No difference in patient satisfaction or quality of care provided by nurses or GPs for low-complexity primary care presentations
- Correspondence to: Dr Grete Moth, Research Unit for General Practice, Aarhus University, Bartholins Alle 2, Aarhus C 8000, Denmark;
Implications for practice and research
General practitioners (GPs) in many countries are subject to a heavy and increasing workload, due to changes in demographics and mounting demands.
It is relevant to search for alternatives to GP care that will ensure a high quality of clinical practice, as well as maintaining patient satisfaction.
As the prevalence of chronic disease increases, both due to an ageing population and more efficient treatment and monitoring of patients with chronic diseases, GPs are experiencing an increased demand for health services.1 ,2 At the same time, an increasing demand exists for high-quality services in the form of same-day consultations.3 This increasing workload calls for developments in the general practice care management, one of which may be more task-sharing between GPs and nurses. Such initiatives have been in existence for many years and have shown positive results in many countries.4 This study examines the issue within the Spanish healthcare environment, where few previous studies have been conducted.
The aim of the study was to compare the effectiveness of care delivered by nurses and GPs in a randomised control study. Patients calling for a same-day appointment with acute, low-complexity symptoms were asked to participate. The intervention group received consultation from a nurse using a decision-support tool. The control group received consultation from a GP.
The primary outcome measures were the resolution of symptoms within 2 weeks and the patient satisfaction. A secondary outcome measure was the proportion of consultation solved by the nurses, defined as one of: (1) no GP involvement; (2) managing the patient after consulting a GP and (3) managing the patient after having referred them to a GP. Non-resolution was defined as the GP taking over the management of care. An intention-to-treat analysis was performed.
Of all the eligible patients 114 did not participate, leaving 1461 participants. No difference was seen between the intervention and control groups in the resolution of symptoms at the 2-week follow-up, neither was there any difference in the patient satisfaction. Regarding the secondary outcome measures, the nurses successfully managed the care for 86.3% patients, with GPs taking over in 13.7% of the consultations.
This study focused on the possibility of nurses replacing GPs in the management of patients with low-complexity acute symptoms. This is a relevant issue in the quest to identify the potential for improvement in care management within the general practice.
A randomised trial is a good choice of study type; allowing patients to choose the type of consultation they would receive might have introduced selection bias. However, it should be noted that 114 eligible patients abstained from participation. These patients may form a specific group that could be associated with the output in a more negative direction, thus involving selection bias. Discussion of this issue would have been beneficial.
In the intention-to-treat analysis, study participants stay in the original group that they were randomised to irrespective of the treatment changes during the study period. This ensures that the randomisation principle is not violated. This analysis is therefore an obvious choice in a randomised trial. In total, 13.7% of consultations shifted from nurses to GPs. According to the intention-to-treat analysis, the outcomes of these consultations still counted as interventions. However, it is possible that the level of satisfaction of these patients was related to the fact that they ultimately saw their GP. The total number of shifts was of a considerable amount and the study's validity would have been strengthened had sensitivity analysis been performed to estimate the consequences if the outcome for these patients had been different.
The role of nurses in care management is highly relevant and further research is needed to identify the areas with the greatest potential to benefit from nurses replacing GPs (eg, types of patients and consultations, preferences of patients and levels of effectiveness). In one study it was found that GPs considered consultations with older patients as suitable for nurse substitution, whereas the older patients themselves were less likely to see nurse-for-GP substitution as a possibility compared with young patients.5 This reveals a further challenge facing the field of care management and demonstrates the need for more research in the area.