Physician-led Care Research Articles

Truth Telling and Treatment Strategies in End-of-Life Care in Physician-Led Accountable Care Organizations: Discrepancies Between Patients' Preferences and Physicians' Perceptions.

Providing patient-centered care from preventive medicine to end-of-life care in order to improve care quality and reduce medical cost is important for accountable care. Physicians in the accountable care organizations (ACOs) are suitable for participating in supportive end-of-life care especially when facing issues in truth telling and treatment strategy. This study aimed to investigate patients’ attitudes toward truth telling and treatment preferences in end-of-life care and compare patients’ attitudes with their ACOs physicians’ perceptions.This nationwide study applied snowball sampling to survey physicians in physician-led ACOs and their contracted patients by questionnaire from August 2010 to July 2011 in Taiwan. The main outcome measures were beliefs about palliative care, attitudes toward truth telling, and treatment preferences.The data of 314 patients (effective response rate = 88.7%) and 177 physicians (88.5%) were analyzed. Regarding truth telling about disease prognosis, 94.3% of patients preferred to be fully informed, whereas only 80% of their physicians had that perception (P < 0.001). Significant differences were also found in attitudes toward truth telling even when encountering terminal disease status (98.1% vs 85.3%). Regarding treatment preferences in terminal illness, nearly 90% of patients preferred supportive care, but only 15.8% of physicians reported that their patients had this preference (P < 0.001).Significant discrepancies exist between patients’ preferences and physicians’ perceptions toward truth telling and treatment strategies in end-of-life care. It is important to enhance physician–patient communication about end-of-life care preferences in order to achieve the goal of ACOs. Continuing education on communication about end-of-life care during physicians’ professional development would be helpful in the reform strategies of establishing accountable care around the world.

The effect of physician-nurse substitution in primary care in chronic diseases: a systematic review.

Chronically ill and ageing populations demand increasing human resources who can provide on-going and frequent follow-up care. We performed a systematic review to assess the effect of physician-nurse substitution on process care outcomes. We searched OVID Medline, Embase, CINAHL and The Cochrane Library for all available dates up to August 2012 and updated in February 2014. We selected and critically appraised published randomised controlled trials (RCT) and followed the PRISMA guidelines for the reporting of systematic reviews. A total of 14 RCTs comprising 10,743 participants met the inclusion criteria. Studies were generally small and suffered from attrition of ≥20% and selection biases. There were 53 process measurements investigated in the 14 RCTs, many of which were unique to specific conditions. Accounts of nurses' roles, responsibilities, tasks, qualifications and training content/components were not described in sufficient detail. Most study estimates showed no significant differences between nurse-led care and physician-led care while less than a half (~40%) favoured nurse-led care. Despite the methodological limitations and the varying nurses' roles and competencies across studies, specially trained nurses can provide care that is at least as equivalent to care provided by physicians for the management of chronic diseases, in terms of process of care. Future, larger studies with better quality methods are needed and should report and assess whether the differences in effects vary due to diversity in roles, qualifications, training competencies and characteristics of clinicians delivering substitution of care.

Is perioperative home the future of surgical patient care?

Is perioperative home the future of surgical patient care?

The perioperative surgical home (PSH): a comprehensive review of US and non-US studies shows predominantly positive quality and cost outcomes.

Policy Points: The perioperative surgical home (PSH) is complementary to the patient-centered medical home (PCMH) and defines methods for improving the patient experience and clinical outcomes, and controlling costs for the care of surgical patients. The PSH is a physician-led care delivery model that includes multi-specialty care teams and cost-efficient use of resources at all levels through a patient-centered, continuity of care delivery model with shared decision making. The PSH emphasizes "prehabilitation" of the patient before surgery, intraoperative optimization, improved return to function through follow-up, and effective transitions to home or post-acute care to reduce complications and readmissions. The evolving concept of more rigorously coordinated and integrated perioperative management, often referred to as the perioperative surgical home (PSH), parallels the well-known concept of a patient-centered medical home (PCMH), as they share a vision of improved clinical outcomes and reductions in cost of care through patient engagement and care coordination. Elements of the PSH and similar surgical care coordination models have been studied in the United States and other countries. This comprehensive review of peer-reviewed literature investigates the history and evolution of PSH and PSH-like models and summarizes the results of studies of PSH elements in the United States and in other countries. We reviewed more than 250 potentially relevant studies. At the conclusion of the selection process, our search had yielded a total of 152 peer-reviewed articles published between 1980 and 2013. The literature reports consistent and significant positive findings related to PSH initiatives. Both US and non-US studies stress the role of anesthesiologists in perioperative patient management. The PSH may have the greatest impact on preparing patients for surgery and ensuring their safe and effective transition to home or other postoperative rehabilitation. There appear to be some subtle differences between US and non-US research on the PSH. The literature in non-US settings seems to focus strictly on the comparison of outcomes from changing policies or practices, whereas US research seems to be more focused on the discovery of innovative practice models and other less direct changes, for example, information technology, that may be contributing to the evolution toward the PSH model. The PSH model may have significant implications for policymakers, payers, administrators, clinicians, and patients. The potential for policy-relevant cost savings and quality improvement is apparent across the perioperative continuum of care, especially for integrated care organizations, bundled payment, and value-based purchasing.

Comprehensive Long-Term Care of Patients With Lung Cancer: Development of a Novel Thoracic Survivorship Program

Recent advances have improved the likelihood of long-term survival for patients with lung cancer. However, little attention has been given to the growing need for dedicated survivorship care for these patients. To address this unmet need, we developed a unique follow-up care model. In 2006, we convened a multidisciplinary working group to design a thoracic survivorship program (TSP) that provides follow-up by a nurse practitioner (NP) trained in survivorship care. Patients with early-stage lung cancer who were disease free for at least 1 year after resection were eligible for the program, which incorporates a standardized approach to cancer surveillance. Data on symptoms and outcomes were prospectively collected. Real-time electronic medical documentation was developed to optimize communication with primary physicians. Data were analyzed for the initial phase of the program, which comprised 655 patients. Ninety-two percent of eligible survivors who remained disease free chose to continue their care in the TSP, rather than receive follow-up with their thoracic surgeon. Clinically significant posttreatment symptoms were common, including fatigue (46%), anxiety (32%), chronic pain (25%), dyspnea (14%), and depression (12%). The majority of recurrences (72%) and second primary cancers (91%) in this cohort were identified by scheduled chest computed tomography at TSP visits. Survivorship care for patients with lung cancer, delivered in our NP-led TSP, is feasible, effective, and well accepted by patients. Through the implementation of a uniform self-sustaining patient-centered system, the TSP model improves on the variation of physician-led follow-up care.

Cochrane Review Brief: Nurse Versus Physician-Led Care for the Management of Asthma

Is nurse–led asthma care as effective as that delivered by a physician in the management of asthma?

Collaboration between Two Restructured Hospitals' Family Physician-Led Transitional Home Care Teams in the Provision of Home Ventilation Respiratory Support

Caring for a patient on a home ventilator requires a trained multidisciplinary home care team. Availability of home medical care support at our restructured hospitals allows timely discharge of these patients to their homes, resulting in decreased hospitalisation stay in an acute hospital; or the need of an intermediate care facility. We described a case where collaboration between two family physician-led transitional home care teams from two restructured hospitals resulted in safe transfer of care for a patient with amyotrophic lateral sclerosis requiring ventilator support. The importance of a multidisciplinary team effort in integration of medical and social care services to reduce unnecessary hospital utilisation was highlighted. The expertise and resources of home medical care teams must continually be enhanced to manage increasing number of patients with complex medical problems, including those requiring home ventilators.

The role of the pharmacist in patient-centered medical home practices: current perspectives

The role of the pharmacist in patient-centered medical home practices: current perspectives Nancy JW Lewis,1 Leslie A Shimp,2 Stuart Rockafellow,2 Jeffrey M Tingen,2 Hae Mi Choe,3 Marie A Marcelino21Private consultancy practice, Rochester Hills, MI, USA; 2Clinical, Social and Administrative Department, University of Michigan College of Pharmacy, Ann Arbor, MI, USA; 3Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI, USAAbstract: Patient-centered medical homes (PCMHs) are the centerpiece of primary care transformation in the US. They are intended to improve care coordination and communication, enhance health care quality and patient experiences, and lower health care costs by linking patients to a physician-led interdisciplinary health care team. PCMHs are widely supported by health care associations, payers, and employers. Health care accreditation organizations have created performance measures that promote the adoption of PCMH core attributes. Public and private payers are increasingly providing incentives and bonuses related to performance measure status. Evidence-based prescription, medication adherence, medication use coordination, and systems to support medication safety are all necessary components of PCMHs. Pharmacists have unique knowledge and skills that can complement the care provided by other PCMH team members. Their experience in drug therapy assessments, medication therapy management, and population health has documented benefits, both in terms of patient health outcomes and health care costs. Through collaborative care, pharmacists can assist physicians and other prescribers in medication management and thus improve prescriber productivity and patient access to care. Pharmacists are engaged in PCMHs through both employment and contractual arrangements. While some pharmacists serve a unique PCMH, others work within practice networks that serve practices within a geographical area. Financial support for pharmacist-provided services includes university funding, external grant funding, payer reimbursement, and allocation of PCMH incentives and bonus funds. There is growing support for pharmacist integration into PCMHs; however, more convincing cost-effectiveness data, as well as performance measures requiring the unique skills of pharmacists, may be needed before pharmacist-provided PCMH services become more widely adopted. Given the continued evolution of the PCMH model of care, ongoing opportunities exist for pharmacists to create an optimal care model that is suitable for PCMHs and rewarding for their profession.Keywords: pharmacy practice, multidisciplinary care, advanced practice, pharmaceutical care

Effects of Physician-Nurse Substitution on Clinical Parameters: A Systematic Review and Meta-Analysis

BackgroundPhysicians’ shortage in many countries and demands of high-quality and affordable care make physician-nurse substitution an appealing workforce strategy. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the impact of physician-nurse substitution in primary care on clinical parameters.MethodsWe systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected peer-reviewed RCTs comparing physician-led care with nurse-led care on changes in clinical parameters. Study selection and data extraction were performed in duplicate by independent reviewers. We assessed the individual study risk of bias; calculated the study-specific and pooled relative risks (RR) or weighted mean differences (WMD); and performed fixed-effects meta-analyses.Results11 RCTs (N = 30,247) were included; most were from Europe, generally small with higher risk of bias. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease and incontinence. Meta-analyses showed greater reductions in systolic blood pressure (SBP) in favour of nurse-led care (WMD −4.27 mmHg, 95% CI −6.31 to −2.23) but no statistically significant differences between groups in the reduction of diastolic blood pressure (DBP) (WMD −1.48 mmHg, 95%CI −3.05 to −0.09), total cholesterol (TC) (WMD -0.08 mmol/l, 95%CI -0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI -0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups.Limitationsdisease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters.Conclusionstrained nurses appeared to be better than physicians at lowering SBP but similar at lowering DBP, TC or HbA1c. There is insufficient evidence that nurse-led care leads to better outcomes of other clinical parameters than physician-led care.

Caseload of a land-based trauma team

Pre-hospital care is provided by a variety of models worldwide. The Tayside Trauma Team responds from Ninewells Hospital in Dundee to provide a physician-led pre-hospital care service targeted primarily at trauma patients. We present a description of the functions of the team, and data detailing the clinical work of the Team over a six-month period. The Team was called out 35 times in six months and attended 22 incidents, some involving multiple casualties. 34 patients received treatment at the scene of an incident. Most incidents were road traffic collisions, although the team also attended falls from height, an assault and a vascular injury. Eight patients (24%) met Injury Severity Score criteria for major trauma (ISS>15). Mean time from 999 calls to Team activation was 20 (range 4-79) min; and mean time from Team dispatch to 'Team mobile' was 4.6 (2-21) min. The Tayside Trauma Team provides a physician-led pre-hospital care response on demand from the Scottish Ambulance Service. It provides critical care interventions at the scene of various incidents (primarily traumatic) to attempt to improve patient outcome. Response times are favourable.

Abstract 18123: An Integrated Resuscitation Service, Combining a Specialist Pre-Hospital Physician Response Unit With Delivery to a Dedicated High-Volume Cardiac Arrest Centre, Optimises Survival Following Cardiac Arrest

Background: Despite advances in resuscitation medicine, survival rates to discharge following out-of-hospital cardiac arrest (OHCA) remain poor. Recent data support early critical care interventions including therapeutic hypothermia (TH) and immediate percutaneous coronary intervention (PCI). In London, a package of high quality physician-led critical care intervention on scene, with the capacity to transfer these patients direct to a PCI centre, is available through the deployment of London’s Air Ambulance specialist Physician Response Unit (PRU). Methods: Prospective data was gathered on OHCA treated by the PRU, which were transferred to a single PCI centre. Data included patient demographics, clinical characteristics, interventions and outcome. Results: Between April 2011 and April 2013, data was obtained on 20 patients, with a mean age of 59. Clinical characteristics - presenting rhythm: VF 65%, asystole 15%, PEA 15%, VT 5%. Return of spontaneous circulation (ROSC) was achieved at scene in 75%. PRU interventions: Advanced airway management 90%, rapid sequence induction 50%, early TH 45%, mechanical CPR (mCPR) during transfer 15%. Overall survival to ICU was 50%, with overall survival to discharge 45%. Of those patients who underwent emergency angiography, 71% survived to ICU, with 64% surviving to discharge. Of patients presenting in VF, 62% survived to discharge. Interestingly, 66% of patients who received TH survived to discharge, compared with 45% where TH was not used. All patients who underwent successful PCI survived to discharge with good neurological outcomes. 9 patients had a confirmed single vessel culprit lesion treated by PCI, one patient had complex mutlivessel disease complicated by cardiogenic shock and underwent mutivessel PCI, and 2 patients had an undiagnosed underlying cardiomyopathy. Conclusions: In selected cases, outcomes following OHCA can be optimized by integrating a PRU cardiac arrest service, enabling direct triage of patients to a cardiac arrest centre, with early application of neuroprotective strategies, mCPR, circulatory support and interventional cardiology techniques.

An integrated resuscitation service, combining a specialist prehospital physician response unit with delivery to a dedicated high-volume cardiac arrest centre, optimises survival following cardiac arrest

Purpose and background: Despite recent advances in resuscitation medicine, survival rates to discharge following out-of-hospital cardiac arrest (OHCA) remain poor. Recent data support early critical care interventions including therapeutic hypothermia (TH) and immediate percutaneous coronary intervention (PCI). In London, a package of high quality physician-led critical care intervention on scene, with the capacity to transfer these patients direct to a PCI centre, is available through the deployment of London's Air Ambulance specialist Physician Response Unit (PRU).

‘Interception’: a model for specialist prehospital care provision when helicopters are not available

The deployment of specialist teams to incident scenes by helicopter and the delivery of critical care interventions such as Rapid Sequence Induction of anaesthesia to patients are becoming well-established components...

Data-driven transformation to an oncology patient-centered medical home.

As the use of EMR systems increases, new standardized quality measures that incorporate patient- and payer-centric outcomes need to be developed, and data must be collected in a manner that will not distract the physician-led care team from the delivery of quality patient care.

A Closer Look at Complex Chronic Care Coordination

Capturing and documenting the coordinated activities of the physician-led care team for complex chronic care.

Nurse versus physician-led care for the management of asthma

Asthma is the most common chronic disease in childhood and prevalence is also high in adulthood, thereby placing a considerable burden on healthcare resources. Therefore, effective asthma management is important to reduce morbidity and to optimise utilisation of healthcare facilities. To review the effectiveness of nurse-led asthma care provided by a specialised asthma nurse, a nurse practitioner, a physician assistant or an otherwise specifically trained nursing professional, working relatively independently from a physician, compared to traditional care provided by a physician. Our scope included all outpatient care for asthma, both in primary care and in hospital settings. We carried out a comprehensive search of databases including The Cochrane Library, MEDLINE and EMBASE to identify trials up to August 2012. Bibliographies of relevant papers were searched, and handsearching of relevant publications was undertaken to identify additional trials. Randomised controlled trials comparing nurse-led care versus physician-led care in asthma for the same aspect of asthma care. We used standard methodological procedures expected by The Cochrane Collaboration. Five studies on 588 adults and children were included concerning nurse-led care versus physician-led care. One study included 154 patients with uncontrolled asthma, while the other four studies including 434 patients with controlled or partly controlled asthma. The studies were of good methodological quality (although it is not possible to blind people giving or receiving the intervention to which group they are in). There was no statistically significant difference in the number of asthma exacerbations and asthma severity after treatment (duration of follow-up from six months to two years). Only one study had healthcare costs as an outcome parameter, no statistical differences were found. Although not a primary outcome, quality of life is a patient-important outcome and in the three trials on 380 subjects that reported on this outcome, there was no statistically significant difference (standardised mean difference (SMD) -0.03; 95% confidence interval (CI) -0.23 to 0.17). We found no significant difference between nurse-led care for patients with asthma compared to physician-led care for the outcomes assessed. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. More studies in varied settings and among people with varying levels of asthma control are needed with data on adverse events and health-care costs.

Midwives' care can be as safe as physician-led services, and sometimes has better outcomes.

Midwife-led maternity care is as safe as physician-led care for women and babies, and may also have additional health benefits, concludes a review of the evidence by UK researchers.

Updates in the management of intracranial pressure in traumatic brain injury

Traumatic brain injury remains a common and often debilitating event across the world, producing significant burdens upon health and social care. Effective neurocritical care coupled with timely and appropriate neurosurgical intervention can produce significant improvements in patient outcome. There remains controversy about how best to manage intracranial pressure on the ICU; we review the recent literature addressing a number of key variables. Treatment of elevations in intracranial pressure can begin at the roadside and end on the ICU unit via a number of routes. Prehospital physician-led care may produce significant benefits in outcome which extend beyond airway management. Routine use of cooling worsens the respiratory outcomes without large improvement in neurological endpoints. The use of brain tissue oxygen monitoring is extending and increasingly used to guide management. Decompressive craniectomy in refractory intracranial hypertension has been associated with poor functional outcomes; a large multicentre trial is currently comparing it against barbiturate coma. The role of the neurointensivist in outcome for patients who suffer severe traumatic brain injury is key. Targeted therapies are allowing early detection and manipulation of brain ischaemia leading to more individualized treatment.

Comparing midwife‐led and doctor‐led maternity care: a systematic review of reviews

A report of a systematic review of reviews which examines the impact of having midwives-led maternity care for low-risk women, rather than physicians. A rising birth rate, increasing complexity of births, and economic constraints pose difficulties for maternity services in the UK. Evidence about the most effective, cost-effective, and efficient ways to give maternity services is needed. Searches were carried out in August-September 2009 of ten electronic databases, 16 key nursing and research websites, and reference lists of 56 relevant reviews. We also contacted 38 experts for information. No date restrictions were employed. A narrative review of systematic reviews or 'meta review' was conducted using transparent and systematic procedures to limit bias at all stages. Systematic reviews that compared midwife-led care during pregnancy and birth with physician-led care were eligible for inclusion. Three meta-analytic reviews were included. Midwife-led care for low-risk women was found to be better for a range of maternal outcomes, reduced the number of procedures in labour, and increased satisfaction with care. For some maternal, foetal, and neonatal outcomes reviews found no evidence that care led by midwives is different to that led by physicians. No adverse outcomes associated with midwife-led care were identified. For low-risk women, health and other benefits can result from having their maternity care led by midwives rather than physicians. Moreover, there appear to be no negative impacts on mothers and infants receiving midwife-led care.

Concurrent Oral 5 - BHPR Audit/Service Delivery and Research [OP32-OP39]: OP32. Is Nurse-Led Care Effective in Rheumatology? a Systematic Review

Background: The aim of this systematic review was to assess the effectiveness of nurse-led care (NLC) by comparing its outcomes with those of physician-led care or multidisciplinary care in rheumatology. Methods: MEDLINE, EMBASE, CINAHL and EBM reviews (Jan 1988 - Sept 2009) were searched using the terms: (nurse led OR nurse practitioner OR nurse specialist) and (effectiveness OR treatment outcome). The inclusion criteria were: 1) Primary studies with reported patient outcome data 2) RCTs with at least 2 concurrent intervention groups comparing nurse-led care and physician-led or multidisciplinary care. Economic evaluations were excluded. The titles and abstracts identified were screened independently by two reviewers (MN and KV) for relevance and design. Heterogeneity of outcome measures prevented a meta-analysis. Effectiveness of interventions was reported based on the patients’ main outcome(s) at the end of study with corresponding effect sizes. The effect sizes were calculated and reported as standardized mean difference (SMD), relative risk (RR) and ratio of means (RoM) as appropriate. Results: The search yielded 1907 articles, 56 of which met the inclusion criteria but only 8 were in rheumatology and were chosen for a detailed review (see Table). Five studies looked into NLC effectiveness in Rheumatoid arthritis (RA), two in osteoarthritis (OA) and one in fibromyalgia. NLC was compared with care by rheumatologist (RLC), junior hospital doctor (JHD), GP and with inpatient team care or day patient team care. All studies were from the UK and Netherlands and had varying quality with sample sizes ranging from 70 to 210. The primary outcomes were disease activity, functional status, coping with OA, health status for RA patients, patients' perception of their ability to control their RA, nurse-doctor diagnosis agreement and pain control. Although only 5/9 can be considered as nurse-sensitive outcomes, between group analyses of all outcomes demonstrated non-inferiority of NLC. Conclusions: The data in the review support the effectiveness of NLC intervention for patients with RA and OA. More high quality studies are required to demonstrate or refute this observation. Disclosure statement: All authors have declared no conflicts of interest.