title: Effects of substituting nurse practitioners, physician assistants or nurses for physicians concerning healthcare for the ageing population: a systematic literature review.
abstract: OBJECTIVE
  To evaluate the effects of substituting nurse practitioners, physician assistants or nurses for physicians in long-term care facilities and primary healthcare for the ageing population (primary aim) and to describe what influences the implementation (secondary aim).
  
  
  BACKGROUND
  Healthcare for the ageing population is undergoing major changes and physicians face heavy workloads. A solution to guarantee quality and contain costs might be to substitute nurse practitioners, physician assistants or nurses for physicians.
  
  
  METHODS
  A systematic literature review.
  
  
  METHODS
  PubMed, EMBASE, CINAHL, PsycINFO, CENTRAL, Web of Science; searched January 1995-August 2015.
  
  
  METHODS
  Study selection, data extraction and quality appraisal were conducted independently by two reviewers. Outcomes collected: patient outcomes, care provider outcomes, process of care outcomes, resource use outcomes, costs and descriptions of the implementation. Data synthesis consisted of a narrative summary.
  
  
  RESULTS
  Two studies used a randomized design and eight studies used other comparative designs. The evidence of the two randomized controlled trials showed no effect on approximately half of the outcomes and a positive effect on the other half of the outcomes. Results of eight other comparative study designs point towards the same direction. The implementation was influenced by factors on a social, organizational and individual level.
  
  
  CONCLUSIONS
  Physician substitution in healthcare for the ageing population may achieve at least as good patient outcomes and process of care outcomes compared with care provided by physicians. Evidence about resource use and costs is too limited to draw conclusions.
authors.affiliation: Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Marleen H
authors.identifier: http://orcid.org/0000-0001-8346-1379
authors.initials: MH
authors.lastname: Lovink
authors.affiliation: Radboud university medical center, Nijmegen, The Netherlands.
authors.forename: Anke
authors.initials: A
authors.lastname: Persoon
authors.affiliation: Radboud university medical center, Nijmegen, The Netherlands.|Joachim en Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands.
authors.forename: Raymond T C M
authors.initials: RTCM
authors.lastname: Koopmans
authors.affiliation: HAN University of Applied Sciences, Nijmegen, The Netherlands.
authors.forename: Anneke J A H
authors.initials: AJAH
authors.lastname: Van Vught
authors.affiliation: Radboud university medical center, Nijmegen, The Netherlands.|University of Southampton, UK.
authors.forename: Lisette
authors.initials: L
authors.lastname: Schoonhoven
authors.affiliation: Radboud university medical center, Nijmegen, The Netherlands.|HAN University of Applied Sciences, Nijmegen, The Netherlands.
authors.forename: Miranda G H
authors.initials: MGH
authors.lastname: Laurant
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005851:Geriatric Nursing / Q000458:organization & administration*; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration*; D008297:Male; D008875:Middle Aged; D009722:Nurse Practitioners / Q000458:organization & administration*; D010823:Physician Assistants / Q000458:organization & administration*; D011320:Primary Health Care / Q000458:organization & administration*; D011787:Quality of Health Care / Q000458:organization & administration*
keywords: effect of intervention; long-term care facilities; nurse practitioner; physician assistant; physician substitution; primary healthcare for the ageing population; skill mix change; systematic review