Is it justifiable to treat chronic patients by nurse specialists? Evaluation of effects on quality of care
International Journal of Integrated Care, 16 August 2004 - ISSN 1568-4156
Book review
Is it justifiable to treat chronic patients by nurse specialists? Evaluation of effects on quality of care
Bert Vrijhoef
Thesis, Maastricht University, 2002, pp 144,
ISBN 90 5278 364 0
Dennis L. Kodner, PhD, Professor of Urban Public Health and Rose Dobrof Chair & Executive Director, Brookdale Center on Aging of Hunter College, City University of New York

Usual medical care often fails to address the needs of growing numbers of persons suffering from major chronic illnesses. This stems largely from the mismatch between the complex health and psychosocial needs of these patients and health systems, which are primarily designed to treat acute conditions. The effective management of chronic conditions demands a population-based strategy in which clinical care and support services are coordinated not only throughout the lifecycle of the disease, but also the entire continuum of care. Interdisciplinary or multidisciplinary teamwork—especially between physicians and nurses—is essential in the “new” chronic illness management, as is the willingness to restructure professional tasks or functions to enhance efficiency and quality of care. It is within this context that nurse specialists—also known as nurse practitioners, nurse clinicians, and advanced practice nurses—are playing an increasingly pivotal role. But, can nurse specialists handle the chronically ill patients we have traditionally entrusted to the care of physicians, and are the effects on quality positive? These are the essential questions addressed by an impressive doctoral dissertation from the Netherlands, Is it Justifiable to Treat Chronic Patients by Nurse Specialists? Evaluation of Effects on Quality of Care.

The dissertation—mostly a collection of published articles and those submitted for publication—is based on work undertaken at Maastricht University Hospital and by health care organizations in two other Dutch regions (Venlo and Alkmaar) to build integrated care networks or regimens capable of managing the needs of patients with a variety of chronic illnesses, the most important being diabetes mellitus, chronic obstructive pulmonary disease (COPD), and rheumatoid arthritis (RA). The studies reported by the author (and colleagues) focus mainly on the management of stable patients with the first two illnesses. However, the volume also addresses the challenges of identifying patients with “stable” RA.

The eight chapters cover a wide range of topics. Chapter 1 offers an excellent overview of the nature and challenges of chronic care, interdisciplinary teamwork, the tasks and functions that can be performed by nurses at the boundaries of physician practice, and important background on the evolution of integrated care for the chronically ill in the Netherlands (particularly in the Maastricht region). It also defines the all-important research questions, hypotheses, and designs that form the work's underpinnings.

Chapter 2 presents findings on the applicability of low disease activity criteria in the assessment of the stability of RA in outpatients. In RA, the concept and definition of stability is problematic, given the complex nature and great variability of the disease. Without agreement on what constitutes stability, it would be difficult to target care by a nurse specialist. The research in this chapter shows that patients with stable RA can be effectively identified by applying the Disease Activity Score (DAS28)-derived from measures originally developed by the European League Against Rheumatism (EULAR). This suggests that the enrolment of stable RA patients in a nurse specialist panel would be feasible.

Chapter 3 presents a review of the literature on the effectiveness and efficiency of nurse-centred disease management programs for patients with type 2 diabetes and COPD. Good evaluative studies on such models are lacking, since the testing of new delivery models through outcomes research is only now taking hold. Despite the paucity of evidence, analysis of the ten trials identified shows that, depending on the content of the intervention, nurse specialists can play a central role in the management of chronic disease.

The “meat” of the dissertation is found in Chapters 4–7. Chapters 4 and 5 focus on outpatients with stable type 2 diabetes. Chapter 4 investigates a substitution model wherein patient responsibility is shared, but certain core medical tasks are transferred from an internist to a nurse specialist. The nurse specialist—acting as the main provider in lieu of the general practitioner—is studied in Chapter 5. Chapters 6 and 7 examine interventions of nurse specialists in the care of COPD outpatients. Chapter 6 assesses the effects on patient outcomes of transferring the care of stable patients from the pulmonologist to a nurse specialist working under protocol. The effects of the primary care based nurse specialist in the early detection of undiagnosed patients and patients at-risk of COPD are investigated in Chapter 7. Taken together, these four studies show that care provided by nurse specialists is fairly equal to that of physicians—both medical specialists and generalists—on a wide range of key clinical, health status, and patient care outcomes.

In the final chapter, Chapter 8, the author presents a summary of the findings, and concludes with a discussion of methodological considerations and limitations, as well as recommendations for both policy and further research.

Is it justifiable to treat chronic patients by nurse specialists? Thanks to this welcome contribution to the evolving field of integrated care, we can answer ‘Yes.’ The quality of care provided by nurse specialists is, for the most part, equivalent to the usual care provided by physicians—at least for patients with the diseases and in the disease states examined. However, as the author rightly concludes, further outcome-oriented research is needed, particularly with respect to RA and other chronic conditions.

The nurse-centred interventions described in this volume are essential if we are to effectively tackle the challenges of chronic illness in the integrated way these conditions demand. Indeed, with an eye on implementation, the author proposes several important steps on the policy and professional levels to redefine the role and educational requirements of non-physician practitioners, as well as create the capacity for inter-professional teamwork and care coordination.

Is It Justifiable to Treat Chronic Patients by Nurse Specialists? Is an excellent example of how health services research can inform professional practice and public policy by providing the information needed to make better decisions. With its important subject matter, solid research findings, well organised and written text, and nicely presented tables and figures, the dissertation is essential reading, and should be of interest to an international audience. Researchers and scholars will not only feel comfortable with this invaluable work; so will policy-makers, managers, and clinicians who are searching for a sound evidence base to guide the development and implementation of successful new models of integrated care for persons with chronic illness.