title: Substitution of physicians by nurses in primary care: a systematic review and meta-analysis.
abstract: 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.
authors.forename: Nahara Anani
authors.initials: NA
authors.lastname: Martínez-González
authors.forename: Sima
authors.initials: S
authors.lastname: Djalali
authors.forename: Ryan
authors.initials: R
authors.lastname: Tandjung
authors.forename: Flore
authors.initials: F
authors.lastname: Huber-Geismann
authors.forename: Stefan
authors.initials: S
authors.lastname: Markun
authors.forename: Michel
authors.initials: M
authors.lastname: Wensing
authors.affiliation: Institute of Primary Care, University Hospital Zurich, Pestalozzistrasse 24, 8091 Zurich, Switzerland. Thomas.Rosemann@usz.ch.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rosemann
mesh_terms: D002983:Clinical Competence; D003695:Delivery of Health Care / Q000191:economics / Q000592:standards; D006760:Hospitalization; D006801:Humans; D008505:Medical Staff, Hospital; D009741:Nursing Staff, Hospital; D017060:Patient Satisfaction; D032024:Personnel Delegation; D010561:Personnel Staffing and Scheduling; D011320:Primary Health Care / Q000191:economics; D011788:Quality of Life; D016032:Randomized Controlled Trials as Topic; D000078329:Workforce