Task shifting from general practitioners to other health professionals in out-of-hours primary care – a systematic literature review on content and quality of task shifting

Figures & data

Table

Population: Health professionals working in OOH primary care.

Intervention: Task shifting from GPs to other health professionals (e.g. nurses, physician assistants and paramedics).

Comparison: Face-to-face clinic consultations and home visits conducted by GPs compared to other health professionals.

Outcomes: Content: patient characteristics and reasons for encounter Quality: patient satisfaction, safety, and efficiency (e.g. consultation length, prescriptions, tests, investigations, referrals, admissions and return consultations).

Figure 1. PRISMA flow diagram of literature search.

Table 1. Overview of main characteristics of the included articles.

Author Title	Country Year	Study design	Number of patients	Intervention group	Control group	Outcome measures
Van der Biezen et al.* Substitution of general practitioners by nurse practitioners in out-of-hours primary care: a quasi-experimental study	The Netherlands 2016	Quasi-experimental study	Intervention arm: n = 987 (NP) n = 5,053 (GP) Control arm: n = 6,052	1 NP & 4 GPs per shift n = 5 NPs Experience: ≥ 5 years as licenced NP in primary care/elderly care, none in OOH-PC Education: 2-year Master of Nursing Practice (MANP) Training: 3 half days	5 GPs per shift n = 138 GPs Mean age: 49 years, 60% male Experience: 7 years in GPC	Patient characteristics Reason for encounter Productivity
Van der Biezen et al.* The impact of substituting general practitioners with nurse practitioners on resource use, production and healthcare costs during out-of-hours: a quasi-experimental study	The Netherlands 2016	Quasi-experimental study	Intervention arm: n = 987 (NP) 5,053 (GP) Control arm: n = 6,052	1 NP & 4 GPs per shift n = 5 NPs Experience: ≥5 years licenced NP in primary care/elderly care, none in OOH-PC Education: 2-year MANP Training: 3 half days	5 GPs per shift n = 138 GPs Mean age: 49 years, 60% male Experience: 7 years in GPC	Productivity Prescriptions Diagnostic tests Referrals
Van der Biezen et al. Towards an optimal composition of general practitioners and nurse practitioners in out-of-hours primary care teams: a quasi-experimental study	The Netherlands 2017	Quasi-experimental study	Intervention arm: Team 2: n = 3,166 Team 3: n = 3,048 Control arm: Team 1: n = 3,287	Team-2: 3 GPs & 1 NP Team-3: 2 GPs & 2 NPs n = 10 NPs, mean age 45 years Experience: 1.8 years qualified as NP, 1.6 years in OOH-PC Education: 2-year MANP	4 GPs n = 162 GPs Mean age: 48 years, 50% male	Patient characteristics Reason for encounter Safety Productivity Diagnostic tests Prescriptions Referrals
Mason et al.** A pragmatic quasi-experimental multi-site community intervention trial evaluating the impact of Emergency Care Practitioners in different UK health settings on patient pathways (NEECaP Trail)	United Kingdom 2010	Quasi-experimental study	Intervention arm: n = 727 (content) n = 713 (quality) Control arm: n = 889 (content) n = 875 (quality)	ECPs Experiences: paramedic & nursing backgrounds Education: nationally developed core competency programme	GPs	Patient characteristics Reason for encounter Productivity Diagnostic tests Prescriptions Referrals
O’Keeffe et al.** A community intervention trial to evaluate emergency care practitioners in the management of children	United Kingdom 2011	Quasi-experimental study	Intervention arm: n = 350 Control arm: n = 142	Team of ECPs working within GP-led care service Experience: paramedic & nursing backgrounds Education: nationally developed core competency programme	GPs	Patient characteristics Reason for encounter Productivity Diagnostic tests Prescriptions Referrals
Collins Assessing the effectiveness of advanced nurse practitioners undertaking home visits in an out-of-hours urgent primary care service in England	United Kingdom 2018	Observation study	Intervention arm: n = 1,539 (ANPs) Control arm: n = 33,115 (GPs)	ANPs n = 6 ANPs Experience: 4-23 years qualified as ANP, 14 years in OOH-PC	GPs	Patient characteristics Reason for encounter Productivity Prescriptions Referrals
Smits et al. Substitution of general practitioners by nurse practitioners in out-of-hours primary care home visits: A quasi-experimental study	The Netherlands 2019	Quasi-experimental study	Intervention arm: n = 386 (NPs) Control arm: n = 1,215 (GPs)	NPs n = 5 NPs, all male Experience: > 20 years ambulance nurses, 2-6 years in OOH-PC Education: MANP	GPs	Patient characteristics Reason for encounter Patient Satisfaction Productivity Prescriptions Referrals

ANP: advanced nurse practitioner; ECP: emergency care practitioners; GP: general practitioner MANP: master’s degree in advanced nursing practice; n: number; NP: nurse practitioners; OOH-PC: out-of-hour primary care.

* The two articles are based on one study.

** The two articles are based on one study.

Table 2. Risk of bias summary.

Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Total score
Biezen et al. 2016	+	−	+	+	−	−	+	+	+	6
Biezen et al. 2016	+	−	+	+	−	−	+	+	+	6
Biezen et al. 2017	+	−	+	+	−	−	+	+	+	6
Mason et al.	+	+	?	+	−	−	+	+	+	6
O’Keeffe et al.	+	+	?	+	−	−	+	+	+	6
Collins et al.	+	−	?	+	−	−	+	?	?	3
Smits et al.	+	−	+	+	−	−	+	+	+	6

Risk of bias summary, assessed by Joanna Briggs Institute Critical Appraisal Checklist for Quasi-experimental Studies: + = yes,? = unclear and − = no.

Q1: Is it clear in the study what is the ‘cause’ and what is the ‘effect’?, Q2: Were the participants included in any comparisons similar?, Q3: Were the participants included in any comparisons receiving similar treatment/care, other than the exposure or intervention of interest?, Q4: Was there a control group?, Q5: Were there multiple measurements of the outcome both pre and post the intervention/exposure?, Q6: Was follow-up complete and if not, were differences between groups in terms of their follow up adequately described and analysed?, Q7: Were the outcomes of participants included in any comparisons measured in the same way?, Q8: Were outcomes measured reliably?, Q9: Was appropriate statistical analysis used?.

Table 3. Description of content in the included articles.

Study	Intervention	Predefined population for other healthcare professionals	Patient characteristics	Reason for encounter
Clinic consultations
Van der Biezen et al. 2016*	1 NP & 4 GPs per shift	Not: patients < 1 year, patients suffering from psychiatric complaints, abdominal pain, chest pain, neck ailment, headache, or dizziness	Mean age (years): I:32.3 vs C:34.3 I: > aged 2-17 years, C: > older than 64 years (sign. diff.) Male (%): I :51.4 vs C:46.9 Urgency level (%): U1 (Life-threatening visits): I: 0.0 vs. C: 0.1 U2 (Acute visits): I: 2.4 vs. C: 9.5 U3 (Urgent visits): I: 47 vs. C: 47.4 U4 (Routine visits): I: 44.4 vs C: 37.6 U5 (Advice visits): I:6.2 vs C:5.4 I: >U4 vs. C: >U2 (sign. diff.)	> 55% of all patients: skin, musculoskeletal or respiratory system I > C: skin & respiratory complaints C > I: eye, digestive, cardiovascular, & neurological complaints (sign. diff.) 77.5% of all contacts: NPs’ predefined population NPs saw patients outside predefined population: digestive (3.0%), psychological (0.5%), neurological complaints (0.3%), & children < 1 year old (7.3%)
Van der Biezen et al. 2016*	1 NP & 4 GPs per shift	Not: patients < 1 year, patients suffering from psychiatric complaints, abdominal pain, chest pain, neck ailment, headache, or dizziness	NA	NA
Van der Biezen et al. 2017	1 NP & 3 GPs (team 2), 2 NPs & 2 GPs (team 3)	Not: patients < 1 year, patients suffering from psychiatric complaints, abdominal pain, chest pain, neck ailment, headache, or dizziness	NA	All teams: top 4 covered > 2/3 of all patients: skin (21%), musculoskeletal (21%), respiratory (14%), digestive (11%) 80.9% of all contacts fitted NPs’ predefined population
Mason et al.**	ECPs	NA	Mean age (years): I:42.9 vs. C:32.5 Male (%): I:39.6 vs. C:40.3	Paediatric medical patients: I: 18.7% vs. C: 38.9% Paediatric patients with trauma: I: 0.8% vs. C: 0.3% Adult medical patients: I: 64.2% vs. C: 57.5% Adult patients with trauma: I: 13.1% vs. C: 3.1% Elderly falls: I: 3.2% vs. C: 0.1%
O’Keeffe et al.**	ECPs	NA	Mean age (years): I: 4.2 vs. C: 4.3 Male (%): I: 46.5 vs. C: 48.3	Medical general: I: 64.6% vs. C: 71.3% Trauma: I: 4.6% vs C: 0.9% Eye-ear-nose-throat: I: 12.3% vs C: 11.5% Respiratory: I: 18.5% vs C: 16.3%
Home visits
Collins	ANPs	All patients, apart from pregnant women.	NA	The variance and potential complexity range from minor illnesses to more complex conditions. ANPs’ top 10 matched GPs’ top 10 for 9 conditions: lower respiratory tract infection, urinary tract infection, abdominal pain, other reasons for encounter, accidental falls, vomiting, death administration, skin/subcutaneous infections, and terminal care.
Smits et al.	NPs	24 predefined low complex health problems: arm complaints, leg complaints, insult, nosebleeds, extremity trauma, neck trauma, back trauma, skull trauma, thorax trauma, face trauma, abdominal trauma, burn/inhalation trauma, intoxication, shortness of breath, palpitations, neurological failure, disrupted diabetes, thorax pain, back pain, urinary tract problems, wound, fainting, dizziness, and headache.	Mean age (years): I: 73.0 vs. C: 74.6 Male patients (%): I: 45.6 vs. C: 43.3 Urgency level (%): (sign. diff.) U1/Life-threatening visits: I: 0.3 vs. C: 3.0 U2/Acute visits: I: 48.2 vs. C: 53.1 U3/Urgent visits: I: 47.4 vs. C: 41.8 U4/Routine visits: I: 2.8 vs C: 1.8 U5/Advice visits: I: 1.3 vs C: 0.3 Most used triage urgency levels: U2/Acute and U3/Urgent	Most frequent health problem in both groups is shortness of breath Patients with shortness of breath: I: 26.2% vs. C: 32.2% (sign. diff.) Patients with traumas: I: 11.1% vs. C: 6.4% (sign. diff) None of other health problems differed significantly

ANP: advanced nurse practitioner; C: control; ECP: emergency care practitioners; GP: general practitioner; I: intervention; NP: nurse practitioners; NA: not applicable.

* The two articles are based on one study.

** The two articles are based on one study.

Table 4. Efficiency of healthcare provided by other healthcare professionals compared to regular care by GPs.

Study	Intervention	Productivity	Diagnostic tests (%)	Prescriptions (%)	Referrals (%)
Clinic consultations
Van der Biezen et al. 2016*	1 NP & 4 GPs per shift	Mean number of patients/shifts: I: 15.7 vs C:20.1	NA	NA	NA
Van der Biezen et al. 2016*	1 NP & 4 GPs per shift	Mean number of consultations/ hours: I: 2.3 vs C:3.0 (sign.)	X-rays: I: 5.6 vs C: 4.2	I: 37.1 vs: C: 43 (sign.)	I: 5.1 vs C: 11.3 (sign.)
Van der Biezen et al. 2017	I-2: 1 NP & 3 GPs (team 2) I-3: 2 NPs & 2 GPs (team 3)	Mean number of consultations/hour/health professional: I-2: GP: 3.2 vs NP: 2.6 I-3: GP: 3.3 vs NP: 2.5 Autonomous consultations by NPs I-2: 93.4% I-3: 97.5%	NA	NA	NA
Mason et al.**	ECPs	Median episode time (min): I: 87 vs. C: 146 (sign. diff).	I: 16.9 vs. C: 7.1 (sign.)	I: 58.2 vs. C: 56 (sign.)	I: 17.1 vs. C: 10.7. (sign.)
ÓKeeffe et al.**	ECPs	Median episode time (min): I: 81 vs. C: 140. (sign. diff).	I: 7 vs. C: 2.3 (sign.)	I: 45.1 vs. C: 54.9 (sign.)	I: 12.8 vs. C: 9.3 (sign.)
Home visits
Collins	ANPs	Average length of time (min/contact): I: 33 vs C: 37 Median length of time: I = C: 26 min. Completed < 40 min: I = C: 72% Average proportion of homes visits/all contacts/night shift: no difference Response times: 1-hour response time: I: 33.9% vs. C: 74.9% No other differences	NA	Intervention’s top 20 prescriptions matched 18 of top 20 control prescriptions.	I: 12.9 vs. C: 16.3
Smits et al.	NPs	Mean length (mins): I: 34.1 vs. C: 21.1 (sign.)	NA	I: 19.9 vs. C: 30.6 (sign.)	I: 24.1 vs. C: 15.9 (sign.)

ANP: advanced nurse practitioner; C: control; ECP: emergency care practitioners; GP: general practitioner; I: intervention; NP: nurse practitioners; NA: not applicable.

* The two articles are based on one study.

** The two articles are based on one study.

Availability of data and materials

The data used during the current study are available from the corresponding author upon reasonable request.