January 2001

Grant Results

National Program

Changes in Health Care Financing and Organization

SUMMARY

In the University Hospitals of Cleveland's Collaborative Care Unit, nurse practitioners manage the delivery of care and clinical decision-making. This project examined the impact of the collaborative care model on costs and quality of care at the hospital using a randomized controlled trial over a two-year period.

The investigators collected a wide range of outcome measures through patient interviews and medical record reviews, including functional status, symptom severity, patient satisfaction, mortality, hospital-acquired complications, use of consultations and hospital costs.

This project was part of the Robert Wood Johnson Foundation (RWJF) national program Changes in Health Care Financing and Organization (HCFO) (for more information see Grant Results).

Key Findings

  • Patient outcomes were similar on the collaborative care unit and traditional care units. According to the researchers, this finding suggests that nurse practitioners can successfully manage a wider spectrum of patients, and teaching hospitals can implement collaborative care, using nurse practitioners in an advanced role, without fear that the quality of care will suffer.
  • Patients whose care requires 24-hour monitoring and patients with undifferentiated or unclear admitting diagnoses would be best cared for on a traditional unit, under the care of resident physicians. However, these patients comprise only a small portion of patients admitted to the general medical wards of teaching hospitals.
  • The study team also noted that increased use of mid-level practitioners within academic medical centers would leave resident physicians with more time to pursue their educational objectives, particularly in the area of ambulatory care.

Funding
RWJF supported the project with a grant of $509,891 between September 1992 and February 1996.

 See Grant Detail & Contact Information
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THE PROBLEM

While inpatient care delivered in the nation's teaching hospitals has traditionally been the domain of physicians, some hospitals have experimented with using nurse practitioners in an expanded role. University Hospitals of Cleveland has had its Collaborative Care Unit (CCU) in operation since 1990. In the CCU, nurse practitioners manage the delivery of care and clinical decision-making. Collaborative care (CC) has three elements:

  1. Integrated patient assessment by physicians, nurses, and nurse practitioners.
  2. Nursing-initiated patient management using explicit protocols.
  3. Patient-centered case management designed for heterogeneous groups of medical patients rather than patients with a single diagnosis.

Cleveland's CCU has provided care for acutely ill patients without the services of resident physicians.

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THE PROJECT

This project examined the impact of the collaborative care model on costs and quality of care at the University Hospitals of Cleveland using a randomized controlled trial. Over a two-year period, 381 general medical patients were assigned to either a CCU or a traditional unit. (Of the 381 patients deemed eligible for the study, 193 were assigned to the CCU and 188 were assigned to traditional units. However, 63 of the 193 patients assigned to the CCUs were subsequently reassigned to traditional care units based on physician request.) The investigators collected a wide range of outcome measures through patient interviews and medical record reviews, including functional status, symptom severity, patient satisfaction, mortality, hospital-acquired complications, use of consultations, and hospital costs. The project team also looked at the types of patients suited to the collaborative care model.

Although sample sizes limited the researchers' ability to demonstrate significant differences between CC and traditional care patients, they were able to gain valuable insights into the potential effects of the CC model on the quality and efficiency of patient care.

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FINDINGS

  • Patient outcomes were similar on the CCU and traditional care units. According to the researchers, this finding suggests that nurse practitioners can successfully manage a wider spectrum of patients, and teaching hospitals can implement CC, using nurse practitioners in an advanced role, without fear that the quality of care will suffer.
  • Patients whose care requires 24-hour monitoring and patients with undifferentiated or unclear admitting diagnoses would be best cared for on a traditional unit, under the care of resident physicians. However, these patients comprise only a small portion of patients admitted to the general medical wards of teaching hospitals. The study team also noted that increased use of mid-level practitioners within academic medical centers would leave resident physicians with more time to pursue their educational objectives, particularly in the area of ambulatory care.

Communications

A chapter appeared in The Acute Care Nurse Practitioner — Origin and Promise (1996) and an article was published in Nurse Practitioner. Presentations were made at a number of conferences including the International Primary Care Conference. See the Bibliography.

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AFTER THE GRANT

The investigators highlighted an area that should be examined in future research on the use of mid-level practitioners in advanced roles in teaching hospitals: the cost-effectiveness of hospital units that use mid-level practitioners in comparison with those that use resident physicians whose salaries are artificially low. The study team expected to see improved efficiency, and cost savings in the use of diagnostic tests with nurse practitioners. They hypothesized that the care delivered by nurse practitioners would be more targeted toward key patient problems and less focused on peripheral complaints.

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GRANT DETAILS & CONTACT INFORMATION

Project

Evaluating Alternative Health Care Delivery Models for Teaching Hospitals

Grantee

University Hospitals of Cleveland (Cleveland,  OH)

  • Amount: $ 509,891
    Dates: September 1992 to February 1996
    ID#:  020553

Contact

Project Director: Gary E. Rosenthal, M.D.
(216) 368-0726

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Publications

Gedwill A, Mack S, Mlakar D and Vanek R. "Actualization of the Acute Care Nurse Practitioner Role: The Experience of University Hospitals of Cleveland." The Acute Care Nurse Practitioner — Origin and Promise. Edited by B. Daly. New York: Springer Publishing Company, 1996.

Genet CA, Brennan PF, Ibotson-Wolff S, Phelps C, Rosenthal G, Landefeld CS and Daly B. "Nurse Practitioners in a Teaching Hospital Setting." Nurse Practitioner, 20(9): 47–54, 1995. Abstract available online.

Brennan PF, Landefeld CS, Daly B, Fortinsky RH, Phelps C and Rosenthal GE. "Implementation of a Nurse Practitioner-Physician Collaborative Practice Model in an Academic Health Center." Unpublished.

Brennan PF and Daly B. "Information Requirements of Advanced Practice Nurses." Advanced Practice Nursing Quarterly, 2(3): 54–57, 1996. Abstract available online.

Pioro MH, Landefeld CS, Brennan PF, Daly B, Fortinsky RH, Malone U and Rosenthal GE. "Randomized Controlled Trial of an Inpatient Nurse Practitioner Service." Journal of Investigative Medicine, 44: 229A, 1996.

Pioro MH, Landefeld CS, Brennan PF, Daly B, Fortinsky RH and Rosenthal GE. "Validity of Alternative Patient-Centered Measures in Assessing the Impact of Hospitalization." Unpublished.

Presentations and Testimony

"Collaborative Clinical Service in a Teaching Hospital: Demonstration and Evaluation," at the 14th Annual Midwest Alliance in Nursing Conference, Cleveland, November 1993.

"Quantification of Dimensions of Nursing Practice Models," at the ANA Council of Nurse Researchers, Washington, November 1993.

"Collaborative Care: An Alternative Model for Organizing Health Care Delivery in Teaching Hospitals," at The Nurse Practitioner Symposium, Denver, May 1994.

"Collaborative Care: An Alternative Model for Organizing Health Care Delivery in Teaching Hospitals," at the International Primary Care Conference, London, England, June 1994.

"Evaluation of an In-Patient Acute Care Nurse Practitioner Service," at the Acute Care Nurse Practitioner Consensus Conference, Hartford, CT, April 1996.

"Randomized Controlled Trial of an Inpatient Nurse Practitioner Service," at the American Federation of Clinical Research, Washington, May 1996.

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Report prepared by: Karin Gillespie
Reviewed by: Marian Bass
Reviewed by: Molly McKaughan
Program Officer: Nancy L. Barrand

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