非工作时间用执业护士替代全科医生对资源利用、医疗产出及医疗保健成本的影响：一项准实验研究
The impact of substituting general practitioners with nurse practitioners on resource use, production and health-care costs during out-of-hours: a quasi-experimental study.
作者信息
Van Der Biezen Mieke, Adang Eddy, Van Der Burgt Regi, Wensing Michel, Laurant Miranda
机构信息
Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
出版信息
BMC Fam Pract. 2016 Sep 13;17(1):132. doi: 10.1186/s12875-016-0528-6.
BACKGROUND
The pressure in out-of-hours primary care is high due to an increasing demand for care and rising health-care costs. During the daytime, substituting general practitioners (GPs) with nurse practitioners (NPs) shows positive results to contribute to these challenges. However, there is a lack of knowledge about the impact during out-of-hours. The current study aims to provide an insight into the impact of substitution on resource use, production and direct health-care costs during out-of-hours.
METHODS
At a general practitioner cooperative (GPC) in the south-east of the Netherlands, experimental teams with four GPs and one NP were compared with control teams with five GPs. In a secondary analysis, GP care versus NP care was also examined. During a 15-month period all patients visiting the GPC on weekend days were included. The primary outcome was resource use including X-rays, drug prescriptions and referrals to the Emergency Department (ED). We used logistic regression to adjust for potential confounders. Secondary outcomes were production per hour and direct health-care costs using a cost-minimization analysis.
RESULTS
We analysed 6,040 patients in the experimental team (NPs: 987, GPs: 5,053) and 6,052 patients in the control team. There were no significant differences in outcomes between the teams. In the secondary analysis, in the experimental team NP care was associated with fewer drug prescriptions (NPs 37.1 %, GPs 43 %, p < .001) and fewer referrals to the ED (NPs 5.1 %, GPs 11.3 %, p = .001) than GP care. The mean production per hour was 3.0 consultations for GPs and 2.4 consultations for NPs (p < .001). The cost of a consultation with an NP was €3.34 less than a consultation with a GP (p = .02).
CONCLUSIONS
These results indicated no overall differences between the teams. Nonetheless, a comparison of type of provider showed that NP care resulted in lower resource use and cost savings than GP care. To find the optimal balance between GPs and NPs in out-of-hours primary care, more research is needed on the impact of increasing the ratio of NPs in a team with GPs on resource use and health-care costs.
TRIAL REGISTRATION
ClinicalTrials.gov ID NCT01388374 .
背景
由于医疗需求的增加和医疗保健成本的上升，非工作时间基层医疗的压力很大。在白天，用执业护士（NP）替代全科医生（GP）已显示出有助于应对这些挑战的积极成果。然而，对于非工作时间的影响，我们缺乏相关了解。本研究旨在深入了解替代措施对非工作时间资源使用、工作量及直接医疗保健成本的影响。
方法
在荷兰东南部的一个全科医生合作社（GPC），将由4名全科医生和1名执业护士组成的试验组与由5名全科医生组成的对照组进行比较。在二次分析中，还对全科医生诊疗与执业护士诊疗进行了检查。在15个月的期间内，纳入了所有在周末前往GPC就诊的患者。主要结局是资源使用情况，包括X光检查、药物处方以及转诊至急诊科（ED）的情况。我们使用逻辑回归来调整潜在的混杂因素。次要结局是每小时的工作量以及使用成本最小化分析得出的直接医疗保健成本。
结果
我们分析了试验组的6040名患者（执业护士：987名，全科医生：5053名）和对照组的6052名患者。两组之间的结局没有显著差异。在二次分析中，试验组中执业护士诊疗与全科医生诊疗相比，药物处方更少（执业护士为37.1%，全科医生为43%，p < 0.001），转诊至急诊科的情况也更少（执业护士为5.1%，全科医生为11.3%，p = 0.001）。全科医生每小时的平均工作量为3.0次诊疗，执业护士为2.4次诊疗（p < 0.001）。与全科医生诊疗相比，执业护士诊疗的每次诊疗成本低3.34欧元（p = 0.02）。
结论
这些结果表明两组之间没有总体差异。尽管如此，对医疗服务提供者类型的比较显示，执业护士诊疗比全科医生诊疗导致更低的资源使用和成本节约。为了在非工作时间基层医疗中找到全科医生和执业护士之间的最佳平衡，需要更多关于在全科医生团队中增加执业护士比例对资源使用和医疗保健成本影响的研究。
试验注册
ClinicalTrials.gov标识符NCT01388374 。
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