Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review

Martin-Misener, Ruth; Harbman, Patricia; Donald, Faith; Reid, Kimberly J.; Kilpatrick, Kelley; Carter, Nancy; Bryant‐Lukosius, Denise; Kaasalainen, Sharon; Marshall, Deborah A.; Charbonneau-Smith, Renée; DiCenso, Alba

doi:10.1136/bmjopen-2014-007167

Cited by 190 publications

(207 citation statements)

References 38 publications

Supporting

Mentioning

174

Contrasting

Unclassified

Order By: Relevance

“…22 Furthermore, evidence shows that nurse practitioners in primary care professional roles have equivalent or superior patient outcomes and are potentially cost saving. 42 This finding suggests the potential of nurse practitioner-physician comanagement to be more cost effective than 2 physicians comanaging care. More cost-effective studies about nurse practitionerphysician comanagement are warranted.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

Norful

Jacq

Carlino³

et al. 2018

Ann Fam Med

View full text Add to dashboard Cite

PURPOSE Various models of care delivery have been investigated to meet the increasing demands in primary care. One proposed model is comanagement of patients by more than 1 primary care clinician. Comanagement has been investigated in acute care with surgical teams and in outpatient settings with primary care physicians and specialists. Because nurse practitioners are increasingly managing patient care as independent clinicians, our study objective was to propose a model of nurse practitioner-physician comanagement. METHODSWe conducted a literature search using the following key words: comanagement; primary care; nurse practitioner OR advanced practice nurse. From 156 studies, we extracted information about nurse practitioner-physician comanagement antecedents, attributes, and consequences. A systematic review of the findings helped determine effects of nurse practitioner-physician comanagement on patient care. Then, we performed 26 interviews with nurse practitioners and physicians to obtain their perspectives on nurse practitioner-physician comanagement. Results were compiled to create our conceptual nurse practitioner-physician comanagement model. RESULTSOur model of nurse practitioner-physician comanagement has 3 elements: effective communication; mutual respect and trust; and clinical alignment/ shared philosophy of care. Interviews indicated that successful comanagement can alleviate individual workload, prevent burnout, improve patient care quality, and lead to increased patient access to care. Legal and organizational barriers, however, inhibit the ability of nurse practitioners to practice autonomously or with equal care management resources as primary care physicians.CONCLUSIONS Future research should focus on developing instruments to measure and further assess nurse practitioner-physician comanagement in the primary care practice setting. Ann Fam Med 2018;16:250-256. https://doi.org/10.1370/afm.2230. INTRODUCTIONW ith imminent staffing shortages in the health care profession and an increase in the volume of patients seeking primary care services, patient loads are increasing rapidly, thus making it difficult for a single primary care professional to manage all patient care needs effectively and efficiently.1-4 Therefore, policy makers are calling for new primary care delivery models to meet the increased demands for care, especially due to patients with multiple comorbidities requiring more complex primary care visits. Different models of care delivery have been proposed, including team-based care, yet these models often have variability in task allocation and professional roles.5 Identifying innovative models of care delivery is increasingly important to meet these demands in primary care.One proposed care delivery model includes having more than 1 primary care professional comanaging the same patient and sharing the workload responsibilities or care management tasks. Researchers have explored comanagement of patients by 2 physicians in primary care, 6 and by a physician and a nonphysician ...

show abstract

Section: Discussionmentioning

confidence: 99%

“…42 This finding suggests the potential of nurse practitioner-physician comanagement to be more cost effective than 2 physicians comanaging care. More cost-effective studies about nurse practitionerphysician comanagement are warranted.…”

mentioning

confidence: 99%

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

Norful

Jacq

Carlino³

et al. 2018

Ann Fam Med

View full text Add to dashboard Cite

show abstract

“…Few studies, however, have compared APCs and physicians specifically in providing inefficient or low-value care. The existing literature is limited and shows mixed results, with some studies showing increased value and others showing no net change or lower value associated with APCs (15, 34, 35). Moreover, these studies focused mainly on health care costs, and few investigated the use of guideline-discordant and low-value health services as we did in our study.…”

Section: Discussionmentioning

confidence: 99%

Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians

Mafi¹,

Wee²,

Davis³

et al. 2016

Ann Intern Med

View full text Add to dashboard Cite

Background Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. Objective To compare use of low-value services among U.S. APCs and physicians. Design Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office-versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient’s primary care provider (PCP). Setting National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. Patients Patients presenting with upper respiratory infections (URIs), back pain, or headache. Measurements Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). Results 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. Limitation NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. Conclusion APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians’ perceptions that APCs provide lower-value care than physicians for these common conditions. Primary Funding Source U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

show abstract

“…There is a discrepancy of perspectives, however, regarding NP reimbursement rates, hospital admitting privileges and having a NP lead a medical home (Donelan, DesRoches, Dittus, & Buerhaus, 2013). For example, a recent systematic review found potential for cost savings when NPs complement physician-based care (Martin-Misener et al, 2015). Yet, while the American College of Physicians (ACP) (2009) supports the expansion of NP scope of practice to help alleviate the strain in primary care, other medical organizations firmly believe that primary care patients should be strictly physician-managed (American Academy of Family Physicians, 2012).…”

Section: Introductionmentioning

confidence: 99%

Nurse practitioner–physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care

Norful

Swords

Marichal

et al. 2019

Health Care Manage Rev

View full text Add to dashboard Cite

Background The U.S. primary care system is under tremendous strain to deliver care to an increased volume of patients with a concurrent primary care physician shortage. Nurse Practitioner (NP)-physician co-management of primary care patients has been proposed by some policymakers to help alleviate this strain. To date, no collective evidence demonstrates the effects of NP-physician co-management in primary care. Purpose This is the first review to synthesize all available studies that compare the effects of NP-physician co-management to an individual physician managing primary care. Methods The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) framework guided the conduct of this systematic review. Five electronic databases were searched. Titles, abstracts, and full texts were reviewed and inclusion/exclusion criteria applied to narrow search results to eligible studies. Quality appraisal was performed using Downs and Black’s quality checklist for randomized and nonrandomized studies. Results Six studies were identified for synthesis. Three outcome categories emerged: 1) PCP adherence to recommended care guidelines; 2) empirical changes in clinical patient outcomes; and 3) patient/caregiver quality of life. Significantly more recommended care guidelines were completed with NP-physician co-management. There was variability of clinical patient outcomes with some findings favoring the co-management model. Limited differences in patient quality of life were found. Across all studies, the NP-physician co-management care delivery model was determined to produce no detrimental effect on measured outcomes, and in some cases, was more beneficial in reaching practice and clinical targets. Practice Implications The use of NP-physician co-management of primary care patients is a promising delivery care model to improve the quality of care delivery and alleviate organizational strain given the current demands of increased patient panel sizes and primary care physician shortages. Future research should focus on NP-physician interactions and processes to isolate the attributes of a successful NP-physician co-management model.

show abstract

Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review

Cited by 190 publications

References 38 publications

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

Nurse Practitioner–Physician Comanagement: A Theoretical Model to Alleviate Primary Care Strain

Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians

Nurse practitioner–physician comanagement of primary care patients: The promise of a new delivery care model to improve quality of care

Contact Info

Product

Resources

About