We wish to comment upon the systematic review of the equivalence of
nurse practitioner and physicians by Horrocks and colleagues. (1)
The authors report higher levels of patient satisfaction for patients
of NP’s. While important, it is unclear if patient satisfaction is a valid
measure of the quality of practice. Moreover, of the five trials presented
regarding patient satisfaction (2-6), three ask prospective patients if it
was acceptable with them to see a nurse practitioner rather than a
physician. (2-4) Therefore, only those patients predisposed to be
accepting of NP’s were included in the studies.
The authors also report that NP’s undertook more investigations and
had longer consultations. The absolute difference of less than four
minutes in consultation time is of questionable clinical importance and
may reflect the practice setting enjoyed by the NP’s. It is unclear if the
finding that NP’s ordered more tests per patient is a marker of better or
worse practice, and may inflate costs.
We believe that the authors’ assertions about the quality of care are
not supported by the data they present. The authors state that NP’s
identified physical abnormalities more often than physicians did, without
qualifying that the cited data are from 1975 and only refer to well-baby
exams. (7) The observations that NP’s made more complete records,
communicated better and were as proficient in the ordering and
interpretation of x-ray films are based only upon patients with minor
injuries seen in an emergency room. (8,9) It may not be reasonable to make
the leap that such conclusions would hold true in adults, more currently,
outside the ER or in more seriously ill patients.
With these limitations in mind, we question the author’s ability to
conclude that “NP’s can provide care that leads to increased satisfaction
and similar health outcomes.” Even more dubious is the conclusion that
NP’s provided care of equivalent or superior quality when compared to
physicians. We do agree with the authors that the ability of NP’s to
identify “rare but important health problems” needs further research.
Although the authors cite some of the weakness of their data, they propose
that their review supports an increased involvement of NP’s in primary
care. We feel that this conclusion is out of proportion to the presented
data, and that patients and policy-makers would be better served by using
this review as no more than a springboard to more methodologically sound
investigations.
William Rifkin M.D.
Maimonides Medical Center,
Brooklyn, NY USA
Arthur Rifkin M.D.
Long Island Jewish Medical Center-Hillside Hospital ,
Glen Oaks, NY USA
John Horiszny M.D.
Red Hook, NY USA
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: 819-23.
2. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled
trial comparing cost effectiveness of general practitioners and nurse
practitioners in primary care. BMJ 2000; 320: 1048-53.
3. Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Nurse
management of patients with minor illnesses in general practice:
multicentre, randomised controlled trial. BMJ 2000; 320: 1038-43.
4. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P.
Randomised controlled trial of nurse practitioner versus general
practitioner care for patients requesting “same day” consultations in
primary care. BMJ 2000; 320: 1043-8.
5. Mundinger MO, Kane RL, Lenz ER, Totten A, Tsai W-Y, Cleary PD. Primary
care outcomes in patients treated by nurse practitioners or physicians: a
randomized trial. JAMA 2000; 283: 59-68.
6. Winter C. Quality health care: patient assessment. MSc thesis. Long
Beach CA: California State University, 1981.
8. Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of
minor injuries by emergency nurse practitioners or junior doctors: a
randomised controlled trial. Lancet 1999; 354: 1321-6.
9. Cooper M. An evaluation of the safety and effectiveness of the
emergency nurse practitioner in the treatment of patients with minor
injuries: a pilot study. Glasgow: Accident and Emergency, Glasgow Royal
Infirmary, 2001. (Typescript)
Rapid Response:
Some Concerns
We wish to comment upon the systematic review of the equivalence of nurse practitioner and physicians by Horrocks and colleagues. (1)
The authors report higher levels of patient satisfaction for patients of NP’s. While important, it is unclear if patient satisfaction is a valid measure of the quality of practice. Moreover, of the five trials presented regarding patient satisfaction (2-6), three ask prospective patients if it was acceptable with them to see a nurse practitioner rather than a physician. (2-4) Therefore, only those patients predisposed to be accepting of NP’s were included in the studies.
The authors also report that NP’s undertook more investigations and had longer consultations. The absolute difference of less than four minutes in consultation time is of questionable clinical importance and may reflect the practice setting enjoyed by the NP’s. It is unclear if the finding that NP’s ordered more tests per patient is a marker of better or worse practice, and may inflate costs.
We believe that the authors’ assertions about the quality of care are not supported by the data they present. The authors state that NP’s identified physical abnormalities more often than physicians did, without qualifying that the cited data are from 1975 and only refer to well-baby exams. (7) The observations that NP’s made more complete records, communicated better and were as proficient in the ordering and interpretation of x-ray films are based only upon patients with minor injuries seen in an emergency room. (8,9) It may not be reasonable to make the leap that such conclusions would hold true in adults, more currently, outside the ER or in more seriously ill patients.
With these limitations in mind, we question the author’s ability to conclude that “NP’s can provide care that leads to increased satisfaction and similar health outcomes.” Even more dubious is the conclusion that NP’s provided care of equivalent or superior quality when compared to physicians. We do agree with the authors that the ability of NP’s to identify “rare but important health problems” needs further research.
Although the authors cite some of the weakness of their data, they propose that their review supports an increased involvement of NP’s in primary care. We feel that this conclusion is out of proportion to the presented data, and that patients and policy-makers would be better served by using this review as no more than a springboard to more methodologically sound investigations.
William Rifkin M.D.
Maimonides Medical Center, Brooklyn, NY USA
Arthur Rifkin M.D.
Long Island Jewish Medical Center-Hillside Hospital , Glen Oaks, NY USA
John Horiszny M.D.
Red Hook, NY USA
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: 819-23.
2. Venning P, Durie A, Roland M, Roberts C, Leese B. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. BMJ 2000; 320: 1048-53.
3. Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. BMJ 2000; 320: 1038-43.
4. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ 2000; 320: 1043-8.
5. Mundinger MO, Kane RL, Lenz ER, Totten A, Tsai W-Y, Cleary PD. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA 2000; 283: 59-68.
6. Winter C. Quality health care: patient assessment. MSc thesis. Long Beach CA: California State University, 1981.
7. Hoekelman RA. What constitutes adequate well-baby care? Pediatrics 1975; 55: 313-26.
8. Sakr M, Angus J, Perrin J, Nixon C, Nicholl J, Wardrope J. Care of minor injuries by emergency nurse practitioners or junior doctors: a randomised controlled trial. Lancet 1999; 354: 1321-6.
9. Cooper M. An evaluation of the safety and effectiveness of the emergency nurse practitioner in the treatment of patients with minor injuries: a pilot study. Glasgow: Accident and Emergency, Glasgow Royal Infirmary, 2001. (Typescript)
Competing interests: No competing interests