Using nurse practitioners to implement an intervention in primary care for high-utilizing patients with medically unexplained symptoms

Abstract

Patients with medically unexplained symptoms (MUS) often are a source of frustration for clinicians, and despite high quality biomedical attention and frequent diagnostic tests, they have poor health outcomes. Following upon progress in depression treatment approaches, we developed a multidimensional treatment protocol for deployment by primary care personnel. This multi-faceted intervention for MUS patients emphasized cognitive-behavioral principles, the provider-patient relationship, pharmacological management, and treating comorbid medical diseases. We deployed it in an HMO using nurse practitioners (NP) to deliver the intervention to 101 patients, while 102 controls continued to receive medical care from their usual primary care physician. Successful deployment of the intervention required training the NPs, continuing support for the NPs in their management of this difficult population, and establishing strong communication links with the HMO. This paper addresses the practical considerations of using primary care personnel to implement a complex intervention in primary care, and it includes a discussion of special challenges encountered as well as solutions developed to overcome them.

Introduction

Medically unexplained symptoms (MUS) are physical complaints for which there is no documented organic disease explanation [1]; these symptoms occur commonly among the general patient population [1], [2], [3], [4], [5], [6], [7], [8]. Indeed, in primary care it is estimated that only 16% of new symptoms prove to have an organic disease basis [9]. When combined with high-utilization, MUS can become debilitating for patients and costly to the health care system [10], [11], [12], [13], [14], [15], [16]. Depression, anxiety and impaired mental and physical functioning often accompany the physical symptoms MUS patients experience [17], [18], [19], [20]. MUS is one of medicine’s great challenges at many levels [21].

In the context of a randomized control trial (RCT), we developed and implemented a twelve-month intervention to address the needs of MUS patients and to manage their symptoms in a primary care setting. We tested hypotheses that intervention patients would show significantly more improvement on mental and physical health function measures twelve months after entry into the study as compared to control patients.

The intervention exemplified integrated biopsychosocial principles by focusing on: 1) common comorbid medical conditions; 2) psychological distress – by screening patients for depression and anxiety, prescribing standard pharmacological treatment if indicated, and by weaning patients from any addicting medications; 3) cognitive behavioral treatment (CBT) to help patients manage their physical symptoms and reframe their attitudes toward them [22], [23], [24], [25], [26]; and 4) the patient-provider relationship (PPR) and communication by using a recently reported evidence-based patient-centered method [27], [28], [29], [30], [31].

We chose nurse practitioners (NPs) to deploy the intervention for several practical reasons. First, nurse practitioners are educated with a biopsychosocial orientation that is conducive to effective management of MUS patients [32], [33], [34], [35], [36] and NPs are known to be effective with medical [33], [37] as well as psychological problems [36]. In contrast, numerous studies show that the biomedical disease emphasis of physician training does not prepare many of them to manage either difficult mental health problems or MUS patients whose predominant physical symptoms have no disease origin [38], [39], [40], [41], [42]. Second, training for the intervention required over eighty hours of experiential learning that would have been difficult to schedule with practicing physicians. Third, the HMO employed three nurse practitioners that, if used to deploy the intervention, could ensure continuity of care at the end of the study and/or ease the transition to usual care for the intervention patients. We report here how we addressed key design and implementation issues, particularly those surrounding deployment of the intervention.