Substitution of physicians by nurses in primary care: a systematic review and meta-analysis
Open accessAbstract
Background: In many countries, substitution of physicians by nurses has become common due to the shortage of physicians and the need for high-quality, affordable care, especially for chronic and multi-morbid patients. We examined the evidence on the clinical effectiveness and care costs of physician-nurse substitution in primary care. Methods: We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected and critically appraised published randomised controlled trials (RCTs) that compared nurse-led care with care by primary care physicians on patient satisfaction, Quality of Life (QoL), hospital admission, mortality and costs of healthcare. We assessed the individual study risk of bias, calculated the study-specific and pooled relative risks (RR) or standardised mean differences (SMD); and performed fixed-effects meta-analyses. Results: 24 RCTs (38,974 participants) and 2 economic studies met the inclusion criteria. Pooled analyses showed higher overall scores of patient satisfaction with nurse-led care (SMD 0.18, 95% CI 0.13 to 0.23), in RCTs of single contact or urgent care, short (less than 6 months) follow-up episodes and in small trials (N ≤ 200). Nurse-led care was effective at reducing the overall risk of hospital admission (RR 0.76, 95% CI 0.64 to 0.91), mortality (RR 0.89, 95% CI 0.84 to 0.96), in RCTs of on-going or non-urgent care, longer (at least 12 months) follow-up episodes and in larger (N > 200) RCTs. Higher quality RCTs (with better allocation concealment and less attrition) showed higher rates of hospital admissions and mortality with nurse-led care albeit less or not significant. The results seemed more consistent across nurse practitioners than with registered or licensed nurses. The effects of nurse-led care on QoL and costs were difficult to interpret due to heterogeneous outcome reporting, valuation of resources and the small number of studies. Conclusions: The available evidence continues to be limited by the quality of the research considered. Nurse-led care seems to have a positive effect on patient satisfaction, hospital admission and mortality. This important finding should be confirmed and the determinants of this effect should be assessed in further, larger and more methodically rigorous research.
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Many studies with strong research designs have shown nursing-intensive primary care models to be safe and effective.
“Many studies with strong research designs have shown nursing-intensive primary care models to be safe and effective.8,11,18-26”
From Evaluating the cost of NP-led vs. GP-led primary care in British Columbia (2024) · cites this paper as [21]
The Abstract Results report 24 randomized trials and pooled reductions in hospital admissions and mortality with nurse-led care. But the Discussion’s methodological appraisal says no included study met all assessed quality criteria, and the Abstract Results note that higher-quality trials showed higher admission and mortality rates with nurse-led care, though these differences were less or not significant. The paper therefore supports promising effectiveness findings, not the unqualified claim that strong studies have established these models as safe and effective. (LLM, conf=0.88)
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- Authors
- Martínez-González, N. A., Djalali, S., Tandjung, R., Huber-Geismann, F., Markun, S., Wensing, M., & Rosemann, T.
- Affiliations
- University Hospital Zurich (CH)
- Radboud University Medical Center (NL)
- Corresponding author
- Rosemann, Thomas
- Venue
- BMC Health Services Research
- Published
- 2014-05-12
- Volume
- 14
- Issue
- 1
- Pages
- 214-214
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC4065389
- OpenAlex
- W2138392956
- Cited by
- 310
- References
- 50
- Citations by year
- 2026: 10 · 2025: 18 · 2024: 26 · 2023: 24 · 2022: 26 · 2021: 24 · 2020: 36 · 2019: 35 · 2018: 28 · 2017: 36 · 2016: 25 · 2015: 19 · 2014: 2 · 2013: 1
- FWCI
- 4.65
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Health Services Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Radboud Repository (Radboud University) (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, cc-by)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, cc-by)
- Radboud Repository (Radboud University) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Funders
- Schweizerische Akademie der Medizinischen Wissenschaften
- Topics
- Health Sciences › Health Professions › General Health Professions › Nursing Roles and Practices
- Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
- Health Sciences › Nursing › Research and Theory › Nursing education and management
- Keywords
- nurse-led care, primary care, nurse practitioners, registered nurses, licensed nurses, patient satisfaction, hospitalization, mortality, quality of life, health care costs, physician shortage
- MeSH terms
- Workforce, Clinical Competence, Delivery of Health Care, Hospitalization, Humans, Medical Staff, Hospital, Nursing Staff, Hospital, Personnel Staffing and Scheduling, Primary Health Care, Quality of Life, Randomized Controlled Trials as Topic, Patient Satisfaction, Personnel Delegation
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