CADTH: Rx for Change Database
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Browse » Organizational: Revision of Professional Roles - Nursing » Review » Individual Studies
Substitution of doctors by nurses in primary care
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care.
Cochrane Database Syst Rev 2005 (2):CD001271. [PubMed]
Sources of funding: No funding or perceived conflict of interest
Main author affiliation: Dr. M. Laurant, University of Nijmegen, Nijmegen, Netherlands
Q: Is physician-nurse substitution in primary care effective for improving patient
outcomes, process of care, resource utilization, and costs?
BACKGROUND
The focus of this review was on nurses functioning as
substitutes for physicians in the primary care setting,
whereby the tasks formerly performed by physicians
are transferred to nurses. The performance of the two
clinician groups are then compared.
INCLUSION
Individual studies from systematic review
SEARCH FOR EVIDENCE: Up to 2002
INCLUDED STUDIES: 16
STUDIES RELATED TO PRESCRIBING: 8
STUDY DESIGN: RCT, CBA.
STUDY CHARACTERISTICS:
Target population: Nurses, Physicians.
Intervention(s): Revision of professional
roles - Nursing.
Setting: Communities, Not stated (primary
care settings).
Patients Reviewed: Not specified, Specific
diagnose or clinical condition, Other,
Drug Related Outcome Categories:
Appropriate use, Appropriate use - choice.
Other Outcome Categories: Professionalpatient communication, Test ordering,
Referrals, Other, Other resource use,
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AUTHORS' ANALYSIS OF DATA:
Vote counting based statistical significance, Metaanalysis.
REVIEW QUALITY: 8
RESULTS - OVERALL
A substantial reanalysis of this review was undertaken.
Although authors do not specify the actual settings in the
included studies, of interest to the review were primary
care settings (excluding accident and emergency). Authors
identified that unit of analysis errors were an issue in only
a few studies. The majority of included studies were RCTs,
and of those, authors state it is unclear whether
contamination occurred. Small numbers of nurses were
included in these studies, and most studies also included
small numbers of physicians, if at all reported. Nurses
substituting doctor care was generally ineffective for
improving appropriate care (n=16), although over half of
the included studies reported mixed results among
reported outcomes. Fixed-effects meta-analyses for a
number of outcomes were conducted; behaviours range
from generally ineffective to generally effective with a
range in effect sizes from no effect to medium effect
sizes, but few studies were located (n=3 for each metaanalysis).
RESULTS - RELATED TO PRESCRIBING
A subset of included studies evaluated prescribing-related
outcomes. Nurses substituting doctor care was generally
ineffective for improving appropriate use (n=7). No effect
size was shown with the meta-analysis (n=3). Insufficient
evidence exists for appropriate use - choice (n=1).
CONCLUSIONS - OVERALL
High quality review. Nurses substituting doctor care was
generally ineffective for improving appropriate care,
although over half of the studies reported mixed results.
CONCLUSIONS - RELATED TO PRESCRIBING
High quality review. Nurses substituting doctor care was
generally ineffective for improving appropriate use.
EFFECTIVENESS
High quality review. Revision of professional roles Nursing was generally ineffective for improving
appropriate care, including for the appropriate use of
prescribing.
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Table of Results
Comparison
Outcome
N
Analysis
Results
Nurse care vs
doctor care
Appropriate
care
16
Vote counting based on
direction of effect. RD
(95% CI) from metaanalysis.
Vote counting 1/16 studies (mixed
designs) favoured intervention and 9/16
studies reported mixed results: generally
ineffective. 3/16 studies had only patient
outcome data available. Vote counting
1/13 RCTs favoured intervention and 8/13
reported mixed results: generally
ineffective. Meta-analyses (fixed effects, 3
RCTs each, pooled RD) Scheduled return
visits: 2/3 RCTs favoured intervention, RD
7% (CI 4% to 10%; H p=0.002,
I2=83.7%). Mixed effects with medium
effect sizes. High heterogeneity.
Prescriptions ordered: 2/3 RCTs favoured
intervention, RD 0% (CI -3% to 2.5%; H
p=0.23, I2=31.3%). Mixed effects with no
effect size. Low heterogeneity. Hospital
referral: 1/3 RCTs favoured intervention,
RD 0.2% (CI -0.07% to 0.4%; H p=0.13,
I2=51.5%). Generally ineffective with no
effect size. Moderate heterogeneity.
Attendance at accident & emergency: 3/3
RCTs favoured intervention, RD 0.3% (CI 1% to 0.42%; H p=0.93, I2=0%).
Generally effective with no effect size. No
to minimal heterogeneity. Hospital
admission: 2/3 RCTs favoured
intervention, RD 1% (CI 0.2% to 1.9%; H
p=0.19, I2=39.7%). Mixed effects with
small effect sizes. Low heterogeneity.
Prescribing-related outcomes (n=8):
APPROPRIATE USE: Vote counting 1/7
studies (mixed designs) favoured
intervention: generally ineffective. Vote
counting 0/5 RCTs favoured intervention:
generally ineffective. Meta-analysis
(above) pooled RD 0%: no effect size.
APPROPRIATE CHOICE: Vote counting 0/1
RCTs favoured intervention: insufficient
evidence.
Notes:
H=heterogeneity
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Last Updated January 7, 2008
http://cadth.ca/index.php/en/compus/optimal-ther-resources/interventions/systematic-revie... 1/16/2008