Effects of physician-nurse substitution on clinical parameters: a systematic review and meta-analysis.
Effects of physician-nurse substitution on clinical parameters: a systematic review and meta-analysis.
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DOI：
10.1371/journal.pone.0089181
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发表时间：
2014
期刊：
影响因子：
3.7
通讯作者：
Rosemann T
中科院分区：
文献类型：
--
作者：
Martínez-González NA;Tandjung R;Djalali S;Huber-Geismann F;Markun S;Rosemann T
许多国家的医生短缺以及对高质量和负担得起的护理的需求使医生-护士替代成为一种有吸引力的劳动力战略。本研究的目的是对随机对照试验（RCT）进行系统回顾和荟萃分析，以评估初级保健中医生-护士替代对临床参数的影响。我们系统检索了截至2012年8月的奥维德Medline和Embase、科克伦图书馆和CINAHL;选择了同行评审的RCT，比较了医生主导的护理与护士主导的护理在临床参数变化方面的差异。研究选择和数据提取由独立审查员进行，一式两份。我们评估了个体研究的偏倚风险;计算了研究特异性和合并的相对风险（RR）或加权平均差（WMD）;并进行了固定效应荟萃分析。纳入了11项RCT（N =30，247）;大多数来自欧洲，通常规模较小，偏倚风险较高。 在所有的研究中，护士都为包括艾滋病毒、高血压、心力衰竭、脑血管疾病、糖尿病、哮喘、帕金森病和尿失禁在内的复杂疾病提供护理。荟萃分析显示，收缩压（SBP）降低幅度更大，有利于护士主导的护理（WMD −4.27 mmHg，95% CI −6.31至−2.23），但在舒张压（DBP）降低方面，组间无统计学显著差异（WMD −1.48 mmHg，95%CI −3.05至−0.09）、总胆固醇（TC）（WMD -0.08 mmol/l，95%CI -0.22至0.07）或糖化血红蛋白（WMD 0.12%HbAc1，95%CI -0.13至0.37）。在确定的其他32个临床参数中，不到五分之一的人赞成护士领导的护理，而25个组之间没有显着差异。只有少数几个卫生保健系统提供针对特定疾病的干预措施，研究的数量和质量不足，参数众多。经过培训的护士在降低SBP方面似乎优于医生，但在降低DBP、TC或HbA 1c方面相似。没有足够的证据表明，护士主导的护理比医生主导的护理导致更好的其他临床参数的结果。
Physicians’ shortage in many countries and demands of high-quality and affordable care make physician-nurse substitution an appealing workforce strategy. The objective of this study is to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) assessing the impact of physician-nurse substitution in primary care on clinical parameters. We systematically searched OVID Medline and Embase, The Cochrane Library and CINAHL, up to August 2012; selected peer-reviewed RCTs comparing physician-led care with nurse-led care on changes in clinical parameters. Study selection and data extraction were performed in duplicate by independent reviewers. We assessed the individual study risk of bias; calculated the study-specific and pooled relative risks (RR) or weighted mean differences (WMD); and performed fixed-effects meta-analyses. 11 RCTs (N = 30,247) were included; most were from Europe, generally small with higher risk of bias. In all studies, nurses provided care for complex conditions including HIV, hypertension, heart failure, cerebrovascular diseases, diabetes, asthma, Parkinson’s disease and incontinence. Meta-analyses showed greater reductions in systolic blood pressure (SBP) in favour of nurse-led care (WMD −4.27 mmHg, 95% CI −6.31 to −2.23) but no statistically significant differences between groups in the reduction of diastolic blood pressure (DBP) (WMD −1.48 mmHg, 95%CI −3.05 to −0.09), total cholesterol (TC) (WMD -0.08 mmol/l, 95%CI -0.22 to 0.07) or glycosylated haemoglobin (WMD 0.12%HbAc1, 95%CI -0.13 to 0.37). Of other 32 clinical parameters identified, less than a fifth favoured nurse-led care while 25 showed no significant differences between groups. disease-specific interventions from a small selection of healthcare systems, insufficient quantity and quality of studies, many different parameters. trained nurses appeared to be better than physicians at lowering SBP but similar at lowering DBP, TC or HbA1c. There is insufficient evidence that nurse-led care leads to better outcomes of other clinical parameters than physician-led care.
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