Skip to main navigation menu Skip to main content Skip to site footer

Review article: Biomedical intelligence

Vol. 145 No. 0506 (2015)

The effect of physician-nurse substitution in primary care in chronic diseases: a systematic review

  • Nahara Anani Martínez-González
  • Thomas Rosemann
  • Ryan Tandjung
  • Sima Djalali
Cite this as:
Swiss Med Wkly. 2015;145:w14031


BACKGROUND: Chronically ill and ageing populations demand increasing human resources who can provide on-going and frequent follow-up care. We performed a systematic review to assess the effect of physician-nurse substitution on process care outcomes.

METHODS: We searched OVID Medline, Embase, CINAHL and The Cochrane Library for all available dates up to August 2012 and updated in February 2014. We selected and critically appraised published randomised controlled trials (RCT) and followed the PRISMA guidelines for the reporting of systematic reviews.

RESULTS: A total of 14 RCTs comprising 10,743 participants met the inclusion criteria. Studies were generally small and suffered from attrition of ≥20% and selection biases. There were 53 process measurements investigated in the 14 RCTs, many of which were unique to specific conditions. Accounts of nurses’ roles, responsibilities, tasks, qualifications and training content/components were not described in sufficient detail. Most study estimates showed no significant differences between nurse-led care and physician-led care while less than a half (~40%) favoured nurse-led care.

CONCLUSIONS: Despite the methodological limitations and the varying nurses’ roles and competencies across studies, specially trained nurses can provide care that is at least as equivalent to care provided by physicians for the management of chronic diseases, in terms of process of care. Future, larger studies with better quality methods are needed and should report and assess whether the differences in effects vary due to diversity in roles, qualifications, training competencies and characteristics of clinicians delivering substitution of care.


  1. World Health Organization. The world health report: working together for health. Geneva, Switzerland: World Health Organization, 2006.
  2. World Health Organization. Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. Geneva, Switzerland: World Health Organization, 2008.
  3. World Health Organization. World Health Statistics 2012: Indicator compendium. Geneva, Switzerland: World Health Organization, 2012.
  4. World Health Organization. Global Health Workforce Alliance: Reviewing Progress, Renewing Commitment. Progress Report on the Kampala Declaration and Agenda for Global Action. Geneva, Switzerland: World Health Organization, 2011.
  5. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med. 2006;81:782–7.
  6. Buchan J, O’May F. Determining skill mix in the health workforce: guidelines for managers and health professionals. Geneva, Switzerland: World Health Organization, 2000.
  7. De Geest S, Moons P, Callens B, Gut C, Lindpaintner L, Spirig R. Introducing Advanced Practice Nurses / Nurse Practitioners in health care systems: a framework for reflection and analysis. Swiss Med Wkly. 2008;138:621–8.
  8. Chopra M, Munro S, Lavis JN, Vist G, Bennett S. Effects of policy options for human resources for health: an analysis of systematic reviews. Lancet. 2008;371:668–74.
  9. Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002;324:819–23.
  10. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev 2005:CD001271
  11. Martinez-Gonzalez NA, Tandjung R, Djalali S, Huber-Geismann F, Markun S, Rosemann T. Effects of physician-nurse substitution on clinical parameters: a systematic review and meta-analysis. PLoS One 2014;9:e89181.
  12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009;6:e1000100.
  13. Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA. 1999;282(11):1054–60.
  14. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials. BMJ. 2011;343:d5928.
  15. Higgins JPT GS, (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0: The Cochrane Collaboration, 2011. Available from
  16. Fergusson D, Aaron SD, Guyatt G, Hebert P. Post-randomisation exclusions: the intention to treat principle and excluding patients from analysis. BMJ. 2002;325:652–4.
  17. Review Manager (Revman) [Computer program]. Version 5.2.4. for Windows. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012 [].
  18. Andryukhin A, Frolova E, Vaes B, Degryse J. The impact of a nurse-led care programme on events and physical and psychosocial parameters in patients with heart failure with preserved ejection fraction: a randomized clinical trial in primary care in Russia. Eur J Gen Pract. 2010;16(4):205–14.
  19. Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: a randomized trial of nurse led clinics in primary care. Heart. 1998;80(5):447–52.
  20. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM. Secondary prevention in coronary heart disease: baseline survey of provision in general practice. BMJ. 1998;316(7142):1430–4.
  21. Campbell NC, Thain J, Deans HG, Ritchie LD, Rawles JM, Squair JL. Secondary prevention clinics for coronary heart disease: randomized trial of effect on health. BMJ. 1998;316(7142):1434–7.
  22. Chan D, Harris S, Roderick P, Brown D, Patel P. A randomized controlled trial of structured nurse-led outpatient clinic follow-up for dyspeptic patients after direct access gastroscopy. BMC Gastroenterol. 2009;9:12.
  23. Delaney EK, Murchie P, Lee AJ, Ritchie LD, Campbell NC. Secondary prevention clinics for coronary heart disease: a 10–year follow-up of a randomized controlled trial in primary care. Heart. 2008;94(11):1419–23.
  24. Denver EA, Barnard M, Woolfson RG, Earle KA. Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. Diabetes Care. 2003;26(8):2256–60.
  25. Dierick-Van Daele ATM, Metsemakers JFM, Derckx EWCC, Spreeuwenberg C, Vrijhoef HJM. Nurse practitioners substituting for general practitioners: Randomized controlled trial. J Adv Nurs. 2009;65(2):391–401.
  26. Flynn BC. The effectiveness of nurse clinicians' service delivery. Am J Public Health. 1974;64(6):604–11.
  27. Hesselink AE, Penninx BW, van der Windt DA, van Duin BJ, de Vries P, Twisk JW, et al. Effectiveness of an education programme by a general practice assistant for asthma and COPD patients: results from a randomized controlled trial. Patient Educ Couns. 2004;55(1):121–8.
  28. Houweling ST, Kleefstra N, van Hateren KJJ, Groenier KH, Meyboom-de Jong B, Bilo HJG. Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomized controlled trial. J Clin Nurs. 2011;20(9/10):1264–72.
  29. Jarman B, Hurwitz B, Cook A, Bajekal M, Lee A. Effects of community based nurses specialising in Parkinson’s disease on health outcome and costs: randomized controlled trial. BMJ. 2002;324(7345):1072–5.
  30. Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, et al. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting “same day” consultations in primary care. BMJ. 2000;320(7241):1043–8.
  31. Kuethe M, Vaessen-Verberne A, Mulder P, Bindels P, van Aalderen W. Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: Randomised controlled trial with two-year follow-up. Primary Care Respiratory Journal. 2011;20(1):84–91.
  32. Lewis CE, Resnik BA. Nurse clinics and progressive ambulatory patient care. N Engl J Med. 1967;277(23):1236–41.
  33. Murchie P, Campbell NC, Ritchie LD, Deans HG, Thain J. Effects of secondary prevention clinics on health status in patients with coronary heart disease: 4 year follow-up of a randomized trial in primary care. Fam Pract. 2004;21(5):567–74.
  34. Murchie P, Campbell NC, Ritchie LD, Simpson JA, Thain J. Secondary prevention clinics for coronary heart disease: four year follow up of a randomized controlled trial in primary care. BMJ. 2003;326(7380):84.
  35. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomized controlled trial. BMJ. 2005;330(7493):707.
  36. Shum C, Humphreys A, Wheeler D, Cochrane MA, Skoda S, Clement S. Nurse management of patients with minor illnesses in general practice: multicentre, randomized controlled trial. BMJ. 2000;320(7241):1038–43.
  37. Voogdt-Pruis HR, Beusmans GHMI, Gorgels APM, Kester ADM, Van Ree JW. Effectiveness of nurse-delivered cardiovascular risk management in primary care: A randomized trial. Br J Gen Pract. 2010;60(570):40–6.
  38. Royal College of Nursing. Advanced Nurse Practitioners – an RCN Guide to the Advanced Nurse Practitioner Role, Competences and Programme Accreditation. In London: RCN; 2012.
  39. Cooper R, Stoflet S. Diversity and consistency: the challenge of maintaining quality in a multidisciplinary workforce. J Health Serv Res Policy. 2004;9(Suppl 1):39–47.
  40. Association of American Medical Colleges. Physician Shortages to Worsen Without Increases in Residency Training; 2011.
  41. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of non-physician clinicians. JAMA. 1998;280(9):788–94.
  42. Delamaire M, Lafortune G. Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries, OECD Health Working Papers, 2010;No. 54, OECD Publishing. Available from–en
  43. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014, Feb 25. DOI: 10.1016/S0140–6736(13)62631–8.
  44. Blegen MA, Goode CJ, Park SH, Vaughn T, Spetz J. Baccalaureate education in nursing and patient outcomes. J Nurs Adm. 2013;43:89–94.
  45. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J. Hospital nurse practice environments and outcomes for surgical oncology patients. Health Serv Res. 2008;43:1145–63.
  46. Kutney-Lee A, Sloane DM, Aiken LH. An increase in the number of nurses with baccalaureate degrees is linked to lower rates of postsurgery mortality. Health Aff. (Millwood) 2013;32:579–86.
  47. Tourangeau AE, Doran DM, McGillis Hall L, O’Brien Pallas L, Pringle D, Tu JV, Cranley LA. Impact of hospital nursing care on 30-day mortality for acute medical patients. J Adv Nurs. 2007;57:32–44.
  48. Morgan S. What are the differences in nurse practitioner training and scope of practice in the US and UK? Nurs Times. 2010;106:21–4.
  49. Leventhal ME, Denhaerynck K, Brunner-La Rocca HP, Burnand B, Conca-Zeller A, Bernasconi AT, et al. Swiss Interdisciplinary Management Programme for Heart Failure (SWIM-HF): a randomised controlled trial study of an outpatient inter-professional management programme for heart failure patients in Switzerland. Swiss Med Wkly. 2011;141:w13171.
  50. Lugtenberg M, Burgers JS, Westert GP. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Quality & safety in health care. 2009;18(5):385–92.
  51. Thomas L, Cullum N, McColl E, Rousseau N, Soutter J, Steen N. Guidelines in professions allied to medicine. Cochrane Database Syst Rev. 2000(2):Cd000349.
  52. Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ. 1997,157(4):408–16.
  53. Sargent GM, Forrest LE, Parker RM. Nurse delivered lifestyle interventions in primary health care to treat chronic disease risk factors associated with obesity: a systematic review. Obes Rev. 2012;13(12):1148–71.
  54. Rosemann T, Joest K, Korner T, Schaefert R, Heiderhoff M, Szecsenyi J. How can the practice nurse be more involved in the care of the chronically ill? The perspectives of GPs, patients and practice nurses. BMC Fam Pract. 2006;7:14.
  55. Deeks JJ, Dinnes J, D’Amico R, Sowden AJ, Sakarovitch C, Song F, et al. Evaluating non-randomized intervention studies. Health technology assessment (Winchester, England). 2003;7(27):iii-x, 1–173.
  56. Hoff TJ, Witt LC. Exploring the use of qualitative methods in published health services and management research. Med Care Res Rev. 2000;57(2):139–60.
  57. Möhler R, Bartoszek G, Meyer G. Quality of reporting of complex healthcare interventions and applicability of the CReDECI list – a survey of publications indexed in PubMed. BMC Med Res Methodol. 2013;13(1):1–8.

Most read articles by the same author(s)

1 2 3 > >>