for the main comparison.
| Nurse‐led primary care compared with doctor‐led primary care for patient outcomes, process of care and utilisation | ||||||
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Patient or population: all presenting patients in primary care Settings: UK (n = 6), Netherlands (n = 3), USA (n = 3), Canada (n = 3), Sweden (n = 1), Spain (n = 1), South Africa (n = 1) Intervention: substitution of doctors with nurses for primary care Comparison: routine doctor‐led primary care | ||||||
| Outcomes | Impact | Number of participants (studies) | Certainty of the evidence (GRADE) | |||
| Illustrative comparative risks* (95% CI) | Effect estimate (95% CI) | Results in words | ||||
| Assumed risk | Corresponding risk | |||||
| Doctor‐led primary care | Nurse‐led primary care | |||||
|
Mortality follow‐up: 0.5 to 48 months Mean = 21 (SD 19) months |
6.29 per 1000 |
4.84 per 1000 (4 to 6) |
RR 0.77 (0.57 to 1.03) |
Nurse‐led primary care may lead to slightly fewer deaths among certain groups of patients, compared to doctor‐led care. However, the results vary and it is possible that nurse‐led primary care makes little or no difference to the number of deaths. | 36,529 (8)1 | ⊕⊕⊝⊝ a Low |
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Patient health status follow‐up: 0.2 to 47 months Mean = 14 (SD 12) months |
Compared to doctor‐led care, nurse‐led primary care probably slightly improves blood pressure control; probably leads to similar outcomes for diabetes indicators and measures of disease activity and pain in people with rheumatological disorders; may lead to similar outcomes for physical functioning; and leads to similar outcomes for cholesterol | Clinical outcomes (3) Self‐reported measurements (13)2 |
⊕⊕⊕⊝ b Moderate | |||
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Satisfaction and preferences follow‐up: 0.5 to 25 months Mean = 12 (SD 10) months |
Patient satisfaction is probably slightly higher in nurse‐led primary care compared to doctor‐led primary care. | 16,993 (7)3 | ⊕⊕⊕⊝ c Moderate | |||
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Quality of life follow‐up: 6 to 25 months Mean = 15 (SD 9) months |
Quality of life may be slightly higher in nurse‐led primary care compared to doctor‐led primary care. | 16,002 (6)4 | ⊕⊕⊝⊝d Low | |||
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Process of care follow‐up: 0.5 to 48 months Mean = 17 (SD 15) months |
We are uncertain of the effects of nurse‐led care on process of care because the certainty of this evidence was assessed as very low. | (10)5 | ⊕⊝⊝⊝e Very low |
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Utilisation (consultations, prescriptions, tests, investigations, and services) follow‐up: 0.2 to 48 months Mean = 14 (SD 13) months |
Consultations: Compared to doctor‐led primary care, consultation length is probably longer in nurse‐led primary care; there may be little or no difference in scheduled return visits; and the number of return visits attended is slightly higher for nurses. Prescriptions, tests and investigations: There is little or no difference between nurses and doctors in the number of prescriptions and may be little or no difference in the number of tests and investigations ordered. Use of other services: There may be little or no difference between nurses and doctors in the likelihood of hospital referrals and hospital admissions; little or no difference in attendance at accident and emergency units. |
(16)6 | ⊕⊕⊕⊝ f Moderate | |||
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Costs follow‐up: 0.2 to 48 months Mean = 14 (SD 14) months |
We are uncertain of the effects of nurse‐led care on the cost of care because the certainty of this evidence was assessed as very low. | (9)7 | ⊕⊝⊝⊝ g Very low | |||
| *The basis for the assumed risk is the mean control group risk across studies for pooled results. The corresponding risk is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; SD: standard deviation. aDowngraded by 1 for imprecision owing to a wide confidence interval that includes no effect and downgraded by 1 for clinical heterogeneity as the trials contributing to this estimate are quite varied (some focus on people with specific health issues and others on more generalist primary care attenders). bDowngraded by 1. Outcomes were downgraded by 1 for inconsistency, imprecision, indirectness or high risk of bias. The certainty of the evidence is moderate for all outcomes listed, apart for physical functioning for which the certainty of evidence was low and cholesterol for which the certainty of evidence was high. cDowngraded by 1 for inconsistency. dDowngraded by 1 for imprecision, due to a wide confidence interval that touches on the null, and 1 for inconsistency eNon‐comparable results and therefore downgraded to very low. fDowngraded by 1. Outcomes were downgraded by 1 for inconsistency, imprecision or high risk of bias. gNon‐comparable results (the types of costs assessed varied widely and a range of different approaches were used to value resources and calculate costs) and therefore downgraded to very low. 1Campbell 2014; Hemani 1999; Lattimer 1998; Ndosi 2013; Sanne 2010; Shum 2000; Spitzer 1973; Voogdt‐Pruis 2010. 2Campbell 2014; Chambers 1978; Chan 2009; Dierick‐van Daele 2009; Houweling 2011; Iglesias 2013; Larsson 2014; Lattimer 1998; Lewis 1967; Moher 2001; Mundinger 2000; Sanne 2010; Shum 2000; Spitzer 1973; Venning 2000; Voogdt‐Pruis 2010. 3Campbell 2014; Dierick‐van Daele 2009; Iglesias 2013; Larsson 2014; Mundinger 2000; Shum 2000; Venning 2000. 4Campbell 2014; Chan 2009; Dierick‐van Daele 2009; Houweling 2011; Mundinger 2000; Ndosi 2013. 5Campbell 2014; Dierick‐van Daele 2009; Houweling 2011; Moher 2001; Mundinger 2000; Ndosi 2013; Shum 2000; Spitzer 1973; Venning 2000; Voogdt‐Pruis 2010. 6Campbell 2014; Chan 2009; Dierick‐van Daele 2009; Hemani 1999; Houweling 2011; Iglesias 2013; Larsson 2014; Lattimer 1998; Lewis 1967; Moher 2001; Mundinger 2000; Ndosi 2013; Shum 2000; Spitzer 1973; Venning 2000; Voogdt‐Pruis 2010. 7Campbell 2014; Chambers 1978; Chan 2009; Dierick‐van Daele 2009; Lattimer 1998; Lewis 1967; Ndosi 2013; Spitzer 1973; Venning 2000. *there may be additional data in the Campbell 2014 articles that have not been extracted | ||||||
| GRADE Working Group grades of evidence.
High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different† is moderate.
Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different† is high.
Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high †Substantially different = a large enough difference that it might affect a decision. | ||||||