The St John's randomized trial of the family practice nurse: health outcomes of patients. Health maintenance service: ambulatory patient care in the general medical clinic. A comparison of resource utilization in nurse practitioners and physicians. Randomised controlled trial comparing cost effectiveness of general practitioners and nurse practitioners in primary care. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care. Cluster randomised controlled trial to compare three methods of promoting secondary prevention of coronary heart disease in primary care. Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. Safety and effectiveness of nurse telephone consultation in out of hours primary care: randomised controlled trial. The South Wiltshire Out of Hours Project (SWOOP) Group. A nurse practitioner as the first point of contact for urgent medical problems in a general practice setting. The effectiveness of nurse clinicians' service delivery. Reducing alcohol consumption. Comparing three brief methods in family practice.
From June 1975, to May 1976, in a large family practice in St. John's, Newfoundland, a randomized controlled trial was conducted to assess the effectiveness of a family practice nurse. Effectiveness was assessed using standardized health outcome measures of physical, emotional, and social function which could be applied easily and objectively by non-clinicians to the two groups of patients under study: patients receiving conventional care and patients receiving care from the family practice nurse. After establishing the comparability of these two groups of patients at the beginning of the study, these measurements showed similar levels of physical, emotional, and social function in the two groups after 1 year of receiving either family practice nurse or conventional care. These results agree with previous controlled trials of family practice nurses which have indicated that family practice nurses are effective and safe. nan Nurse practitioners increasingly provide primary care in a variety of settings. Little is known about how resource utilization for patients assigned to nurse practitioners compares with that for patients assigned to physicians.
                To compare health care resource utilization for adult patients assigned to a nurse practitioner with that for patients assigned to a resident or attending physician.
                Prospective, quasi-randomized study.
                Primary care clinic at a Veterans Affairs medical center.
                450 new primary care patients: 150 were assigned to a nurse practitioner, 150 to a resident physician, and 150 to an attending physician.
                We collected data on laboratory and radiologic testing, specialty care, primary care, emergency or walk-in visits, and hospitalizations over a 1-year period. We also collected information on baseline chronic illnesses, blood pressure, and weight.
                Resource utilization for patients assigned to a nurse practitioner was higher than that for patients assigned to a resident in 14 of 17 utilization measures (3 were statistically significant) and higher in 10 of 17 measures when compared with patients assigned to an attending physician (3 were statistically significant). None of the utilization measures for patients in the nurse practitioner group was significantly lower than those for either physician group.
                In a primary care setting, nurse practitioners may utilize more health care resources than physicians. To compare the cost effectiveness of general practitioners and nurse practitioners as first point of contact in primary care.
                Multicentre randomised controlled trial of patients requesting an appointment the same day.
                20 general practices in England and Wales.
                1716 patients were eligible for randomisation, of whom 1316 agreed to randomisation and 1303 subsequently attended the clinic. Data were available for analysis on 1292 patients (651 general practitioner consultations and 641 nurse practitioner consultations).
                Consultation process (length of consultation, examinations, prescriptions, referrals), patient satisfaction, health status, return clinic visits over two weeks, and costs.
                Nurse practitioner consultations were significantly longer than those of the general practitioners (11.57 v 7.28 min; adjusted difference 4. 20, 95% confidence interval 2.98 to 5.41), and nurses carried out more tests (8.7% v 5.6% of patients; odds ratio 1.66, 95% confidence interval 1.04 to 2.66) and asked patients to return more often (37. 2% v 24.8%; 1.93, 1.36 to 2.73). There was no significant difference in patterns of prescribing or health status outcome for the two groups. Patients were more satisfied with nurse practitioner consultations (mean score 4.40 v 4.24 for general practitioners; adjusted difference 0.18, 0.092 to 0.257). This difference remained after consultation length was controlled for. There was no significant difference in health service costs (nurse practitioner 18.ll pound sterling v general practitioner 20.70 pound sterling adjusted difference 2.33 pound sterling - 1.62 pound sterling to 6.28 pound sterling).
                The clinical care an health service costs of nurse practitioners and general practitioners were similar. If nurse practitioners were able to maintain the benefits while reducing their return consultation rate or shortening consultation times, they could be more cost effective than general practitioners. To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.
                Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).
                10 general practices in south Wales and south west England.
                1368 patients requesting same day consultations.
                Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.
                Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.
                This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations. To assess the effectiveness of three different methods of promoting secondary prevention of coronary heart disease in primary care.
                Pragmatic, unblinded, cluster randomised controlled trial.
                Warwickshire.
                21 general practices received intervention; outcome measured in 1906 patients aged 55-75 years with established coronary heart disease.
                Audit of notes with summary feedback to primary health care team (audit group); assistance with setting up a disease register and systematic recall of patients to general practitioner (GP recall group); assistance with setting up a disease register and systematic recall of patients to a nurse led clinic (nurse recall group).
                At 18 months' follow up: adequate assessment (defined) of 3 risk factors (blood pressure, cholesterol, and smoking status); prescribing of hypotensive agents, lipid lowering drugs, and antiplatelet drugs; blood pressure, serum cholesterol level, and plasma cotinine levels.
                Adequate assessment of all 3 risk factors was much more common in the nurse and GP recall groups (85%, 76%) than the audit group (52%). The advantage in the nurse recall compared with the audit group was 33% (95% confidence interval 19% to 46%); in the GP recall group compared with the audit group 23% (10% to 36%), and in the nurse recall group compared with the GP recall group 9% (-3% to 22%). However, these differences in assessment were not reflected in clinical outcomes. Mean blood pressure (148/80, 147/81, 148/81 mm Hg), total cholesterol (5.4, 5.5, 5.5 mmol/l), and cotinine levels (% probable smokers 17%, 16%, 19%) varied little between the nurse recall, GP recall, and audit groups respectively, as did prescribing of hypotensive and lipid lowering agents. Prescribing of antiplatelet drugs was higher in the nurse recall group (85%) than the GP recall or audit groups (80%, 74%). After adjustment for baseline levels, the advantage in the nurse recall group compared with the audit group was 10% (3% to 17%), in the nurse recall group compared with the GP recall group 8% (1% to 15%) and in the GP recall group compared with the audit group 2% (-6% to 10%).
                Setting up a register and recall system improved patient assessment at 18 months' follow up but was not consistently better than audit alone in improving treatment or risk factor levels. Understanding the reasons for this is the key next step in improving the quality of care of patients with coronary heart disease. To assess the acceptability and safety of a minor illness service led by practice nurses in general practice.
                Multicentre, randomised controlled trial.
                5 general practices in south east London and Kent representing semi-rural, suburban, and urban settings.
                1815 patients requesting and offered same day appointments by receptionists.
                Patients were assigned to treatment by either a specially trained nurse or a general practitioner. Patients seen by a nurse were referred to a general practitioner when appropriate.
                The general satisfaction of the patients as measured by the consultation satisfaction questionnaire. Other outcome measures included the length of the consultation, number of prescriptions written, rates of referral to general practitioners, patient's reported health status, patient's anticipated behaviour in seeking health care in future, and number of patients who returned to the surgery, visits to accident and emergency, and out of hours calls to doctors.
                Patients were very satisfied with both nurses and doctors, but they were significantly more satisfied with their consultations with nurses (mean (SD) score of satisfaction 78.6 (16. 0) of 100 points for nurses v 76.4 (17.8) for doctors; 95% confidence interval for difference between means -4.07 to -0.38). Consultations with nurses took about 10 minutes compared with about 8 minutes for consultations with doctors. Nurses and doctors wrote prescriptions for a similar proportion of patients (nurses 481/736 (65.4%) v doctors 518/816 (63.5%)). 577/790 (73%) patients seen by nurses were managed without any input from doctors.
                Practice nurses seem to offer an effective service for patients with minor illnesses who request same day appointments. Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers.
                To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit.
                Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment.
                Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center.
                Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510).
                Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider.
                No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).
                In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable. To determine the safety and effectiveness of nurse telephone consultation in out of hours primary care by investigating adverse events and the management of calls.
                Block randomised controlled trial over a year of 156 matched pairs of days and weekends in 26 blocks. One of each matched pair was randomised to receive the intervention.
                One 55 member general practice cooperative serving 97 000 registered patients in Wiltshire.
                All patients contacting the out of hours service or about whom contact was made during specified times over the trial year.
                A nurse telephone consultation service integrated within a general practice cooperative. The out of hours period was 615 pm to 1115 pm from Monday to Friday, 1100 am to 1115 pm on Saturday, and 800 am to 1115 pm on Sunday. Experienced and specially trained nurses received, assessed, and managed calls from patients or their carers. Management options included telephone advice; referral to the general practitioner on duty (for telephone advice, an appointment at a primary care centre, or a home visit); referral to the emergency service or advice to attend accident and emergency. Calls were managed with the help of decision support software.
                Deaths within seven days of a contact with the out of hours service; emergency hospital admissions within 24 hours and within three days of contact; attendance at accident and emergency within three days of a contact; number and management of calls in each arm of the trial.
                14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments. Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective. The aim of this study was to examine the suitability of nurse practitioners for assessing and managing urgent clinical problems presenting in primary care.
                Patients registered at a suburban group practice presenting with acute medical problems were offered the choice of seeing a GP or a nurse practitioner. The outcomes of 1000 consultations were analysed by recording the repeat consultation rate, the prescription-issue rate and the rate of referral to secondary care, as well as investigating patient satisfaction and the number of dysfunctional consultations and misdiagnoses.
                Patients reported a high level of satisfaction with nurse practitioner consultations, and there were no recorded instances of medical sequelae due to poor diagnosis or mismanagement. Nurse and doctors saw patients with similar age and sex distributions, but the results suggested that there was a significant difference between the morbidity of problems seen. There was also a difference in the outcomes of repeat consultation rate and the prescription issue rate, although there was little difference in the rate of referral for secondary care.
                As patients expressed a high level of satisfaction with the nurse practitioner, this suggests that given the choice, patients in primary care can safely and effectively 'self triage' themselves between GPs and nurse practitioners. nan To compare the effects of three brief methods of reducing alcohol consumption among family practice patients.
                Patients randomly assigned to one of three interventions were assessed initially and at 3-, 6-, and 12-month follow-up appointments.
                Family practice clinic composed of 12 primary care physicians seeing approximately 6000 adults monthly in a small urban community, population 40,000.
                Through a screening questionnaire, 134 men and 131 women were identified as hazardous drinkers (five or more drinks at least once monthly) during an 11-month screening of 1420 patients. Of 265 patients approached, 180 agreed to participate and 159 (83 men and 76 women) actually participated in the study.
                Three interventions were studied: brief physician advice (5 minutes), two 30-minute sessions with a physician using cognitive behavioural strategies or two 30-minute sessions with a nurse practitioner using identical strategies.
                Quantity and frequency (QF) of drinking were used to assess reduction in hazardous drinking and problems related to drinking over 12 months of follow up.
                No statistical difference between groups was found. The QF of monthly drinking was reduced overall by 66% (among men) and 74% (among women) for those reporting at least one hazardous drinking day weekly at assessment (N = 96). Men reported drinking significantly more than women.
                These results indicated that offering brief, specific advice can motivate patients to reduce their alcohol intake. There was no difference in effect between brief advice from their own physician or brief intervention by a physician or a nurse.
The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. 
While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.