Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care. The aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilization including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilization was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs. 

Laurant M, Reeves D, Hermens R, Braspenning J, Grol R et al/ 2009