diabetes Care 1998;21: 1037-43.
Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. Ann Intern Med 1998;129: 605-12.
So WY, Tong PC, Ko GT, Leung WY, Chow CC, Yeung VT, et al. Effects of protocol-driven care versus usual outpatient clinic care on survival rates in patients with type 2 diabetes. Am J Manag Care 2003;9: 606-15.
Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001;(1): CD001481.
The chronic care model is widely accepted as a standard for improving care for people with chronic conditions.1 In the United States, projects to put the chronic care model into practice often centre around doctors. Yet the healthcare literature and the experience of many efforts to improve chronic care indicate that nurses, not doctors, are the key to implementing the chronic care model in a patient centred care team. By nature of their education and role, nurses are in a position to champion transformation of chronic care. In many nations, but not in the United States, nurses have been taking this central role for decades.w1
The essence of the chronic care model is the interaction between an informed, activated patient and a prepared, proactive practice team.w2 Indeed, such a team is nearly always needed to enable patients to become adequately informed and activated. What is the record of doctors in informing and activating patients?
A study of family physicians in the United States found that patients making an initial statement of their problem were interrupted by the doctor after an average of 23 seconds.2 Half of patients finish an office visit not understanding what they were told by the doctor.3 The commonest reason for patients not taking their medicines as prescribed is poor communication from doctor to patient.w3 In a study of treatment decisions in over 1000 audiotaped outpatient visits to doctors, the patient was not involved in the decisions 91% of the time.4 Poorly informed passive patients are less likely to adopt healthy behaviours, and they have poorer clinical outcomes than informed, activated patients.5
These failures are often due to the interaction between individual doctors and a dysfunctional system. Some doctors may simply be uncaring and paternalistic. Almost all become less collaborative when they are running two hours behind schedule. Given multiple competing demands, providing care that is consistent and compliant with guidelines in a 15 minute visit is beyond the reach of most primary care doctors, however well trained and well intentioned they may be.6 w4 Lack of time is a considerable barrier, preventing doctors from providing sufficient information to their patients and blocking their ability to share decisions in practice.7 w5-w7
Numerous studies show the central role of nurses in implementing components of the chronic care model, most importantly planned chronic care visits. In Kaiser Permanente's trial of planned visits by groups of people with diabetes led by a nurse educator, participants had significantly lower glycated haemoglobin levels and lower use of hospitals than controls.8 Other work has shown that patients attending a clinic for planned visits led by nurses had improved glycated haemoglobin levels that were also lower than those of patients who got the usual care.9 10 In yet another study, patients attending a diabetes clinic with a nurse, compared with those getting the usual care, had lower mortality and a lower incidence of adverse clinical events (myocardial infarction, angina, revascularisation procedures, end stage renal disease) after a median follow up of seven years.11 A Cochrane review found that planned nursing visits can improve healthy behaviours and patients' outcomes in diabetes; it concluded that nurses "can even replace physicians in delivering many aspects of diabetes care, if detailed management protocols are available, or if they receive training."12
Many of the positive outcomes seen in planned care visits with nurses may be due to better communication between nurse and patient. In a randomised controlled trial of people with diabetes in general practice, analysis of taped discussions showed that nurses covered more topics in the consultations, and more often mentioned diet, alcohol use, smoking, and weight, than did the doctors. Patients were more likely to take the lead in discussing behaviour change with nurses than with doctors.w8 In focus groups, patients preferred nurse led shared care for managing diabetes over doctor led care by a ratio of nearly 6 to 1.w9 w10
Even though evidence and examples show the pivotal role played by nurses in improving chronic care, several barriers inhibit the spread of nurse led programmes in the United States (see bmj.com). The nursing shortage has made nurses difficult to recruit; few insurance plans pay for care provided by nurses; and nursing education in the United States does not emphasise the role that nurses can play in chronic illness care. In some health systems, nurses are under-used, taking blood pressures and putting patients into rooms rather than providing education for and encouraging self management by chronically ill patients. Until these barriers are overcome, the potential for nurses to lead a national effort in the United States to improve chronic illness care may be thwarted.
Thomas Bodenheimer, adjunct professor
Department of Family and Community Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA (Tbodenheimer@medsch.ucsf.edu)
Kate MacGregor, research director
Department of Family and Community Medicine, University of California at San Francisco, San Francisco General Hospital, San Francisco, CA 94110, USA
Nancy Stothart, clinical care specialist
Whatcom County Pursuing Perfection Project, Bellingham, WA 98225, USA
References w1-w10 and details of nurse led projects are on bmj.com
Competing interests: None declared.
References
Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Affairs 2001;20(6): 64-78.
Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the patient's agenda. JAMA 1999;281: 283-7.
Roter DL, Hall JA. Studies of doctor-patient interaction. Annual Rev Public Health 1989;10: 163-80.
Braddock CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W. Informed decision making in outpatient practice. JAMA 1999;282: 2313-20.
Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med 2002;17: 243-52.
Yarnell KSH, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? Am J Public Health 2003;93: 635-41.
Kaplan SH, Gandek B, Greenfield S, Rogers WH, Ware JE. Patient and visit characteristics related to physicians' participatory decision-making style. Med Care 1995;33: 1176-87.
Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care 1999;22: 2011-7.
Peters AL, Davidson MB. Application of a diabetes managed care program. Diabetes Care 1998;21: 1037-43.
Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. Ann Intern Med 1998;129: 605-12.
So WY, Tong PC, Ko GT, Leung WY, Chow CC, Yeung VT, et al. Effects of protocol-driven care versus usual outpatient clinic care on survival rates in patients with type 2 diabetes. Am J Manag Care 2003;9: 606-15.
Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Cochrane Database Syst Rev 2001;(1): CD001481.