BMJ  2005;330:682-683 (26 March), doi:10.1136/bmj.330.7493.682

Editorial

Nurse led care

Determining long term effects is harder than measuring short term costs

What's the difference between medical and nursing care? The answer is not straightforward, but shortages in the medical workforce mean that nurses are increasingly called on to undertake work that was previously done by doctors (such as undertaking surgery,¹ prescribing drugs, performing triage in emergency departments), whereas shortages in the nursing workforce mean that healthcare assistants now do many tasks that nurses are trained to do. This fluidity in professional roles and competencies enables the health workforce to respond to need, but are outcomes for patients being improved? Do these benefits come at an additional cost, and if so, are they worth paying for?

Over the past decade, research has increasingly compared nurse led care with usual care for aspects of health care previously delivered by doctors. However, nurse led care does not have one meaning. Nurse led care can be usefully viewed as a continuum with, at one end, nurses undertaking highly protocol driven, focused tasks (cardioversion,² colposcopy, smoking cessation) and, at the other end, responding to far more diverse challenges in terms of clinical decision making, such as first contact care and rehabilitation. The extent to which doctors' work can be delegated effectively is likely to be influenced, in part, by the type and complexity of the associated decision tasks. This issue of the BMJ presents two economic evaluations of nurse led care—each occupying a different place on this continuum. The paper by Raftery et al (p 707) is an evaluation of nurse led secondary prevention of coronary heart disease and has several strengths, including its basis in a randomised controlled trial with four years' follow up and a cost effectiveness analysis.³ The authors conclude that primary care based, nurse led secondary prevention of coronary heart disease is highly cost effective, since the cost per patient was only £136 ($260; 195) greater in the intervention group, but the benefits (fewer deaths and improvements in medical care and patient lifestyle) make this highly worth while, with a cost per quality adjusted life year (QALY) of £1097.

The second study, an evaluation of nurse led intermediate care in an acute setting (p 699), represents a more complex nursing role that demands multifarious clinical decisions (although patients reaching intermediate care have been "filtered" through medical diagnosis and initial treatments).⁴ These authors undertook a cost minimisation analysis—they viewed the clinical outcomes in the intermediate care and standard hospital care arms as equivalent and merely totalled up and compared the costs. Walsh et al found, as have others,⁵ that nurse led intermediate care in acute settings is more expensive than standard hospital based care for the inpatient phase, but the longer term costs and benefits are more uncertain.

Close inspection of the clinical outcomes in the trial by Walsh et al⁶ reveals that patients who received nurse led intermediate care had better functional outcomes at discharge, although this did not reach significance. However, this lack of statistical significance is not the same as "no difference" in functional outcomes. A meta-analysis of 10 studies of nurse led intermediate care⁷ (which includes the Walsh trial⁶) identified a statistically significant benefit of nurse led intermediate care on functional status at discharge, as well as reductions in the proportion of patients discharged to institutional care and in readmissions. This indicates that the increase in functional status may be clinically (and potentially economically) important and warrants further study.

In an editorial in the BMJ Briggs counselled against cost minimisation analysis in favour of cost effectiveness analysis since studies are rarely powered to confidently identify clinical equivalence.⁸ Hence, the lack of a statistically significant difference in effectiveness should not be used as a justification for a cost minimisation analysis. While the higher costs of nurse led intermediate care are due to an increased length of stay, existing analyses have failed to determine whether these costs are offset by lower costs (of health care and particularly social care) and health benefits gained in the longer term.

The ways in which nursing teams in the nurse led units make decisions about discharge also need to be explored. Nurses may, rightly or wrongly, be more conservative in discharging patients. They may err on the side of caution, but the benefits of these conservative decisions can only be judged with longer term follow up.

Do these two new studies help us understand the differences between medical and nursing care? We think they usefully remind us that nursing care is not necessarily less costly and that the extra costs may be worth the benefits but that health outcomes need to be measured carefully in studies of sufficient power. It should not be assumed that the outcomes of nursing and medical care are equivalent.

The skills of healthcare professionals and their assistants are much in demand and constitute a limited resource that needs to be deployed in the most cost effective way. Although UK health policy supports the development of nursing roles, as nurses take on more duties and responsibilities we must also question what, if anything, is being lost from nursing, to whom and does it matter?

(nac2{at}york.ac.uk), Department of Health Sciences, University of York, York YO10 5DD

Department of Health Sciences, University of York, York YO10 5DD

Centre for Health Economics, University of York, York YO10 5DD

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Papers p 699 and Primary care p 707

Competing interests: KS and GR have conducted and published evaluations of nurse led intermediate care.

References

1. BBC News Online. Training nurses to do surgery. http://news.bbc.co.uk/2/hi/health/3580453.stm (accessed 10 Mar 2005).
2. Currie MP, Karwatowski SP, Perera J, Langford EJ. Introduction of nurse led DC cardioversion service in day surgery unit: prospective audit. BMJ 2004;329: 892-4.[Abstract/Free Full Text]
3. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. The cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised trial. BMJ 2005;330: 707-10.[Abstract/Free Full Text]
4. Walsh B, Steiner A, Pickering RM, Ward-Basu J. Economic evaluation of nurse led intermediate care versus standard acute care for post-acute medical patients: cost minimisation analysis of data from a randomised controlled trial. BMJ 2005;330: 699-702.[Abstract/Free Full Text]
5. Griffiths P, Harris R, Richardson G, Hallett N, Heard S, Wilson-Barnett J. Substitution of a nursing-led inpatient unit for acute services: randomized controlled trial of outcomes and cost of nursing-led intermediate care. Age Ageing 2001;30: 483-8.[Abstract/Free Full Text]
6. Steiner A, Walsh B, Pickering RM, Wiles R, Ward J, Brooking JI. Therapeutic nursing or unblocking beds? A randomised controlled trial of a post-acute intermediate care service. BMJ 2001;322: 453-60.[Abstract/Free Full Text]
7. Griffiths PD, Edwards MH, Forbes A, Harris RL, Ritchie G. Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database Syst Rev 2004;(4): CD002214.
8. Briggs A. Economic evaluation and clinical trials: size matters. BMJ 2000;321: 1362-3.[Free Full Text]

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