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The American Journal of Managed Care December 2010
Step-Up Care Improves Impairment in Uncontrolled Asthma: An Administrative Data Study
Robert S. Zeiger, MD, PhD; Michael Schatz, MD, MS; Qiaowu Li, MS; Feng Zhang, MS; Anna S. Purdum, PharmD, MS; and Wansu Chen, MS
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Tami L. Mark, PhD; Leslie B. Montejano, MA; Henry R. Kranzler, MD; Mady Chalk, PhD; and David R. Gastfriend, MD
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Peter M. Lynch, MPH; Aylin Altan Riedel, PhD; Navendu Samant, MS; Ying Fan, MS; Tim Peoples, MA; Jenifer Levinson; and Scott W. Lee, MD
Medication Adherence: The Search for Interventions That Work
Justin Gatwood, MPH; and Steven R. Erickson, PharmD
Part D Coverage Gap and Adherence to Diabetes Medications
Qian Gu, PhD; Feng Zeng, PhD; Bimal V. Patel, PharmD, MS; and Louis C. Tripoli, MD
Modes of Delivery for Interventions to Improve Cardiovascular Medication Adherence
Sarah L. Cutrona, MD, MPH; Niteesh K. Choudhry, MD, PhD; Michael A. Fischer, MD, MPH; Amber Servi, BA; Joshua N. Liberman, PhD; Troyen A. Brennan, MD, JD; and William H. Shrank, MD, MSHS
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Jennifer R. Webb, MA; Joseph Feinglass, PhD; Gregory Makoul, PhD; Cheryl L. Wilkes, MD; Daniel P. Dunham, MD, MPH; David W. Baker, MD, MPH; and Michael S. Wolf, PhD, MPH
"Under the Radar": Nurse Practitioner Prescribers and Pharmaceutical Industry Promotions
Elissa C. Ladd, PhD, RN, FNP-BC; Diane Feeney Mahoney, PhD, APRN, BC, FGSA, FAAN; and Srinivas Emani, PhD
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Roderick S. Hooker, PhD
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Nurse Practitioner Comanagement for Patients in an Academic Geriatric Practice
David A. Ganz, MD, PhD; Brandon K. Koretz, MD; Julia K. Bail, RN, MSN, GNP-C; Heather E. McCreath, PhD; Neil S. Wenger, MD, MPH; Carol P. Roth, RN, MPH; and David B. Reuben, MD

Nurse Practitioner Comanagement for Patients in an Academic Geriatric Practice

David A. Ganz, MD, PhD; Brandon K. Koretz, MD; Julia K. Bail, RN, MSN, GNP-C; Heather E. McCreath, PhD; Neil S. Wenger, MD, MPH; Carol P. Roth, RN, MPH; and David B. Reuben, MD

Nurse practitioner comanagment improved quality of care for 5 chronic conditions in an academic geriatrics practice.

Objective: To determine whether nurse practitioner (NP) comanagement can improve the quality of care for 5 chronic conditions in an academic geriatrics practice.


Study Design and Methods: From September 2006 to September 2007, 18 primary care geriatricians were divided into an intervention group that could refer patients to an NP for comanagement of dementia, depression, falls, heart failure, and/or urinary incontinence, or a control group that indicated which patients would have been referred to the NP for these conditions. The NP used structured visit notes to guide care delivery for the 5 conditions concordant with Assessing Care of Vulnerable Elders-3 (ACOVE-3) quality indicators. We reviewed charts to determine adherence to recommended processes of care.


Results: A total of 200 patients (108 intervention, 92 control) were eligible for at least 1 process of care recommended by ACOVE-3 for the 5 conditions. Patients' mean (SD) age was 85 years (7 years), 67% were women, and patients were eligible for a mean (SD) of 6.9 (4.4) processes of care. Intervention patients were eligible for more care processes than controls (7.8 vs 5.9 processes per patient; P = .002). Quality of care was higher for patients in the intervention group compared with the control group (54% vs 34% of care processes completed; P <.001). The adjusted absolute difference between intervention and control groups in care processes completed was 20% (95% confidence interval = 13%, 27%).


Conclusion: NP comanagement of 5 chronic conditions was associated with higher quality of care, even in a practice of geriatricians.

(Am J Manag Care. 2010;16(12):e343-e355)

A nurse practitioner markedly improved the quality of care for dementia, depression, falls, heart failure, and urinary incontinence in an academic geriatrics practice.


  • Adding a nurse practitioner focused on managing these 5 chronic conditions improved adherence to recommended geriatric care by 20% in a setting where all physician providers were geriatricians.


  • Improved quality of care came at the expense of 2.6 additional visits to the nurse practitioner per patient during a 13-month period.
The United States needs a more robust primary care system, yet fewer medical students are pursuing careers in primary care.1,2 This quandary, coupled with the need for interprofessional collaboration to care effectively for older adults,3 has renewed interest in care models that maintain the primary care physician (PCP) as the key decision maker with patients, but involve others in care implementation, including registered nurses with additional training (eg, nurse practitioners [NPs]), social workers, and physician assistants.4,5 Data suggest that NPs focused on a particular condition can provide at least comparable quality of care for that condition and sometimes achieve better patient  outcomes.6,7 However, informationis sparse regarding the effectiveness of NP comanagement of complex  older patients in outpatient settings. An NP/social worker team collaborating with PCPs and a geriatrician-led interdisciplinary team improved the quality of medical care for low-income seniors,8 and a trial of a registered nurse working with    teams of PCPs to improve care for older adults with multimorbidity has shown an early beneficial effect on quality.9 In addition, specialized nurses, NPs, or psychologists have successfully comanaged patients with depression or dementia in primary care.10,11

Available studies do not, however, address whether NP comanagement can improve quality in a primary care practice staffed by geriatricians. By virtue of their training, interest, and patient population served, geriatricians are likely to be expert in managing geriatric conditions. Yet many of the barriers to providing recommended care that affect all PCPs (eg, lack of time during the office visit, inability to overcome existing practice habits)12 also confront geriatricians. This study’s goal was to evaluate a quality improvement program that  compared usual primary care by academic geriatricians with care comanaged by an NP for 5 chronic conditions: dementia, depression, falls, heart failure, and urinary incontinence.


The quality improvement project ran from July 1, 2006, to September 30, 2007. Subsequently, University of California, Los Angeles Institutional Review Board approval was obtained to examine de-identified data. Table 1 contains a description of the project setting.


The project consisted of run-in (July 1, 2006 to August 30, 2006) and intervention (September 1, 2006 to September 30, 2007) periods. For these periods, an experienced, gerontology-certified NP (JKB), who was hired specifically for the comanagement role, was supported by a grant from the John A. Hartford Foundation. The NP was colocated with the geriatricians at the large outpatient clinic (see Table 1 for details on practice locations).

During the run-in period, the NP customized condition-specific structured visit notes based on previous versions13 to address the Assessing Care of Vulnerable Elders-3 (ACOVE-3) quality indicators for the 5 chronic conditions14-18 and American College of Cardiology/American Heart Association heart failure guidelines.19 These note templates were designed to support Medicare documentation requirements and could be used for both initial and follow-up visits. The run-in period also allowed time for the NP to develop her practice style, familiarize herself with clinic operations, and build trust among the referring physicians while seeing patients together with her supervisor (BKK). The practice also developed condition-specific patient education handouts (based on published materials20 and other materials21) and referrals to local community resources, most of which were available to both intervention and control physicians.

Before the intervention period, physicians were first paired by patient volume; then 1 physician from each pair was selected by coin toss to be able to refer to the NP. Intervention physicians could refer only their primary care patients, not other physicians’ patients whom they might have seen while covering. Control physicians could not refer patients to the NP but were requested to indicate which patients they would have referred.

During the intervention period, the night before a physician’s scheduled clinic, practice staff clipped an additional sheet to each patient’s chart. Control physicians were asked to note which (if any) of the 5 conditions would have prompted referral of the patient for NP comanagement and the priority level for each “referred” condition (more than 1 condition could have the same priority level). Intervention physicians were asked to note whether they would like the patient to see the NP for any of the 5 conditions and the priority level for each referred condition. The clinic scheduler received completed forms and, in the case of intervention patients, arranged an appointment with the NP. The NP could order tests and treatments without approval from the patient’s geriatrician, but could obtain guidance if needed. The NP delegated certain tasks to clinic nurses, including orthostatic vital signs, urinalyses, bladder scans, and visual acuity measurement. Patient follow-up visits were scheduled by the NP as needed. After each visit, the NP e-mailed or faxed geriatricians a written assessment and plan; she handled more urgent issues via phone or pager.

The project was introduced at a faculty meeting in September 2006, with follow-up by BKK (the clinical champion) to reinforce the importance of referrals. In February 2007, one pair of high-volume physicians switched roles, with the intervention physician switching to the control group and vice versa, because the physician originally assigned to the intervention group was not referring patients to the NP. This switch was made to increase the number of NP referrals.

For participating intervention and control physicians who were internists, the practice successfully applied to the American Board of Internal Medicine to receive credit for the Practice Improvement Module of the Maintenance of Certification program on the basis of this project. After the project period, all geriatricians could make referrals to the NP.


After project completion, 2 abstractors, who had worked as physicians outside the United States, were trained by a nurse researcher with extensive experience in chart abstraction (CPR). Abstractors reviewed both the paper and electronic medical record using structured forms. All intervention and a sample of control group records were reviewed (see Appendix A for details on control group selection).

The chart abstraction focused on determining eligibility for, and completion of, care processes specified by relevant ACOVE-3 quality indicators for vulnerable elders, the population served by the practice (see Appendix B for indicator list). The quality indicators specify a time window during which relevant care should be completed; if this window extended beyond the end of the project period for a particular indicator, the patient was considered ineligible for that indicator. The abstractors’ decision about completion of recommended   processes of care was based on the entire chart, regardless of who completed the care process or for which conditions the patient was referred to the NP. Thus, the care reviewed for patients in the intervention group was a compriorbination of both physician and NP care, and included project conditions that physicians had chosen not to refer to the NP. Abstractors were not blind to intervention versus control group status (because structured visit notes appeared only in intervention patients’ records) but were blind to which    conditions patients were referred for.

Fifteen charts were reabstracted (8 for test-retest reliability and 7 for inter-rater reliability), demonstrating a pooled kappa22 of 0.64 for agreement on eligibility for care processes and (where agreement existed on eligibility) 0.31 for completion of care processes. Data from the paper abstraction forms were entered electronically (with more than 99% accuracy). Abstractors also reviewed encounter data in the electronic health record to determine the number of geriatrician and NP office visits in the intervention and control groups.

Data Analysis

Patient demographics were limited to information in the chart, which included age and sex. Patients were assigned to the intervention or control group based on the group status of their primary geriatrician. For the 2 physicians who switched intervention/control group status during the project, analysis was based on actual referrals (intervention or control) at the time of referral rather than intention to treat. Adherence to each recommended care process was scored dichotomously (process completed/not completed). The percent adherence was computed for the intervention and control groups, both in aggregate and stratified by condition. The primary analysis included all of the patient’s conditions. In a sensitivity analysis, we included only those conditions designated as “top priority” for referral to the NP on the referral sheets. Details on statistical analyses may be found in Appendix C.


Charts from 275 patients (139 intervention, 136 control) were reviewed. For 2 patients, no record was found of any geriatric outpatient care; these patients were excluded. Of the remaining 273 patients, 200 (73%, 108 intervention, 92 control) were eligible for at least 1 ACOVE-3 process of care; these patients were eligible for a total of 1384 care processes (mean of 6.9 processes per patient [SD 4.4 processes]). Patients’ mean age was 85 years (SD 7 years); 67% were women. Age and sex did not differ by intervention versus control group assignment (P = .35 and P = .51, respectively). Intervention patients were eligible for more processes of care than controls (7.8 vs 5.9 processes per patient; P = .002).

Quality of care was higher for the intervention group than for the control group (54% vs 34% of care processes completed; P <.001). The adjusted difference in quality of care  between intervention and control groups remained significant (P <.001), and the bootstrapped quality of care difference between groups was 20% favoring the intervention group (95% confidence interval = 13%, 27%). Quality of care was higher in the intervention group for all 5 conditions, and the improvement was statistically significant for dementia, falls, and incontinence (Table 2). When we restricted quality-of-care data to those conditions designated by physicians as top prior ity for referral to the NP (found in 148 patients, 74% of  the sample eligible for at least 1 care process), quality of care was 60% in the intervention group and 38% in controls (P <.001). The intervention group had higher quality of care across all 5 conditions, and the improvement was statistically significant for dementia, falls, and heart failure (Table 2).

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