Effects of Physician-Nurse Substitution on Clinical Parameters: A Systematic Review and Meta-Analysis

Abstract

BackgroundPhysicians’ shortage in many countries and demands of high-quality and affordable care make physician-nurse substitution an appealing workforce strategy. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the impact of physician-nurse substitution in primary care on clinical parameters.MethodsWe systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected peer-reviewed RCTs comparing physician-led care with nurse-led care on changes in clinical parameters. Study selection and data extraction were performed in duplicate by independent reviewers. We assessed the individual study risk of bias; calculated the study-specific and pooled relative risks (RR) or weighted mean differences (WMD); and performed fixed-effects meta-analyses.Results11 RCTs (N = 30,247) were included; most were from Europe, generally small with higher risk of bias. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease and incontinence. Meta-analyses showed greater reductions in systolic blood pressure (SBP) in favour of nurse-led care (WMD −4.27 mmHg, 95% CI −6.31 to −2.23) but no statistically significant differences between groups in the reduction of diastolic blood pressure (DBP) (WMD −1.48 mmHg, 95%CI −3.05 to −0.09), total cholesterol (TC) (WMD -0.08 mmol/l, 95%CI -0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI -0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups.Limitationsdisease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters.Conclusionstrained nurses appeared to be better than physicians at lowering SBP but similar at lowering DBP, TC or HbA1c. There is insufficient evidence that nurse-led care leads to better outcomes of other clinical parameters than physician-led care.

Team-based care for improving hypertension management among outpatients (TBC-HTA): study protocol for a pragmatic randomized controlled trial

“…A similar proportion has been found in Switzerland [6]. Furthermore, due to ageing populations, busy clinical workloads, and shortage of physicians in most healthcare systems, new approaches to hypertension care, involving pharmacists [7, 8] or nurses [9, 10], could be a promising approach to improve BP management and control.…”

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

“…A review assessed the impact on clinical outcomes of physician-nurse substitution in primary care, and included 11 randomised trials (Martínez-González 2014). Most studies were conducted in high-income countries.…”

“…However, only five reviews reported adverse effects (Dudley 2011; Martínez-González 2014; Ngo 2013; Parker 2013; Wilson 2011), and one review did not find any studies reporting adverse effects (Van Lonkhuijzen 2012). Wilson 2011 reported undesirable effects on patient outcomes, and Dudley 2011 on access, coverage or utilisation, both with low- or very low-certainty evidence.…”

A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK

“…Martinez-Gonzalez et al (2015) [1] identified twelve randomized controlled trials (RCTs) comprising 22, 617 patients specifically focussing upon the impact of shifting care traditionally delivered by physicians to nurse practitioners in primary care. Three quarters of these studies were conducted in Europe and nurse-led care was provided for patients with heart or lung disease, diabetes mellitus, digestive or skin disease, or infectious diseases.…”