Not accounting for the most important variable in consultations (time) skewes results.
The systematic review by Horrocks et al (1) comparing the level of
care between nurse practitioners and doctors was very interesting and the
authors should be congratulated for their well designed study.
Results are debatably unsurprising; patients were more satisfied
after consultations with nursing practitioners were longer and resulted in
more investigations.
Spending more time and doing more has a psychological effect on the
patient. The outcomes, however, were not improved compared to the shorter
and less investigation
oriented consultations by doctors. This may suggest a less focused
approach by the nursing practitioners, and also addresses the issue of
experience, but this was difficult to standardise for.
The limitations of the study are probably more interesting than the
results at this stage and should be considered in future efforts. The
studies included in the review were considerably heterogeneous with
respect to the autonomy of
the nurses involved. The background support network provided by physicians
was not specified. Whether individual or team approach was employed was
unclear
(surely whatever the conclusions the former should be the main aim).
Patients in the NHS have long complained of lack of time during
consultations. Had the studies standardised for time differences, which
are an integral and most inevitable part of every NHS doctor's pressure
factor, would satisfaction
levels still be higher in the nursing practitioner group? One wonders if
the severe limitations of the study allow at all any robust conclusions.
That longer consultations make happier patients is no surprise and was
probably the most
important factor that should have been accounted for. A similar result
would probably have emerged if one had compared, without the limitations
of time,
final year medical students vs consultants !
Until strong studies are performed with standardisation of the time
pressure factor, of the patient populations and of the target outcomes,
any conclusions are weak. This should perhaps have been the main
conclusion of the systematic
review. As the authors suggest, further research is needed to evaluate the
safety of any weak or premature findings in this potentially great
initiative.
A. K. Demetriades
UCL Hospitals NHS Trust
andreas.demetriades@doctors.org.uk
1. Horrocks S, Anderson E, Salisbury C. Systematic review of whether
nurse practitioners working in primary care can provide equivalent care to
doctors. Br Med J 2002,
324;819-823 (April 6).
Competing interests:
No competing interests
10 May 2002
Andreas K Demetriades
Senior House Officer
University College London Hospitals Trust, WC1N 6AU
Rapid Response:
Not accounting for the most important variable in consultations (time) skewes results.
The systematic review by Horrocks et al (1) comparing the level of care between nurse practitioners and doctors was very interesting and the authors should be congratulated for their well designed study.
Results are debatably unsurprising; patients were more satisfied after consultations with nursing practitioners were longer and resulted in more investigations. Spending more time and doing more has a psychological effect on the patient. The outcomes, however, were not improved compared to the shorter and less investigation oriented consultations by doctors. This may suggest a less focused approach by the nursing practitioners, and also addresses the issue of experience, but this was difficult to standardise for.
The limitations of the study are probably more interesting than the results at this stage and should be considered in future efforts. The studies included in the review were considerably heterogeneous with respect to the autonomy of the nurses involved. The background support network provided by physicians was not specified. Whether individual or team approach was employed was unclear (surely whatever the conclusions the former should be the main aim).
Patients in the NHS have long complained of lack of time during consultations. Had the studies standardised for time differences, which are an integral and most inevitable part of every NHS doctor's pressure factor, would satisfaction levels still be higher in the nursing practitioner group? One wonders if the severe limitations of the study allow at all any robust conclusions. That longer consultations make happier patients is no surprise and was probably the most important factor that should have been accounted for. A similar result would probably have emerged if one had compared, without the limitations of time, final year medical students vs consultants !
Until strong studies are performed with standardisation of the time pressure factor, of the patient populations and of the target outcomes, any conclusions are weak. This should perhaps have been the main conclusion of the systematic review. As the authors suggest, further research is needed to evaluate the safety of any weak or premature findings in this potentially great initiative.
A. K. Demetriades UCL Hospitals NHS Trust andreas.demetriades@doctors.org.uk
1. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. Br Med J 2002, 324;819-823 (April 6).
Competing interests: No competing interests