Additional tables

Additional tables

Randomised controlled trials included in review

Observational studies included in review

Methodological quality of randomised controlled trials

Methodological quality of observational studies

Health status and health related quality of life

Quality of care in randomised controlled trials

Table A Randomised controlled trials included in review (9 were in general practice setting)

Reference	Patient sample (setting and No of patients)	Setting (No of sites)	*No of nurse practitioners (qualification level) and No of doctors**	Main outcomes	Comment
Sackett et al 1974^W1Spitzer et al 1974^W2	Family practice: nurse practitioners, 540 families, 1529 people; doctors 1058 families, 2796 people. Subsample for patient satisfaction and health status interviews: nurse practitioners 296; doctors 521	Family practice (1)	2 Nurse practitioners (2); 2 doctors	Health status; deaths; patient satisfaction; quality of care; cost effectiveness	Power calculation not reported. Families were randomly allocated but had the option to swap groups (2 from doctor group and 5 from nurse practitioner group swapped.) Only 67% of patients managed entirely by nurse practitioners as nurses needed to refer to physicians for advice for a third of patients. Care over time study
Hoekelman 1975^W3	Well baby care: nurse practitioners 103; doctors 143	Paediatric clinic; private paediatric practice (2)	23 Paediatric nurse practitioners (2); 4 doctors	Service use; maternal knowledge; maternal compliance; abnormality detection rate	Power calculation not reported. Study complicated by comparing nurse practitioners across clinic and private practice settings. Care over time study
Burnip et al 1976^W4	Well child care: nurse practitioners 474; doctors 678	Medical centres (2)	6 Paediatric nurse practitioners (3); doctors not reported	Prescriptions; investigations; health service costs; service use	Power calculation not reported. 15.7% of mothers seeing nurse practitioners wanted to change provider. Care over time study
Chambers and West 1978^W5	Family practice: nurse practitioners 296; doctors 572	Family practice (1)	1 Nurse practitioner (2); 1 doctors	Patient health status: physical, emotional, and social function	Power calculation not reported. High (37%) unexplained dropout rate and big difference between groups. Care over time study
Winter 1981^W6	Primary care: nurse practitioners 25; doctors 25	Primary care clinic (1)	5 Nurse practitioners (2); 5 doctors	Patient satisfaction with quality of care	Power calculation not reported. MSc thesis. Small study. Sample: high ratio females to male providers, and preferences expressed could have been due to sex of providers
Cooper 2001^W7	Patients with minor injuries: nurse practitioners 102; doctors 102	Emergency department (1)	Nurse practitioners (4) not reported; doctors not reported	Patient satisfaction; length of consultation; No of radiographs; internal referrals; unplanned return visits; quality of care	Unpublished report: pilot study for proposed randomised controlled trial¾ study too small to detect real differences
Sakr et al 1999^W8	Patients with recent traumatic injury: nurse practitioners 704; doctors 749	Emergency department (1)	Nurse practitioners (3) not reported; doctors not reported	Patient satisfaction; adequacy of care	Use of 2 research registrars could have increased variation between them, such as whether radiography was needed
Kinnersley et al 2000^W9	Patients requesting same day appointments: nurse practitioners 652; doctors 716	General practices (10)	10 Nurse practitioners (2); doctors not reported	Patient satisfaction; resolution of symptoms and concerns at 2 weeks; length of consultation; prescriptions; investigations; referrals; return consultations; costs	Possible selection bias. High refusal rate¾ 216 (12.3%) people refused to participate
Mundinger et al 2000^W10	Patients requiring primary care after emergency department visit: nurse practitioners 806; doctors 510	Primary care (5)	7 Nurse practitioners (1); 17 doctors	Patient satisfaction; health status; physiological measurements; healthcare utilisation	Study may be too small to detect differences for sicker patients. Recruitment bias: only 58% of those screened were recruited, and high attrition as 32.4 % randomised participants did not attend their first appointment, and those who stayed in study differed significantly at baseline. Care over time study
Shum et al 2000^W11	Patients requesting same day appointments: nurse practitioners 900; doctors 915	General practices (5)	5 Nurse practitioners (3) 19 doctors	Patient satisfaction; health status; prescriptions; length of consultation; referrals to doctor; admissions; quality of care measures	Study did not have enough power to detect differences in rare outcomes. Some ambiguity about inclusion¾ nurses not described as nurse practitioners but given this type of training to assess and manage patients autonomously
Venning et al 2000^W12	Patients requesting same day appointments: nurse practitioners 651; doctors 665	General practices (20)	20 Nurse practitioners:(1 and 2); doctors not reported	Length of consultation; prescriptions; investigations; referrals; return consultations; patient satisfaction; health status; costs	No prior power calculation for costs. Not clear how many patients could not attend experimental sessions

*(1)=Recognised nurse practitioner programme in higher education institution leading to qualification at degree level or above; (2)=extended training in higher education institution, relevant to practice as nurse practitioner, leading to award that is less than degree level; (3)=extended training outside higher education institution relevant to enhanced practice as nurse practitioner; (4)=not possible to assign qualification.

Table B Observational studies included in review (17 were in general practice setting)

Study reference	Patient sample (setting and No of patients)	Setting (No of sites)	*No of nurse practitioners (qualification level) and doctors**	Main outcomes	Comment
Richards and de Castro 1973^W13	Children attending emergency room follow up clinic for primary care (66 nurse practitioners; 47 doctors)	Primary care (1)	3 Nurse practitioners (4); 1 doctor	Patient satisfaction with communication; quality of care	Small study. Only one physician¾ female (sex probably significant in assessing communication)
Russo et al 1975^W14	113 children attending paediatric primary care outpatients (113 nurse practitioners; 113 doctors)	Primary care (1)	6 Nurse practitioners (3); 6 doctors	Quality of care	Small study. Patients were assessed by both providers and where researcher thought parents’ report was influenced by previous examination the patient was excluded; numbers not reported
Linn 1976^W15	Patients attending ambulatory care settings (273 nurse practitioners; 957doctors)	Primary care (10)	10 Nurse practitioners (2); doctors not reported	Patient satisfaction	No discussion of sampling or analysis. Some patients in conventional care group seen only by nurses
Komaroff et al 1976^W16	Ambulatory care patients with upper respiratory tract infections, genitourinary symptoms (73 nurse practitioners; 47doctors)	Ambulatory care (1)	1 Nurse practitioner (2); 1 doctor	Patient satisfaction; resolution of symptoms; length of consultation; internal referrals; costs	Likelihood of selection bias. Small sample size and power calculation not reported
De Angelis and McHugh 1977^W17	Children attending acute paediatric clinic (245 nurse practitioners; 211 doctors)	Primary care (1)	3 Nurse practitioners (3); 3 doctors	Quality of care; cost effectiveness	Power calculation not reported. Costs not fully reported
Goodman and Perrin 1978^W18	5 scenarios of mother concerned about her child’s health presented to nurse practitioners and paediatricians (19 nurse practitioners; 69 doctors)	Primary care: evening phone calls (1)	5 Nurse practitioners (1 and 2); 23 doctors	Quality of care; maternal satisfaction; length of calls	Not clear if assessors blind. Small sample of nurse practitioner calls. Higher scores in interviewing skills correlated with higher satisfaction and longer length of call
Graham 1978^W19	Children presenting with new episodes of sore throat (138 nurse practitioners; 136 doctors)	Primary care (1)	2 Nurse practitioners (3); 3 doctors	Patient or parent satisfaction; quality of care indicators; investigations
Hastings et al 1980^W20	Patients who were prison inmates (176 nurse practitioners; 136 doctors)	Prison clinic (3)	6 Nurse practitioners (3); doctors not reported	Workload; quality of care; health status; patient satisfaction; mortality; test result compared to work performance of nurse practitioners; costs; return consultations	Care over time study
Salkever et al 1982^W21	Episodes of otitis media and sore throat treated by physicians and nurse practitioners (438 nurse practitioners; 361doctors)	Primary care (1)	4 Nurse practitioners (4); 4 doctors	Costs; investigations; internal referrals; consultation times; return consultations; prescriptions	Complex study involving analysis of patient encounters supplemented by small observational study to record consultation times
Powers et al 1984^W22	Patients attending emergency room (31 nurse practitioners; 31doctors)	Emergency department (1)	1 Nurse practitioner (1); 20 doctors	Patient knowledge satisfaction; compliance; resolution of problems; quality of care	Small sample size, multiple outcomes, some differences likely to be due to chance
Dunn and Higgins 1986^W23	Isolated North American Indian communities requiring health care (98 338 nurse practitioners; 14 935 doctors)	Primary care (27)	Nurse practitioners (4) not reported; doctors not reported	Range of health problems encountered; diagnostic and management patterns; prescriptions	Differences probably related to types of patients and differences in diagnostic tendencies. Isolated communities, but in developed country: ambiguity about inclusion. Little relevance to United Kingdom. Care over time study
Salisbury and Tettersell 1988^W24	Patients attending general practice (210 nurse practitioners; 836 doctors)	General practice (1)	1 Nurse practitioner (3) 1; 1 doctor	Patient satisfaction; prescriptions; referrals; presenting problems and activities of nurse practitioners	No comparative data for patient satisfaction
Campbell et al 1990^W25	Patients attending a family practice (136 nurse practitioners; 276 doctors)	Primary care (60)	Nurse practitioners (2) not reported; doctors not reported	Quality of care: provider style of delivering health care	Results may be confounded by sex and case mix of sample
Rhee and Dermyer 1995^W26	Patients attending university emergency department (30 nurse practitioners; 30 doctors)	Emergency department (1)	1 Nurse practitioner (1); doctors not reported	Patient satisfaction	Ambiguity over control group, unspecified number of medical students included. Strong socioeconomic selection bias as telephone survey, unable to reach 40% of prospective sample
Freij et al 1996^W27	Patients attending with minor injuries, injuries distal to knee and elbow (150 nurse practitioners; 150 doctors)	Emergency department and minor injury unit (2)	6 Nurse practitioners (3); doctors not reported	Quality of care: number of appropriate requests for radiography, number of correct interpretations of radiographs	Compared senior house officers and nurse practitioners by expert review of records (records selected at two monthly intervals). Study in two different settings
Myers et al 1997^W28	Patients requesting urgent appointments for medical problems (500 nurse practitioners; 500 doctors)	General practice (1)	1 Nurse practitioners (1); doctors not reported	Prescriptions; referrals; admissions; return consultations	Patients self selected care, some outcomes stated were not reported (misdiagnoses and dysfunctional consultations), differences in morbidity between two groups
Bond et al 1998^W29 (EROS 2)	General practice patients (305 nurse practitioners 343 doctors)	General practice (4)	4 Nurse practitioners (3); 28 doctors	Patient views of service; return consultations	Variability across sites
Jones et al 1998^W30	Simulated patients requesting primary care (9 nurse practitioners; 9 doctors)	Primary care (6)	3 Nurse practitioners (4); 3 doctors	Frequency of asking about urinary incontinence	Small study. Sex bias of providers. 26% of providers realised they were seeing a simulated patient
Meek et al 1998^W31	20 radiographs of distal limbs for interpretation by senior house officer and nurse practitioners	Emergency department (13)	58 Nurse practitioners (4); 84 doctors	Quality of care: correct interpretation of radiographs	Comparatively few films. Not reported whether assessor was blind
Overton Brown and Anthony 1998^W32	50 radiographs and case histories to be interpreted and compared with consultant radiologist gold standard	Emergency department (1)	7 Nurse practitioners (3); 14 doctors	Quality of care: accuracy of interpretation of distal radiographs	Uses receiver operating characteristic method. This analysis gives graphic representation of whole spectrum of sensitivity and specificity decisions
Reveley 1998^W33	Patients attending for same day appointments (113 nurse practitioners; 173 doctors)	General practice (1)	1 Nurse practitioner (1); 7 doctors	Patient perceptions; length of consultations; prescriptions; referrals	Pilot study. Differences in organisation of care between providers. Interviews non-blind, subjective, fewer doctor than nurse practitioner patients, no formal assessment of satisfaction, based on convenience sample. Confounding sex bias
Byrne et al 2000^W34	Patients with minor injuries (57 nurse practitioners; 57 doctors)	Emergency department, minor accident treatment centre (2)	Nurse practitioners (4) not reported; doctors not reported	Patient satisfaction	Three different settings compared. Results for the two most similar settings (emergency department and minor injury department attached to an emergency department) have been included. Doctors data gathered in June and July but nurse practitioners gathered in September to January
Cox and Jones2000^W35	Patients attending practice with sore throat (188 nurse practitioners; 247 doctors)	General practice (1)	Nurse practitioners (3) not reported; doctors not reported	Patient satisfaction; resolution of symptoms at 5 days; follow up at 1 month of patients with unresolved symptoms; use of analgesia; return consultation rates; prescriptions	Patients self selected provider. Nurse practitioners saw younger and probably less ill patients. Follow up by unblinded researcher

Table C Methodological quality of randomised controlled trials

Reference	Allocation concealment	Follow up for 80% of participants in doctor and nurse practitioner arms	Blind assessment of outcomes, or objective measures	Outcomes assessed at baseline	Reliable outcome measures	Allocation by practice or site to protect against contamination
Sackett et al 1974^W1	?	Done	Done	Done	Done	Not done
Hoekelman 1975^W3	?	Not done	Done	Not done	Done	Not done
Burnip et al 1976^W4	?	Done	?	Not done	?	Not done
Chambers et al 1978^W5	?	Not done	Done	Done	Done	Not done
Winter 1981^W6	?	Not done	Done	Not done	Not done	Not done
Cooper 2001^W7	Done	Not done	Done	Not done	Done	Not done
Sakr et al 1999^W8	Done	Not done	Done	Not done	Done	Not done
Shum et al 2000^W11	Done	Not done	Done	Not done	Done	Not done
Venning et al 2000^W12	Done	Not done	Done	Done	Done	Not done
Kinnersley et al 2000^W9	Done	Not done	Done	Done	Done	Not done
Mundinger et al 2000^W10	?	Not done	Done	Done	Done	Done

?=Unclear or some measures only.

Table D Methodological quality of observational studies

Reference	Baseline characteristics reported and similar	Follow up for 80% of participants in doctor and nurse practitioner arms	Blind assessment of outcomes, or objective measures	Outcomes assessed at baseline	Reliable outcome measures	Allocation by practice or site to protect against contamination
Richards and de Castro 1973^W13	Done	Not applicable	?	Not done	Not done	Not done
Russo et al 1975^W14	Done	Not applicable	?	Not done	Not done	Not done
Komaroff et al 1976^W16	Done	Done	?	Not done	Not done	Not done
Linn 1976^W15	Not done	?	?	Not done	Not done	Not done
De Angelis and McHugh 1977^W17	Done	Not applicable	?	Not done	Not done	Not done
Goodman and Perrin 1978^W18	Done	Not applicable	Done	Not applicable	?	Not done
Graham 1978^W19	Done	Not done	?	Not done	?	Not done
Hastings et al 1980^W20	?	Done	Done	?	Not done	Not done
Salkever et al 1982^W21	Done	Not applicable	Done	Not done	Done	Not done
Powers et al 1984^W22	Done	Done	?	Not done	Not done	Not done
Dunn and Higgins 1986^W23	Not applicable	Not applicable	?	Not done	Not done	Not done
Salisbury and Tettersell 1988^W24	Done	Done	?	Not applicable	Not done	Not done
Campbell et al 1990^W25	Done	Not applicable	Done	Not applicable	Not done	?
Rhee and Dermyer 1995^W26	Done	Not applicable	Done	Not done	Not done	Not done
Freij et al 1996^W27	?	Not done	Done	Not applicable	?	Not done
Myers et al 1997^W28	Done	Done	?	Not done	?	Not done
Jones and Bunner 1998^W30	Not done	Not applicable	Done	Not applicable	Not done	Not done
Meek et al 1998^W31	Not done	Not applicable	Done	Not applicable	?	Not done
Bond et al 1998^W29 (EROS 2)	Done	Not done	Not done	Not done	Not done	Not done
Overton-Brown and Anthony 1998^W32	Done	Not applicable	Done	Not applicable	?	Not done
Reveley 1998^W33	Done	?	?	Not done	Not done	Not done
Byrne et al 2000^W34	Not done	Not done	Done	Not done	Done	Not done
Cox and Jones 2000^W35	Done	Done	?	Not done	?	Not done

?=Unclear or some measures only.

Table E Health status and health related quality of life (randomised controlled trials)

Reference	Measure used	Results	Conclusion	Comment
Sackett et al 1974^W1(reports Spitzer et al 1974^W2)	Measures of physical function adapted from previous instruments; health index used for measures of emotional and social function	Unimpaired mobility, vision, hearing: nurse practitioners 255/296 (86%), doctors 458/521 (88%). Able to undertake daily activities: nurse practitioners 266/296 (90%), doctors 469/521 (90%). Freedom from bed days: nurse practitioners 255/296 (86%), doctors 453/521 (87%). Emotional function indices (1=good): nurse practitioners mean 0.583 (SD 0.187), doctors mean 0.577 (SD 0.187). Social function indices: nurse practitioners mean 0.832 (SD 0.249), doctors mean 0.839 (SD 0.274). Deaths (rate per 1000): nurse practitioners 4 (2.7), doctors 18 (6.0)	Health status measurements equivalent in both groups. Physical function compared with baseline data	Power calculation not reported. Only 67% of patients received their care exclusively from nurse practitioners; of deaths reported none of patients seeing nurse practitioners were preventable
Chambers and West 1978^W5	WHO/ICS MCU: health index used for measures of emotional and social functioning	Patients classified as "healthy" (χ²^{P<0.01): nurse practitioners, 181/296 (61%), doctors: 284/569 (50%). Emotional function indices: nurse practitioners comparable to doctors (}χ²^{P<0.01). Social function indices: nurse practitioners comparable to doctors (}χ²^P<0.01)	Both groups of patients had similar outcomes; nurse group had better physical function	Power calculation not reported. Only one of each practitioner. Multiple outcomes
Sakr et al 1999^W8	Satisfaction questionnaire incorporating health status measures*	Reported improved health: nurse practitioners, 373/409 (91.1%), doctors: 421/469 (89.8). Not improved as expected (P=0.41): nurse practitioners, 36/409 (8.8%), doctors: 48/469 (10.2%). Not returned to normal activities (P=0.45): nurse practitioners:74/424 (17.5%), doctors: 76/488 (15.6%)	No significant difference between groups	Power calculation not reported
Kinnersley et al 2000^W9	Satisfaction questionnaire (CSQ) incorporating health status measures	Resolution of symptoms: nurse practitioners 401/484 (82.8%), doctors 450/529 (85.1%). Resolution of concerns: nurse practitioners 221/484 (45.7%), doctors 233/529 (44.0%)	No significant differences between groups	Prior power calculation
Mundinger et al 2000^W10	Short form SF-36*	Physical summary (P=0.92): nurse practitioners mean 40.83 (SD 11.58), doctors mean 40.29 (SD 11.42). Mental summary (P=0.92): nurse practitioners mean 44.64 (SD 13.75), doctors mean 44.29 (SD 13.58). Physiological measures: no differences in physiological status for asthma (P=0.77) and diabetes patients (P=0.82). Slight difference in diastolic blood pressure 82 v 85 mm Hg (P=0.04)	No significant differences in health outcomes at six months follow up. Difference in hypertension measurements only marginally of significance	Prior power calculation
Shum et al 2000^W11	Satisfaction questionnaire (CSQ) incorporating health status measures	Patients rate condition cured or improved (P=0.906): nurse practitioners 558/672 (83%), doctors 546/661 (82.6%)	Health outcomes not significantly different between practitioners	Prior power calculation. Nurses had longer consultation times
Venning et al 2000^W12	SF-36*	Physical functioning (P=0.48): nurse practitioners mean 80.78 (SD 25.11), doctors mean 82.09 (SD 24.74)	No significant differences between the groups pre or post consultation in any dimension	Power calculation not reported

*Validated or referenced in paper as previously tested measure.

Table F Quality of care in randomised controlled trials

Reference	Measure	Results	Conclusion	Comment
Spitzer et al 1974^W2	Management of 10 indicator conditions. Use of 13 common drugs	Adequate management: nurse practitioner 115/167 (69%), doctor 148/225 (66%). Adequate drug prescription: nurse practitioner 160/226 (71%), doctor 213/284 (75%)	No significant differences in quality of care between nurse practitioners and doctors	Power calculation not reported. Uncertain validity of measures
Hoekelman 1975^W3	Physical examination of study children at age 15months by paediatrician	Abnormalities undetected: nurse practitioner 6/103 (5.8%), doctor 21/143 (14.7%)	Nurse practitioners missed fewer abnormalities	Power calculation not reported. Assessor was not blinded to provider. Different settings
Cooper 2001^W7	Clinic referral forms completed by the reviewing doctor. Patient satisfaction questionnaire. Audit of 10% sample of notes (max score 30)	Appropriate referrals (P=0.5): nurse practitioner 31/34 (91.2%), doctor 27/28 (96.4%). Satisfactory management (P=0.25): nurse practitioner 36/38 (94.7%), doctor 28/28 (100). Patient understood advice (P=0.08): nurse practitioner 79.9/85 (94.1%), doctor 65.9/78 (84.6%). Mean satisfaction scores (P=0.06): nurse practitioner (n=11) 26.45, doctor (n=9) 24.52. No missed injury: nurse practitioner 101/102 (99%), doctor 101/102 (99%)	Significant differences between nurse practitioners and doctors in patients’ understanding of advice. Nurse practitioners had a higher average score on a quality audit of notes	Study too small to have detected significant differences in outcome of missed injury rates. In two cases nurse practitioners were considered to have mismanaged patients. Assessor may not have been blinded to provider. Audit of notes by researcher but measure had been tested (r=0.68, P<0.01). Study took place during last 2 months of senior house officer rotation therefore comparatively experienced
Sakr et al 1999^W8	A standardised record was assessed to check adequacy of care on items regarded as important in quality of care, compared to research registrar and emergency consultant	No important errors: nurse practitioner 639/704 (90.8%), doctor 745/749 (99.4%). Mechanism of injury: nurse practitioner 703/704 (99.8%); doctor 669/749 (89.3%). Accurate medical history recorded: nurse practitioner 533/704 (76%), doctor 410/749 (55%). Clinically important recording error (P=0.01): nurse practitioner 1/704 (0.15%), doctor 11/749 (1.5%). Examination: nurse practitioner 678/704 (96.3%), doctor 729/749 (97.3%). Treatment or advice: nurse practitioner 673/704 (95.6%), doctor 705/749 (94.1%). Radiograph interpretation: nurse practitioner 428/440 (97.2%), doctor 457/473 (96.6%). Follow up: nurse practitioner 684/704 (97.2%), doctor 714/749 (95.3%)	Nurse practitioner care was equivalent to doctors and better in accurate recording of the medical history and interpretation of radiographs
Kinnersley et al 2000^W9	Patient satisfaction questionnaire (CSQ) with additional items regarding understanding of care given by provider	Cause of illness: odds ratio 0.58 (95% confidence interval, 0.44 to 0.76); nurse practitioner 501/652 (81%), doctor 491/716 (72%). Relief of symptoms: 0.32 (0.24 to 0.43); nurse practitioner 548/652 (86%), doctor 467/716 (68%). Act if problem persists: 0.61 (0.41 to 0.90); nurse practitioner 584/652 (93%), doctor 604/716 (88%). How to reduce recurrence: 0.19 (0.09 to 0.38) to 1.57 (0.46 to 5.23) (range reported because odds ratios varied significantly across practices ) nurse practitioner 205/652 (34%), doctor 139/716 (21%). Patient given advice about self medication (χ²=21.123, P<0.001); nurse practitioner 193/868 (22.2%), doctor 119/871 (13.7%)	Patients of nurse practitioners received more information about prevention, cause, relief of symptoms, and what to do if the problem persisted than did those of doctors	Only similar, small numbers of patients in both groups would self manage in future. Authors suggest this might be due to prescriptions validating the decision to go to see general practitioner
Shum et al 2000^W11	Doctor and nurse practitioner report of healthcare behaviour	Patient given advice about general self management (χ²=117.766, P<0.001); nurse practitioner 709/868 (81.7%), doctor 502/871 (57.6)	Patients of nurse practitioners were given more information on self management and self medication	Not validated measure

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