1. Kennedy, Maureen Shawn MA, RN

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The Cochrane Collaboration, an international-nonprofit organization that reviews medical research worldwide, recently compiled the results of 16 studies examining the substitution of physicians by nurses in the provision of primary care. The effects of the substitution were assessed according to patient outcomes (including morbidity, mortality, satisfaction, compliance, and preference), the process of care (such as practitioners' adherence to clinical guidelines, the quality of care, and practitioners' level of involvement in the patient's care), use of resources (for example, the frequency and length of consultations, return visits, prescriptions, testing and investigations, and referrals for other services), and direct and indirect costs.


Called "Substitution of Doctors by Nurses in Primary Care," the review found that the patients who were cared for by nurses had health outcomes comparable to those among patients receiving care from physicians, at least in the short term.


Among patients who needed urgent care, satisfaction was higher when a nurse, rather than a physician, provided the first contact. Those with chronic diseases were also more satisfied when care was managed by a nurse. The reviewers speculate that the greater satisfaction with nurses may be a result of the fact that nurses tend to have longer consultations with patients and give them more information on their conditions. However, these longer consultations also meant that the nurses were less productive than the physicians and that despite their lower salaries, they didn't help reduce the cost of care. In addition, greater satisfaction didn't translate into preference-patients did not necessarily prefer receiving care from a nurse. (The reviewers suggest that preference may vary according to the seriousness of a disease: while patients with "minor" problems may prefer being cared for by a nurse, those with more serious conditions may prefer the care of a physician, even if the consultation is shorter.) And while one study has shown that nurses can help lighten physicians' workloads, another has revealed that adding nurses to physicians' teams doesn't reduce the physicians' workloads, perhaps because nurses provide care that patients don't generally receive when consulting a physician.


The report concludes that while it may be possible to substitute nurses for physicians in primary care, more studies are needed in order to assess whether substitution can help reduce physicians' workloads or the costs of care. Jan Towers, PhD, NP-C, CRNP, FAANP, director of health policy for the American Academy of Nurse Practitioners, says this report makes it clear once again that NPs can substitute for physicians "with no interference in the quality of care." She states that although the authors found no cost savings in the short term, she believes savings would be realized in the long term because "NPs do more health teaching and place more emphasis on prevention than physicians do." For Towers, "the question is not whether NPs decrease physicians' workloads but whether they increase access to preventive care." -Dalia Sofer


Laurant M, et al. Cochrane Database Syst Rev 2005(2):CD001271.

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