May 2, 2005 Many primary care responsibilities can be safely transferred from doctors to appropriately trained nurses, says a new review of evidence. Yet there is little proof that such a shift reduces physician workload or health-care costs.
“The findings may be considered controversial by health care professionals and policymakers, as there is a widely held belief that nurses can save physicians’ time and reduce costs,” says lead reviewer Miranda Laurant of Radboud University, Nijmegen in the Netherlands.
Demand for primary care services has increased in many countries due to aging populations, rising patient expectations and changing health-care approaches. At the same time, availability of general practitioners may be limited, and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges.
According to the American Nurses Association, “Some 60 to 80 percent of primary and preventive care traditionally done by doctors can be done by a nurse for less money.” The evidence, however, shows that nurses’ lower salaries do not necessarily equate to lower overall costs. The ANA advocates for removing regulatory and legislative barriers to increased use of nurses as health care providers.
The systematic review included 16 studies totaling more than 25,000 patients in the United Kingdom, United States and Canada.
The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
In each study, nurses were responsible for one of the following types of care: first contact and ongoing care for general patients; routine management of patients with chronic conditions; or first contact care for patients seeking urgent attention.
In the first two categories, the reviewers found no appreciable differences between doctors and nurses in health outcomes, process of care, resource utilization or cost.
Among urgent-care patients, health outcomes were similar for nurses and doctors. Moreover, nurses tended to provide longer consultations, offer more information, recall patients more frequently and receive higher patient-satisfaction ratings.
Because nurses spent more time with each patient, however, they saw fewer patients per hour. In four of five studies on nurse-led urgent care, lower salary costs were offset by this so-called “lower productivity” and increased use of resources.
“As salary differentials between nurses and doctors may vary from place to place and over time, the net saving to health care services, if any, will be highly context dependent,” note the reviewers.
The single study that investigated the impact of nurses on doctors’ workload confirmed reductions in demand for doctors when nurses responded to patients needing after-hours care. While such substitution may save time for physicians, note the authors, it is also possible that doctors’ workloads may remain unchanged either because there was previously unmet need or because nurses generate demand for care where previously there was none.
A 2004 controlled trial by Laurant and others, which was not included in the review, found that adding nurses to doctors’ teams did not reduce physician workload. Further research on physicians’ workload and behavior is needed, Laurant says.
Overall, the review findings suggest that appropriately trained nurses can produce the same high-quality primary care as doctors and achieve similar health outcomes for patients. Laurant cautions, however, that many of the studies had methodological limitations, and follow-ups of less than one year left long-term health outcomes unclear. In addition, most studies included only a few nurses, so the findings may reflect personal variations rather than broad trends.
Laurant M, et al. Substitution of doctors by nurses in primary care (Review). The Cochrane Database of Systematic Reviews 2005, Issue 2
The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.
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