Clinical question
How effective are nurses as substitutes for doctors in primary care (in terms of patient outcomes, processes of care and utilisation, including volume and cost)?
Bottom line
Trained nurses, such as nurse practitioners, practice nurses and registered nurses, provided care that was equal to, or of better quality than, that provided by primary care doctors, and achieved equal or better health outcomes for patients. Nurses provided more health advice to patients and achieved slightly higher levels of patient satisfaction, compared with primary care doctors. Compared with doctors, nurses probably had longer consultations, and their patients were slightly more likely to keep follow‐up appointments. There was little or no difference in the number of prescriptions issued, and there was little or no difference in the numbers of tests and investigations ordered, or in patients’ use of other services. The study periods ranged from 2 weeks to 48 months, and involved mainly high-income countries.
Caveat
The nursing level was often unclear or varied between, and even within, studies. It was not possible to determine the effects of nurse‐led care on process of care and the costs of care because the certainty of this evidence was assessed as very low. The impacts on the amount of information offered to patients and on the extent to which guidelines were followed were uncertain. Only 3 studies assessed the impact of nurses on doctor behaviour.
Context
Current and expected problems – such as ageing, increased prevalence of chronic conditions and multimorbidity, increased emphasis on healthy lifestyle and prevention, and substitution of care from hospitals by care provided in the community – encourage countries worldwide to develop new models of primary care delivery. Owing to the fact many tasks do not necessarily require the knowledge and skills of a doctor, interest in using nurses to expand the capacity of the primary care workforce is increasing. Substitution of nurses for doctors is one strategy used to improve access, efficiency and quality of care.
Cochrane Systematic Review
Lavant M et al. Nurses as substitutes for doctors in primary care. Cochrane Reviews, 2018, Issue 7. Art. No.: CD001271.DOI: 10.1002/14651858. CD001271.pub3. This review contains 18 studies involving 41,446 patients.
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