Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care.

Abstract

Objective To ascertain any differences between care from nurse practitioners and that from general practitioners for patients seeking "same day" consultations in primary care.

Design Randomised controlled trial with patients allocated by one of two randomisation schemes (by day or within day).

Setting 10 general practices in south Wales and south west England.

Subjects 1368 patients requesting same day consultations.

Main outcome measures Patient satisfaction, resolution of symptoms and concerns, care provided (prescriptions, investigations, referrals, recall, and length of consultation), information provided to patients, and patients' intentions for seeking care in the future.

Results Generally patients consulting nurse practitioners were significantly more satisfied with their care, although for adults this difference was not observed in all practices. For children, the mean difference between general and nurse practitioner in percentage satisfaction score was -4.8 (95% confidence interval -6.8 to -2.8), and for adults the differences ranged from -8.8 (-13.6 to -3.9) to 3.8 (-3.3 to 10.8) across the practices. Resolution of symptoms and concerns did not differ between the two groups (odds ratio 1.2 (95% confidence interval 0.8 to 1.8) for symptoms and 1.03 (0.8 to 1.4) for concerns). The number of prescriptions issued, investigations ordered, referrals to secondary care, and reattendances were similar between the two groups. However, patients managed by nurse practitioners reported receiving significantly more information about their illnesses and, in all but one practice, their consultations were significantly longer.

Conclusion This study supports the wider acceptance of the role of nurse practitioners in providing care to patients requesting same day consultations.

Introduction

General practices need to provide care for patients who request "same day" consultations because they are too ill or otherwise unable to wait for an appointment. The numbers of these "extra" patients are difficult to predict and increasing.[1] They are normally seen by general practitioners, although recently nurse practitioners have taken on this work.[2-4] The Royal College of Nursing has developed training for nurse practitioners, although there is no requirement for nurses seeing these patients to hold specific qualifications.

Previous studies of nurse practitioners have found high levels of patient satisfaction, low levels of prescribing, and little need to refer patients to general practitioners.[4 5] However, these studies were observational and usually involved single practitioners. Our aim was to investigate whether nurse practitioner care differs from general practitioner care for patients requesting same day consultations.

Methods

Recruitment of clinicians

Nurse practitioners were defined as nurses employed in general practice who had completed the nurse practitioner diploma course at either the Royal College of Nursing Institute of Advanced Nursing, or the department of nursing, midwifery, and health care, University of Wales. All nurse practitioners who had completed this training at least one year previously and were working in south Wales or south west England were contacted by their educational institutions. Practices that expressed interest were visited. Relevant local research ethics committees approved the study.

Recruitment of patients and randomisation

Patients seeking a `same day' consultation were recruited. Originally we planned to randomise patients to general practitioner or nurse practitioner care by day of consulting. However, this strategy was not acceptable to all practices so we offered two methods of randomisation (by day and within day). and allowed practices to choose their preferred method.

Patients requesting same day appointments who were prepared to consult either a general practitioner or a nurse practitioner were informed about the study in general terms. Consent was obtained when patients attended the surgery, and they were told which clinician they would see. All practices had a trained member of staff (the project coordinator) to manage the study procedure, under the supervision of the project research officer. The randomisation schemes were generated at the department of general practice in Cardiff, University of Wales College of Medicine.

In practices using randomisation by day, all patients consulting on a particular day saw the same type of practitioner. Practices were supplied with a calendar of their study period with the days allocated at random as nurse practitioner or general practitioner days by block randomisation. Block randomisation was used to ensure balance between the days allocated to the two types of practitioner.

Some of the practices that chose to randomise patients within day had appointments for same day patients fitted in throughout the day while others had unbooked consulting sessions. For practices which had fitted in appointments, the order in which the appointments were to be used was organised…