An economic evaluation was conducted alongside an RCT between May and October 2006, wherein a convenience sample of 12 nurse practitioners and 50 GPs working in 15 general practices participated and are referred to as ‘study practices’. Patients of study practices were also compared with those in an external reference group, who received treatment from one of 17 GPs working in five general practices without the involvement of a nurse practitioner.
How this fits in
Studies evaluating substitution of care have revealed only limited evidence on cost-effectiveness. This study indicates that from practice and societal perspectives, nurse practitioner consultations cost significantly less than GP consultations at study practices. Direct costs of consultations at study practices were significantly less than those of consultations in external reference practices, while no significant differences in costs from a societal perspective were found between these two types of practices. When involving nurse practitioners in the care of patients with common conditions, substantial economic savings could be used for redesigning primary care.
Comparisons were made between study practices and external reference practices, and between nurse practitioner consultations and GP consultations at study practices. The general practices range in size from solo practices (one GP) to health centres (five GPs). General practices in the external reference group range from duo practices (two GPs) to group practices (four GPs). Details about the design are described in Appendix 1.10 A description of the nurse practitioner role is further described in Box 1.
Box 1. Nurse practitioner job description.
General definition of a nurse practitioner
‘A registered nurse with additional education and training, who works within an expanded scope of practice that includes diagnosing, prescribing, and treating medical conditions within specific settings.’28
Nurse practitioners in the Dutch project
Target population: patients with common conditions
A specified set of common conditions was compiled for which patients seek medical attention. These common conditions will often lead to minor health problems. Patients had respiratory and throat symptoms, ear and nose symptoms, musculoskeletal symptoms and injuries, skin injuries, urinary symptoms, gynaecological symptoms, or problems related to older age.
Tasks performed
Based on triage by the practice assistant, patients with common conditions are referred to the nurse practitioner. The nurse practitioner works independently during consultations and home visits. The activities undertaken, according to practice guidelines derived by the Dutch College of General Practitioners,12 are symptom assessment, physical examinations where appropriate, diagnosing and making decisions for further treatment, prescriptions, referrals to primary or secondary services, and clinical investigations. The nurse practitioner has no full authority to prescribe medications; the GP is always available for consultation and to assign prescriptions. The nurse practitioner has access to the electronic medical records and reported consultations.
Training
Before starting a nurse practitioner training programme, the nurse practitioners has an average of 12 years' work experience (standard deviation = 7.6 years). A specific 2-year practice-oriented training programme has been developed, which consists of the Higher Professional Education Master's Degree Advanced Nursing Practice, and also includes a medical course on managing common conditions. During the training programme, the nurse practitioner is supervised by a GP.
