Nurses’ work in relation to patient health outcomes: an observational study comparing models of primary care

Abstract

Background Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into different models of primary care. We describe nurse work in relation to these models of care; populations with high health need; and patient health outcomes. Methods Cross-sectional study (30 September 2018), data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥65 years), HbA1c testing in adults with diabetes, immunisations (6 months), ambulatory sensitive hospitalisations (0-14, 45-64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics. Results Nurse FTE, and combined nurse, nurse practitioner and general practitioner FTE, were substantially higher in Trust/NGO, Māori, and Pacific practices than Traditional, Corporate, or Health Care Home practices. A progressive increase of clinically complex patients was associated with more clinical input and higher scores on all outcome measures. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Compared to general practitioners, nurses undertook more cardiovascular risk assessment in all models of care except PHO/DHB, and more cervical screening in Pacific, Trust/NGO and Māori practices. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, PHQ9 assessment, HbA1c testing) were in Māori, Trust/NGO and Pacific practices. There was an 8-fold difference, across models of care, in percentage of PHQ9 undertaken by nurses and a 5-fold difference in cervical screening and HbA1c testing. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree. Conclusions Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release GP FTE to be utilised for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner FTE is required, especially in practices with high volumes of complex patients.