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A Randomized Trial

Mary O. Mundinger, DrPH; Robert L. Kane, MD; Elizabeth R. Lenz, PhD; Annette M. Totten, MPA; Wei-Yann Tsai, PhD; Paul D. Cleary, PhD; William T. Friedewald, MD; Albert L. Siu, MD, MSPH; Michael L. Shelanski, MD, PhD

JAMA. 2000;283:59-68.

Context  Studies have suggested that the quality of primary care delivered by nurse practitioners is equal to that of physicians. However, these studies did not measure nurse practitioner practices that had the same degree of independence as the comparison physician practices, nor did previous studies provide direct comparison of outcomes for patients with nurse practitioner or physician providers.

Objective  To compare outcomes for patients randomly assigned to nurse practitioners or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit.

Design  Randomized trial conducted between August 1995 and October 1997, with patient interviews at 6 months after initial appointment and health services utilization data recorded at 6 months and 1 year after initial appointment.

Setting  Four community-based primary care clinics (17 physicians) and 1 primary care clinic (7 nurse practitioners) at an urban academic medical center.

Patients  Of 3397 adults originally screened, 1316 patients (mean age, 45.9 years; 76.8% female; 90.3% Hispanic) who had no regular source of care and kept their initial primary care appointment were enrolled and randomized with either a nurse practitioner (n = 806) or physician (n = 510).

Main Outcome Measures  Patient satisfaction after initial appointment (based on 15-item questionnaire); health status (Medical Outcomes Study Short-Form 36), satisfaction, and physiologic test results 6 months later; and service utilization (obtained from computer records) for 1 year after initial appointment, compared by type of provider.

Results  No significant differences were found in patients' health status (nurse practitioners vs physicians) at 6 months (P = .92). Physiologic test results for patients with diabetes (P = .82) or asthma (P = .77) were not different. For patients with hypertension, the diastolic value was statistically significantly lower for nurse practitioner patients (82 vs 85 mm Hg; P = .04). No significant differences were found in health services utilization after either 6 months or 1 year. There were no differences in satisfaction ratings following the initial appointment (P = .88 for overall satisfaction). Satisfaction ratings at 6 months differed for 1 of 4 dimensions measured (provider attributes), with physicians rated higher (4.2 vs 4.1 on a scale where 5 = excellent; P = .05).

Conclusions  In an ambulatory care situation in which patients were randomly assigned to either nurse practitioners or physicians, and where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians, patients' outcomes were comparable.

Author Affiliations: School of Nursing (Drs Mundinger and Lenz and Ms Totten), Joseph L. Mailman School of Public Health (Dr Tsai), and College of Physicians and Surgeons (Dr Shelanski), Columbia University, New York, NY; University of Minnesota School of Public Health, Minneapolis (Dr Kane); Department of Health Care Policy, Harvard Medical School, Boston, Mass (Dr Cleary); Metropolitan Life Insurance Company, New York, NY (Dr Friedewald); and The Mount Sinai Medical Center, New York, NY (Dr Siu).

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