Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7341.819 (Published 06 April 2002) Cite this as: BMJ 2002;324:819
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This is a fascinating study indeed. People are always more satisfied by personal attention and opportunities to talk. We can all do that.In these days of evolving roles for professionals, doctors can regain lost grounds by playing as Nurse Practioners. So GPs coluld be given an additional honorary title of Nurse Practitioner. This way they will be able and indeed allowed to spend more time with their patients. This will solve all the problems of the NHS and restore happiness all around that has been eludiung us so far.
Competing interests: No competing interests
Horrocks et al (1) have concluded a few ambitious points in their review which are worth discussing further.
Firstly, they mention the lack of difference in health outcomes between NPs and physicians. Most of the trials included in their review are short term trials which were inherently not designed to determine the health outcomes of chronic diseases like diabetes, asthma and hypertension which may take decades to advance.
Secondly, they highlighted higher patient satisfaction by NPs. As is well known and elementary knowledge that patient satifaction, although important, is not a reliable measure of the standard of care. Thus, it certainly has no role to play in the complicated process of the ability to diagnose and provide relevent medical care. It has also been demostrated that patient satisfaction correlates strongly with patient adherence(2).
Finally, more time spent with patients as well as more tests ordered by nurse practitioners proves their inability to carry out the diagnosis and subsequent care in a time limited and efficient manner.
Increasing shortages in primary care delivery facing developed nations leads us to consider this fundamental question of how to provide cheaper care. This is central to the evolution of the nurse practitioner concept in the United States. We struggle to deal with issues of costs of health professional training, resource utilization, as well as the safety of health care.
It is naive to consider the fact that the expert services through the several years of training from a physician can be matched by 24 months of training of a registered nurse in all aspects. Certainly, if this were true, we would have shut down physicians in the primary care world years ago and MDs would only be in speciality fields.
The role of the nurse practitioner is not to be compared with or to replace the physicians but, rather, to increase the access to quality health care for many patients whose health care needs are within the limited scope of the training of the NP. Unfortunately, a few of us go far and beyond this simple goal and attempt to bring comparison when none exists.
We have no competing interests.
Reference:
1)Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002;324:819-823 (6 April).
2)Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220.
Competing interests: No competing interests
In the U.S., 42 of the 50 states require nurse practitioners to work "in collaboration with" physicians. And, Federal law governing reimbursement under Medicare also requires a collaborative arrangement. The UK has its own barriers to nurse practitioner practice. So, research on nurse practitioners' performance when not "working in a team supported by doctors" will not be forthcoming until laws are changed. Any recent efforts in the U.S. to change state laws have been met with vigorous opposition from the American Medical Association and state medical societies.
However, because the vast majority of primary care visits (in the U.S., at any rate) are for acute minor illnesses, increased employment of nurse practitioners would seem irresistable to law and policy makers in the future.
Competing interests: No competing interests
Physicians are often cast into a role that imposes demands time- consuming tasks known to deprive patients of the quality of care demonstrated herein by Nurse Practitioners. In a treatment environment where an appropriate triage protocol is closely supervised by the physician, delegated to Nurses, Physician Assistants, and Nurse Practitioners, treatment outcome presents the highest standard of care efficiently to all the patient population.
A brief look through the literature expansively demonstrates this suggestion:
--With the increased emphasis on accountability, cost, and quality in health care, models of care delivery are being restructured. Stutts examined the planning, implementation, and evaluation of a model of care delivery for neonates based on customer, staff nurse, nurse practitioner, and attending physician perceptions of care and their suggestions for improvement. [1]
--Nurse-based intervention has been observed to reduce chronic NSAID usage and costs in primary care resulting cost-effective outcome when maintained in long term fashion. This intervention package could be readily applicable to primary care. [2]
--Based on the distribution of admitting diagnoses, a subset of patients was identified that could be removed from routine care by residents and could instead be cared for by non-physician providers (i.e., physician assistants and nurse practitioners) using clinical pathways. The cohort was large enough to reduce the number of patients per resident to within national accreditation guidelines, and to provide faculty with more time available for teaching. [3]
The fact that increased quality of care results when Nurse Practitioners are directed to resolving patient complaints sends a wonderful message to clinicians. Treatment quality and quantity improves when standard triage methods are recruited when the physician becomes the medical team-supervisor and treatment authority is delegated to Nurse Practioners. Such a practice affords the physician a better opportunity to focus on specific patients whose quality of care may depend on more of the physician's time and personalized treatment presence.
I have no competing interests in this subject area. Bill Misner Ph.D.
REFERENCES [1]-Stutts A. Developing innovative care models: the use of customer satisfaction scores. J Nurs Adm. 2001 Jun;31(6):293-300.
[2]-Jones AC, Coulson L, Muir K, Tolley K, Lophatananon A, Everitt L, Pringle M, Doherty M. A nurse-delivered advice intervention can reduce chronic non-steroidal anti-inflammatory drug use in general practice: a randomized controlled trial. Rheumatology (Oxford). 2002 Jan;41(1):14-21.
[3]-Abrass CK, Ballweg R, Gilshannon M, Coombs JB. A process for reducing workload and enhancing residents' education at an academic medical center. Acad Med. 2001 Aug;76(8):798-805.
Competing interests: No competing interests
The most obvious conclusion to draw from this study is that if the length of consultation is 3.6 minutes longer, patients will be more satisfied.
This is, oddly enough, what GPs have been saying for some time.
The increase in satisfaction extends to both parties to the consultation, not just the patient so it seems a good idea.
So shall we equalise satisfaction by equalising the length of consultation, while of course seeing every patient who requests it and doing so rapidly? The obstacle here seems only to be the insufficient numbers of both doctors and nurses which, again is hardly a new surprise, and the BMA and GPs have been telling successive governments and passing echelons of health service administrata for no less than a dozen years.
Whether satisfaction is the end point we should be aiming for, even if is bilateral, is of course another matter. A patient who attends desiring a particular treatment will b satsified if he departs with it, whether it is an antibiotic or quack nostrum for a cough, an unecessary and poorly evidence-based operation or an exposure to radiation whcih will not rule in or out any diagnosis nor guide treatment. In a fee for service organisation, or one in which the driving force is a need to score highest in paitnet satisfaction, behaviour is distinctly different from those where either evidence-based of finance-based drivers are applied.
Having enough people involved to provide useful services in reasonable working conditions is the sensible aim, and I do not think the conclusions of this paper are born out by its subject matter, nor that it advances this aim.
Competing interests: No competing interests
Editor - Horrocks et al report that nurse practitioners in primary care have higher levels of patient satisfaction than doctors with no difference in short-term health outcomes (1). However their conclusions should be viewed with caution. Many of the studies included in their meta -analysis had methodological flaws. Some were subject to selection bias, had low sample size and were not double blinded. Some studies had high refusal rates and there is no information on the percentage of patients requesting to transfer to a doctor. The studies looked only at patients requesting same-day appointments for minor illnesses. These patients may differ from the general population and it is not possible to extrapolate the results to other areas of primary care (2).
It is acknowledged that the nurse practitioners had longer consultations and length of consultation is a good predictor of patient satisfaction (3). General Practitioners working to tight timescales need to develop a high degree of medical efficiency. However shorter consultations with high technical medical efficiency are related to poorer communication and less patient satisfaction (4). The authors did not adjust the odds ratios for duration of consultation to demonstrate the strength of the effect.
Many general practitioners find patients requesting urgent appointments for minor illnesses very frustrating and this may adversely affect patient satisfaction. The influences on GP’s attitudes to these patients are complex (5) and may include length of service and burnout. Nurse practitioners are relatively new additions to the primary care team and the influences on their attitudes may be different.
Perhaps most importantly of all time and quality pressures on GPs are completely different and include other commitments such as paperwork and home visits. This is therefore a comparison between chalk and cheese. The only conclusion that can be drawn is that this subset of patients prefer longer consultations with healthcare workers with fewer time constraints.
However it would be interesting to repeat the studies in ten years time when perhaps nurse practitioners may also be offering seven minute appointments, are bogged down in paperwork and have half a dozen house calls to do at the end of surgery.
Steven Nimmo General Practitioner Barton Surgery, Horn Lane, Plymstock, Devon PL6 8NN
Reference List
(1) Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working jn primary care can provide equivalent care to doctors. BMJ 324, 819-823. 2002. Ref Type: Generic
(2) Neal RD, Wickenden G, Cottrell D, Mason J, Rugiano J, Clarkson P et al. The use of primary, secondary, community and social care by families who frequently consult their general practitioner. Health Soc Care Community 2001; 9(6):375-382.
(3) Campbell SM, Hann M, Hacker J, Burns C, Oliver D, Thapar A et al. Identifying predictors of high quality care in English general practice: observational study. BMJ 2001; 323(7316):784-787.
(4) Goedhuys J, Rethans JJ. On the relationship between the efficiency and the quality of the consultation. A validity study. Fam Pract 2001; 18(6):592-596.
(5) Morris CJ, Cantrill JA, Weiss MC. GPs' attitudes to minor ailments. Fam Pract 2001; 18(6):581-585.
Competing interests: No competing interests
I am gratified to see such a sound overview on this topic but must point out that "Patient Satisfaction" is a notoriously unreliable assessment of standard of care provided. The Medical profession has long been aware of the importance of a bedside manner but has been driven from bedside manner by scientific observation of outcomes, and the sad fact that a generation of revered Doctors with impeccable bedside manners included several with appalling standards of objective practice, who where likely to practice poorly for extended periods because their patients where very satisfied with them and unlikely to complain.As the profession contemplates clinical governance and professional assessment as a way of improving standards should we not advise our nursing colleagues of the fallacy of assuming care is good if patients like it and bad if they do not like it? I suspect our nursing colleagues are some way behind us in this matter, the ideal is effective care delivered in a manner liked by the patients, and too many published articles on Nurse practitioners display or even attempt to display evidence of clinical outcomes.Let us not suggest "Patient satisfaction" is the prime clinical determinant, nor "outcome measures" alone justifies arrogance and brusque behaviour, but admit that the complex multifaceted assessment of our colleagues we all make asindividuals as to how we regard their standard of care provision has not yet produced an effective universally accepted validated scale with relative quantification of the merits of desirable qualities.
Competing interests: No competing interests
Today's Physician is continually over-reaching to meet a multiple time-consuming tasks that may deprive the patient of the patient-centered care demonstrated by the Nurse Practitioners in this paper. In a treatment evironment where an appropriate triage protocol is closely supervised by the physician, delegated to Nurses, Physician Assistants, and Nurse Practitioners, treatment outcome presents the highest standard of care efficiently to all the patient population. That Nurse Practioners take more time to treat and resolve each patient's complaint sends a much- needed message to clincians to delegate treatment by either standard triage or medical professional specialty. Once a treatment team is reorganized in this manner, the physician team supervisor may have a better opportunity to also devote more time to patients whose care requires the most in terms of time, testing, and treatment protocols.
I have no competing interests in this subject arena. Bill Misner Ph.D.
Competing interests: No competing interests
The fine research of Horrocks et al again demonstrates what Americans have experienced in anesthesia care for 120 years: superior quality of care from nurses. Two thirds of all anesthetics in the US are delivered by Certified Registered Nurse Anesthetists, half of all hospitals in the US rely exclusively on CRNAs, and no scientific study to date has been able to detect any difference in quality of care between anesthesia delivered by CRNAs or that delivered by anesthesiologists.
How can this be? The most basic reason, from my personal experience of almost 40 years, appears to be that CRNAs bring to their anesthesia practice a strong tradition of hands-on care and close observation of the patient, while physicians in their training somehow are taught that hands- on care equates with manual labor, and they abhor that.
Kudos to our British colleagues and to the BMJ. Perhaps CRNAs could help shorten your waiting lists for surgery?
Competing interests: No competing interests
Another systematic review
I am sorry to see that the BMJ continues its descent into the banal world of "systematic reviews". These are not projects of any research value, they diminish the value of reasonable trials and add confusion.
I am to conclude that there is no need to see a GP when a nurse is just as good ?
Competing interests: No competing interests