1. Nurse practitioner in General Practice: The Expedition A.T. M. Dierick- van Daele, J.F.M. Metsemakers, E.W.C.C. Derckx, C. Spreeuwenberg, H.J.M. Vrijhoef 14 May Copenhagen

3. Project Nurse Practitioner in General Practice (NPGP) Background Increasing and changing demand of care Need to increasing service capacity Shortness of physicians Literature review NP: high quality of care/ higher patient satisfaction NP: limited evidence for cost effectiveness

4. Definition nurse practitioner (NP) registered nurses additional education and training - i.e. Master in Advanced Nursing Practice expanded scope of practice working in specific settings

5. Training program 1. Patient care diagnosing, prescribing, and treating medical conditions of patients with common complaints 2. Collaboration coordination of care, professional collaboration 3. Quality of the care projects and research, evidence based practice, education

6. Specified set of common complaints respiratory and throat complaints ear and nose complaints musculoskeletal complaints and skin injuries urological complaints gynaecological complaints sexual transmitted diseases geriatric problems

7. Objective To evaluate effects on the process and outcomes of care as provided by GPs or specially trained NPs for patients at first point of contact.

9. Research method

10. Randomised controlled trial Patients: > 16 years, common complaints, initial consultation Within NPGP-project: Intervention group: NP consultation Reference group : GP consultation Outside NPGP-project: External reference group: GP consultation (costs only) Patients: –common complaints –> 16 years old –initial consultation

11. Participants 15 general practices within the NPGP project: –Twelve NPs –Twelve lectured GPs –31 GPs Five external reference practices outside the NPGP project - 17 GPs Region: Southern of The Netherlands

12. Outcome and data collection Quality of the care: -Patient perceptionsQuestionnaires (T1, T2) -Effectiveness of the consultation Questionnaires (T0, T2) -Compliance practice guidelinesData-extraction Costs: -Medical consumptionData-extraction -Follow up consultationQuestionnaire (T2) -Time of durationStopwatch -Presence of illness Questionnaire (T2)

13. Calculation of costs Direct costs within health care sector: -Medical consumption -Follow up consultation -Time of duration -Salary costs Costs outside the health care sector: -Productivity costs

14. Analyses Descriptive statistics Two tailed T-test, Chi-squared test, ANOVA Bootstrapping Sensitivity analysis, subgroup analysis, linear regression and mixed model analysis

15. Results

16. Flowchart Assesed for eligibility (n=2000). Inclusion Exclusion (n=499) Randomisation (n=1501) Consultation NP Allocated to intervention (n=817) Received allocated intervention (n=759) Consult ation GP Allocated to intervention (n=684) Received allocatied intervention (n=650) Completed questionnaires T0 and TI (n=693)Completed questionnaires T0 and TI (n=613) Completed questionnairesT2 (n=517)Completed questionnaires T2 (n=492)

17. Patient characteristics NP consultation within NPGP- practices GP consultations within NPGP practices N= 1397N=1350P Sexe Male/ Female (%)38.2/ 61.840.0 /60.00.41 Age; years mean (SD)42.8 (16.5)46.1 (16.16)0.001 Consultations NPGP- practices Consultations external reference practices N= 1397N=1350P Sexe Male/ Female (%)39.0/ 61.039.4/ 60.60.83 Age; years mean (SD)45.1 (16.7)47.2 (18.2)0.001

18. NP consultations versus GP consultations (NPGP practices) No significant differences in: Patient perspections (Likert scale 0-10: mean 8.2 both groups) Effect of the treatment, compliance practice guidelines, medical consumption, presence of illness Significant differences in: Advice follow up consultation(NP 50%; GP 41%) Follow up consultation (NP 23.5%; GP 18.5%) Time of duration (NP 12.2 min; GP 9.2 min)

19. Costs per consultation within NPGP practices Costs*NP (I) N=747 Mean GP (R) N=650 Mean ∆I-RP--alue Based on norm income GP €31.94€40.15-€8.210.001 Based on salary GP in employment €31.94€38.33-€6.390.007 Based on salary GP employed by other GPs €31.94€37.15-€5.530.02 *costs: prescriptions, referrals, diagnostic procedures, follow up consultations, time of duration, salary costs *kosten gebaseerd op recepten, aanvullend diagnostisch onderzoek, verwijzingen, vervolgconsulten, duur van het consult, salaris-en opleidingskosten **inclusief productiviteitskosten

20. Costs per consultations: NPGP practices vs reference practices Costs*NPGP practices N= 1397 Mean External reference practices N=1350 Mean ∆I-RP-value Based on norm income GP €35.76€39.21-€3.450,04 Based on salary GP in employment €34.92€37.39-€2.470,13 Based on salary GP employed by other GPs €34.50€36.51-€2,010,22 costs: prescriptions, referrals, diagnostic procedures, follow up consultations, time of duration, salary costs *kosten gebaseerd op recepten, aanvullend diagnostisch onderzoek, verwijzingen, vervolgconsulten, duur van het consult, salaris-en opleidingskosten **inclusief productiviteitskosten

21. Costs including productivity costs (patients <65 years old) NP consultations vs GP consultations: within NPGP practices: –NP consultations € 9.18 cheaper (P<0.001) Consultations within NPGP practices vs consultations ext. reference practices: –Consultations within NPGP practices € 2.60 cheaper (P 0.13)

23. Conclusion NPs provide equivalent quality of care than GP by a specified set of common complaints NPs are likely to generate less costs than GPs NPs contribute to the accessibility and availability of primary care NP could also lead to GPs having more time for patients with chronic diseases or multi morbidity

24. Reconsiderations Elements of a HTA -study Meaning of cost differences Exploration of factors influencing costs Attention for implementation

25. Take care Thank you for your attention…