142143CHAPTER 7

Ambulatory Nurse Practitioner Outcomes

Mary Jo Goolsby

1.  Review the purpose and importance of measuring and documenting outcomes of individual nurse practitioner (NP) practices

2.  Briefly summarize some of the literature on NP outcomes

3.  Describe the categories and examples of outcome measures relevant to ambulatory NPs

4.  Discuss practical considerations for selecting outcomes and a measurement approach

5.  Provide examples of how to approach outcome measurement in practice

6.  Discuss available resources relevant to primary care outcome measurement

1.  What are two potential measures in each of the following categories for a patient diagnosed with diabetes: physiologic, behavioral/knowledge, and resource utilization?

2.  What two enabling factors support NP entry into outcome measurement?

3.  Describe an outcome measure plan for a patient diagnosed with a chronic illness, based on a national evidence-based clinical recommendation.

4.  How do performance measures and outcome measures differ? Provide a brief summary, with an example of each related to a specific condition.

144The potential outcomes of ambulatory care match the broad range of conditions and patients encountered in these settings, whether primary or specialty care. NPs in primary care settings care for patients with both chronic and acute conditions. While they manage the range of well-defined acute to complex chronic conditions, they also address their patients’ health promotion and disease prevention needs. The incidence of many chronic conditions, such as hypertension, chronic obstructive pulmonary disease (COPD), and diabetes, is increasing and many of these patients routinely seek care in primary care settings, along with patients with acute conditions, such as pneumonia, urinary tract infections, and upper respiratory infections. In both primary and specialty ambulatory care, NPs will want to measure outcomes of routine management, as well as acute illnesses and exacerbations.

This author’s interest in ambulatory care outcome measurement stems from her first assignment as a new NP to a military internal medicine clinic in the early 1980s. The creation of a one-page form on each of her patients, most of whom had been referred for management of one or more chronic conditions, allowed quick access to patient-specific information, such as blood pressure, lipids, blood glucose, and weight, recorded immediately following each encounter because the patients’ health records were maintained outside the clinic. Initially planned as a means of responding readily to patient needs when records were unavailable, before long, curiosity prompted comparisons of the data over time. As the primary care provider for adults with chronic conditions, such as hypertension, diabetes, COPD, and heart failure, these forms allowed for extraction of clinical comparison over time and the habit of outcome measurement was born. Summaries of the data trends soon found their way into administrative reports describing the practice and benefits associated with referrals to an NP. Over the years, technology and outcome measurement skills improved, allowing for enhanced analysis and reporting of practice outcomes.

It can be intimidating to contemplate establishing a formal process for measuring outcomes. However, it is increasingly expected that providers such as NPs measure and report their outcomes as an objective indication of their quality, safety, cost-effectiveness, and patient centeredness. This chapter builds on the early chapters of this textbook by providing a practical framework that ambulatory care NPs can use in implementing outcome measurement in their practices. It (a) reviews the purpose and importance of measuring and documenting outcomes of individual NP practices, (b) briefly summarizes some of the literature on NP outcomes, (c) describes the categories and examples of outcome measures relevant to ambulatory NPs, (d) discusses practical considerations for selecting outcomes and a measurement approach, (e) provides examples of how to approach outcome measurement in practice, and (f) discusses available resources relevant to primary care outcome measurement (see Table 7.1).

  IMPORTANCE/PURPOSE OF PRIMARY CARE OUTCOME MEASUREMENT

As noted in earlier chapters, there are many reasons for conducting outcome measurement in practice. Outcome research should ultimately improve the health of our patients. Further, many stakeholders are interested in how and to what degree we improve the health of those we serve. These stakeholders include our current and potential patients, employers, colleagues, payers, policy makers, and others. They are interested in knowing how much NP care costs and saves, what precisely NPs do in their patient encounters, and the objective patient-centered benefits of that care. Ambulatory providers who receive fee-for-service payments from the Centers for Medicare & Medicaid Services (CMS) are increasingly expected to participate in the Physician Quality Reporting System (PQRS). Not specific to physicians, PQRS reporting can result in incentive payments and/or payment adjustments. It is a major example of the increasing expectation for public reporting of data by health care systems, organizations, and providers in smaller practices. As practitioners of a relatively new role created in the mid-1960s, NPs must continue to document the outcomes of their care.

145TABLE 7.1    Ambulatory Outcome Measures

ADL, activities of daily living; IADL, instrumental activities of daily living; QOL, quality of life.

146Evaluation of clinical outcomes is now an expectation of the NP role. The National Organization of Nurse Practitioner Faculties lists a number of competencies relative to outcome measurement in the 2012 NP Core Competencies (National Organization of Nurse Practitioner Faculties, 2012). Examples of outcome-related competencies are evident throughout the domains, including using evidence to continuously improve the quality of care; evaluating the relationships among factors, such as cost, quality, and so on; and improving outcomes through application of clinical investigative skills.

  SUMMARY OF EXISTING PRIMARY CARE NP OUTCOME LITERATURE

The published research on NP outcomes has consistently supported the quality and cost-effectiveness of NP practice. In 1974, a classic report of the Burlington Trial documented outcomes in mortality, as well as physical, emotional, and social function, concluding that NP and physician outcomes were comparable (Spitzer et al., 1974). The Congressional Budget Office reviewed studies on NP practice and outcomes in 1979, with the conclusion that the NPs’ outcomes, diagnoses, and management were at least as good as those of physicians. In 1986, the Office of Technology Assessment came to the same conclusions. Later, meta-analyses of NP care had similar findings (Brown & Grimes, 1995; Horrocks, Anderson, & Salisbury, 2002; Laurant et al., 2004), as have additional review articles (Cunningham, 2004). Mundinger et al. (2000) and Lenz, Mundinger, Kane, Hopkins, and Lin (2004) described primary care outcomes of patients assigned to either physicians or NPs, finding equivalent outcomes for both sets of patients. Regarding cost-effectiveness of NP care, studies have also consistently demonstrated that NPs provide quality care efficiently with reduced cost, compared with physicians (Burl, Bonner, & Rao, 1994; Chenowith, Martin, Penkowski, & Raymond, 2005; Office of Technology Assessment, 1981; Paez & Allen, 2006; Roblin et al., 2004). Newhouse et al. (2011) conducted a systematic review of the published literature (1990–2008) on NPs and other advanced practice registered nurses (APRNs), confirming that the evidence continues to support high-quality outcomes associated with NP care. More recent reports demonstrate similar outcomes. Virani et al. (2015) found similar outcomes among outpatient cardiovascular patients whether seen by a physician, NP, or physician assistant. Perloff, DesRoches, and Buerhaus (2016) analyzed large CMS data sets, reporting that the outpatient costs for Medicare beneficiaries assigned to NPs were 18% lower than the costs for beneficiaries assigned to physicians.

  MEASURES RELEVANT TO AMBULATORY CARE PRACTICE

The outcomes selected by a given NP will depend on factors such as the type of practice, areas of interest, and available resources. Even in a focused subspecialty-type practice, there are several options to measure. Outcomes can be categorized in many 147ways. One categorization (Table 7.1) would classify outcomes as best demonstrating one of the following: physiologic status, psychosocial status, functional status, behavioral activities and knowledge, symptom control, patient perception, or resource utilization. Within each category, there are likely measures relevant to any area of practice. Another common area of measurement that does not fit the definition of outcome but which must be considered relevant to contemporary ambulatory care involves performance measures.

Physiologic status involves those biomarkers that are usually readily available in the course of routine patient care. They include routinely collected vital signs, such as blood pressure, pulse, and temperature; physical exam findings, such as lung sounds and weight; and laboratory values, such as glucose and lipid levels. Abnormal findings in these physiologic markers are often the defining characteristics of health problems and the targets of care; thus, they provide a means of later following response to and outcomes of treatment. For instance, the outcomes of diabetes, hypertension, or hyperlipidemia management should include measurement of blood glucose/glycosylated hemoglobin, blood pressure, or lipids, respectively. A feature of physiologic measures, such as vital signs and laboratory findings, is that they are objective and quantified. Laboratory studies, in particular, are usually validated against some control procedure. The quality of vital signs and physical examination findings is dependent on the quality of the equipment and technique used in obtaining the measures.

Although psychosocial status includes measures often included in the history and which are qualitative in nature, psychosocial measures can be quantified through use of validated tools. Examples of psychosocial outcomes include mentation, mood and affect, attitude, coping status, and general social functioning. While psychosocial status outcomes often involve some degree of subjectivity, there are a number of validated and quantitative scales available, depending on the focus of concern. For instance, there are validated scales to measure depression and anxiety, confusion, and dementia. Depending on the outcome of interest, sources are often available to discuss measurement options. For example, the Mini-Mental State Examination is a common tool for cognitive function, well published and validated. Harvan and Cotter (2006) review and compare a range of dementia-screening tools for use in clinical practice.

Specific functional status involves the ability to achieve routine activities of daily living (ADL) and instrumental activities of daily living (IADL), and can be measured with global functional scales or measures more specific to select abilities such as mobility and communication. A number of measures of functionality exist, including the physical activities of daily living and instrumental activities of daily living scales, as well as the 10-minute Screener for Geriatric Conditions. Others include the Functional Independence Measure Scale and the Barthel Scale.

Behavioral activities and knowledge include areas of both therapeutic competence and understanding of treatments. Therapeutic competence involves the ability to perform the skills necessary to carry out prescribed or recommended treatments, as well as the ability to solve problems related to therapeutic guidance. Understanding is related to basic knowledge regarding recommended diet, medications, and treatments without a behavioral component. Knowledge tests have been developed and described in the literature for select conditions. Measurement of behavioral activity competence is more complex to assess than knowledge, by comparison.

148Symptom control is another area of outcomes where the history often includes the basic related details, but requires further quantification to serve as an outcome measurement. Examples of the symptoms that could be quantified as outcome measures include level of pain, fatigue, dyspnea, nausea, constipation, diarrhea, and incontinence. There are a number of validated scales to measure many symptoms, and pain scales are perhaps among the better known. One means of assessing specific symptoms would be to use a 10-centimeter visual analog scale (VAS), where the poles of the scale represent symptom extreme (complete absence of the symptom versus worst possible degree of the symptom), or having the symptom similarly rated using a numerical scale.

Patient perceptual category, relative to the patient centeredness of care, includes areas such as a patient’s perceived quality of life (QOL) and expressed satisfaction with care. QOL refers to patients’ satisfaction with their life circumstances and sense of well-being. It can further relate to a more narrowed focus of satisfaction with specific components of the patient’s life, for instance, with how a specific symptom affects life quality. There are general and condition-specific QOL scales, and a VAS can also be used to measure perceived QOL. In contrast, satisfaction refers to satisfaction with the patient experience and care received. Patient perceptions also include a patient’s determination of progress toward meeting goals. For instance, patients can identify their personal goals for treatment, and then subsequently rate the degree to which they are able to accomplish the goal over time.

Resource utilization involves a range of outcomes, such as numbers of hospitalizations or readmissions, length of stay for any admission, the cost of care, and unplanned office or emergency visits. In many cases, it is difficult to accurately identify all hospitalizations or emergency visits, along with the cost for each, as dependent on the patient’s recall. However, within a well-defined system such as a managed care organization, accountable care organization, or hospital-anchored system, pulling electronic or paper records of other visits, admissions, and associated costs such as those related to diagnostic studies and prescription medications is more easily accomplished. In addition to identifying any change in resource utilization associated with care, cost analysis of the actual care provides another outcome indicator.

Recommendations for performance, quality, and outcome assessment measures are available through a number of national initiatives and repositories, such as the National Quality Forum (NQF), the National Committee for Quality Assurance (NCQA), and the National Quality Measures Clearinghouse (NQMC). These entities are generally engaged in interprofessional development, recommendation, and/or dissemination of quality measures for systems, organizations, and providers, so that it is critical to identify measures created for outpatient practice. An increasingly important source of outcome measures is available through the PQRS program.

Many recommended measures include a focus on performance, rather than the ultimate outcome. It is worthwhile considering the difference between performance measures and outcomes of care. Performance measures document what is performed or done, rather than the outcomes of that practice. Performance measures sometimes serve as surrogates for actual outcomes in various reporting programs. With the increasing availability of electronic health records, queries of coded procedures allow ready identification of completed clinical activities. Certainly, current “pay-for-performance” mandates are based primarily on documenting the resources available and the processes 149implemented, as opposed to actual outcomes, so that incentives are based on providers documenting activities such as making appropriate referrals, ordering and monitoring suggested laboratory studies, and administering or ordering recommended treatments (e.g., pneumonia vaccines for persons 65 years of age or older, or beta-blockers for patients experiencing a myocardial infarction) rather than the associated outcomes that are subject to a number of intervening influences. Although clinical recommendations often imply that specific activities should result in improved outcomes, it is ideal to document the results of the performance measures, as well as the performance, to validate the desired result.

  SELECTING PRACTICAL OUTCOMES OF INTEREST

With the broad range of potential outcomes of primary care NP practice, the dilemma becomes determining what should and can be measured. It is advisable to start with an answerable question and then proceed to select the available measures and/or type of data that will contribute to the answer. Certainly one deciding factor should be the provider’s own areas of interest and questions. Other considerations will include the context in which the care is delivered, the resources available to support outcome measurement, and anticipated patient variables.

The decision to measure outcomes of practice may be based on questions the NP has regarding how his or her practice outcomes compare to some benchmark or published report. In practices with an established performance improvement (PI) process, there may be baseline data that support the need for improvements and that trigger outcome measures. Just as PI activities typically focus on conditions of large volume, high cost, and high risk, these same three criteria are helpful in guiding decisions on where to expend energy in outcome measures.

The practice context is important, as practices vary in the range and quality of resources helpful to outcome measurement. The progress toward broad implementation of electronic health records in ambulatory practice offers great promise for increased ability to automate queries regarding specific outcomes or activities performed. Practices with a well-designed electronic health record have an advantage when it comes to identifying relevant patients and tracking and measuring outcomes and performance. When selecting outcome data to be collected from an electronic system, it is critical to ensure that data are accurately coded and entered. The use of narrative notations rather than precoded options limits the utility of pulling needed data once entered. It also remains critical that the language of the system accurately fits the data and the practice involved. Another organizational consideration involves a philosophical expectation or mission that could mandate select measures used for outcomes and collegial support for the effort. Because it is rare for a health care provider to be the sole provider in an ambulatory clinic, it is often helpful for the team of providers to collaborate and select clinical topics and outcomes of interest. Moores, Breslin, and Burns (2002) describe the process of talking through problems with peers as a means of bringing the issue into focus as an answerable question.

Another type of resource specific to practices is the type of economic resources available for patient care. If a practice has a largely indigent population, the type of measures 150readily available may differ from one with a more affluent patient population, unless the practice has additional sources of funding to support patient care needs.

Patient-specific variables must be considered when planning outcome measurement. For instance, patients who tend to seek episodic care are not easily followed over time and short-term outcomes will be important rather than outcomes that are measured over time. For episodic visits, sometimes a performance measure may be helpful, such as the percentage of patients with a given diagnosis who receive or do not receive antibiotics, or the percentage of patients meeting specified criteria who receive appropriate immunization during visits. Of course, efforts to enhance continuity could be implemented and then long-term follow-up included as a measure itself.

In considering relevant outcome measures, ambulatory NPs must also consider what is recommended for select conditions; published clinical recommendations or guidelines provide an excellent source for outcome selection. These often identify a number of measures that could be used to track response to treatment, including specific validated tools. When focusing on a specific condition, it is often favorable to use condition-specific measures that will be more sensitive to change with treatment of that select condition whenever possible. For instance, while asthma affects psychosocial and functional outcomes, these may also be affected by a number of other comorbid conditions, so that these other conditions confound the response to care. By measuring specific asthma variables, outcomes are more easily attributed to treatment of that specific condition. There are scales to assess outcomes of treatment of conditions, such as arthritis, asthma, fibromyalgia, and benign prostatic hyperplasia, in addition to the relevant physiologic markers, such as pulmonary functions, blood glucose, and blood pressure. For varied conditions, generic outcomes could be used. For instance, generic functionality measures, or SF-36 v2 Health Survey, are broadly used. Scales of QOL could be responsive to a number of health changes, as would pain scales.

When the topic of interest has been identified and feasible outcome measures identified based on the characteristics of the practice, patient population, and providers, a plan should be written to guide the continuing effort. While most NPs may be more comfortable with associating the outcome measurement process with continuous quality improvement (CQI) or PI than with more formal “research,” outcome measurement is a form of exploratory research (Breslin, Burns, & Moores, 2002) and the methodological issues are important considerations. An important benefit of establishing a written plan early in the planning process is that the plan will help to identify any related costs as well as added resources needed. In addition, even with CQI/PI projects, it is advisable to discuss the plans with a representative from the affiliated institutional review board or research board, to determine whether a formal application and approval are expected.

  CASE EXAMPLES

  The Shotgun Approach

The first case is an example of the importance of carefully thinking through the outcome measurement approach and how the alternative, using a “shotgun” approach to outcome measurement, can “backfire.” A newly hired NP inherited a disease management practice for patients with asthma and/or COPD, finding that her predecessor had created 151a very broad plan for measuring the outcomes of the practice. At the baseline, initial visit, and again at 3, 6, 12, and 18 months, patients would be assessed with a focused history and physical, as well as by completing the following measures: the Center for Epidemiology Depression Scale, the State-Trait Depression and Anxiety Scale, the SF-36 Medical Outcomes Scale, the Modified Dyspnea Index, a record of peak flow use, history of tobacco use, medication list, a number of VASs (QOL, dyspnea), and a 6-minute walk with pulse oximetry, breath sounds, peak flow, and pulmonary functions before and after. In addition, the system’s records were queried at these intervals for any emergency department visits and hospitalizations, as well as the costs and charges for each. Needless to say, even in a 1-hour visit, it was hard to conceive how anyone would accomplish all of the necessary outcome measures, if time were to be spent on patient problem solving, support, and education. The clinic’s previous NP provider had recently resigned and, historically, patients rarely returned after the second visit.

The NP manager and interim NP provider reviewed the processes and interviewed some of the practice’s patients. Patients shared that they saw little benefit in participating in all of the multi-item scales and found numerous depression, anxiety, medical outcomes, and dyspnea scales difficult to understand and confusing. Moreover, it seemed that collecting outcome measures had become the focus of the clinic, rather than the delivery of care directed toward improving their health.

After reviewing available measures relevant for COPD and asthma, the characteristics of the patient population, and feedback from patients, measurement procedures changed to allow for the emphasis to be on patient-centered care delivery. Necessary outcomes were embedded in the encounter record, with the number of outcomes significantly abbreviated. After testing the new plan, it seemed feasible and beneficial to record responses from dyspnea VAS and other relevant symptom ratings (e.g., shortness of breath, cough, and interrupted sleep), peak flow averages, and tobacco use, as well as to quarterly system queries to document a cost analysis of resource utilization. Subsequently, the continuity of care immediately improved; patients remained in the clinic; and the outcomes improved as time was allotted for shared decision making and education of patients about their conditions. The physiologic measures showed improvement. The population’s emergency department visits were cut in half, and the number of hospitalizations was decreased to approximately 15% of the historical data following enrollment to the clinic. On an ongoing basis, the clinic has been able to demonstrate positive outcomes and to serve as a model for other disease-managed clinics.

  Triangulation

An earlier chapter describes combining quantitative and qualitative efforts in outcome measurements to provide for triangulation. An NP involved in the pulmonary management described previously monitored tobacco use in her patients. Instituting the “Five-A” approach (ask about patient’s habits, advise of consequence of smoking, assess willingness to quit, assist with cessation plan development, and arrange for follow-up) to smoking cessation and providing support based on her patient’s level of readiness, she wanted to measure the outcomes of the process.

She asked all newly referred patients whether or not they smoked and, for those who did smoke, the number of cigarettes used per day. Thus, the measures used were tobacco 152use (Yes/No) and number of cigarettes, collected from each patient at the first visit and again at 3, 6, and 12 months. At baseline and at 3 and 6 months, the percentage of patients who smoked was 45%, 43%, and 49%, respectively, and the number of packs per day for patients who smoked was 0.91, 0.65, and 0.60, respectively. Certainly, the decrease in amount of tobacco used per smoker was positive, but the anticipated outcome had included a decreasing percentage of smokers, not an increase.

The NP instituted a series of interviews with the patients to explore the tobacco use. For instance, she wondered whether prior to the first appointment, a number of patients might have “quit” smoking due to initial concern over their respiratory symptoms, but were unable to maintain abstinence. Instead, she found that the percentage of her patients who smoked was actually stable over time; however, some patients indicated that they had not been forthright in sharing whether they smoked during their initial visit, concerned that their care might be affected or that they would be lectured for the practice. Only after they developed a comfort with the new provider through a couple of visits, were they more likely to be open about their tobacco use.

The series of interviews also identified a number of other issues and challenges related to tobacco use for her patients. When the NP identified that her standard practice was not successful in helping her patients quit smoking, she used the findings to obtain external funding for an individualized tobacco-cessation program. The funded program provided a range of resources for patients during the smoking-cessation process and did result in a decreased percentage of smokers. However, without the qualitative interviews, the necessary information would not have been identified to further improve practice and later outcomes.

  APPROACHES TO OVERCOMING POTENTIAL BARRIERS TO OUTCOME MEASUREMENT

There are many potential barriers to outcome measurement. These include lack of confidence, time, and support, as well as limited data analysis resources.

Primary care NPs are likely to struggle with where to start with outcome measurement and to be intimidated by the concept. Primary care is fraught with many competing demands and the need to remain current on the recommended approach to many conditions. This may leave little time for the individual NP to prepare himself or herself for practice in outcome measures and, with the broad range of conditions encountered, to even decide what measures are important. Depending on the practice setting, there may not be a significant level of support for outcome measures or the emphasis may be on the basic performance measures rather than actual outcomes. Finally, given availability of outcome measures, many NPs will lack the initial knowledge of how to analyze the data.

Luckily, there are several resources that will facilitate the outcome measurement process. Resnick (2006) provides a four-step process to implementing outcome research. While her discussion is directed toward implementation of projects that will develop new and generalizable knowledge rather than limited findings to one practice setting, the steps provide examples of how to go about the process as well as encouragement for NPs contemplating the process. The other resources cited earlier also provide guidance.

153Key facilitators include the NP’s desire to improve practice and to optimize the outcomes of care. In fact, an ideal way to launch outcome measurement may be through practice improvement projects. Practice, or performance, improvement is an area of growing interest by multiple professions. Physicians, in particular, have PI expectations as part of their maintenance of certification requirements. Thus, in multiprofessional ambulatory practices, there is a growing tendency for PI to be implemented and often to involve team efforts—with all providers participating. NPs often are familiar with the PI process, regardless of which particular model they have used in their prior nursing practice. PI encompasses the principles important to overall outcome measurement: the target variables should be important to the practice, based on evidence, designed to measure improvement, and be practical to identify. A benefit of a PI focus is that there are a number of recognized PI models (e.g., plan-do-check-act, model for improvement, or plan-do-study-act [PDSA]) that describe a step-by-step approach for measurement over time.

Another factor facilitating NP efforts in outcome measures is the clinical expertise that NPs bring to their practice. A sound knowledge of a clinical area supports understanding of expected outcomes of care, which should provide direction on how to proceed in measurement activities.

Finally, even when NPs practice in a setting without other providers with similar interests in outcome measurement, it can be very helpful for NPs to establish a collaborative process with providers in other settings who have similar needs. Through collaboration, the providers are able to work together to establish outcome processes and strategies for success. Alternatively, an external mentor can be sought to coach through the process. Finally, there are networks for practice-based research in which providers can participate to become involved in the research process.

  SUMMARY

Measuring and documenting outcomes of NP practices in ambulatory and specialty settings is essential in order to identify the impact of the role and to evaluate the care provided. As NPs in primary care settings care for patients with both chronic and acute conditions and manage the range of acute to complex chronic conditions, many opportunities exist for demonstrating the impact of such care. Measures relevant to ambulatory care NP practice span the spectrum from health promotion and disease prevention to management of complex health care conditions and prevention of exacerbations. This chapter has presented an overview of practical considerations for selecting outcomes pertaining to ambulatory NP practice, measurement approaches, examples of how to approach outcome measurement in practice, and resources relevant to primary care outcome measurement.

 

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