The value of advanced nursing practice in secondary prevention and disease management has been well-documented. There is little evidence, however, specific to the role of the nurse practitioner in outpatient cardiac rehabilitation (CR). In an effort to explore the potential value of this role, all patients referred to a hospital-based outpatient CR program over the course of one year were evaluated by a nurse practitioner prior to entry. The purpose of the observation was to determine the frequency with which a significant finding would be identified. The 30-minute nurse practitioner visit included a history and physical examination to determine any special rehabilitation-related concerns, and an in-depth discussion of coronary artery disease and secondary prevention priorities and treatment goals individualized for each patient. A total of 366 patients were seen by the nurse practitioner during this observation. Significant findings included deviation from current evidence-based guidelines for secondary prevention of coronary artery disease and/or congestive heart failure, suboptimal treatment of comorbidities, identification of clinical findings that warranted delaying rehabilitation, and others. Of the 366 patients, a significant finding was established in 121 (33%). Significant findings were then communicated back to the referring physicians, and subsequent action was documented to assure proper resolution. Subjective outcomes such as improved patient satisfaction and fewer problems experienced by the patients during CR sessions were anecdotally reported but not measured.

While not a rigorous scientific trial, this observation suggests great potential for improved clinical outcomes associated with nurse practitioner role, by enhancing adherence to evidence-based treatment for secondary prevention among CR patients. While CMS is pursuing effective strategies for payment-for-performance in various arenas, current regulations serve as a barrier to nurse practitioner practice in the outpatient CR setting by restricting reimbursement for these services to physicians. Documentation of improved outcomes resulting from nurse practitioner practice in CR may serve to challenge the current reimbursement structure.