The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasi-experimental study.
The pressure in out-of-hours primary care is high due to an increasing demand for care and rising health-care costs. During the daytime, substituting general practitioners (GPs) with nurse practitioners (NPs) shows positive results to contribute to these challenges. However, there is a lack of knowledge about the impact during out-of-hours. The current study aims to provide an insight into the impact of substitution on resource use, production and direct health-care costs during out-of-hours.



At a general practitioner cooperative (GPC) in the south-east of the Netherlands, experimental teams with four GPs and one NP were compared with control teams with five GPs. In a secondary analysis, GP care versus NP care was also examined. During a 15-month period all patients visiting the GPC on weekend days were included. The primary outcome was resource use including X-rays, drug prescriptions and referrals to the Emergency Department (ED). We used logistic regression to adjust for potential confounders. Secondary outcomes were production per hour and direct health-care costs using a cost-minimization analysis.



We analysed 6,040 patients in the experimental team (NPs: 987, GPs: 5,053) and 6,052 patients in the control team. There were no significant differences in outcomes between the teams. In the secondary analysis, in the experimental team NP care was associated with fewer drug prescriptions (NPs 37.1 %, GPs 43 %, p < .001) and fewer referrals to the ED (NPs 5.1 %, GPs 11.3 %, p = .001) than GP care. The mean production per hour was 3.0 consultations for GPs and 2.4 consultations for NPs (p < .001). The cost of a consultation with an NP was €3.34 less than a consultation with a GP (p = .02).



These results indicated no overall differences between the teams. Nonetheless, a comparison of type of provider showed that NP care resulted in lower resource use and cost savings than GP care. To find the optimal balance between GPs and NPs in out-of-hours primary care, more research is needed on the impact of increasing the ratio of NPs in a team with GPs on resource use and health-care costs.



ClinicalTrials.gov ID NCT01388374 .
Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands. mieke.vanderbiezen@radboudumc.nl.
Mieke
0000-0001-6682-2558
M
Van Der Biezen
Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
Eddy
E
Adang
Foundation for Development of Quality Care in General Practice, Tilburgseweg-West 100, 5652 NP, Eindhoven, The Netherlands.
Regi
R
Van Der Burgt
Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.|Department of General Practice and Health Services Research, Heidelberg University, INF Marsilius Arkaden, Heidelberg, Germany.
Michel
M
Wensing
Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.|Faculty of Health and Social Studies, HAN University of Applied Sciences, P.O. Box 6960, 6503 GL, Nijmegen, The Netherlands.
Miranda
M
Laurant
D000328:Adult; D039602:After-Hours Care / Q000191:economics / Q000458:organization & administration*; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004526:Efficiency; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D058005:General Practitioners; D017048:Health Care Costs; D006295:Health Resources / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D009722:Nurse Practitioners; D011320:Primary Health Care / Q000191:economics; D011859:Radiography / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D000078329:Workforce
Costs; General practitioner; Nurse practitioner; Out-of-hours care; Resource use; Skill mix; Substitution