May, 2017 - SUPPORT Summary of a systematic review | print this article |

What are the effects of physician-nurse substitution in primary care?

Physician shortage in many countries and demands of high quality and affordable care make physician nurse substitution an appealing workforce strategy.Substitution refers to nurses both performing tasks and taking responsibility for care that formerly would have been performed by physicians.

Key messages

  • Nurse led care probably leads to a lower systolic blood pressure and lower CD4 cell counts in HIV/AIDs patients compared to physicianled care
  • Nurseled care compared to physicianled care probably leads to little or no difference in other clinical parameters, such as diastolic blood pressure, total cholesterol level, and glycosylated haemoglobin concentrations.
  • Most of the studies were conducted in high income countries.
    • The applicability of the findings may be affected by cultural and economic differences, patient populations, services provided in primary care settings, and the availability and level of nurses’ skills.

Background

According to the World Health Organization, the global number of healthcare providers (physicians, nurses and midwives) remains lower than required per 1,000 population. The low number of physicians, changes in working culture, and trends in retirement have contributed greatly to this shortage. There are pressing demands for high quality affordable care, due to the escalating growth and ageing of the population, patients’ expectations, and the costs incurred managing complex conditions. One response to these changes is to substitute nurses for physicians. This is an appealing strategy due to its potential to address workforce shortages, maldistribution of workload, and to reduce costs.



About the systematic review underlying this summary

Review objectives: To assess the impact of physician nurse substitution in primary care on clinical parameters.
Type of What the review authors searched for What the review authors found
Study designs & interventions

Randomised trials that examined physician nurse substitution

Eleven randomised trials. Nurses had full clinical autonomy to manage patients’ disease (1 trial); Nurses made independent decisions for several tasks, but still needed minor support or short communication with the physicians (10 trials). In all trials, the physicians performed standard care.

Participants

Patients of all ages seeking first contact or undergoing care for all conditions including mental health and addiction restricted to primary care

32,247 participants with mean age raging between 11.2 to 67.1 years. Thirty five percent (35%) of the population were males (10 trials) and females only (1 trial).

Patients showed up with a range of complex conditions including cerebro vascular disease, hypertension, heart failure, diabetes mellitus, asthma, incontinence, Parkinson’s disease and HIV

Settings

-General practices, community orambulatory care settings   -No geographical limitation                           

The studies were conducted in the UK (2), The Netherlands (4), USA (2), South Africa (2) and Russia (1).

Outcomes

-Clinical parameters that detected changes in the clinical status or physiological capability of patients in relation to various forms of disease

-Measures of quality of life, satisfaction, mortality, hospital admissions, progression of disease, and process of care were excluded

Changes in blood pressure (5), cholesterol and triglycerides concentration (4), glycosylated haemoglobin level (4), lung and kidney function (1), various parameters of cardiac function (1), frequency of incontinent episodes (1), mobility stand up test and bone sustaining fracture in patients with Parkinson’s disease (1), and CD4 cell counts in HIV/AIDS patients (1)

Date of most recent search: August 2012
Limitations:This is a well conducted systematic review with only minor limitations, restricted to English language and published studies.
Martínez González NA, Tandjung R, Djalali S, et al. Effects of physician nurse substitution on clinical parameters: a systematic review and meta analysis. PLoS ONE 2014; 9(2): e89181.

Martínez González NA, Tandjung R, Djalali S, et al. Effects of physician nurse substitution on clinical parameters: a systematic review and meta analysis. PLoS ONE 2014; 9(2): e89181.

Summary of findings

This review included 11 randomised trials that assessed the impact of physician nurse substitution in primary care on clinical parameters. Most studies were conducted in high income countries. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease, and incontinence.The review excluded measures of quality of life, satisfaction, mortality, hospital admissions, progression of disease, and process of care.

 Substitution of physicians by nurses in primary care

  • Nurseled care probably leads to a lower systolic blood pressure and lower CD4 cell counts in HIV/AIDs patients compared to physicianled care. The certainty of this evidence is moderate.
  • Nurseled care probably leads to little or no difference in other clinical parameters such as lowering diastolic blood pressure, lowering total cholesterol level, or glycosylated haemo-globin concentrations compared to physicianled care. The certainty of this evidence is moderate.

Substitution of physicians by nurses in primary care

People: Patients of all ages seeking first contact or undergoing care for all conditions restricted to primary care.
Settings
: USA, UK, The Netherlands, Russia, and South Africa
Intervention
: Substitution of physicians by nurses (nurseled primary care)
Comparison
:Standard care provided by physicians (physicianled primary care) 
Outcomes

Weighted mean difference(95% CI)

Quality of the evidence
(GRADE)
Comments
Systolic blood pressure (mmHg)

-4.27

(-6.31 to -2.23)

 


Moderate
Nurse-led care led to an av-erage decrease of 4.27 mmHg in systolic blood pressure.

Diastolic blood pressure

(mmHg)

-1.48

(-3.05 to 0.09)

 


Moderate
There was little or no difference between between nurseled care and physicianled care in decreasing diastolic blood pressure.

Total cholesterol

(mmol/L)

 

-0.08

(-0.22 to 0.07)

 

Moderate There was little or no difference between nurseled care and physicianled care in decreasing the mean levels of total cholesterol.

Glycosylated heamoglobin

(% HbA1c)

 

0.12

(-0.13 to 0.37)

 

 

 

Moderate There was little or no difference between nurseled care and physicianled care in reducing glycosylated haemoglobin concentrations (HbA1c).
HIV/AIDs: CD4 count for Anti Retroviral Therapy initiation.

20

(9.29 to 30.71)

 

Moderate Patients receiving nurse-led care had lower CD4 cell counts compared to patients who received physicianled care.
GRADE: GRADE Working Group grades of evidence (see above and last page)
* The weighted mean differences (WMD) of the absolute endpoint measurements for nurses and physicians were calculated

 



 


 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY

All studies except one were conducted in high income countries.

 

  • The single study conducted in a middle income country found that nurseled care probably leads to lower CD4 cell counts in HIV/AIDs patients compared to physicianled care.

While it may be possible to substitute nurses for physicians in some low income settings, the applicability of the findings may be limited by:

- cultural and economic differences

-patient populations

-services provided in primary care settings

-availability of nurses in different health systems

-nurses’ skills and experiences

-nurses’ roles and levels of clinical autonomy during substitution

-definition of boundaries and task allocation in clinical practices

 

  • Because nurses are trained to provide care in various settings and for a wide range of complex conditions, in most cases, this requires special-ised skills and the use of guidelines for successful disease management when physician nurse substitution takes place.
EQUITY
The systematic review did not address equity issues.
Substituting nurses for physicians in primary care has the potential to reduce inequities in access to healthcare by increasing access in underserved communities where there is scarcity of physicians.
ECONOMIC CONSIDERATIONS
The systematic review did not address costs, cost effectiveness, or sustainability of nurse substitution.

The relatively lower salary cost of nurses compared to physicians might translate into economic savings.

 

  • However, calculation of potential savings should take into consideration the availability and skills of nurses, costs of additional training and provision of supportive supervision, and possible increased referrals, which might offset the anticipated savings.
MONITORING & EVALUATION

Nurseled care probably leads to similar and in some cases improved clinical parameters in primary care compared to physicianled care.

 

  • This review did not provide evidence on the effectiveness of the intervention on patient important outcomes, patient satisfaction, or costs.

Given the uncertainties about the impact of intervention on important outcomes and costs, as well as uncertainty about the applicability of the evidence to low income countries, substituting nurses for physicians in low income countries should be pilot tested and rigorously monitored and evaluated.


*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 income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods

 

Additional information

Related literature

Laurant M, Reeves D, Hermens R, Braspenning J, et al. Substitution of doctors by nurses. Cochrane Database Syst Rev 2005; 2:CD001271.

This summary was prepared by

Lama Bou Karroum and Racha Fadlallah, Center for Systematic Reviews on Health Policy and Systems Research, American University of Beirut, Lebanon.

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi 

Acknowledgements

This summary has been peer reviewed by: Tomas Pantoja, Cristian Mansilla, Nahara Martinez Gonzalez and Thomas Rosemann.

This review should be cited as

Martínez González NA, Tandjung R, Djalali S, et al. Effects of physician nurse substitution on clinical parameters: a systematic review and meta analysis. PLoS ONE 2014; 9(2): e89181.

The summary should be cited as

Karroum LB, Fadlallah R. What are the effects of physician nurse substitution in primary care? A SUPPORT Summary of a systematic review. May 2017. www.supportsummaries.org

Keywords

evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, task shifting, health work force, skill mix, nurse physician substitution

 



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