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Table 5 Complexity Quotes

From: Complexity as a factor for task allocation among general practitioners and nurse practitioners: a narrative review

Source Quotes
Qualitative study design
O’Brien et al. 2008, US “The physician often has a more in-depth background in some of the complex medical issues and takes the leadership in that.”
Parker et al. [24], AU “Some consumers saw that seeing a nurse practitioner for minor ailments would ‘free up the GP’ to deal with more complex medical concerns, but was also connected to not wasting the GP’s time.” “These values and skills provided the basis for the focus group respondents’ approval towards appropriately trained nurse practitioners being acceptable primary health care providers, in particular for minor ailments and less complex conditions.”
O’Malley et al. [25], US “Primary care physicians provide comprehensive whole-person care, including preventive, acure and complex care needs.” “Nurse care manager (relatively new role, most often filled by RN): works with complex patients on care plan, goals, education; monitor periodic labs and results.” “Offloading of routine tasks to MAs and LPNs resulted in increased job satisfaction for physicians in several practices, who could instead focus on patients’ more complex and personal needs.”
Van der Biezen et al. [26], NL “Some GPs wanted to employ the PA/NP in order to replace a GP, to expand the number of patients in their practice or to create job opportunities for their own professional development (e.g. focussing on more complex patients, more time for study or ancillary activities).” “[...] we initiated to work with NPs to meet the increase in patients so that GPs can focus on the complex patients.” “As a consequence of the PA/NP treating the less complex patients, all GPs expected a difference in their own caseload. While some GPs considered this an opportunity for their own professional growth and enhancing job satisfaction, others feared a more complex caseload. This included a fear of losing routine in treating minor ailments or an increased work pressure due to more complex complaints during surgery hours.”
Lovink et al. [27], NL “NPs were reported to be competent to screen older adults with complex care needs.” “The introduction of NPs, PAs and RNs changed the role of GPs from a more clinical expert role for all patients to a more coordinating role with focus as clinical expert on the more complex patients. Positive perceived effects were that the workload for the GPs became lower, that their practices could be larger and that they had more time to focus on the more complex patients. Negative perceived effects were that the GPs had less patient contact and less freedom because they should be available for the NP, PA or RN and that the GPs only had consultations for complex patients increasing the caseload as NPs, PAs and RNs only had consultations for less complex patients.”
Boman et al. [28], NO/FI “The GNPs were also envisioned to take on a linking role between patient and health services, taking on a case management role especially for patients with comorbidity and complex care needs.”
Côté et al. [29], CA “For many physicians, collaboration with PHCNPs has meant that their own case loads have included more medically complex patients, while less medically vulnerable patients are being directed toward the PHCNPs.”
Pelletier et al. [30], CA “Respondents felt that PHCNPs enable family physicians to manage more chronically ill patients with more complex health situations. However, this redistribution was perceived by some to increase physicians’ workload because physicians would then be dedicating more of their time to complex cases.” “Most respondents observed that PHCNPs devote most of their time to a highly diversified clientele and to acute care for a great variety of minor medical problems.”
Quantitative study designs
Ohman-Strickland et al. [31], US “For instance, when a practice uses either PAs or NPs, the practice’s overall performance may reflect the distribution of patients to clinicians. Complex patient cases may be assigned to physicians, more routine or acute cases may be assigned to PAs, and cases requiring a more preventive approach may be assigned to NPs. Theoretically, this could lead to more efficient and individualized patient care.”
Everett et al. [32], US “Populations served by PA/NPs and doctors differ demographically but not in complexity.”
Subramanian et al. [33], US “Most NPs and some PAs in the VHA system practice more or less independently, or under delayed physician supervision, and manage patients requiring high levels of decision-making complexity.”“We can say that given the expanding role of midlevel providers in delivering primary care to complex patients, we need to better understand whether differences in BP treatment change by provider type at a single visit lead to long-term differences in BP management and control.”
Yarnall et al. [34], US “Additional nonphysician clinicians - including physician assistants (PAs) and nurse practitioners (NPs) - can expand the amount of time available for patient care and allow physicians to focus on the most complex medical care issues.”
Chung et al. [35], US “PCP’s with NP-PA were found to have a greater likelihood of treating patients with complex conditions instead of referring them to specialists.” “PCPs with NP-PA were also found to provide appropriate care to the complex patients. These findings indicate that NP-PA enable PCP to concentrate on patients with more complex conditions thus reducing the number of referrals.” “The use of NP-PA is viewed as being causally linked to increases in treating patients with complex conditions.”
Mian et al. [36], CA “Referrals of clients from FPs to PHCNPs may reflect both FPs’ reliance on NPs’ unique competencies and “value-added” skills in communication and employment of NPs as substitution for less complex care [as supported by previous evidence].”
Morgan et al. [37], US “Nurse practitioner and PA patients had slightly lower DCG complexity scores than physician patients (physicians, 0.89; NPs, 0.84; PAs, 0.82) [but] can be considered similar across the three provider groups.”
“The finding of only small differences in this measure of patient complexity challenges the prevailing notion that NPs and PAs see patients who are less medically complex than those cared for by physicians.” “Within encounters for established patients, physicians staffed slightly more visits towards the more complex end of the spectrum than did NPs or PAs.”
“Overall, NPs, PAs, and physicians filled similar roles in VHA primary care clinics, although there were some differences in patient complexity and purpose of visits.”
Donelan et al. [38], US “Clinicians who agreed with this statement were asked to identify the types of services that were primarily handled by physicians: 43.8% of physicians and 21.1% of nurse practitioners cited care for more complex cases [...].”“Although physicians and nurse practitioners differed significantly on most items, the majority of the two groups reported that most services were performed by both providers, with the exception that only 28.3% of physicians agreed that nurse practitioners provided services for complex chronic conditions that were complicated by coexisting conditions or were not yet well controlled.”
Everett et al. [39], US “Panels with PAs or NPs as supplemental providers that provided care to at least one patient with a risk score of 2.0 or greater (that is, twice the average predicted use of services for older patients) were categorized as providing care to highly complex patients.”
“Patients with supplemental PAs or NPs who did not treat highly complex patients consistently experienced similar or better outcomes, compared to patients receiving physician-only care. In contrast, patients with supplemental PAs or NPs who did treat highly complex patients experienced several worse outcomes, again compared to patients receiving physician-only care.”
“For example, if the primary goal is more frequent testing of glycemic control, then the addition of supplemental PAs or NPs who do not treat highly complex patients but who do deliver care for chronic conditions might be appropriate.”
Everett et al. [40], US “Panels with PA/NPs as usual providers appear to have a higher proportion of socially complex patients, when defined according to poverty (Medicaid), disability, and co-morbid dementia and depression. [...]. In contrast, the clinical complexity of patient panels appears similar regardless of usual provider type [...].”
“The probability of patients having a visit with a supplemental physician (5–48%) is significantly higher on panels with PA/NPs as usual providers [...]. [...]. PA/NPs may not have the clinical expertise to meet all the medical needs of older, complex patients with diabetes and refer the patient to physicians more frequently. Alternatively, it could be a deliberate approach to ensure participation of both providers in the PA/NP-physician dyad and adequate access to care for socially complex patients.”
Dahrouge et al. [41], CA “Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits.”
“To maximize NPs’ ability to care for their own patients with minimal consultation with FPs, CHCs might have used intake questionnaires to determine whether an incoming patient would be assigned to an NP (less medical complexity) or FP (greater medical complexity). Nurse practitioners who found themselves caring for more medically complex patients were probably obliged to have FPs provide care that they were unable to provide themselves, potentially explaining the finding that shared care patients had characteristics intermediate to the FP care and NP care patients.”
“Compared with FPs, NPs saw patient panels that were less medically complex but more socially complex.”
Ku et al. [42], US “We measured productivity as the number of weighted medical visits per center in 2012. Weighting is important because medical visits vary in the complexity of care required, which may also influence the type of staff involved.”
“This signals that weighting increases the apparent contribution of physicians and decreases the apparent contribution of advanced-practice staff [including NPs], which suggests that physicians are more involved in complex visits, compared to the advanced- practice staff.” “Our analyses support evidence that physicians tend to be more involved in care for patients with complex conditions, compared to nonphysician medical staff [including NPs].”
Kuo et al. [43], US “The frequent specialist consultations suggest that NPs recognize limitations in their training when caring for medially complex individuals with multiple comorbidities.”
“[...] NPs may deliver care to healthier, less medically complex individuals than PCPs, but comparing results from unmatched analyses shows that nonpooling propensity score matching reduced the differences between the two groups on several measurements for disease and medication management.”
Park [44], US “The use of NPs and PAs may continue to accelerate with the growth of PCMHs because it allows them to accommodate patients and enable care coordination, thereby ensuring physicians more time to devote to complex cases.”
Reckrey et al. [45], US “Team-based models of care are an important way to meet the complex medical and psychosocial needs of the homebound.”
“It was expected that the nurse practitioner would help most with straightforward cases, freeing physicians to address complex care situations when they returned to the office, but the nurse practitioner instead took an enhanced role in the management of the most-complex patients on the Team Approach physician panels.”
Marcum et al. [46, 47], US “Our findings are consistent in that PCPs were more likely than NPs and PAs to prescribe to older patients, who often take multiple medications due to chronic co-morbidity. Given an older, more complex patient panel, PCPs may be more likely to prescribe from a broader prescription armamentarium, including newly approved drugs.”
Raji et al. [48], US “The NP-MD team model may best serve the needs of the switch group patients whose health conditions have become more complex following their recent hospitalizations or new diagnoses.”
Van der Biezen et al. [49], NL “Moreover, in the current study the NPs were primarily responsible for treating minor ailments. The complexity of tasks can differ between regions and countries.”
D’Afflitti et al. [50], US “[...]A full-time NP saw patients for 6 half-day clinic sessions. [...]. Such care included phone calls to patients for chronic disease management, test result follow-up, care coordination with specialists, and outrreach to medically and socially complex patients in an effort to keep them engaged in care.”
Yang et al. [51], US “Primary care nurse practitioners, physician assistants, and physicians at the Veterans Health Administration care for diabetic patients with similar medical complexity.”
Morgan et al. [52], US “These results combine with our previous findings to provide additional support for the use of PAs and NPs in the primary care of complex patients.”
“This study, combined with previous findings that diabetes care quality in the VA did not differ by primary care provider type, suggests that NPs and PAs can effectively manage primary care for medically complex patients with diabetes without increasing total care costs.”
Other study designs
Fletcher et al. (mixed methods) [53], US “Potential benefits to VHA from the use of NPs include being able to provide care to more patients at the primary care level, and providing additional time for physicians to spend with more complex patients.”
“One rationale for using NPs in primary care is that physicians are more readily available to handle complex cases.”
“In contrast, most of the physicians who commented on the NPs’ competence tended to think that NPs were not qualified to manage a panel of complex patients without constant, direct MD supervision.”
“Most physicians emphasized the importance of NPs working within a limited scope of practice or caring for simple cases. “NPs are always the best working under direct supervision with doctors. They can be utilized best as case managers or seeing low complexity patients.”
“Fifty-eight (78%) of MD respondents agreed that NPs are well integrated into “our” practice setting, but 42 (58%) agreed that NPs care for patients who are too complex and 38 (52%) affirmed that NPs are often assigned patients too complicated for the NPs’ abilities.”
“There appears to be a fine line between NPs’ desires for autonomy and being pushed beyond their scope of practice in a large system with many complex patients.”
Dierick-van Daele et al. (mixed methods) [54], NL “The NPs should assess, diagnose and treat a specified set of common complaints. Therefore, they needed to possess medical knowledge and use practice guidelines on minor health problems derived from the Dutch College of General Practitioners.”
Quote from GP: “We share home visits of patients with complex care (palliative care). It is comfortable and professional, when I do not have to do this all by myself. I feel that I have a new partner in these situations.” “As NPs mainly treat patients with common complaints this might also lead to GPs having more time for patients with chronic diseases or multi-morbidity.”
Sustaita et al. (review) [55], US “Many physicians feel overwhelmed with routine responsibilities, such as completing forms, taking patient telephone calls, performing physical exams, and attending to urgent unscheduled appointments. An NP can take ownership of these responsibilites so that the physician may spend more time with higher-acuity or more complex patients.”
Freund et al. (comparison) [56], NL “Area B (nurse practitioner): Clinical diagnosis and treatment of less complex presentations (minor illnesses) and also chronic care management”
Helms et al. (case study) [57], AU “The PHC-NP has his own caseload but also receives referrals from GP, nursing and allied health team members within the co-op, for the opinion and management of complex cardiovascular conditions and lifestyle modification interventions, as this is his area of primary expertise and interest.”
“It was also felt that GP productivity increased because the PHC-NP would manage clients with complex chronic diseases, who take a great deal of time and attention in their management.”
Bodenheimer & Bauer (perspective) [2, 58], US “Physicians will probably focus on diagnostic conundrums and lead team caring for patients with complex health care needs.”
Hunter et al. (mixed methods) [59], CA “Introduction of the NP role improved access to care in an area short of primary care providers, with 817 previously unattached patients added to the NP’s caseload. Access was also improved for some complex patients.”
Collins (mixed methods) [60], UK “The variance and potential complexity ranges from minor illness to more complex conditions such as terminal care.”
  1. Sources: US United States, NL Netherlands, CA Canada
  2. Settings: VHA Veteran’s Health Association, SDNPC Sudbury district nurse practitioner clinics, CHC Community health centre, PCMH Patient-centred medical homeProfessionals: NP Nurse practitioner, MD Medical doctor, GP General practitioner, RN Registered nurse, MA Medical assistant, LPN Licensed practice nurse, PA Physician assistant, PCP Primary care physician, FP Family physician, PHCNP Primary health care nurse practitionerOthers: BP Blood pressure, PHC Primary health care, DCG Diagnostic cost groups.