The (Cost-)Effectiveness of Nurse Practitioners Working at the Primary Out of Hours Emergency Service

Primary Health Care Clinical Trial

Official title:

A Study on the (Cost-)Effectiveness of Nurse Practitioners Working at the Primary Out of Hours Emergency Service and the Feasibility of Implementing These Nurses

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT01388374
• Other study ID #: 80-82800-98-227
• Status: Completed
• Phase: N/A
• First received: July 4, 2011
• Last updated: April 21, 2015
• Start date: December 2010
• Est. completion date: October 2012

Study information

• Verified date: April 2015
• Source: Radboud University
• Contact: n/a
• Is FDA regulated: No
• Health authority: Netherlands: ZonMw, Netherlands Organisation for Health Research and Development
• Study type: Interventional

Clinical Trial Summary

The aim of this study is to explore whether the implementation of Nurse Practitioners can lead to a more accessible and efficient patient care at the primary out of hours service.

The primary objectives of the proposed study are:

1. What are the effects of the implementation of NPs on the primary out of hours service in comparison with the current out of hours service? Effects in terms of accessibility, objective and subjective workload of general practitioners, quality of care and patient satisfaction.

2. How efficient is the implementation of NPs in the primary out of hours services?

3. What is the feasibility of the implementation of NPs in the out of hours services? And under which conditions?

4. What are the barriers and facilitating factors considering the implementation of NPs?

Description:

The emergency care and primary out of hours care in the Netherlands is under pressure. There is a rising demand from patients for acute care at the primary out of hours service (run by General Practitioners) as well as for the emergency departments (EDs) at the hospitals. The workload for healthcare professionals in these acute care setting is high. Without changes in the organization of primary out of hours care and emergency care, the quality, accessibility and efficiency of the acute care can't be guaranteed in the future.

The substitution of care from General Practitioners (GPs) to Nurse Practitioners (NPs) is seen as one possible solution to decrease the GPs' workload and improve accessibility and efficiency of care without reducing the quality of care.

It turned out that about 80% of the acute complaints is U3 and U4 (low complex and not urgent) and does not necessarily to be seen by a physician.

Based on previous research we expect that the NPs are competent to diagnose and treat almost all low complex and not urgent complaints. During surgery hours (day time) the NPs act in about 90% of the consultations independently.

Hypothetical substitution of care should contribute to enhancing quality, improving accessibility and reducing the workload of doctors. It can also benefit the efficiency of the acute (primary out of hours) care.

However, specific scientific evidence for this is lacking.

In this study we examine whether substitution of care from GPs to NPs in a primary out of hours care setting can contribute to a more accessible and efficient patient care. Also the feasibility of implementing NPs in a primary our of hours setting is examined.

Comparison: Care provided by the Nurse Practitioner will be compared to care provided by a General Practitioner.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 12092
• Est. completion date: October 2012
• Est. primary completion date: July 2012
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: Both
• Age group: 1 Year and older

Eligibility

Inclusion Criteria:

• Patients (with urgency U2, U3, or U4) requesting an appointment at the primary out of hours emergency service during the weekend between 10.00 and 17.00 hours.

Exclusion Criteria (patients seen by a NP):

• Patients under the age of 1 year

• Patients with psychiatric complaints

• Patients with abdominal pain, abdominal infections, chest pain or neck complaints (angina pectoris), headache and dizziness.

Study Design

Allocation: Non-Randomized, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Health Services Research

Related Conditions & MeSH terms

• Emergencies
• Out of Hours Medical Care
• Primary Health Care

Intervention

Other:
• 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).

Locations

Country	Name	City	State
Netherlands	Centrale Huisartsen Post (CHP)	Eindhoven	Noord-Brabant

Sponsors (2)

Lead Sponsor	Collaborator
Radboud University	ZonMw: The Netherlands Organisation for Health Research and Development

Country where clinical trial is conducted

Netherlands, 

References & Publications (63)

Adang EM, Wensing M. Economic barriers to implementation of innovations in health care: is the long run-short run efficiency discrepancy a paradox? Health Policy. 2008 Dec;88(2-3):236-42. doi: 10.1016/j.healthpol.2008.03.014. Epub 2008 May 8. — View Citation

Barber JA, Thompson SG. Analysis and interpretation of cost data in randomised controlled trials: review of published studies. BMJ. 1998 Oct 31;317(7167):1195-200. Review. — View Citation

Bos N et al (2009). Het gebruik van spoedzorg Regio Utrecht 2009. Utrecht: Julius Centrum.

Bruurs et al. Het ijs is gebroken. Eerste ervaringen met physician assistant stemmen hoopvol. Med Contact; 60:443-6.

Burgt R van der, Derckx E, Toemen T (2009). Taakherschikking in de huisartsenzorg: ANW -eindrapport preparatory grant ZonMW-. Eindhoven, Stichting KOH

Bussemakers et al (2007). De rolverdeling. Taak-herschikking en taakverdeling in de huisartsenpraktijk. Med Contact; 62 (28): 1216-8.

Carret ML, Fassa AG, Kawachi I. Demand for emergency health service: factors associated with inappropriate use. BMC Health Serv Res. 2007 Aug 18;7:131. — View Citation

Cartwright WS. Methods for the economic evaluation of health care programmes, second edition. By Michael F. Drummond, Bernie O'Brien, Greg L. Stoddart, George W. Torrance. Oxford: Oxford University Press, 1997. J Ment Health Policy Econ. 1999 Mar 1;2(1):43. — View Citation

Dale J, Green J, Reid F, Glucksman E. Primary care in the accident and emergency department: I. Prospective identification of patients. BMJ. 1995 Aug 12;311(7002):423-6. — View Citation

De Jongh M & Welling G (2009). Analyse zorgvraag Huisartsenpost Eindhoven. Eindhoven: De Centrale Huisartsenposten Zuidoost Brabant

de Leeuw et al (2009). Taakherschikking in de huisartsenpraktijk: introductie van de Physician Assistant. Utrecht: UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijns Geneeskunde.

Derckx & Toemen (2005). Tussen Cure en Care. Nurse Practitioner in de huisartsenpraktijk verdient ichtzelf terug. Med Contact; 60(49):1992-5.

Derckx, EWCC et al (2006). De Nurse Practitioner in de huisartsenpraktijk biedt perspectief! Modern Medicine; 30(3): 103-7.

Derckx, EWCC, vander Burgt M.R, de Bakker D. Vrijhoef HJM (2009): Naar een landelijke implementatie van de NP en de PA in de eerste lijn.Eindhoven: Stichting KOH

Dierick-van Daele AT, Metsemakers JF, Derckx EW, Spreeuwenberg C, Vrijhoef HJ. Nurse practitioners substituting for general practitioners: randomized controlled trial. J Adv Nurs. 2009 Feb;65(2):391-401. doi: 10.1111/j.1365-2648.2008.04888.x. — View Citation

Dierick-van Daele AT, Spreeuwenberg C, Derckx EW, Metsemakers JF, Vrijhoef BJ. Critical appraisal of the literature on economic evaluations of substitution of skills between professionals: a systematic literature review. J Eval Clin Pract. 2008 Aug;14(4):481-92. doi: 10.1111/j.1365-2753.2008.00924.x. Epub 2008 Jul 9. Review. — View Citation

Dierick-van Daele AT, Steuten LM, Metsemakers JF, Derckx EW, Spreeuwenberg C, Vrijhoef HJ. Economic evaluation of nurse practitioners versus GPs in treating common conditions. Br J Gen Pract. 2010 Jan;60(570):e28-35. doi: 10.3399/bjgp10X482077. — View Citation

Dierick-van Daele et al (2008). Nurse practitioner in de huisartsenpraktijk: onderzoeksrapport. Maastricht/Eindhoven: UMC Maastricht en Stichting KOH.

Engelen L & Schoonhoven L (2009). Arbeidsmarktproblematiek binnen de spoedzorgketen. Nijmegen: Acute Zorgregio Oost.

Giesen P, et al (2005). How urgent is the presented morbidity on the GP cooperative? Huisarts Wet; 48: 207-10.

Giesen P, et al (2007). Medische zorg buiten kantooruren: de huisartsenpost of de spoedeisende eerste hulp? Huisarts Wet;50(5):202-6.

Giesen P, et al (2009). Te snel naar de huisartsenpost. Medisch Cont; 64(6)239-42.

Giesen P, Franssen E, Mokkink H, van den Bosch W, van Vugt A, Grol R. Patients either contacting a general practice cooperative or accident and emergency department out of hours: a comparison. Emerg Med J. 2006 Sep;23(9):731-4. — View Citation

Grol R & Schrijvers AJP (2005). Onderzoeksprogramma Spoedzorg. Nijmegen/Utrecht: Centre for Quality of Care Research/ Julius Centrum

Grol R, Wensing M. (red) Implementatie Effectieve verbetering van de Patiëntenzorg. Maarssen: Elsevier Gezondheidszorg. 3e herziene druk. 2006. ISBN 90 352 2852 9; NUR 882

Harmsen M, Adang EM, Wolters RJ, van der Wouden JC, Grol RP, Wensing M. Management of childhood urinary tract infections: an economic modeling study. Value Health. 2009 Jun;12(4):466-72. doi: 10.1111/j.1524-4733.2008.00477.x. Epub 2008 Dec 11. — View Citation

Helsloot et al (2006). De eerste schakel. De huisartsgeneeskundige inbreng in de acute zorgketen. Medisch Cont; 61(6): 653-5.

Hollinghurst S, Horrocks S, Anderson E, Salisbury C. Comparing the cost of nurse practitioners and GPs in primary care: modelling economic data from randomised trials. Br J Gen Pract. 2006 Jul;56(528):530-5. Review. — View Citation

Hooker (2000). The economic basis of physician assistant practice. Physician Assist; 24: 51-66.

Hooker et al (2007). The globalization of the physician assistant profession. Journal of Physician Assistant Education; 18: 76-85.

Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ. 2002 Apr 6;324(7341):819-23. Review. — View Citation

IGZ (2004). Spoedeisende hulpverlening; haastige spoed niet overal goed. Den Haag: IGZ

Jaarsma-van Leeuwen I, Hammacher ER, Hirsch R, Janssens M. [Patients without referral treated in the emergency room: patient characteristics and motives]. Ned Tijdschr Geneeskd. 2000 Feb 26;144(9):428-31. Dutch. — View Citation

Jabaaij et al (2006). Diensten de deur uit. Huisartsen verkopen meer ANW-diensten aan een waarnemer. Med Contact; 61 (46): 1840-2.

Kinnersley P, Anderson E, Parry K, Clement J, Archard L, Turton P, Stainthorpe A, Fraser A, Butler CC, Rogers C. Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care. BMJ. 2000 Apr 15;320(7241):1043-8. — View Citation

Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009 Dec;66(6 Suppl):36S-89S. doi: 10.1177/1077558709346277. Review. — View Citation

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 Apr 18;(2):CD001271. Review. — View Citation

Laurant MG, Hermens RP, Braspenning JC, Akkermans RP, Sibbald B, Grol RP. An overview of patients' preference for, and satisfaction with, care provided by general practitioners and nurse practitioners. J Clin Nurs. 2008 Oct;17(20):2690-8. doi: 10.1111/j.1365-2702.2008.02288.x. Epub 2008 Jul 17. Review. — View Citation

Laurant MGH (2007). Changes in skill mix. The impact of adding nurses to the primary care team. [Thesis] Nijmegen: Radboud University Nijmegen.

Leibowitz R, Day S, Dunt D. A systematic review of the effect of different models of after-hours primary medical care services on clinical outcome, medical workload, and patient and GP satisfaction. Fam Pract. 2003 Jun;20(3):311-7. Review. — View Citation

McCarthy ML, Zeger SL, Ding R, Levin SR, Desmond JS, Lee J, Aronsky D. Crowding delays treatment and lengthens emergency department length of stay, even among high-acuity patients. Ann Emerg Med. 2009 Oct;54(4):492-503.e4. doi: 10.1016/j.annemergmed.2009.03.006. Epub 2009 May 6. — View Citation

Meulepas M, Laurant M, Derckx E. (2009). Taakherschikking in de huissartsenzorg: POH GGZ als versterking van de eerstelijns GGZ. Modellenwwegwijzer POH GGZ. Eindhoven:Meetpunt Kwaliteit.

Meulepas MA (2007). Evaluation of a chronic care model for primary care. [Thesis] Nijmegen: Radboud University Nijmegen.

Meyboom-de Jong B, van der Kam WJ, Pierik EG, Bosveld HP. [No Friday afternoon peak in the number of patients referred to the emergency room at De Weezenlanden Hospital of Zwolle, May/June 1997]. Ned Tijdschr Geneeskd. 1999 Dec 18;143(51):2562-6. Dutch. — View Citation

Miller W, Riehl E, Napier M, Barber K, Dabideen H. Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified Level II trauma center. J Trauma. 1998 Feb;44(2):372-6. — View Citation

Ministerie van VWS. Beleidsvisie acute zorg. Oktober 2003.

Moll van Charante E, Giesen P, Mokkink H, Oort F, Grol R, Klazinga N, Bindels P. Patient satisfaction with large-scale out-of-hours primary health care in The Netherlands: development of a postal questionnaire. Fam Pract. 2006 Aug;23(4):437-43. Epub 2006 Apr 26. — View Citation

Oostenbrink et al (2004). Handleiding voor kostenonderzoek, methoden en richtlijnprijzen voor economische evalauties in de gezondheidszorg. Den Haag

RVZ (2003). Acute zorg [Achtergrondstudie].( www.rvz.net )

Schermerhorn et al. (2010). De huisartsenpost te druk? Er gloort licht aan de horizon.... De NP!. Gorinchem: CHP Gorinchem.

Sixma et al (2008). Handboek CQI Ontwikkeling: ricthlijnene en voorschriften voor de ontwikkeling van een CQI meetinstrument (versie 2.0). Utrecht: Centrum Klantervaringen Zorg.

Spenkelink-Schut et al (2006). De Phyisician Assistant. Een niuewe masteropleiding binnen het medisch domein van de gezondheidszorg in Nederland. Vakblad voor opleiding in het gezondheidszorgonderwijs; 5: 18-22.

Spenkelink-Schut et al (2009). Training the Physician Assistant in the Netherlands. JEPA; 19 (40): 46-53.

Thompson SG, Barber JA. How should cost data in pragmatic randomised trials be analysed? BMJ. 2000 Apr 29;320(7243):1197-200. Review. — View Citation

Toemen Th. (2006). Master of ANP-Huisartsenzorg 2004-2006: overzicht inhoud en ICPC-codes modules patiëntenzorg huisarts-geneeskunde. Stichting KOH, Eindhoven.

Toemen Th., Ram P. (2006). De NPH-opleiders begeleid -begeleiding van opleiders van nurse practitioners werkzaam in de huisarstenpraktijk. Stichting KOH, Eindhoven.

Tummers, G. (2002) Workorganisation, work characteristics and their physiological effects on nurses in the Netherlands. International Journal of stressmanagement, 9(3), 183-206.

van Uden CJ, Crebolder HF. Does setting up out of hours primary care cooperatives outside a hospital reduce demand for emergency care? Emerg Med J. 2004 Nov;21(6):722-3. — View Citation

van Uden CJ, Winkens RA, Wesseling GJ, Crebolder HF, van Schayck CP. Use of out of hours services: a comparison between two organisations. Emerg Med J. 2003 Mar;20(2):184-7. — View Citation

VHN (2009). Benchmarkbulletin 2008. Utrecht: VHN.

Vrijhoef B (2002). Effect evaluation of substituting physicians for nurses in the care for chronically ill. Maastricht: University of Maastricht.

Wensing M, Grol R, Asberg J, van Montfort P, van Weel C, Felling A. Does the health status of chronically ill patients predict their judgements of the quality of general practice care? Qual Life Res. 1997 May;6(4):293-9. — View Citation

Wester F. (1995) Strategieën voor kwalitatief onderzoek. Coutinho 3e druk, Bussum

* Note: There are 63 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Accessibility of care	Number of patients that have a consult at the Primary Out of Hours Emergency Service; Waiting time; Productivity by NPs in comparison with productivity by GPs.	15 months	No
Secondary	Quality and safety of care	Quality and safety of care will be measured by video/audio recording. In total, 60 consultations/visits will be recorded. 30 of the General Practitioner and 30 of the Nurse Practitioner. The care between these two disciplines will be compared according to the practice guidelines for General Practitioners (list of indicators).; Furthermore, we report the amount of adverse events and complications. Also complaints by the patients will be recorded.	15 months	Yes
Secondary	Patient satisfaction	Patient satisfaction will be measured by a questionnaire (CQ-index). At baseline and three times during the intervention period questionnaires will be sent to patients who had a consult at the Primary Out of Hours Emergency Service.	15 months	No
Secondary	Feasibility	Barriers and facilitators will be explored. We collect this information through semi-structured interviews with GPs, practice assistants, NPs and physicians working at the Primary Out of Hours Emergency Service.	15 months	No
Secondary	Efficiency of care	To measure the efficiency of healthcare, we will measure type of consultation; duration of the consult; type of care provider; number of patients; number of prescriptions; number of test & investigations ordered, referral to other healthcare providers and the emergency department.; These data will be derived from the electronic medical records and patient questionnaires.	15 months	No
Secondary	Workload	Objective workload will be measured by the numbers of consults, taking into account the urgency levels of the complaints. This data will be derived from the electronic medical records; Subjective workload will be measured by a questionnaire. General practitioners as well as the practice assistants at the Primary Out of Hours Emergency Service receive a questionnaire before and after the intervention period to measure satisfaction with care and workload issues	15 months	No
Secondary	Knowledge/competence of the NPs	After 9 months, we will measure the knowledge of NPs with regard to a number of frequently presented complaints. We will use a 'knowledge test' used to examine the knowledge of GP trainees. Besides NPs also a random selection of GPs (with similar experience of practice) will be invited to fill in the knowledge test.	15 months	No
Secondary	Cost-analysis	All costs related to care provided by NPs and GPs will be calculated, including number of consultations, resource use, referrals, etc. We will also include the costs for training of GPs and NPs.; The EQ-D5 will be used as standardized measure for health status of the patient.	15 months	No

External Links

•   Projectdescription and dutch documentation related to the project