Advanced practice nurses achieve results equal to or better than those of GPs in cardiovascular risk management in primary care
- Correspondence to Marije Koelewijn-van Loon
Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands;
Many patients at high risk for cardiovascular disease (CVD) are managed in primary care. According to national and international guidelines, measures to prevent CVD, such as patient education, can be delegated to practice nurses in primary care. Studies have shown reductions in cardiovascular risk factors in rehabilitation programmes, but the effect of primary prevention of CVD by practice nurses is unclear.1 2
The study by Voogdt-Pruis and colleagues is a pragmatic randomised trial of the clinical effectiveness of nurses as substitutes for GPs in cardiovascular risk management. A greater decrease in the mean value of five risk factors was found in the practice nurse group than in the GP group, but after confounders and baseline risk factors were controlled for, a statistically significant decrease was found only for total cholesterol. The authors conclude that compared with GPs, nurses achieved the same or even better results in cardiovascular risk management.
The study included a high number of patients at elevated risk for CVD, defined as a 10-year CVD risk of ≥10%. One strength of this study over most other studies of primary prevention of CVD was the inclusion of high-risk patients. Another strength was that half of the patients in the nurse group received self-report questionnaires on body mass index and smoking behaviour to validate self-reported answers from patients in the GP group. One weakness of the study was that the majority of the patients (71%) had already been diagnosed with CVD, and hence were already very much aware of the need for lifestyle change and risk reduction; the challenge is primary prevention among patients who do not yet have a diagnosis of CVD. In addition, the content of the intervention is unclear: there is no description of the training of the nurses, or of how motivational interviewing was used in cardiovascular risk management or how patients were involved in decision-making. Another problem lies in the design of the study, as it compares a nurse-led intervention with GP-led usual care. It is therefore unknown whether the effect is caused by the nurses as substitutes for GPs or by the fact that the nurses were specifically trained in cardiovascular risk management. Moreover, it is possible that the nurses performed well because this new task recognised their position within the general practice. Most GPs are already acquainted with risk management but are unfamiliar with lifestyle counselling. Risk management is new for practice nurses, but they have more experience with lifestyle counselling. This difference could be a plausible explanation for the outcome in this study. The question remains whether it is correct to conclude that the simple delegation of cardiovascular risk management to practice nurses will lead to improvements in patient outcomes; certainly there is a need for more and better training of all healthcare professionals.
Although one strong aspect of this study was that it was executed in daily practice, the lack of a more balanced control group, such as a GP group with the same training as the nurse group, must lead to caution in drawing conclusions. However, delegation of cardiovascular risk management to practice nurses seems reasonable. Further research should investigate to what extent and under what conditions practice nurses can be effective in the primary prevention of CVD.
Competing interests None.