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Mundinger MO, Kane RL, Lenz ER, et al. Primary Care Outcomes in Patients Treated by Nurse Practitioners or Physicians: A Randomized Trial. JAMA. 2000;283(1):59–68. doi:10.1001/jama.283.1.59
Author Affiliations: School of Nursing (Drs Mundinger and Lenz and Ms Totten), Joseph L. Mailman School of Public Health (Dr Tsai), and College of Physicians and Surgeons (Dr Shelanski), Columbia University, New York, NY; University of Minnesota School of Public Health, Minneapolis (Dr Kane); Department of Health Care Policy, Harvard Medical School, Boston, Mass (Dr Cleary); Metropolitan Life Insurance Company, New York, NY (Dr Friedewald); and The Mount Sinai Medical Center, New York, NY (Dr Siu).
Context Studies have suggested that the quality of primary care delivered by
nurse practitioners is equal to that of physicians. However, these studies
did not measure nurse practitioner practices that had the same degree of independence
as the comparison physician practices, nor did previous studies provide direct
comparison of outcomes for patients with nurse practitioner or physician providers.
Objective To compare outcomes for patients randomly assigned to nurse practitioners
or physicians for primary care follow-up and ongoing care after an emergency
department or urgent care visit.
Design Randomized trial conducted between August 1995 and October 1997, with
patient interviews at 6 months after initial appointment and health services
utilization data recorded at 6 months and 1 year after initial appointment.
Setting Four community-based primary care clinics (17 physicians) and 1 primary
care clinic (7 nurse practitioners) at an urban academic medical center.
Patients Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years;
76.8% female; 90.3% Hispanic) who had no regular source of care and kept their
initial primary care appointment were enrolled and randomized with either
a nurse practitioner (n = 806) or physician (n = 510).
Main Outcome Measures Patient satisfaction after initial appointment (based on 15-item questionnaire);
health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic
test results 6 months later; and service utilization (obtained from computer
records) for 1 year after initial appointment, compared by type of provider.
Results No significant differences were found in patients' health status (nurse
practitioners vs physicians) at 6 months (P = .92).
Physiologic test results for patients with diabetes (P
= .82) or asthma (P = .77) were not different. For
patients with hypertension, the diastolic value was statistically significantly
lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services
utilization after either 6 months or 1 year. There were no differences in
satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months
differed for 1 of 4 dimensions measured (provider attributes), with physicians
rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).
Conclusions In an ambulatory care situation in which patients were randomly assigned
to either nurse practitioners or physicians, and where nurse practitioners
had the same authority, responsibilities, productivity and administrative
requirements, and patient population as primary care physicians, patients'
outcomes were comparable.
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