Substitution of doctors by nurses in primary care

 

Abstract

Background

Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care.

Objectives

Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs.

Search methods

The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix).

Selection criteria

Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses.

Data collection and analysis

Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes.

Main results

4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.

In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable.

In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.

Authors' conclusions

The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less.

While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.

 

Plain language summary

In primary care, it appears that appropriately trained nurses can produce as high quality care and achieve as good health outcomes for patients as doctors. However, the research available is quite limited.

Many countries have sought to shift the provision of primary care from doctors to nurses in order to reduce the demand for doctors and improve healthcare efficiency. The expectation is that nurses working as substitutes can provide as high quality care as doctors at lower cost. This review found that quality of care is similar for nurses and doctors but it is not known if it decreases the doctor's workload. Nurses tend to provide more health advice and achieve higher levels of patient satisfaction compared with doctors. Even though using nurses may save salary costs, nurses may order more tests and use other services which may decrease the cost savings of using nurses instead of doctors.

 

摘要

背景

護理人員取代醫師執行初級照護

在發展中的國家主要照護服務的需求增加，由於人口的老化、病人的期望增加、及從醫院轉移到社區的照護的改革。在這同時，提供服務的醫師有限以及成本的壓力增加。在這樣的挑戰下，將照護從醫師轉移到護士是一個可能的因應方式。如此的期望是在維持照護品質下，護士 – 醫師的替代將可降低成本及醫師的工作負荷。

目標

我們的要旨是去評估醫師 – 護士替代的影響，在初級照護中病人的結果、照護過程、及包括成本的資源利用。病人結果包括：罹病率、死亡率、滿意度、遵從情形、及喜好的選擇。照護過程的結果包括：從事者固守臨床指引、照護的標準或品質、及從事者健康照護活動(例如，提供建議)。資源利用的評估為：諮詢的頻次和長度、訪視利潤、處方、試驗和調查、轉診的服務、及直接或間接的成本。

搜尋策略

搜尋以下的資料庫從1966年到2002年：Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register。搜尋的條件明確說明設定(初級照護)、專業人員(護士)、研究設計(隨機控制試驗、控制前和後的研究、打斷時間序列)、及主題(例如技術混合)。

選擇標準

研究包括護士與醫師提供類似初級照護服務的比較(排除意外及緊急的服務)。醫師的初級照護包括：一般開業醫師、家庭醫師、小兒科醫師、一般內科醫師或老年醫學專家。護士的主要照護包括：臨床護士、開業護士、臨床護理專家(clinical nurse specialists)、或進階臨床護士(advanced practice nurses)。

資料收集與分析

研究的選擇和資料摘取，由兩位評論者各自獨立進行，當有不同意見時則經由討論決定。應用統合分析(Metaanalysis)分析至少3篇隨機控制試驗的結果，以獲得適當的介入措施效果的報告。使用半量性的方法綜合其他結果。

主要結論

4253篇論文被篩選出25篇，有關的研究有16篇符合我們納入條件的標準。在7篇研究，護士對第一次接觸和持續照護的所有目前的病人承擔責任。其結果因為是調查不同指標的研究，因此限制了資料統合的機會。一般而言，在醫師及護士對病人健康照護的結果、照護過程、資源利用或成本，沒有什麼不同。 5篇研究中，在辦公或上班以外的時間，無法緊急諮詢的情況下，假設護士承擔對第一次接觸照護病人的責任。對護士及醫師的病人的健康結果是類似的，但是病人對護士領導的照護滿意度較高。護士比醫師傾向提供較長的諮詢，給予病人較多的訊息及回應病人較頻繁。對醫師工作負荷及直接照護成本的影響是多變的。 在4篇研究中，護士承擔特定慢性情況的病人持續管理的責任。其結果因為是調查不同指標的研究，因此限制了資料統合的機會。一般而言，在醫師及護士對病人健康照護的結果、照護過程、資源利用或成本，沒有什麼不同。

作者結論

這個研究的發現建議，適當受過訓練的護士可以產生與醫師照護一樣高品質的照護，且能達到病人良好健康的成果。無論如何，這個結論應該謹慎的檢視，因為僅有一個研究有力的評價照護的等效，很多研究有方法學上的限制，且病人的追蹤一般為12月或更少。 醫師 – 護士的替代有可能降低醫師的工作負荷及直接照護成本，達到在特定照護情況減少依賴(醫師)。醫師的工作量可能維持不變，例如，例如因為護士遇見以前未遇見過的病患的需要，或者因為護士對先前沒有過的經驗提出照護要求。在費用方面的節省取決於在醫生和護士之間的工資差別的大小，且可能補償護士比醫生有較低的生產力之故。

翻譯人

本摘要由高雄榮民總醫院林麗英翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

在初級照護中，顯示適當有受過訓練的護士可以產生高品質的照護及完成和醫師ㄧ樣的良好的病人的健康成果。無論如何，此研究的可用性是相當受限的。 在很多國家看到提供初級照護從醫師轉移至護士，以降低對醫師的需求及改善健康照護效益。期望在較低的成本下，護士替代醫師的工作能提供和醫師ㄧ樣高品質的照護。此評論發現護士和醫師的照護品質是類似的，但是並不知道是否降低了醫師的工作量。護士傾向提供較多的健康建議，及達到比醫師較高程度的病人滿意度。即使僱用護士可以節省薪資成本，護士可能開立更多的測試，並使用護士取代醫生所節省的成本來用於其他的服務。