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When it comes to providing health care for an aging nation, the bad news is no longer news. We already lack sufficient numbers of gerontologists and other professionals — nurses, social workers, pharmacists, aides — trained in geriatrics, and the shortage is projected to increase.
The good news, confirmed by a study in the Journal of the American Geriatrics Society, is that nurse practitioners can markedly improve the quality of care for older patients.
Say you have recently begun to experience troubling urinary incontinence. Your primary care doctor should offer you “behavioral/lifestyle treatment,” like Kegel exercises (which men as well as women can do). So says an evidence-based practice model, called ACOVE 2, developed to help guide health professionals through complex geriatric conditions.
How closely care hews to the model’s recommendations is expressed as a percentage. “It’s like a report card,” said Dr. David Reuben, director of geriatrics at the University of California, Los Angeles, and lead author of the new study. Behavioral treatments, not drugs, should be the first line of defense against incontinence, he said, because for most people, “it’s been shown over and over that it’s at least as effective and without the side effects.”
In his team’s study of 500 people over age 75, patients with incontinence at two primary care practices were either seen by a physician alone or managed jointly by a primary care doctor and a nurse practitioner. What percentage were treated according to the ACOVE 2 quality indicators? The report card, please.
Of the patients seen only by a physician, not one was told about Kegel exercises or other non-drug methods for reducing incontinence.
Of the patients treated by a physician and a nurse practitioner, 95 percent were offered non-drug approaches.
The U.C.L.A. researchers looked at four common conditions: urinary incontinence, falls, depression and dementia.
All four tend to receive lousy scores on ACOVE report cards, meaning patients with those conditions receive a small percentage of the recommended assessments and treatments — even though they are problems with serious consequences. “People who fall break hips,” Dr. Reuben said. “People with incontinence are limited in going out and participating in social life. These are major reasons for institutionalization.”
When it came to treating depression, patients seeing a doctor and a nurse practitioner received about the same care as those treated by doctors alone. In both groups, patients received 60 percent to 63 percent of recommended care.
But when patients showed up with one of the other three conditions, the addition of nurse practitioners meant much higher scores. Patients who saw a nurse practitioner along with a doctor received 80 percent of the recommended assessments and treatments for falls (compared with 34 percent for those who only saw a doctor), 59 percent for dementia (versus 38 percent) and 66 percent for incontinence (versus a particularly dismal 19 percent).
The nurse practitioners may have paid more attention, Dr. Reuben said, because “managing these conditions was their job. They were focused on it, and they had the time to do it comprehensively.” And these were general nurse practitioners, not those specializing in geriatrics — a track being phased out nationally in favor of a supposedly more integrated adult nurse-practitioner program.
Before readers accuse me of physician-bashing, let Dr. Reuben explain the benefits of the team approach. “There are certain things doctors do well, certain things they don’t do well, certain things nurse practitioners do better,” he said. He added that he sympathized with primary care doctors working with elderly patients who have many chronic conditions: “The job is too big. It’s too complicated. There’s too much to do.”
In the case of incontinence, explaining behavioral treatment takes considerable time. “What doctor seeing 14 patients in one morning is going to be able to sit down and explain Kegel exercises?” Dr. Reuben said. “It’s just not going to happen.”
So adding nurse practitioners to the mix sounds like a smart response, especially given how many more geriatric patients the health care system will have to handle in coming years.
But back to the bad news: This was hardly the first study to demonstrate the advantages of teams in geriatric care, yet professional territoriality and mistrust have prevented much progress. “Getting physicians to delegate is a huge issue,” Dr. Reuben said. In fact, a number of physicians participating in this study would not refer their patients to the nurse practitioners.
“When are we going to learn to acknowledge and appreciate the skills and abilities of each member of the health care team?” asked Dr. Barbara Resnick, a gerontologist at the University of Maryland, in an exasperated editorial accompanying the study.
Maybe not soon. In May, the New England Journal of Medicine reported the results of a mail survey of 505 physicians and 467 nurse practitioners, which revealed starkly different opinions on the nurse practitioners’ role. Do doctors provide higher-quality examinations and consultations than nurse practitioners during the same kind of primary care visit? Two-thirds of the doctors said yes. Three-quarters of the nurse practitioners said no.
The realm of aging and caregiving contains so many questions we can’t yet answer and problems we don’t know how to solve. We can’t cure Alzheimer’s disease or even say what causes it. But we know how to use nurse practitioners to improve geriatric care. We just don’t.
Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”