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Return to table of contentsthe model and the presence of nurse practitioners inmost physician offices suggests that future studies arewarranted to understand how best to implement this.PMID: 17077419 [PubMed - indexed for MEDLINE]Substitution of doctors by nurses in primary care.Laurant M, Reeves D, Hermens R, et al.Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271.University of Nijmegen Centre for Quality of CareResearch, Nijmegen, NetherlandsBACKGROUND: Demand for primary care serviceshas increased in developed countries due to populationageing, rising patient expectations, and reforms thatshift care from hospitals to the community. At the sametime, the supply of physicians is constrained and thereis increasing pressure to contain costs. Shifting carefrom physicians to nurses is one possible response tothese challenges. The expectation is that nurse-doctorsubstitution will reduce cost and physician workloadwhile maintaining quality of care. OBJECTIVES: Ouraim was to evaluate the impact of doctor-nurse substitutionin primary care on patient outcomes, process ofcare, and resource utilization including cost. Patientoutcomes included: morbidity; mortality; satisfaction;compliance; and preference. Process of care outcomesincluded: practitioner adherence to clinical guidelines;standards or quality of care; and practitioner health careactivity (e.g. provision of advice). Resource utilizationwas assessed by: frequency and length of consultations;return visits; prescriptions; tests and investigations;referral to other services; and direct or indirect costs.SEARCH STRATEGY: The following databases weresearched for the period 1966 to 2002: Medline; Cinahl;Bids, Embase; Social Science Citation Index; BritishNursing Index; HMIC; EPOC Register; and CochraneControlled Trial Register. Search terms specified the setting(primary care), professional (nurse), study design(randomized controlled trial, controlled before-andafter-study,interrupted time series), and subject (e.g.skill mix). SELECTION CRITERIA: Studies wereincluded if nurses were compared to doctors providing asimilar primary health care service (excluding accidentand emergency services). Primary care doctors included:general practitioners, family physicians, pediatricians,general internists or geriatricians. Primary care nursesincluded: practice nurses, nurse practitioners, clinicalnurse specialists, or advanced practice nurses. DATACOLLECTION AND ANALYSIS: Study selection anddata extraction was conducted independently by tworeviewers with differences resolved through discussion.Meta-analysis was applied to outcomes for which therewas adequate reporting of intervention effects from atleast three randomized controlled trials. Semi-quantitativemethods were used to synthesize other outcomes.MAIN RESULTS: 4253 articles were screened of which25 articles, relating to 16 studies, met our inclusion criteria.In seven studies the nurse assumed responsibility forfirst contact and ongoing care for all presenting patients.The outcomes investigated varied across studies so limitingthe opportunity for data synthesis. In general, noappreciable differences were found between doctors andnurses in health outcomes for patients, process of care,resource utilization or cost. In five studies the nurseassumed responsibility for first contact care for patientswanting urgent consultations during office hours orout-of-hours. Patient health outcomes were similar fornurses and doctors but patient satisfaction was higherwith nurse-led care. Nurses tended to provide longerconsultations, give more information to patients andrecall patients more frequently than did doctors. Theimpact on physician workload and direct cost of carewas variable. In four studies the nurse took responsibilityfor the ongoing management of patients with particularchronic conditions. The outcomes investigated variedacross studies so limiting the opportunity for datasynthesis. In general, no appreciable differences werefound between doctors and nurses in health outcomesfor patients, process of care, resource utilization or cost.AUTHORS’ CONCLUSIONS: The findings suggestthat appropriately trained nurses can produce as highquality care as primary care doctors and achieve as goodhealth outcomes for patients. However, this conclusionshould be viewed with caution given that only onestudy was powered to assess equivalence of care, manystudies had methodological limitations, and patientfollow-up was generally 12 months or less. Whiledoctor-nurse substitution has the potential to reducedoctors’ workload and direct healthcare costs, achievingsuch reductions depends on the particular contextof care. Doctors’ workload may remain unchangedeither because nurses are deployed to meet previouslyunmet patient need or because nurses generate demandfor care where previously there was none. Savings incost depend on the magnitude of the salary differentialbetween doctors and nurses, and may be offset by thelower productivity of nurses compared to doctors. PMID:15846614 [PubMed - indexed for MEDLINE]Scope of Practice Data Series: Nurse practitioners • Appendix65