title: The impact of physician-nurse task shifting in primary care on the course of disease: a systematic review.
abstract: BACKGROUND
  Physician-nurse task shifting in primary care appeals greatly to health policymakers. It promises to address workforce shortages and demands of high-quality, affordable care in the healthcare systems of many countries. This systematic review was conducted to assess the evidence about physician-nurse task shifting in primary care in relation to the course of disease and nurses' roles.
  
  
  METHODS
  We searched MEDLINE, Embase, The Cochrane Library and CINAHL, up to August 2012, and the reference list of included studies and relevant reviews. All searches were updated in February 2014. We selected and critically appraised published randomized controlled trials (RCTs).
  
  
  RESULTS
  Twelve RCTs comprising 22,617 randomized patients conducted mainly in Europe met the inclusion criteria. Nurse-led care was delivered mainly by nurse practitioners following structured protocols and validated instruments in most studies. Twenty-five unique disease-specific measures of the course of disease were reported in the 12 RCTs. While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported.
  
  
  CONCLUSIONS
  Trained nurses may have the ability to achieve outcome results that are at least similar to physicians' for managing the course of disease, when following structured protocols and validated instruments. The evidence, however, is limited by a small number of studies reporting a broad range of disease-specific outcomes; low reporting standards of interventions, roles and clinicians' characteristics, skills and qualifications; and the quality of studies. More rigorous studies using validated tools could clarify these findings.
authors.affiliation: Institute of Primary Care, University of Zurich, University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland. Nahara.Martinez@usz.ch.
authors.forename: Nahara A
authors.initials: NA
authors.lastname: Martínez-González
authors.affiliation: Institute of Primary Care, University of Zurich, University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland. Ryan.Tandjung@usz.ch.
authors.forename: Ryan
authors.initials: R
authors.lastname: Tandjung
authors.affiliation: Institute of Primary Care, University of Zurich, University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland. Sima.Djalali@usz.ch.
authors.forename: Sima
authors.initials: S
authors.lastname: Djalali
authors.affiliation: Institute of Primary Care, University of Zurich, University Hospital of Zurich, Pestalozzistrasse 24, CH-8091, Zurich, Switzerland. Thomas.Rosemann@usz.ch.
authors.forename: Thomas
authors.initials: T
authors.lastname: Rosemann
mesh_terms: D003695:Delivery of Health Care; D006801:Humans; D009722:Nurse Practitioners; D010820:Physicians; D011320:Primary Health Care; D024382:Professional Role