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

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  • Nahara Anani Martínez-González
  • Ryan Tandjung
  • Sima Djalali
  • Flore Huber-Geismann
  • Stefan Markun
  • Thomas Rosemann

Abstract

Background: Physicians’ 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. Methods: We 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. Results: 11 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. Limitations: disease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters. Conclusions: trained 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.

Suggested Citation

  • Nahara Anani Martínez-González & Ryan Tandjung & Sima Djalali & Flore Huber-Geismann & Stefan Markun & Thomas Rosemann, 2014. "Effects of Physician-Nurse Substitution on Clinical Parameters: A Systematic Review and Meta-Analysis," PLOS ONE, Public Library of Science, vol. 9(2), pages 1-11, February.
    • Handle: RePEc:plo:pone00:0089181
    DOI: 10.1371/journal.pone.0089181
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    2. Kenneth F Schulz & Douglas G Altman & David Moher & for the CONSORT Group, 2010. "CONSORT 2010 Statement: Updated Guidelines for Reporting Parallel Group Randomised Trials," PLOS Medicine, Public Library of Science, vol. 7(3), pages 1-7, March.
    3. Sebastiaan T Houweling & Nanne Kleefstra & Kornelis JJ van Hateren & Klaas H Groenier & Betty Meyboom‐de Jong & Henk JG Bilo, 2011. "Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial," Journal of Clinical Nursing, John Wiley & Sons, vol. 20(9‐10), pages 1264-1272, May.
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    1. Maier, Claudia B., 2015. "The role of governance in implementing task-shifting from physicians to nurses in advanced roles in Europe, U.S., Canada, New Zealand and Australia," Health Policy, Elsevier, vol. 119(12), pages 1627-1635.
    2. Andréa Sonenberg & Hillary Knepper & Joyce Pulcini, 2015. "Implementing the ACA: The Influence of Nurse Practitioner Regulatory Policies on Workforce, Access to Care, and Primary Care Health Outcomes," Poverty & Public Policy, John Wiley & Sons, vol. 7(4), pages 336-356, December.

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