Author + information
- Costas T. Lambrew, MD, MACC, Chair,
- James T. Dove, MD, FACC,
- Beth A. Friday, RN, BSN,
- Caroline Lloyd Doherty, MSN, CRNP, ACNP,
- Michael A. Nocero Jr, MD, MACC,
- C.Richard Schott, MD, FACC and
- L.Samuel Wann, MD, MACC
Nurses have assisted physicians in delivering care for generations. During the past half-century cardiologists, nurses, and other non-physician clinicians have collaborated in a variety of ways in various contexts to develop new models of healthcare delivery to patients with known or suspected heart disease. The most visible and dramatic example of the development of the team-care concept in cardiology was the creation of the coronary care unit concept in the 1960s. Nurses and other non-physician clinicians (such as nurse practitioners and physician assistants) and individuals trained to assist in diagnostic tests (such as sonographers and X-ray technicians) are now indispensable members of the cardiac care team.
The need to provide efficient, high-quality care to a large and growing population of patients with cardiovascular disease has catalyzed the development of several models of team care in various inpatient and outpatient settings. Increasingly, non-physician clinicians (under the supervision of a physician) are providing many services traditionally provided by cardiologists (1). Cardiologists employ nurses, medical assistants, and technologists to support the office- or clinic-based care of their patients. In some contexts, private cardiologists or cardiology groups employ non-physician clinicians to help them care for their hospitalized patients. The role of non-physician health clinicians in cardiology practices varies widely. This reflects, in part, the diversity of cardiology practices in the U.S. The 2002 ACC workforce survey reflects this diversity (Fig. 1).
Hospitals also employ a wide range of individuals who provide a spectrum of clinical, technical, and support services to cardiac inpatients. As the complexity and demands of cardiac care have increased over the past generation, many types of health professionals have been incorporated into cardiac team care including nutritionists, clinical pharmacists, exercise physiologists, ECG technicians, pacemaker nurses, hemodynamic monitoring technicians, clinical biomedical engineers, imaging technologists, and emergency medical technologists, among others. The number of clinical nurse specialists, nurse practitioners, and physician assistants that have joined the cardiac care team in recent years has increased significantly as demand for cardiovascular services has grown in response to advances in the field and an expanding population of patients with cardiovascular disease.
Cardiologists play a critical role in leading these comprehensive cardiac care teams that provide care to inpatients and outpatients with cardiovascular disease. As we seek to improve the coordination of acute inpatient care with ongoing outpatient management of patients with chronic cardiovascular disease, it is important that the cardiac care team is used effectively and efficiently. This will have benefits not just for the individual patient but also for society as a whole. The cardiac care team model can also enhance the attractiveness of cardiology practice at a time when new medical graduates and all physicians are seeking a better work–life balance.
This working group believes that the present and projected shortage of cardiologists in the U.S. can be mitigated to some extent by increasing the use and improving the efficiency of non-physician clinicians. This would allow cardiologists to use their unique skills and abilities to cope with increasing demand for their specialized services. Moreover, the optimal use of the cardiac care team model should help individual cardiologists and groups of cardiologists to achieve a better work–life balance. This, in turn, should increase the appeal of cardiology as a career goal for some highly qualified candidates who perceive it as a specialty where physicians are overworked and have little control over their practices or their lives.
It is important to acknowledge that most private and academic practices already depend on these individuals to help them cope with the high demand for cardiovascular services. Meanwhile, the supply of physician assistants and nurse practitioners is somewhat limited, and there is growing concern about the nation's shortage of nurses, a situation that is likely to worsen (2,3). There were 2.6 million registered nurses in the U.S. as of January 1, 2003, and approximately 120,000 of them were advanced practice nurses (nurse practitioners or clinical nurse specialists) (4,5). It is unknown how many of these are employed by cardiologists, and we believe the ACC should help develop a method to quantify and track this important segment of the nation's cardiology workforce. Of the 50,000 physician assistants in practice, about 3% of them are in cardiology practice, and an additional 3% are in cardiothoracic surgical practice.
The duties of non-physician cardiovascular clinicians are determined by a combination of factors, including local traditions and needs as well as rules and regulations created by hospitals, organizations, licensing bodies, and the government. In the outpatient and inpatient setting, an increasing number of cardiologists employ nurse clinicians, nurse practitioners, and/or physician assistants to help them perform the initial clinical assessment of the patient, document the findings of the history and physical examination and the treatment plan, communicate with patients and family members, and help provide routine follow–up care. Each of these activities is supervised by the cardiologist who outlines a plan of diagnosis and treatment for each patient.
In hospital practice many cardiologists also use non-physician clinicians to help them deliver a broad spectrum of diagnostic and therapeutic services. For example, many hospitals with active interventional cardiology programs have trained non-physician clinicians to perform specific tasks such as post-procedure catheter removal and groin care. Duke University Hospital investigators reported their experience recently with training physician assistants to perform diagnostic coronary angiography under the supervision of a staff cardiologist (6). This demonstrates that workforce shortages and high demand for cardiovascular services continue to stimulate innovation in the delivery of heart care. Increasingly, in response to new ACGME regulations that restrict work and on-call hours, hospitals are hiring non-physician clinicians to provide some services that traditionally were the responsibility of internal medicine residents or cardiology trainees.
The growing demand for cardiac services and progressive subspecialization has led some private and academic practices to hire general internists to complement the care they deliver. Of course, family physicians and general internists provide many services to patients with stable, chronic cardiovascular diseases without the active involvement of cardiologists. In many rural or underserved urban locations physician assistants and nurse practitioners provide primary care without on-site supervision by a physician (5,7). In contrast to primary care, unsupervised or independent practice by non-physician clinicians in cardiology is rare. As discussed by Working Group 6, future development of telemedicine and electronic medical records may further enhance the ability of non-physician clinicians to provide primary and preventive cardiac care at the same time these innovations promote greater collaboration between cardiologists and primary care physicians.
Great variation exists in the geographic distribution of cardiologists and in numbers of cardiac services delivered across the U.S. (8). Uwe Reinhardt, a leading health care economist, notes, however, that “no one knows what differences in the quality of patients' lives are associated with the stunning geographic variations in practice style” (9). Wennberg et al. (8)have claimed that the clearest predictor for per capita consumption of cardiac services is the per capita distribution of cardiologists. This broad spectrum of usage presumably reflects a combination of over- and underuse with respect to expert consensus or evidence-based guidelines that hope to define appropriate care for specific cardiac conditions. The ACC/AHA guidelines are designed to provide evidence-based recommendations to help physicians and others provide appropriate care. These guidelines should be helpful to non-physician clinicians as well as the cardiologists who supervise their activities and actions.
There are financial implications of shifting more responsibilities from physicians to non-physician clinicians. Third-party payers may encourage the expanded use of non-physician clinicians mainly to reduce the costs of care. Therefore, it is important that we develop better ways to evaluate outcomes so decisions about the sharing or shifting of specific responsibilities can be based on evidence that these innovations enhance outcomes. Currently, there is great interest in developing outcome measures that will be useful to individual practitioners and to institutions as they introduce care models designed to provide more efficient and cost-effective care. As the role of non-physician clinicians in the care of patients with cardiovascular disease expands, we must be able to demonstrate that models we use maintain or enhance outcomes compared with traditional approaches.
Although the expanded use of non-physician clinicians helps cardiologists provide care more efficiently, this model presents some challenges with respect to the boundaries that define the content and value of specialty care (10). Close collaboration between cardiologists and non-physician clinicians is important if the goals of increased access and efficiency are to be achieved. Meanwhile, a lack of coordination and autonomous, unsupervised practice by non-physician clinicians may result in less desirable outcomes and other problems (11,12).
Pharmacists are a valuable part of the health care team, and closer collaboration between them, physicians, and non-physician clinicians is also desirable. Pharmacists possess extensive knowledge of clinical pharmacology and drug interactions. They often have complete and up-to-date individual patient prescription records that may not be readily available to the various independent physicians prescribing for a single patient. Pharmacists are also in an ideal position to alert both patients and their physicians to potential side effects and drug interactions and to suggest alternatives. There are some areas of tension, however. For example, cardiologists share concerns voiced by other physicians that granting pharmacists independent authority to substitute “equivalent” drugs for those initially prescribed is problematic. It usurps the physician's authority to prescribe specific medications for valid reasons based on his or her interpretation of the unique clinical situation. Meanwhile, unauthorized substitution does not free the patient's physician from responsibility for potential adverse effects or complications that might result from unauthorized substitution. Effective communication is key to resolution and prevention of these types of conflict between professionals. As discussed by Working Group 6, the Internet, the electronic medical record, and other advances in data storage and communication may facilitate the successful integration of non-physician clinicians and cardiologists into a highly effective cardiac care team.
Non-physician clinicians and the American College of Cardiology
The ACC recognizes the major contributions that non-physician clinicians have made and continue to make to the care of patients with cardiovascular disease. In order to better understand the spectrum of roles and relationships that have evolved in different care contexts over the past several years, the ACC created a Cardiac Care Team Task Force in 2002. This task force convened focus groups of nurses and physician assistants to learn how they function as part of a cardiac care team and to assess their educational and professional interests and needs.
The discussions were very informative and helpful. It was especially valuable to learn from participants in the focus groups about the various roles and responsibilities of non-physician clinicians in different care contexts. We believe that ACC members, as they evaluate options to help them cope with increasing practice demands, will find it very helpful to learn how their colleagues around the country have incorporated non-physician clinicians and other health care professionals into their inpatient and outpatient practices. This should help cardiologists decide whether (and how) to incorporate non-physician clinicians into their own practices as they confront increasing workloads at a time when recruiting cardiologists is becoming increasingly difficult in many settings.
Non-physician clinicians undertake many activities on behalf of the cardiologists or institutions that employ them. In addition to providing direct patient care, nurses, physician assistants, and other non-physician health professionals have been assigned the responsibility of gathering data to profile practice patterns using ACC/AHA guidelines and various tools that have been developed to facilitate continuous quality improvement. This is true for practices and institutions that participate in the ACC's National Cardiovascular Data Registry (NCDR) or are required by payers to provide information regarding utilization and/or outcomes.
The Cardiac Care Team Task Force delivered its report to the ACC Board of Trustees (BOT) early last year. That report supported a recommendation that the BOT establish a new membership category for non-physician clinicians. In March 2003, the BOT unanimously approved a motion that nurses, nurse practitioners, clinical nurse specialists, and physician assistants involved actively in cardiology practice can apply to become an associate member of the ACC if they are sponsored by an ACC member. This historic decision resulted in the creation of a new category of membership, the Cardiac Care Associate. In addition, the ACC created a Cardiac Care Team Committee, now co-chaired by a cardiologist and a nurse, that includes nurses, physician assistants, and fellows of the ACC.
The immediate goals of the Cardiac Care Team Committee include: 1) identifying and promoting awareness of cardiac team care practice models that operate efficiently and effectively, 2) collecting information about the various approaches used to train non-physician clinicians to perform their assigned duties effectively in different institutional contexts, 3) encouraging the ACC to develop and/or identify educational programs and tools that would be of special interest to cardiology non-physician clinicians, 4) identifying opportunities for cardiologists and non-physician clinicians to meet and network (e.g., at ACC Chapter meetings or receptions at the ACC Annual Scientific Sessions), and 5) identifying ACC committees, working groups, and task forces that would benefit from the appointment of one or more non-physician clinicians. The final report of the ACC Cardiac Care Team Task Force will expand on this short list of opportunities that we have identified to enhance collaboration and communication between physician and non-physician members of the cardiac care team.
The ACC BOT decision reflects its conviction that the care of patients with cardiovascular disease can be enhanced by the cardiac care team approach, when the members of that team are supervised appropriately by a cardiovascular specialist. Cardiologists in many practice settings have demonstrated by their actions that they value collaboration as a vitally important component of high-quality health care delivery. The ACC should encourage further refinement of the various models now in place in order to publicize best practices with respect to the cardiac care team model.
Effective national organizations exist for nurses and physician assistants. These groups address advocacy issues on behalf of the health care professionals they represent and the patients their members serve. The ACC should seek to identify common issues with these organizations and coordinate advocacy efforts. Understandably, issues related to scope of practice and appropriate reimbursement for services delivered by non-physician clinicians will need further discussion as the cardiac care team approach continues to evolve. Throughout these discussions it is important to acknowledge the vital role that the cardiologist plays in coordinating team care in addition to providing many services directly to patients.
The remainder of our working group report consists of observations and recommendations we believe would further enhance the cardiac care team models that are continuing to emerge and evolve throughout the nation. From the Cardiac Care Team Taskforce focus groups and from internal ACC data it became apparent that the college's educational programs and products are used widely and valued highly by non-physician clinicians who care for patients with cardiovascular disease. The nurses with whom we spoke felt that contemporary national nursing organizations serve many useful purposes, but their publications and meetings do not focus on cardiology. As a result, many non-physician clinicians rely on the ACC, AHA, and local hospital-based conferences for their formal continuing education in cardiology. Indeed, it became apparent that nurses and physician assistants perceived the ACC's educational programs and products as the most important benefit of potential membership in the college.
We identified several areas that would enhance ACC educational activities related to non-physician clinicians and other health professionals:
1. Nurses who attend the ACC Annual Scientific Sessions or other ACC-sponsored CME programs and/or who use ACC products should be able to receive continuing nursing education credits for these educational activities.
2. The Spotlight Session for non-physician health professionals which was piloted at the ACC Annual Scientific Sessions (and attracted 600 attendees in 2003) should be continued and publicized widely.
3. When relevant and appropriate (based on the topic, purpose, and target audience), non-physician clinicians who are Cardiac Care Associate members of the College should be invited to participate in ACC programs as speakers, panelists, or co-chairs.
4. Cardiac Care Associate members of the ACC should be appointed to educational planning committees and other College committees, task forces, and working groups where their perspective would inform the discussions and enhance the outcomes.
5. The ACC should develop programs and products designed to help prepare nurses and physician assistants to function effectively as non-physician clinicians in a cardiology practice. These programs, designed to supplement prior education and work experience and on-the-job training, should be offered at various sites around the country. The ACC chapters could play a significant role in developing and sponsoring these educational programs.
6. Chapters should invite nurses, nurse practitioners, and physician assistants to attend their educational programs and (when appropriate) to participate as speakers and panelists to foster interdisciplinary education. Topics relevant to their roles in practice should be presented.
7. Non-physician health professionals should be encouraged to submit articles relevant to cardiology practice for publication in ACC journals.
8. Condensed versions (e.g., pocket format) of ACC/AHA guidelines should be made available to members of the cardiac care team.
9. Tools should be developed that facilitate recording, retrieving, and analyzing the data required by the ACC/AHA performance measures.
10. Focused educational modules for cardiology non-physician clinicians should be developed that would help prepare them for practice as part of a cardiologist-led cardiac care team. Topics might include preventive cardiology and patient counseling in nutrition and exercise, management of chronic heart failure, the conduct of office-based research studies, data management for performance measurement, and use of performance based guidelines, among others.
Conclusions and recommendations
The members of Working Group 5 believe that the cardiac care team model (in which appropriately trained non-physician clinicians are supervised by a cardiovascular specialist) can enhance both access to and the quality of cardiovascular care. Various models of this nature already exist. They have grown, in part, as a pragmatic response for several years to the gap between the demand and supply of highly trained cardiovascular specialists. As our nation seeks ways to cope with the growing burden of cardiovascular disease, we suggest that the ACC consider several steps to facilitate recruitment, training, efficient and effective use, and acceptance of non-physician clinicians in cardiology practice:
1. The ACC (possibly in cooperation with other organizations) should create a member survey designed to gather detailed information on the use of cardiovascular non-physician clinicians in several contexts (e.g., academic and various private practice models). This survey should collect information about methods used to train non-physician clinicians, their responsibilities and scope of practice, reimbursement issues, and integration within the practice, among other things.
2. The ACC should analyze the results of the survey and use them as one method to inform cardiologists about care team models that appear to be very successful in terms of incorporating non-physician clinicians in the inpatient and outpatient practice of cardiology.
3. The ACC should describe the potential benefits of employing non-physician clinicians to cardiology office managers and administrators.
4. The ACC should educate the public that high-quality cardiac care is a team effort, and that a cardiovascular specialist is the coordinator of this skilled team. Patients should appreciate that non-physician clinicians can significantly enhance the ability of the cardiologist to give patients the best possible care. Handouts and other materials for office waiting areas should be developed to spread the message that sophisticated, state-of-the-art cardiovascular care depends on a coordinated team effort.
- American College of Cardiology Foundation
Working Group 5 References
- Hooker R.S.,
- Berlin L.E.
- Harper D.C.,
- Johnson J.
- Ward D.,
- Berkowitz B.
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- ↵Salsberg, E. Making Sense of the System: How States Can Use Health Workforce Policies to Increase Access and Improve Quality of Care. Milbank Memorial Fund Electronic Report. Available at: http://www.milbank.org/reports/2003salsberg/2003salsberg.html. Accessed December 1, 2003
- Phillips R.L. Jr..,
- Harper D.C.,
- Wakefield M.,
- Green L.A.,
- Fryer G.E. Jr.
- Wennberg D.E.,
- Birkmeyer J.D.
- Reinhardt U.E.