Nurse practitioner in General Practice:The Expedition

A .T. M. Dierick- van Daele,

J.F.M. Metsemakers, E.W.C.C. Derckx,

C. Spreeuwenberg, H.J.M. Vrijhoef

14 May Copenhagen

Project Nurse Practitioner in General Practice (NPGP)

Background• Increasing and changing demand of care• Need to increasing service capacity• Shortness of physicians

Literature review• NP: high quality of care/ higher patient satisfaction• NP: limited evidence for cost effectiveness

Definition nurse practitioner (NP)

• registered nurses

• additional education and training - i.e. Master in Advanced Nursing Practice

• expanded scope of practice

• working in specific settings

Training program

1. Patient care

diagnosing, prescribing, and treating medical conditions of patients with common complaints

2. Collaboration

coordination of care, professional collaboration

3. Quality of the care

projects and research, evidence based practice, education

Specified set of common complaints

• respiratory and throat complaints• ear and nose complaints• musculoskeletal complaints and skin

injuries• urological complaints• gynaecological complaints • sexual transmitted diseases• geriatric problems

Objective

• To evaluate effects on the process and outcomes of care as provided by GPs or specially trained NPs for patients at first point of contact.

Research method

Randomised controlled trial

Patients: > 16 years, common complaints, initial consultation

Within NPGP-project:

Intervention group: NP consultation

Reference group : GP consultation

Outside NPGP-project:

External reference group: GP consultation (costs only)

• Patients:– common complaints– > 16 years old– initial consultation

Participants

• 15 general practices within the NPGP project: – Twelve NPs– Twelve lectured GPs – 31 GPs

Five external reference practices outside theNPGP project- 17 GPs

• Region: Southern of The Netherlands

Outcome and data collection

Quality of the care:- Patient perceptions Questionnaires (T1, T2)- Effectiveness of the consultation Questionnaires (T0, T2) - Compliance practice guidelines Data-extraction

Costs:- Medical consumption Data-extraction- Follow up consultation Questionnaire (T2)- Time of duration Stopwatch- Presence of illness Questionnaire (T2)

Calculation of costs

Direct costs within health care sector:- Medical consumption- Follow up consultation- Time of duration- Salary costs

Costs outside the health care sector: - Productivity costs

Analyses

• Descriptive statistics

• Two tailed T-test, Chi-squared test, ANOVA

• Bootstrapping

• Sensitivity analysis, subgroup analysis, linear regression and mixed model analysis

Results

Flowchart

Assesed for eligibility (n=2000) .

InclusionExclusion (n=499)

Randomisation (n=1501)

Consultation NPAllocated to intervention (n=817) Received allocated intervention (n=759)

Consult ation GPAllocated to intervention (n=684) Received allocatied intervention (n=650)

Completed questionnaires T0 and TI (n=693) Completed questionnaires T0 and TI (n=613)

Completed questionnairesT2 (n=517) Completed questionnaires T2 (n=492)

Patient characteristics

NP consultation within

NPGP- practices

GP consultations within

NPGP practices

N= 1397 N=1350 P

Sexe Male/ Female (%) 38.2/ 61.8 40.0 /60.0 0.41

Age; years mean (SD) 42.8 (16.5) 46.1 (16.16) 0.001

Consultations

NPGP- practices

Consultations external

reference practices

N= 1397 N=1350 P

Sexe Male/ Female (%) 39.0/ 61.0 39.4/ 60.6 0.83

Age; years mean (SD) 45.1 (16.7) 47.2 (18.2) 0.001

NP consultations versus GP consultations (NPGP practices)

No significant differences in: • Patient perspections (Likert scale 0-10: mean 8.2 both

groups) • Effect of the treatment, compliance practice guidelines,

medical consumption, presence of illness

Significant differences in:• Advice follow up consultation (NP 50%; GP 41%) • Follow up consultation (NP 23.5%; GP 18.5%)• Time of duration (NP 12.2 min; GP 9.2 min)

Costs per consultation within NPGP practices

Costs* NP (I)N=747Mean

GP (R)N=650 Mean

∆I-R P--alue

Based on norm income GP

€31.94 €40.15 -€8.21 0.001

Based on salary GP in employment

€31.94 €38.33 -€6.39 0.007

Based on salary GP employed by other GPs

€31.94 €37.15 -€5.53 0.02

*costs: prescriptions, referrals, diagnostic procedures, follow up consultations, time of duration, salary costs

*kosten gebaseerd op recepten, aanvullend diagnostisch onderzoek, verwijzingen, vervolgconsulten, duur van het consult, salaris-en opleidingskosten**inclusief productiviteitskosten

Costs per consultations: NPGP practices vs reference practices

Costs* NPGP practices

N= 1397 Mean

External reference practicesN=1350 Mean

∆I-R P-value

Based on norm income GP

€35.76 €39.21 -€3.45 0,04

Based on salary GP in employment

€34.92 €37.39 -€2.47 0,13

Based on salary GP employed by other GPs

€34.50 €36.51 -€2,01 0,22

costs: prescriptions, referrals, diagnostic procedures, follow up consultations, time of duration, salary costs

*kosten gebaseerd op recepten, aanvullend diagnostisch onderzoek, verwijzingen, vervolgconsulten, duur van het consult, salaris-en opleidingskosten**inclusief productiviteitskosten

Costs including productivity costs (patients <65 years old)

• NP consultations vs GP consultations: within NPGP practices: – NP consultations € 9.18 cheaper (P<0.001)

• Consultations within NPGP practices vs consultations ext. reference practices:– Consultations within NPGP practices € 2.60

cheaper (P 0.13)

Conclusion

NPs provide equivalent quality of care than GP by a specified set of common complaints

NPs are likely to generate less costs than GPs

NPs contribute to the accessibility and availability of primary care

NP could also lead to GPs having more time for patients with chronic diseases or multi morbidity

Reconsiderations

• Elements of a HTA -study

• Meaning of cost differences

• Exploration of factors influencing costs

• Attention for implementation

Take care

Thank you for your attention…