An updated Cochrane Review – Nurses as substitutes for doctors in primary care – was published last month and analysed 17 randomised trials comparing first contact and ongoing care provided by primary care nurses and doctors (GPs) to similar patients with similar health needs.
The authors said the review was prompted by moves in many countries to use nurses more to help address the growing health needs due to chronic disease and an ageing population but also doctor and other health worker shortages.
The review concluded that for some “ongoing and urgent physical complaints and for chronic conditions” nurses – such as nurse practitioners, practice nurses and registered nurses – “probably provide equal or possibly even better quality of care” compared to primary care doctors.
The review findings included:
- Care delivered by nurses, compared to care delivered by doctors, probably generated similar or better health outcomes for a broad range of patient conditions including heart disease, diabetes, rheumatism and blood pressure
- Patient satisfaction is probably slightly higher in nurse-led primary care. Quality of life may be slightly higher in patients cared for by nurses
- Nurses probably have longer patient consultation than doctors and their patients are slightly more likely to keep follow-up appointments
- The review found ‘little or no difference’ between nurses and doctors in the number of prescriptions offered and indicated there may also be little difference in the number of tests and investigations ordered, hospital referrals and hospital admissions.
- There was insufficient quality evidence to evaluate the impact of substituting nurse care on the cost of primary care health services
- The evidence was also unclear what level of nursing education led to the best outcomes when nurses were substituted for doctors. (Largely because job titles, education and experience varied widely within and between the study countries).
Of the 17 randomised studies examined six were conducted in the UK, three in the Netherlands, three in the USA, three in Canada and one each in Sweden and South Africa. The majority of the studies looked at nurses ‘substituted’ for doctors in general/family practices (13) but some also involved outpatient nurse clinics and specialised practices.
The studies included involve nurse practitioners, clinical nurse specialists, advanced practice nurses, practice nurses, health visitors, etc. “As the job title, education, and experience of nurses vary considerably among and within countries, we did not select nurses by virtue of their job title,” said the review authors.
In many of the studies nurses could get additional support or advice from a doctor but studies that evaluated nurses ‘supplementing’ (rather than ‘substituting’) the work of primary care doctors were excluded.
The review is the first update of a Cochrane review initially published in 2005 and included nine new randomised studies and dropped seven studies included in the initial review (3 controlled before-after studies, 3 non-randomised trials, and 1 study focusing on mental health problems).
