Efficiency and Cost of Primary Care by Nurses and Physician Assistants

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Abstract
We conducted a prospective study in a prepaid primary-care practice (health-maintenance organization) of a system in which nurses and physician assistants used protocols, and compared the efficiency and costs of this "new-health-practitioner" protocol system to a physician-only nonprotocol system. In five months, we studied 472 patients with any of four common acute complaints — respiratory infections, urinary and vaginal infections, headache, and abdominal pain; a subset of 203 patients was randomly allocated between the two systems. In the new-health-practitioner system physician time per patient was reduced by 92 per cent, from 11.8 to 0.9 minutes, and average visit costs — including practitioner time and charges for laboratory tests and medications — were 20 per cent less (P = 0.01). We conclude that this protocol system saves physician time and reduces costs. (N Engl J Med 298:305–309, 1978)