August, 2008 - SUPPORT Summary of a systematic review | print this article |
Nurse practitioners are nurses who have undergone further training,, often at graduate level, to work autonomously; making independent diagnoses and treatment decisions. It is important to consider whether the evidence supports the notion that nurse practitioners can substitute for doctors by providing safe, effective, and economical front line management of patients.
Low and middle-income countries face a chronic shortage of medical doctors in the public health sector, especially in rural areas. Growing financial pressure to improve the efficiency of health systems is also leading to an increased interest in broadening the scope of practice of nurses. One aspect of this is using nurse practitioners to provide front line care in primary care settings and in emergency departments. Nurse practitioners have been used widely in some high-income countries for many decades, in a variety of settings, including primary care. In low and middle-income countries, nurses are extensively providing care that in other settings would be provided by doctors, if the latter were available.
This summary is based on a systematic review published in 2002 by Horrocks and colleagues, and focuses on the effects of substituting nurses for doctors working in primary care; in the provision of first point of contact, initial assessment and autonomous management of patients.
Review Objectives: To assess the effects of doctor-nurse substitution in primary care. | ||
What the review authors searched for | What the review authors found | |
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Interventions | Comparisons of nurse practitioners and doctors working in a similar way as concurrent controls |
11 randomised controlled trials and 23 observational studies |
Participants | Unselected patients coming to either primary care facilities or emergency departments |
Patients recruited in 8 general practice or unspecified primary care facilities, 2 emergency departments, and 1 paediatric clinic |
Settings | Limited to Europe, North America, Australasia, Israel, South Africa, and Japan |
Studies from Canada, the UK and USA |
Outcomes | Patient satisfaction, health status, process of care measures, quality of care, health service costs | Patient satisfaction, health status, process measures, quality of care, costs |
Date of most recent search: April 2002 | ||
Limitations: This is a good quality systematic review, which found evidence of moderate quality |
Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324:819-23. See in pubmed
The systematic review identified 11 randomised controlled trials and 23 observational studies. We summarised only data from the trials, given their superiority to other designs in assessing the effectiveness of healthcare interventions. However, the review authors reported that the findings of the observational studies replicated those of the randomised controlled trials for all outcomes except costs and investigations.
Five randomised trials reported data on patient satisfaction, seven reported on health status, and six on quality of care. A synthesis of these trials produced the following results:
Patient outcomes and process of care |
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Patient or population: Not specified Settings: Primary care in Canada, the UK and USA Intervention: Primary care in Canada, the UK and USA Comparison: Doctors |
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Outcomes | Impact | Number of Participants (studies) |
Quality of the evidence (GRADE) |
Health status |
No difference in health outcomes (but the review showed substantial heterogeneity in the patient outcomes measured by the studies) |
12,558 |
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Patient satisfaction |
Standardised mean difference +0.27 (+0.07 to +0.47) |
3890 (5 studies) |
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Quality of care | Better for nurse practitioners (but there was a great deal of heterogeneity between studies in the outcomes measured). | 6166 (6 studies) |
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p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page) |
The number of identified trials that assessed resource utilisation and direct costs were five for consultation length, four for prescriptions, five for investigations, six for return consultations, two for referrals, and five for direct costs.
Resource utilisation and healthcare costs |
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Patient or population: Not specified Settings: Primary care in Canada, the UK and USA Intervention: Nurse practitioners Comparison: Doctors |
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Outcomes | Impact | Number of Participants (studies) |
Quality of the evidence (GRADE) |
Consultation length |
Weighted mean difference +3.67 minutes |
4563 |
|
Prescriptions |
Odds Ratio 1.02 |
5364 (4 studies) |
|
Investigations |
Odds Ratio 1.22 |
5469 (5 studies) |
|
Return consultations | Odds Ratio 1.05 (0.87 to 1.28) |
6166 (6 studies) |
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Referrals |
Odds Ratio 0.71 |
2660 (2 studies) |
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p: p-value GRADE: GRADE Working Group grades of evidence (see above and last page) |
Findings | Interpretation* |
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APPLICABILITY | |
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EQUITY | |
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ECONOMIC CONSIDERATIONS | |
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MONITORING & EVALUATION | |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see: |
Carter AJ, Chochinov AH. A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM 2007;9:286-95.
Hollinghurst S, Horrocks S, Anderson E, Salisbury C. Comparing the cost of nurse practitioners and GPs in primary care: modelling economic data from randomised trials. Br J Gen Pract 2006;56:530-5.
Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2004, Issue 4. Art. No.: CD001271. DOI: 10.1002/14651858.CD001271.pub2.
McPherson K, Kersten P, George S, Lattimer V, Breton A, Ellis B, et al. A systematic review of evidence about extended roles for allied health professionals. J Health Serv Res Policy 2006;11:240-47.
O'Connor TM, Hooker RS. Extending rural and remote medicine with a new type of health worker: physician assistants. Aust J Rural Health 2007;15:346-51.
Smetana GW, Landon BE, Bindman AB, Burstin H, Davis RB, Tjia J, Rich EC. A comparison of outcomes resulting from generalist vs specialist care for a single discrete medical condition: a systematic review and methodologic critique. Arch Intern Med 2007;167:10-20.
Charles Shey Wiysonge & Mickey Chopra, South African Medical Research Council, Cape Town, South Africa.
None declared. For details, see
This summary has been peer reviewed by: Chris Salisbury, UK; Laetitia King, Kenya; Tessa Tan Torres, Switzerland; Taghreed Adam, Switzerland; Tracey Perez Koehlmoos, Bangladesh.
Wiysonge CS, Chopra M. Do nurse practitioners working in primary care provide equivalent care to doctors? A SUPPORT Summary of a systematic review. August 2008.