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Are Nurses an Answer to New Primary Care Needs?

The United States has a widely acknowledged shortage of primary care physiciansfewer per capita, in fact, than any other industrialized nation (1). A recent survey (2) found that 16% of U.S. adults who need primary care have to wait a week or more to see a physician. A big reason for this scarcity is money. Primary care pays the least of all of the medical specialties, and interest in this profession is at a low among medical students and residents (3). Meanwhile, the need for primary care physicians is growing as baby boomers retire and the Patient Protection and Affordable Care Act adds millions to the rolls of the newly insured. The nation will need new providers to care for these patients. A recent report (4) projects a shortage of as many as 44000 primary care physicians by 2025. Primary care physicians who are in practice are frequently too busy to provide proper care to their patients. Medical advances have transformed once terminal diseases, such as cancer, AIDS, and congestive heart failure, into complex outpatient conditions that require long-term management. In a study of 6700 patients in 12 metropolitan areas (5), researchers found that the medical care for many ailments, including diabetes, alcoholism, and pneumonia, met national guidelines only slightly more than half of the time. An article published over a decade ago (6) estimated that it would take more than 4 hours a day for a general internist to provide only the preventive care, such as scheduling mammography or colonoscopy screenings, that is currently recommended for an average-sized panel of adult patients (on top of the regular daily workload of managing chronic disorders and acute problems). The amount of time required is overwhelming, the authors wrote (6). If anything, the problem has worsened since then. With such a dire situation at hand, the following question naturally arises: Can other health care providers help to remedy this deficiency? The article by Shaw and colleagues (7) in this issue addresses this question. They report a meta-analysis of 18 studies encompassing 23004 patients from 1980 to 2014 that examines whether nurse-managed protocols, including titration and sometimes initiation of medications under the supervision of a physician, are effective in the outpatient management of adults with diabetes, hypertension, and hyperlipidemia. Of the 18 studies, 16 were randomized, controlled trials. Eleven were conducted in Western Europe, and the remainder was done in the United States. Outcomes were changes in hemoglobin A1c level, blood pressure, and cholesterol level. The results favored nurse-led care over conventional care. In patients treated with nurse-managed protocols, there was a 0.4% decrease in hemoglobin A1c level; a 3.68-mm Hg and 1.56-mm Hg decreases in systolic and diastolic blood pressure, respectively; and a 0.24-mmol/L (9.37-mg/dL) and 0.31-mmol/L (12.07-mg/dL) decreases in low-density lipoprotein and total cholesterol levels, respectively (although the lipid reductions were not statistically significant). The authors concluded that a team approach using nurse-managed protocols has positive effects on the management of adults with the aforementioned chronic conditions. One can almost hear a collective sigh of relief. The United States has approximately 200000 primary care physicians compared with 2.8 million registered nurses (8). For such conditions as diabetes and hypertension, in which treatment can often be distilled into algorithms, nurse-managed protocols could relieve the burden on both patients and primary care physicians. Learning that these protocols may result in improved outcomes over usual care is good news. It is also not surprising. Nurse-led programs for chronic disease management work. In England, nurse-run, protocol-driven clinics are already being used for managing diabetes and other chronic diseases. Studies have shown that nurse-coordinated programs for patients with heart failure, including early follow-up after hospitalization and intensive patient education, have the potential to prolong survival and decrease the frequency of hospital admissions (9). Of course, there are limitations to Shaw and colleagues' meta-analysis. Little information was provided about the interventions or protocols used. Most studies were conducted in Western Europe, and not all of them reported on nurses' training or expertise, which raises the question of whether the studies were similar and should have been pooled. In addition, adverse effects went almost entirely unreported and only 4 of the 18 studies were judged to have a low risk of bias. Perhaps most important, it is unclear whether the reductions in blood pressure or lipid levels were meaningful. For example, systolic and diastolic blood pressure decreased by 3.68 mm Hg and 1.56 mm Hg, respectively. These reductions are statistically but not necessarily clinically significant. More studies that evaluate not only surrogate markers but also hard clinical outcomes must be done. Nevertheless, the finding that nurse-managed protocols may have a positive effect on the treatment of outpatients with chronic conditions is welcome news. Shaw and colleagues' meta-analysis focused on stable outpatients. Whether nurse-managed protocols work for complex or unstable patients remains an open question. Still, this meta-analysis is a small step forward in showing that care teams can and should engage nurses outside of their traditional roles. Like it or not, outpatient medicine has become too complicated for physicians to handle by themselves. We need new models of primary care, and enlisting nurses will be central to this effort. Recognizing that nurse-managed protocols work for common outpatient diseases may be one step toward solving America's primary care problem.