General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care, 2019, Anthony

Andy · Apr 25, 2019

Abstract
Background Previous systematic reviews have found that nurses and pharmacists can provide equivalent, or higher, quality of care for some tasks performed by GPs in primary care. There is a lack of economic evidence for this substitution.

Aim To explore the costs and outcomes of role substitution between GPs and nurses, pharmacists, and allied health professionals in primary care.

Design and setting A systematic review of economic evaluations exploring role substitution of allied health professionals in primary care was conducted. Role substitution was defined as ‘the substitution of work that was previously completed by a GP in the past and is now completed by a nurse or allied health professional’.

Method The following databases were searched: Ovid MEDLINE, CINAHL, Cochrane Library, National Institute for Health and Care Excellence (NICE), and the Centre for Reviews and Dissemination. The review followed guidance from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

Results Six economic evaluations were identified. There was some limited evidence that nurse-led care for common minor health problems was cost-effective compared with GP care, and that nurse-led interventions for chronic fatigue syndrome and pharmacy-led services for the medicines management of coronary heart disease and chronic pain were not. In South Korea, community health practitioners delivered primary care services for half the cost of physicians. The review did not identify studies for other allied health professionals such as physiotherapists and occupational therapists.

Conclusion There is limited economic evidence for role substitution in primary care; more economic evaluations are needed.
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Paywall, https://bjgp.org/content/early/2019/04/22/bjgp19X702425
Currently not available via Sci-hub.

Peter Trewhitt · Apr 25, 2019

I sometimes wonder if getting other people that do some of the things a doctor does ends up being more expensive.

For example if my GP wants to give me an injection I see the GP who then explains about the nurse giving the injection, he then writes it up and informs the nurse, I see the receptionist to arrange another appointment, then see the nurse on another day, when the GP could have done the injection in the time it took to set the additional process in motion.

If it was a course of injections it might be different, but as a one off it must be more expensive.

Mithriel · Apr 26, 2019

I think what this is about is having what are called nurse practitioners. For instance I see a nurse every 4 months to check my diabetes. If my medication needs changed she will check with the doctor and send me a prescription so I only need to consult a doctor if something major happens. In hospitals there are nurses trained to do admissions and some who are there to help and advice junior doctors. When these doctors start on a ward the good ones have always relied on the expertise of nurses who have been involved with a particular speciality, say orthopaedics for many years.

I would rather see a nurse with detailed knowledge of my condition than a doctor who once heard about it years ago in a medical lecture. MS nurses do good work and there have been ME nurses but ousted by psychologists.

Maybe we will have a specialist nurse (who actually knows something!) in every hospital.

JemPD · Apr 26, 2019

Mithriel said: ↑

Maybe we will have a specialist nurse (who actually knows something!) in every hospital.
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wow wouldnt that be great!

Trish · May 13, 2019

Now on sci-hub:
https://sci-hub.se/https://doi.org/10.3399/bjgp19X702425

They only managed to find 6 studies to include, and the main conclusion seems to be that more studies are needed.

Here's their summary:

Summary
Nurse-led care for common, minor health conditions was as effective as and less costly than GP care. Nurse-led preventive care for secondary prevention of heart disease and heart failure was more costly and similar in effectiveness as usual GP care. It is uncertain whether there was a statistically significant difference in the QALY value reported between groups as confidence intervals were not reported in the article. Nurse-led interventions for chronic fatigue syndrome were more costly and less effective.

Pharmacy-led services for the medicines management of coronary heart disease were as effective as, but more costly than, GP care. For managing chronic pain, pharmacy-led care was slightly more effective than GP care for increased cost.

In South Korea, community health nurse practitioners delivered primary care services for half the cost of physicians. There was a lack of economic evidence for role substitution by other groups of allied health professionals such as physiotherapists and occupational therapists.
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The nurse led CFS one was this, which looks like it's the FINE trial cost benefit paper:

Richardson G, Epstein D, Chew-Graham C, Weardon et al. Cost-effectiveness of supported self-management for CFS/ME patients in primary care. BMC Fam Pract 2013; 14: 12

Abstract
Background
Nurse led self-help treatments for people with chronic fatigue syndrome/myalgic encephalitis (CFS/ME) have been shown to be effective in reducing fatigue but their cost-effectiveness is unknown.

Methods
Cost-effectiveness analysis conducted alongside a single blind randomised controlled trial comparing pragmatic rehabilitation (PR) and supportive listening (SL) delivered by primary care nurses, and treatment as usual (TAU) delivered by the general practitioner (GP) in North West England. A within trial analysis was conducted comparing the costs and quality adjusted life years (QALYs) measured within the time frame of the trial. 296 patients aged 18 and over with CFS/ME diagnosed using the Oxford criteria were included in the cost-effectiveness analysis.

Results
Treatment as usual is less expensive and leads to better patient outcomes compared with Supportive Listening. Treatment as usual is also less expensive than Pragmatic Rehabilitation. PR was effective at reducing fatigue in the short term, but the impact of the intervention on QALYs was uncertain. However, based on the results of this trial, PR is unlikely to be cost-effective in this patient population.

Conclusions
This analysis does not support the introduction of SL. Any benefits generated by PR are unlikely to be of sufficient magnitude to warrant recommending PR for this patient group on cost-effectiveness grounds alone. However, dissatisfaction with current treatment options means simply continuing with ‘treatment as usual’ in primary care is unlikely to be acceptable to patients and practitioners.
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It's fascinating and concerning that Chew-Graham and Weardon have themselves stated that neither supportive listening nor the mix of CBT/GET they call pragmatic rehabilitation (PR) is either effective or cost effective, yet they still push PR on the basis that patients want something (even if it's useless).

@dave30th, given your current correspondence over Chew-Graham's claims of the costs of MUS, this surely scuppers her inclusion of ME in her MUS/IAPT ideas.

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General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care, 2019, Anthony

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General medical services by non-medical health professionals: a systematic quantitative review of economic evaluations in primary care, 2019, Anthony

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Trish Moderator Staff Member

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