The Effect of Substitution of Out-of-hours Care From General Practitioners to Nurse Practitioners

The (Cost-)Effectiveness of Substitution in Out-of-hours Primary Care; Towards an Optimal Balance Between General Practitioners and Nurse Practitioners.

The aim of this study is to explore the effects of substitution in out-of-hours primary care. In consecutive stages an extra General Practitioner (GP) is substituted by a Nurse Practitioner (NP) aiming at replacing 3 out of 4 GPs by NPs. Effects are measured in terms of feasibility and cost-efficiency.

Study Overview

• Status: Completed
• Conditions: Out-of-hours Care Services; Primary Healthcare
• Intervention / Treatment: Other: care provided by Nurse Practitioners

Detailed Description

Out-of-hours care in the Netherlands is under pressure. Workload for GPs during out-of-hours care is high and there are concerns about maintaining the quality of care. Since 80% of the complaints shown in out-of-hours care is neither complex nor urgent not all patients necessarily have to be seen by a GP.

A previous study (ID: 80-82800-98-227) indicated that shifting care from GPs to NPs is possible in terms of safety and quality of care and resulted in cost savings due to less treatment. In that study 4 GPs and 1 NP provided care in the experimental condition and 5 GPs provided care in the control condition. Based on the results it is hypothesized that NPs are competent to diagnose and treat at least 75% of the complaints shown in out-of-hours primary care. Substituting more GPs by NPs in out-of-hours care will probably lead to more cost savings.

In the current study care delivered and direct healthcare costs are compared between different team compositions. In the experimental condition care is provided by a team of NPs and GPs. The intervention starts with a team of 4 professionals in both the experimental (3 GPs and 1 NP) and the control (4 GPs) condition; in consecutive stages an extra GP is substituted by an NP aiming at replacing 3 out of 4 GPs with by NPs.

Control: 4 GPs

Stage 1: experimental: 3 GPs & 1 NP

Stage 2: experimental: 2 GPs & 2 NPs

Stage 3: experimental: 1 GP & 3 NPs

Both feasibility and cost-efficiency will lead to recommendations on the optimal balance in a team between GPs and NPs.

• Study Type: Interventional
• Enrollment (Actual): 9647
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Netherlands
  • Noord-Brabant
    • Eindhoven, Noord-Brabant, Netherlands, 5623 EJ
      • Centrale Huisartsen Post (CHP)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Patients (with urgencylevel U2, U3, U4, or U5) requesting an appointment at the primary out-of-hours service during the weekend between 10am and 6pm.

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Non-Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
No Intervention: General Practitioners Care; Usual medical care provided by General Practitioners at the Primary Out-of-Hours Service.
Experimental: Nurse Practitioners Care; Medical care provided by both Nurse Practitioners and General Practitioners at the Primary Out-of-Hours Service.	Other: care provided by Nurse Practitioners; Patients will receive care at the Primary Out of Hours Emergency Service by a Nurse Practitioner instead of a General Practitioner (substitution of care from physicians to nurses).

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The number of consultations per healthcare provider.	To measure substitution of healthcare, the number of consultations per in the experimental and control group, and per healthcare provider will be measured. These data will be derived from electronic medical records.	18 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number and characteristics of patients and experienced workload.	Objective workload will be measured by the numbers of consults, taking into account the urgency levels of the complaints and type of complaint. These data will be derived from electronic medical records. Subjective workload will be measured by interviews and focusgroups.	18 months
Direct healthcare costs related to care provide by NPs and GPs will be calculated.	Costs related to care provided in the experimental and control group, and per discipline will be calculated, including number of consultations, resource use, referrals, and prescriptions.	18 months
Patient characteristics (composite)	Patient characteristics of patients seen in the experimental and control group and per healthcare provider include age, gender, urgency and type of complaint. These data will be derived from electronic medical records.	18 months
The number of prescriptions; number of test & investigations ordered and referral to the emergency department.	The performance of the two conditions as well as the healthcare providers will be measures by number of prescriptions; number of test & investigations ordered and referral to the emergency department. These data will be derived from electronic medical records.	18 months

Collaborators and Investigators

• Sponsor: Radboud University Medical Center
• Collaborators: Stichting Kwaliteit en Ontwikkeling Huisartsenzorg; Centrale Huisartsenpost Eindhoven (CHP)

Publications and helpful links

General Publications

• van der Biezen M, Wensing M, van der Burgt R, Laurant M. Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study. BMJ Open. 2017 May 30;7(5):e015509. doi: 10.1136/bmjopen-2016-015509.

Study record dates

Study Major Dates

• Study Start: May 1, 2014
• Primary Completion (Actual): January 1, 2016
• Study Completion (Actual): January 1, 2016

Study Registration Dates

• First Submitted: March 31, 2015
• First Submitted That Met QC Criteria: April 2, 2015
• First Posted (Estimate): April 3, 2015

Study Record Updates

• Last Update Posted (Estimate): April 7, 2016
• Last Update Submitted That Met QC Criteria: April 6, 2016
• Last Verified: April 1, 2016

More Information

Terms related to this study

• Keywords: Emergency Medical Services; Primary healthcare; Nurse practitioners; Substitution of care
• Other Study ID Numbers: VS_in_spoedzorg