Transition toward a nurse practitioner-managed clinic.

OBJECTIVE: Advanced practice nurses (APNs) have been shown to provide effective quality healthcare when treating dyslipidemia, diabetes, and hypertension. As these conditions become more prevalent, APNs are becoming more widely used and respected and are a cost-effective alternative to physician-based healthcare. The Cleveland Clinic Preventive Cardiology and Rehabilitation program has progressed toward an APN-managed clinic for the past 5 years. METHODS: From 1987 to 1994, the clinic was traditionally a physician-based model. In 1995, physician extenders became part of the practice. In 2002, the transition began toward an APN clinic. An initial change included continuity with one APN when scheduling follow-up visits, triaging telephone contacts, and giving prescriptions. Documentation was changed to include the APN. Policy was revised to allow "incident to" and independent billing to address revenue and accessibility issues. Schedules reflected APNs as providers. Algorithms were developed and revised jointly between APNs and physicians. RESULTS: Patients have verbalized satisfaction with APN care. Survey data over a 12-month period indicated that in 5 of 8 questions pertaining to provider care, percent excellent or very good scores were 83% to 96% using a Likert scale. In the remaining 3 questions, scores ranged from 84% to 94% for the "yes, definitely" response, which was the most favorable response. Total APN visits for May 1, 2006, to May 1, 2007, were 2,522, billed independently, providing $476,031 in charges. Outcomes data for primary and secondary prevention patients showed an average improvement in the following laboratory results: 48 mg/dL total cholesterol, 36 mg/dL low-density lipoprotein, 3.5 mg/dL high-density lipoprotein, 99 mg/dL triglycerides, 3.68 mg/L ultra sensitive C-reactive protein. CONCLUSIONS: APNs are an effective and efficient way to provide cardiovascular risk reduction with an emphasis on medical management, lifestyle habits, and patient education.

Physician - nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care.

Increasing demand to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care. The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care. One hundred fifty-seven patients with hypertension and diabetes mellitus were randomly assigned to their primary care physician and a nurse practitioner or their primary care physician alone. Costs for personnel directly involved in patient management, calculated from hourly rates and encounter time with patients, and pre- and post-study glycosylated hemoglobin (HbA(1c)), high-density lipoprotein cholesterol (HDL-c), satisfaction with care and health-related quality of life (HRQoL) were assessed. Although 1-year costs for personnel were higher in the team-treated group, participants experienced significant improvements in mean HbA(1c) ( - 0.7%, p = 0.02) and HDL-c ( + 2.6 mg dL( - 1), p = 0.02). Additionally, satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups. This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs.