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      The impact of physician–nurse task shifting in primary care on the course of disease: a systematic review

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          Abstract

          Background

          Physician–nurse task shifting in primary care appeals greatly to health policymakers. It promises to address workforce shortages and demands of high-quality, affordable care in the healthcare systems of many countries. This systematic review was conducted to assess the evidence about physician–nurse task shifting in primary care in relation to the course of disease and nurses’ roles.

          Methods

          We searched MEDLINE, Embase, The Cochrane Library and CINAHL, up to August 2012, and the reference list of included studies and relevant reviews. All searches were updated in February 2014. We selected and critically appraised published randomized controlled trials (RCTs).

          Results

          Twelve RCTs comprising 22 617 randomized patients conducted mainly in Europe met the inclusion criteria. Nurse-led care was delivered mainly by nurse practitioners following structured protocols and validated instruments in most studies. Twenty-five unique disease-specific measures of the course of disease were reported in the 12 RCTs. While most (84 %) study estimates showed no significant differences between nurse-led care and physician-led care, nurses achieved better outcomes in the secondary prevention of heart disease and a greater positive effect in managing dyspepsia and at lowering cardiovascular risk in diabetic patients. The studies were generally small, of varying follow-up episodes and were at risk of biases. Descriptive details about roles, qualifications or interventions were also incomplete or not reported.

          Conclusion

          Trained nurses may have the ability to achieve outcome results that are at least similar to physicians’ for managing the course of disease, when following structured protocols and validated instruments. The evidence, however, is limited by a small number of studies reporting a broad range of disease-specific outcomes; low reporting standards of interventions, roles and clinicians’ characteristics, skills and qualifications; and the quality of studies. More rigorous studies using validated tools could clarify these findings.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12960-015-0049-8) contains supplementary material, which is available to authorized users.

          Resumen

          Antecedentes

          La transferencia de tareas del médico a profesionales de enfermería en atención primaria atrae enormemente a los legisladores de salud. Esta estrategia promete abordar la escasez de recursos humanos y demandas de atención asequible y de alta calidad en los sistemas de salud de muchos países. Realizamos una revisión sistemática para evaluar la evidencia sobre la transferencia de tareas médico-enfermería en atención primaria con relación al curso de la enfermedad y a las funciones de enfermería.

          Métodos

          Realizamos búsquedas en los registros de Medline, Embase, Cochrane Library y CINAHL, hasta Agosto del 2012; y en las listas de referencia de los estudios incluidos y de revisiones sistemáticas relevantes. Actualizamos las búsquedas en Febrero del 2014. Seleccionamos y realizamos una valoración crítica de los ensayos controlados aleatorios (ECA) ya publicados.

          Resultados

          Doce ECA realizados principalmente en Europa con 22 617 participantes asignados al azar reunieron los criterios de inclusión. Profesionales de enfermería, principalmente enfermeras médico, dieron el cuidado de atención, mayormente mediante el uso de protocolos estructurados e instrumentos validados. Se reportaron veinticinco medidas únicas del curso de la enfermedad. La mayoría (84 %) de éstas mostraron diferencias no significativas entre grupos, pero el profesional de enfermería consiguió tasas de pacientes significativamente mejores que el médico en la prevención secundaria de enfermedades cardiacas, un efecto positivo mayor en el manejo de dispepsia, y en la reducción del riesgo cardiovascular en pacientes diabéticos. Los estudios fueron generalmente pequeños, de seguimiento variado, y vulnerables a sesgos de selección, detección y deserción. Descripciones de las funciones, calificaciones e intervenciones no se reportan o son incompletas.

          Conclusión

          Profesionales de enfermería capacitados podrían obtener resultados de similitud al médico en el manejo del curso de la enfermedad, mediante el seguimiento de protocolos estructurados e instrumentos validados. La evidencia, sin embargo, se limita a un pequeño número de estudios que reportan una amplia gama de resultados de enfermedades específicas, y un bajo estándar en el reporte de intervenciones, características y funciones del profesional clínico, habilidades y calificaciones; y por la calidad de los estudios. Estudios con mejor calidad de métodos, que utilicen herramientas validadas podrían aclarar estos hallazgos.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12960-015-0049-8) contains supplementary material, which is available to authorized users.

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          Most cited references 35

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          The hazards of scoring the quality of clinical trials for meta-analysis.

           Peter Jüni (1999)
          Although it is widely recommended that clinical trials undergo some type of quality review, the number and variety of quality assessment scales that exist make it unclear how to achieve the best assessment. To determine whether the type of quality assessment scale used affects the conclusions of meta-analytic studies. Meta-analysis of 17 trials comparing low-molecular-weight heparin (LMWH) with standard heparin for prevention of postoperative thrombosis using 25 different scales to identify high-quality trials. The association between treatment effect and summary scores and the association with 3 key domains (concealment of treatment allocation, blinding of outcome assessment, and handling of withdrawals) were examined in regression models. Pooled relative risks of deep vein thrombosis with LMWH vs standard heparin in high-quality vs low-quality trials as determined by 25 quality scales. Pooled relative risks from high-quality trials ranged from 0.63 (95% confidence interval [CI], 0.44-0.90) to 0.90 (95% CI, 0.67-1.21) vs 0.52 (95% CI, 0.24-1.09) to 1.13 (95% CI, 0.70-1.82) for low-quality trials. For 6 scales, relative risks of high-quality trials were close to unity, indicating that LMWH was not significantly superior to standard heparin, whereas low-quality trials showed better protection with LMWH (P<.05). Seven scales showed the opposite: high quality trials showed an effect whereas low quality trials did not. For the remaining 12 scales, effect estimates were similar in the 2 quality strata. In regression analysis, summary quality scores were not significantly associated with treatment effects. There was no significant association of treatment effects with allocation concealment and handling of withdrawals. Open outcome assessment, however, influenced effect size with the effect of LMWH, on average, being exaggerated by 35% (95% CI, 1%-57%; P= .046). Our data indicate that the use of summary scores to identify trials of high quality is problematic. Relevant methodological aspects should be assessed individually and their influence on effect sizes explored.
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            Non-adherence to highly active antiretroviral therapy predicts progression to AIDS.

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              Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial

              Summary Background Robust evidence of the effectiveness of task shifting of antiretroviral therapy (ART) from doctors to other health workers is scarce. We aimed to assess the effects on mortality, viral suppression, and other health outcomes and quality indicators of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) programme, which provides educational outreach training of nurses to initiate and represcribe ART, and to decentralise care. Methods We undertook a pragmatic, parallel, cluster-randomised trial in South Africa between Jan 28, 2008, and June 30, 2010. We randomly assigned 31 primary-care ART clinics to implement the STRETCH programme (intervention group) or to continue with standard care (control group). The ratio of randomisation depended on how many clinics were in each of nine strata. Two cohorts were enrolled: eligible patients in cohort 1 were adults (aged ≥16 years) with CD4 counts of 350 cells per μL or less who were not receiving ART; those in cohort 2 were adults who had already received ART for at least 6 months and were being treated at enrolment. The primary outcome in cohort 1 was time to death (superiority analysis). The primary outcome in cohort 2 was the proportion with undetectable viral loads (<400 copies per mL) 12 months after enrolment (equivalence analysis, prespecified difference <6%). Patients and clinicians could not be masked to group assignment. The interim analysis was blind, but data analysts were not masked after the database was locked for final analysis. Analyses were done by intention to treat. This trial is registered, number ISRCTN46836853. Findings 5390 patients in cohort 1 and 3029 in cohort 2 were in the intervention group, and 3862 in cohort 1 and 3202 in cohort 2 were in the control group. Median follow-up was 16·3 months (IQR 12·2–18·0) in cohort 1 and 18·0 months (18·0–18·0) in cohort 2. In cohort 1, 997 (20%) of 4943 patients analysed in the intervention group and 747 (19%) of 3862 in the control group with known vital status at the end of the trial had died. Time to death did not differ (hazard ratio [HR] 0·94, 95% CI 0·76–1·15). In a preplanned subgroup analysis of patients with baseline CD4 counts of 201–350 cells per μL, mortality was slightly lower in the intervention group than in the control group (0·73, 0·54–1.00; p=0·052), but it did not differ between groups in patients with baseline CD4 of 200 cells per μL or less (0·94, 0·76–1·15; p=0·577). In cohort 2, viral load suppression 12 months after enrolment was equivalent in intervention (2156 [71%] of 3029 patients) and control groups (2230 [70%] of 3202; risk difference 1·1%, 95% CI −2·4 to 4·6). Interpretation Expansion of primary-care nurses' roles to include ART initiation and represcription can be done safely, and improve health outcomes and quality of care, but might not reduce time to ART or mortality. Funding UK Medical Research Council, Development Cooperation Ireland, and Canadian International Development Agency.
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                Author and article information

                Contributors
                Nahara.Martinez@usz.ch
                Ryan.Tandjung@usz.ch
                Sima.Djalali@usz.ch
                Thomas.Rosemann@usz.ch
                Journal
                Hum Resour Health
                Hum Resour Health
                Human Resources for Health
                BioMed Central (London )
                1478-4491
                7 July 2015
                7 July 2015
                2015
                : 13
                Affiliations
                Institute of Primary Care, University of Zurich, University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
                Article
                49
                10.1186/s12960-015-0049-8
                4493821
                26149447
                © Martínez-González et al. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Research
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                © The Author(s) 2015

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