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Trial Flow
Figures and Tables -
Figure 1

Trial Flow

Comparison 1 Doctor‐Nurse substitution study results, Outcome 1 Physical function (better vs not better).
Figures and Tables -
Analysis 1.1

Comparison 1 Doctor‐Nurse substitution study results, Outcome 1 Physical function (better vs not better).

Comparison 1 Doctor‐Nurse substitution study results, Outcome 2 Patient satisfaction.
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Analysis 1.2

Comparison 1 Doctor‐Nurse substitution study results, Outcome 2 Patient satisfaction.

Comparison 1 Doctor‐Nurse substitution study results, Outcome 3 Scheduled return visits.
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Analysis 1.3

Comparison 1 Doctor‐Nurse substitution study results, Outcome 3 Scheduled return visits.

Comparison 1 Doctor‐Nurse substitution study results, Outcome 4 Prescription ordered.
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Analysis 1.4

Comparison 1 Doctor‐Nurse substitution study results, Outcome 4 Prescription ordered.

Comparison 1 Doctor‐Nurse substitution study results, Outcome 5 Hospital referral.
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Analysis 1.5

Comparison 1 Doctor‐Nurse substitution study results, Outcome 5 Hospital referral.

Comparison 1 Doctor‐Nurse substitution study results, Outcome 6 Attendance at Accident&Emergency.
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Analysis 1.6

Comparison 1 Doctor‐Nurse substitution study results, Outcome 6 Attendance at Accident&Emergency.

Comparison 1 Doctor‐Nurse substitution study results, Outcome 7 Hospital admission.
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Analysis 1.7

Comparison 1 Doctor‐Nurse substitution study results, Outcome 7 Hospital admission.

Table 1. Methodological Quality of controlled before and after studies

Study (no)

Power

Unit Analysis Error

80% follow‐up

Comparability

Baseline Assessment

Blinded Assessment

Reliable Outcomes

Contamination

Chambers
1977

Not clear

Yes

Professional ‐ Not clear;
Patients ‐ Done

Done

Done

Done

Not clear

Not clear

Gordon
1974

Not clear

No

Professional ‐ Not clear;
Patients ‐ Done

Done

Not clear

Resource ‐ Done; Patient ‐ Not done

Not clear

Not clear

Myers
1997

Not clear

No

Professional ‐ Not clear;
Patients ‐ Done

Done

Not clear

Done

Not clear

Not done

Figures and Tables -
Table 1. Methodological Quality of controlled before and after studies
Table 2. Methodological quality of randomized controlled trials

Study (no)

Power

Unit Analysis Error

80% follow‐up

Concealment

Baseline Assessment

Blinded Assessment

Reliable Outcomes

Contamination

Chambers
1978

Not done

Yes

Professional ‐ Not clear;
Patient ‐ not done

Not clear

Done

Not clear

Not clear

Not clear

Flynn
1974

Not clear

No

Professional ‐ Not clear;
Patient ‐ done

Not clear

Not clear

Not done

Not done

Not clear

Hemani
1999

Not done

No

Professional ‐ Not clear;
Patient ‐ done

Done

Not clear

Done

Done

Not clear

Kinnersley
2000

Done

No

Professional ‐ Not clear;
Patient ‐ Not done

Done

Not clear

Not done

Done

Not clear

Lattimer
1998

Done

No

Professional ‐ Not clear;
Patient ‐ done

Done

Not clear

Done

Done

Not clear

Lewis
1967

Not clear

No

Professional ‐ Not clear;
Patient ‐ done

Not clear

Not clear

Done

Not clear

Not clear

McIntosh
1997

Done

No

Professional ‐ Not clear;
Patient ‐ done

Not clear

Done

Not done

Done

Not clear

Moher
2001

Not clear

No

Professional ‐ Not clear;
Patient ‐ done

Not clear

Done

Done

Not clear

Done

Mundinger
2000

Done

No

Professional ‐ Not clear;
Patient ‐ Not done

Not clear

Done

Resource ‐ Done;
Patient ‐ Not clear

Resource ‐ Done;
Patient ‐ Not clear

Not clear

Shum
2000

Done

No

Professional ‐ Not clear;
Patient ‐ Done

Done

Not clear

Not done

Done

Not clear

Spitzer
1974

Not clear

Yes

Professional ‐ Not clear; patient ‐ Not clear

Not clear

Done

Mortality ‐ Done; Others ‐ Not clear

Mortality ‐ Done; Others ‐ Not clear

Not clear

Stein
1974

Not clear

No

Professional ‐ Not clear;
Patient ‐Done

Not done

Not clear

Not clear

Not clear

Not clear

Venning
2000

Not clear

No

Professional ‐ Not clear;
Patient ‐ Not done

Done

Not clear

Not done

Health status ‐ done; Others ‐ Not clear

Not clear

Figures and Tables -
Table 2. Methodological quality of randomized controlled trials
Table 3. Patient outcomes

Study (no)

Nurse Role

Health status

Satisfaction

Compliance

Other

Chambers
1978

First contact and ongoing care

Health status:
‐Physical function: nurse better
‐Emotional function: no difference
‐Social function: no difference

Flynn
1974

First contact and ongoing care

Medication: no difference
Diet: no difference

Patients' knowledge:
‐ Exercise: nurse significantly better
‐ Disease complications: no difference
‐ Diet: no difference

Gordon
1974

First contact and ongoing care

Health Status: no difference

Subjective perceptions of clinical care (10 dimensions): no difference

Medication: no difference
Kept appointment: no difference

Mundinger
2000

First contact and ongoing care

Number of Health Complaints ‐ no difference Health Status (10 dimensions): No difference Objective Measures of patient health: ‐ Asthma ‐ peak flow: no difference ‐ Diabetes ‐ blood sugar: no difference ‐ Hypertension: systolic pressure: no difference ‐ Hypertension: disatolic pressure: nurse better

Satisfaction (3 dimensions) no difference in overall satisfaction, but nurse worse on 1 dimension
Would recommend provider to others: no difference

Spitzer
1973

First contact and ongoing care

Health status:
‐Physical function (3 indicators): no difference
‐Emotional function: no difference
‐Social function: no difference

Mortality: no difference

Satisfaction: no difference

Kinnersley
2000

First contact care for urgent problems

Health status:
‐resolution of symptoms: no difference
resolution of concerns: no difference

Satisfaction: ‐ child care: nurse better
‐adult care: no difference
Provider preference: no difference

Latimer
1998

First contact care for urgent problems

Mortality: no difference

Shum
2000

First contact care for urgent problems

Health status: no difference

Satisfaction:
‐general: nurse significantly better
‐professional care: nurse significantly better
‐relationship to provider: no difference
‐adequacy of time: nurse significantly better
‐explanation helpful: no difference
‐advice helpful: no difference

Provider preference: patients preferred nurse significantly more often

Venning
2000

First contact care for urgent problems

Health status: no difference

Objective measures of patient health:
‐Asthma ‐ peak flow: no difference
‐Diabetes ‐ blood sugar: no difference
‐Hypertension ‐ systolic blood pressure: no difference
‐Hypertension ‐ diastolic blood pressure: nurse significantly better

Satisfaction:
Adults
‐General: nurse significantly better
‐Communication: nurse significantly better
‐Distress relief: nurse significantly better
‐Professional care: nurse significantly better
Children
‐General: nurse significantly better
‐Communication with parent: no difference
‐Communication with child: nurse significantly better
‐Distress relief: nurse significantly better
‐Adherence intent: no difference

Lewis
1967

Management of patients with chronic conditions

Health status: resolution of symptoms: nurse better.

Provider preference: nurse better

Kept appointment: no difference

McIntosh
1997

Management of patients with chronic conditions

Health status:
‐reduction in alcohol consumption: no difference

Moher
2001

Management of patients with chronic conditions

Objective measurement health status:
‐Blood pressure: no difference
‐ Cholesterol: No difference
‐ Not Smoking: No Difference

Stein
1974

Management of patients with chronic conditions

Objective measurement health status:
‐Blood sugar: no difference
‐ Weight: no difference

Mortality: no difference

Knowledge: nurse better

Figures and Tables -
Table 3. Patient outcomes
Table 4. Process of Care Outcome

Study (No)

Nurse Role

Provider Care

Chambers,
1977

First contact and ongoing care

Adequate care:
‐ clinical assessment: no difference
‐ drug treatment: no difference

Flynn,
1974

First contact and ongoing care

Recommendations on:
Ordered diet:
‐ diabetic: no difference
‐ low salt: nurse significantly higher frequency
‐ low calorie: no difference
‐ bland: no difference
Exercise:
‐ Increase activities: nurse significantly higher frequency

Gordon,
1974

First contact and ongoing care

Lapses in care: no difference
Subgroup:
‐ stable patients: no difference
‐ unstable patients: nurse significantly fewer lapses

Kinnersley,
2000

First contact and ongoing care

Provision of information:
‐ Cause of illness: nurse significantly more
‐ Relief of symptoms: nurse significantly more
‐ Duration of illness: nurse significantly more
‐ Reduce recurrence: nurse significantly more
‐ Action if problem persists: no difference

Shum,
2000

First contact and ongoing care

Provision of infomation:‐ Self‐medication: nurse significantly more‐ Self‐management: nurse significantly more

Spitzer,
1973

First contact and ongoing care

Adequate treatment:‐ Drug treatment: no difference‐ Management of episodes: no difference

Venning,
2000

First contact and ongoing care

Examinations: no difference

Moher,
2001

Management of patietns with chronic conditions

Adequate assessment:
‐ clinical assessment: no difference
‐ blood pressure: no difference
‐ cholesterol: no difference
‐ smoking status: no difference

Figures and Tables -
Table 4. Process of Care Outcome
Table 5. Resource Utilisation Outcomes

Study (no)

Nurse role

Consultations

Presc'n. & Invest'n.

Other services

Flynn,
1974

First contact and ongoing care

Investigations & tests (11 indicators):
‐nurse significantly more tests for 4 indicators (electrocardiogram; bacteriology; urinalysis; minor X‐ray); the remainder showed no difference.

Nurse‐led care was associated with a significantly higher use of other services

Hemani,
1999

First contact and ongoing care

Consultation rate:
No difference compared to qualified doctors;
Nurse significantly more visits compared to trainee doctors

Lab tests: (6 indicators) no difference

Hospital admission: no difference
Emergency room visits: no difference
Specialty visits: no difference

Mundinger,
2000

First contact and ongoing care

Consultation rate: no difference

Hospital admissions: no difference
Emergency room visits: no difference
Speciality visits: no difference

Kinnersley,
2000

First contact care for urgent problems

Consultation length: Nurse significantly longer

Return Visit:

Recommended: No difference
Re‐attend for same problem: No difference

Prescriptions:No difference

Investigation ordered: no difference

Referral to hospital: no difference

Lattimer,
1998

First contact care for urgent problems

Impact on doctors' workload:
Telephone advice from doctor: significantly fewer with nurse led care
Surgery visits: Significanlty fewer with nurse‐led care
Home visits: Significanlty fewer with nurse‐led care

Hospital admission within 24 hours: no difference

Hospital admission with 3 days: no difference
Emergency room visits: no difference

Referred to hospital emergency room: no difference

Myers,
1997

First contact care for urgent problems

Prescriptions: Nurse signifciantly less

Referral: no difference

Shum,
2000

First contact care for urgent problems

Consultation length: Nurse significantly longer
Return visit: no difference

Prescriptions: No difference

Emergency room visit: no difference
Out‐of‐hours‐calls: no difference

Venning,
2000

First contact care for urgent problems

Consultation length: Nurse significantly longer
Return visit: All visits: nurse significantly more
Asked to return: Nurse significantly more

Prescriptions:
All: no difference
Antibiotics: no difference

Investigations: Nurse significantly more

Referral to hospital: no difference

Moher,
2001

Management of patients with chronic conditions

Prescriptions:
Antihypertensives: no difference
Lipid lowering:no difference
Antiplatelet:no difference

Stein,
1974

Management of patients with chronic conditions

Consultation rate: no difference

Prescriptions:
Changed medication: no difference

Figures and Tables -
Table 5. Resource Utilisation Outcomes
Table 6. Cost Outcomes

Study (no)

Nurse role

Cost outcomes

Notes

Chambers, 1977

First contact and ongoing primary care

Direct cost per 1000 patients per year:
nurses ‐ increase of 26% from $68130 to $85.690
doctors ‐ increase of 21% from $93190 to $112.730

Lattimer, 1998

First contact for patients with urgent problems out‐of‐hours

Annual direct cost nurse‐led service ‐ £81.237 more than doctor‐led service
Savings:
generated in reduced hospital and primary care utilisation £94.422

Net reduction in costs with nurse‐led service
£3728 ‐ £12.3824 (determined by sensitivity analysis)

Spitzer, 1973

First contact and ongoing primary care

Average cost per patient per yearnurses ‐ $297.01doctors ‐ $285.67

Spitzer reported an overall reduction in practice costs following the introduction of nurse practitioners but this finding was based on observational before‐and‐after data. Data obtained from the related randomised controlled trial (reported above) did not support this finding.

Venning, 2000

First contact care for patients with urgent problems

Total direct cost per consultation:Nurses ‐ mean £18.11 (range £0.66 ‐ £297.1) Doctors ‐ mean £20.70 (range £0.78 ‐ £300.6)not significantly different

Lewis, 1967

Ongoing care for patients with stable chronic diseases

Total direct cost per year:nurses ‐ $3.251doctors ‐ $4.199Average cost per patient per year:nurses ‐ $98.51doctors ‐ $127.24

Figures and Tables -
Table 6. Cost Outcomes
Comparison 1. Doctor‐Nurse substitution study results

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Physical function (better vs not better) Show forest plot

3

3211

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.98, 1.05]

2 Patient satisfaction Show forest plot

3

3611

Std. Mean Difference (IV, Fixed, 95% CI)

0.28 [0.21, 0.34]

2.1 Sub‐category

3

3611

Std. Mean Difference (IV, Fixed, 95% CI)

0.28 [0.21, 0.34]

3 Scheduled return visits Show forest plot

3

4022

Risk Ratio (M‐H, Fixed, 95% CI)

1.34 [1.20, 1.49]

4 Prescription ordered Show forest plot

3

4212

Risk Ratio (M‐H, Fixed, 95% CI)

1.00 [0.96, 1.05]

5 Hospital referral Show forest plot

3

17152

Risk Ratio (M‐H, Fixed, 95% CI)

0.79 [0.58, 1.07]

6 Attendance at Accident&Emergency Show forest plot

3

17140

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.94, 1.15]

7 Hospital admission Show forest plot

3

15860

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [1.04, 1.31]

Figures and Tables -
Comparison 1. Doctor‐Nurse substitution study results