Overall, NP consultations were associated with higher patient age, and a higher share of multimorbid and polypharmaceutical patients in comparison to GP consultations. Age remained significantly associated with NP consultations after adjusting for potential confounders, multimorbidity and polypharmacy did not. During NP consultations, vital signs and anthropometric data were measured more frequently, and lab tests were ordered more often. By contrast, medications were prescribed or changed more frequently in GP consultations than in NP consultations.
Interpretation & comparison to existing literature
Bryant-Lukosius et al. (17) suggested in their evaluation framework “PEPPA Plus” to determine the characteristics of patients seen and treated by Swiss NPs in the early stages of role introduction. Our results indicate that the NP had a focus on multimorbid, polypharmaceutical elderly. In fact, almost 20% of her consultations were with patients aged 85+. This might be a consequence from the NP’s postgraduate education, which focused on care for older patients with complex health care needs (22). Another reason could be that these patients were potentially underserved in this practice, and might have been specifically assigned to her within the project. In a qualitative study by Gysin et al. (14), most NPs who work in Swiss family practices reported a similar patient population they served. (24, 25)(22)(14)This goes in line with current political efforts to address the increase in chronic conditions. International studies showed that NPs provide at least equivalent care for people with chronic conditions as physicians, often through patient education, multidimensional assessments and coordination of multiple providers (33, 34). In some countries such as S(26)weden, NPs also have a focus on chronically ill elderly (24). In other countries like the US, Canada, Australia and the UK, NPs treat patients across the age span and take care of minor acute illnesses as well as chronic conditions (10, 25-27). For instance, (30, 31)in Veterans Health Administration facilities, Morgan et al. (28) found that patient age did not differ between NP and GP consultations in primary care offices. However, in the US, NPs can specialize in gerontology, and a study by Hendrix et al. (29) found that these geriatric NPs might be the most appropriate providers of coordinated chronic care to the elderly population. Interestingly, a Dutch study from Van Der Biezen et al. (30) showed that GPs saw more patients aged 65+ in comparison to the NPs. However, this study analyzed out-of-hours primary care consultations. Therefore, comparability might be limited.
Multimorbid, polypharmaceutical elderly are often homebound, and it is possible that the NP in our study conducted more home visits, including visits in nursing homes, than the GPs, which could explain the higher patient age in her consultations. In the US, NPs are the largest type of “full time house call providers” with prescriptive authority (31). In Switzerland, the number of GP home visits have decreased drastically in recent years, and home visits, especially follow-up visits to elderly, have been identified as a task that could potentially be performed by NPs (32).
The NP in our study measured vital signs and anthropometric data or assigned these tasks to practice assistants more frequently compared to the GPs, and ordered lab tests more often. This might be because the NP saw more multimorbid, polypharmaceutical elderly, which usually need closer monitoring, e.g. regular blood pressure measurements in hypertension, weight control in heart failure or frequent HbA1c measurements in diabetes. However, the significant differences remained after adjusting for age, multimorbidity and polypharmacy. This could have several reasons. As a novice and pioneer, the NP was maybe more careful and ordered clinical and lab parameters more often in order not to miss something. Several pioneering NPs in Swiss primary care mentioned similar behavior before (14). International studies found that nurse-led care can result in improved blood pressure control and outcomes, e.g. in diabetes care or cardiovascular prevention (35, 36). These findings were often attributed to stricter guideline adherence. Similarly, Chan et al. (37) found that NP care for patients who suffered from dyspepsia and underwent gastroscopy was effective because of the adherence to standardized follow-ups which included weight measurement. Ohman et al. (38) found that practices with NPs were more likely to measure lab values (e.g. HbA1c, lipid levels or urinary microalbumin levels) compared to practices with physicians and physician assistants or physicians only. These findings are in accordance with our study results.
The two GPs in our study changed and prescribed new drugs more often than the NP. This could be explained by the fact that NPs do not have independent, full prescription rights in Switzerland yet, and educational programs still lack several hours on pharmacology compared to international standards, which could yield in hesitation of prescribing new drugs. De Bruijn-Geraets et al. (39) found that prescription rates of Dutch NPs increased after obtaining full legal practice authority. However, during out-of-hours consultations, Van Der Biezen et al. (30) found that NPs still prescribed less medications compared to GPs. The authors hypothesized that this could result from more patient education. In the UK, nurses can obtain independent prescribing rights after undergoing the necessary training, and several studies have been conducted regarding health outcomes of “non-medical” prescribing (40-42). Venning et al. (43) found no difference between prescription rates of NPs and GPs in the UK. This aligns with the findings of an international systematic review by Laurant et al. (9), which is mostly based on studies from countries at advanced stage of NP role implementation. Furthermore, in the US, Barnes et al. (44) found that independent prescription rights for NPs (i.e. same rights as doctors) may lead to higher participation of NPs in primary care. This finding could be relevant when implementing the NP role in Swiss primary care.
We only had data from one family practice with one NP, which limits the external validity of this study as it was influenced by personal factors (e.g. the NP’s previous experience as a registered nurse) and politically-driven project factors (e.g. the goal to address chronically ill elderly). However, these political factors might reflect what is considered important when new professionals are introduced to a health care system, and may be present even if larger cohorts are investigated. We measured patient characteristics and activities during NP consultations but did not assess or compare the quality of care itself. Further, the practice did not use ICPC-2 codes; hence, we did not have any information on the reasons for encounter. However, Busato et al. (45) showed that using drugs to identify morbidity within FIRE data is as reliable as using ICPC-2 codes. We did not know how much the NP’s activities were influenced by the two supervising GPs, and we could not assess to what extent the NP complemented or substituted the GPs. We could also not measure whether certain activities (e.g. blood pressure measurement) were actually performed by the NP and GPs respectively, or by a practice assistant. There were not sufficient information regarding the site of the consultations; hence, we did not know which consultations took place in the practice or at a patient’s home. Lastly, we could not assess whether missing information was due to non-performance or non-documentation in the EMR. This limitation has been discussed by Djalali et al. (46) when using FIRE data.
Quantitative data from pilot projects provide valuable insights into the NP tasks and activities in Swiss primary care. These insights might trigger suitable regulations and promote further role implementation. Standardized curricula with more pharmacology, and defined scope of practices could allow NPs to focus on a certain groups of patients and prescribe certain drugs more independently, i.e. without GP supervision. This could then lead to more role attractiveness and clarity, and subsequently to higher numbers of NPs working in Swiss family practices. The wider use of EMRs and reimbursement data on NPs could facilitate future research. Further studies with larger numbers are needed to determine their exact role in Swiss primary care, their collaboration and task sharing with GPs and practice assistants, and to scrutinize the quality of care provided by NPs. For example, health insurance data could be used to assess the costs and length of NP consultations once there are separate billing options for NPs.
Our results provide first indications that NPs might have a focus on and could offer care to the growing number of multimorbid, polypharmaceutical elderly in Swiss primary care.