Saving Primary Care, One NP at a Time

This meta-analysis by Martinez-Gonzalez and colleagues examined the effects of task-shifting from physicians to nurse practitioners in primary care. Twenty studies included in the meta-analysis all compared nurse-led care with physician-led care in general practices, including frequency and length of consultations, amount of referrals, prescriptions, tests, investigations ordered, and costs.

Nurses were about 20% more likely to have return consultations and tended to have longer consultations than physicians, but were similar in their use of referrals, prescriptions, or investigations. The researchers speculate that previously demonstrated higher patient satisfaction scores with nurse-led care may be correlated to the higher rates of patient recalls and longer consultations that nurses more often demonstrated.

The meta-analysis also employed two economic evaluations to analyze data from the studies that appraised cost. One found that direct care costs for consultations, including the utilization of prescriptions, referrals, and diagnostic procedures, were lower with nurse-led care. The differences in salary between nurse practitioners (NPs) and physicians were found to be the main cause of cost differences. The other evaluation controlled for time giving advice, prescriptions, referrals, and procedures and found that nurse led care costs are were actually the same or higher than physician led care, supposedly because of the time physicians spent supervising or delegating NP consultations.

Two things are clear—we need a standardized tool for measuring cost-effectiveness in primary care, and NPs should be autonomous in their practice, as they are in about half of 50 states. This nurse advocates for a doctoral degree for nurse practitioners (DNP). Although more expensive up front, an increase in DNP educated nurses could encourage professional autonomy and decrease primary care costs in the long term.

Unsurprisingly, the researchers were frustrated by the lack of detail in the studies’ reporting of nurses’ educational preparation, as this could easily confound results. Educational pipelines into nursing for bedside and advanced practice practitioners continue to evolve. However, DNPs, with their focus on prevention and primary care, are well suited to both decrease costs and increase patient satisfaction.

commentary by Megan Doede

Abstract

Task-shifting from physicians to nurses has gained increasing interest in health policy but little is known about its efficiency. This systematic review was conducted to compare resource utilization with task-shifting from physicians to nurses in primary care. Literature searches yielded 4,589 citations. Twenty studies comprising 13,171 participants met the inclusion criteria. Meta-analyses showed nurses had more return consultations and longer consultations than physicians but were similar in their use of referrals, prescriptions, or investigations. The evidence has limitations, but suggests that the effects may be influenced by the utilization of resources, context of care, available guidance, and supervision. Cost data suggest physician-nurse salary and physician’s time spent on supervision and delegation are important components of nurse-led care costs. More rigorous research involving a wider range of nurses from many countries is needed reporting detailed accounts of nurses’ roles and competencies, qualifications, training, resources, time available for consultations, and all-cause costs. PMID: 25972383

Martinez-Gonzalez, NA, et al. Med Care Res Rev. 2015;72(4):395-418.