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
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Contact: Miranda Laurant
M.Laurant@kwazo.umcn.nl
Center for the Advancement of Health
27-Apr-2005