EDITORIAL Measuring the cost of nurse practitioners This edition of the journal publishes an economic evaluation of women’s health nurses as cervical smear takers. Although several such studies were commissioned and funded by the program for evaluation of cervical screening (as far as I am aware), the others have been published only in minimal detail in the overall report.’ Peer review in a formal paper is welcome, to allow detailed debate. Checklists for the evaluation of such economic analyses show that few of the papers in a sample of American medical journals fulfilled the criteria,‘ but this paper scores well. Most of the costs are meticulously accounted for. The authors describe the assumptions they have made, allowing the reader to decide how much to agree with them. The most crucial assumption is the assignment of either full, half or no cost to smears according to what else occurred in the consultations. Most of the assumptions seem reasonable, but the authors have taken the viewpoint of the program manager, namely the state government, when enumerating the costs. By doing so, they have omitted rent, on the grounds that the women’s health nurses are using facilities that would otherwise not be used, and therefore there is no opportunity cost. While they are strictly correct, if others wished to duplicate or extend such a program to become a regular part of health care, they would have to pay rent. Most other studies of nurse-practitioners allow for medical supervision, reviewing 12 to 33 per cent of the cases seen.3 Perhaps by restricting activity to a narrow range of women’s health problems this cost was reduced, but at least some patients must have been referred, or the nurses may have consulted by telephone. These omissions decrease the apparent cost, so larger scale programs based on this set of assumptions would have difficulty remaining within their budgets. But the other value of costing is to make comparisons. In this case, the comparison is with the major source of cervical smear services, namely general practitioners. Proponents of women’s health nurses argue that their service is better in terms of cost, convenience, and greater acceptability for women, especially by reason of female sex of the providers. They also argue that the quality of the service is higher, and more pleasant for women. Since these services consume public funds, and such comparisons fuel a public debate, these arguments must be addressed in detail. Firstly, the authors quote simply the rebate level of fee for general practitioners, which provides a high estimate. The cost of the smear is contained within the consultation fee, which must cover all costs, including rent. Therefore it is possible to apply the proportion of the consultation devoted to this procedure in a similar way to the assumptions made for the nurses. Using data collected in the General Prac214

tice Morbidity Study, we have estimated that Pap smears occupy 67 per cent of the consultations in which they occur.’ Taking the same viewpoint as these authors, only the cost to government need be considered. Besides, fees in Sydney are generally low; it is easy for a patient to obtain a smear at no personal cost by attending a bulk-billing practice, and about 85 per cent of all general practitioner services in Sydney are indeed bulk-billed (Medicare data). While some women may choose to pay more for competing services, the cost to government does not rise, since the rebate remains the same. Thus, using comparable assumptions, general practitioners provide the service for $13.51, 76 per cent of the $17.68 cheapest estimate by Furber and Donaldson. Secondly, general practitioners are widely spread in every locality, many opening for long hours, so they are very available to working women. Thirdly, it is reasonable to argue that for such intimate examinations a woman provider is more acceptable. However, there are now few areas of our cities where female general practitioners are not readily available. Fourthly, it is argued that women’s health nurses provide a better screening service. It is quite possible that these nurses have had more and better training in vaginal examination and in taking smears than many medical graduates; many older graduates were never taught to take smears, while many recent graduates have had little supervised training in these skill^.^ However, taking cervical smears is a very simple procedure, the technical aspects of which are easily learned, though gentle and considerate technique requires care. The yardstick for quality used by the authors is the proportion of smears with endocervical cells, but they admit doubt about its value.6 Furthermore, the presence of endocervical cells is dependent upon age and hormonal status; unless corrected for these factors, the high endocervical cell rate might merely mean that the nurses were screening many young women, those for whom smears are of little value.’ Since pathology services have started giving feedback to doctors, the endocervical cell content of their smears has increased too. Finally, women’s health nurses might be providing a service which is more pleasant, because they are less hurried in their 30- or 45-minute appointments, and are able to deal with other women’s health issues at the same time. I have no definite measures of the time taken by general practitioners to undertake smear tests, although in the morbidity study, those using time-related billing mostly charged Level B consultations, taking between 5 and 25 minutes. Probably they do not usually spend as much time as the nurses, but they are limited by payment levels, which do not allow consistently long appointments. Clearly, the nurses are in a much better position to provide pleasant and unhurried consultations, and. this is a strong argument in their favour. Reducing appointment duration would reduce their cost, but at the risk of losing this benefit. On the other hand, gen-

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eral practitioners may be providing a more diverse service, ifjudged by the large number of other problems dealt with, many from other body systems beyond the expertise of the women’s health nurses. Ultimately it is necessary to reach a policy decision: the authors ask, in the strained logic of their discussion, whether it is better to establish a series of single-issue services, or to improve the quality of general practice services by education where necessary, with adequate time to allow unhurried consultations, and the provision of follow-up and reminder services. The latter approach has not yet been tested adequately in Australia or most other countries. However, the former has. In the Netherlands, using special smear-takers in health centres was abandoned in favour of encouraging women to attend their own general practitioners. The result was improved compliance from groups at greater risk of neoplastic lesion^.^ In the United States, the provision of primary care by specialists (admittedly medically qualified) is a policy failure8. Walter Spitzer, one of the pioneers of the Nurse Practitioner movement, sadly concluded that the idea is slowly dying, in Canada at least, and a major reason is that their cost-effectivenessis only marginal unless there are substantial differences in basic earning rates between nurses and physicians.9Although nurses may seem to work for lower hourly rates, the good employment conditions that they rightly require ensure that their effective rates for direct patient care are similar to the earnings of general practitioners. In these circumstances, women’s health nurses have a good case for supplementing general practice but not for substitution. In those rural areas where female general practitioners are unavailable, and women may be reluctant to attend a doctor whom they know well for genital examinations, there is good reason for specially trained nurses, and many such doctors welcome their help. In special situations such as Aboriginal settlements, women’s health nurses fill a very important role, taking the extra time

needed to ensure that the women understand their problems and their susceptibility to disease. Such programs are described in the Cervical Screening Report, and though they may be relatively costly, all recognise their contribution. Like new technologies, any new health care delivery method should be evaluated thoroughly before being widely adopted. When there are too many general practitioners, why expend effort developing a new type of professional who will replace their services at higher cost? On the data presented here, in ordinary suburban situations, salaried women’s health nurses do not seem economically worthwhile. Jim Dickinson Canberra References 1 . Australian Health Ministers Advisory Council Cervical Cancer Screening Evaluation Committee. Cervical cancerscseening in Awtmlia: optimfw change. Australian Institute o f Health Prevention Program Evaluation Series N o 2. Canberra: Australian Government Publishing Service, 199 1 . 2. Udvarhelyi IS, Colditz GA, Rai A, Epstein AM. Cost effectiveness and cost-benefit analyses in the medical literature: Are the me1 hods being used correctly?Ann Intern Med 1992; 1 16: 238-44. 3. Lomas J , Stoddart GL. Estimates o f the potential impact of nurse practitioners on future requirements for physicians in office-based general practice. Can J Public Healfh 1985; 76: 119-23. 4. Dickinson JA, Bridges-Webb C, Neary S. The cost o f cervical screening by general practitioners. Med J A w l 1992; 156: 740. 5. Biggs JSC, Humphrey MD. Undergraduate education in obstetrics and gynaecology in Australia and New Zealand 1989. A w f NZ J ObsfefGynaecol 1990; 30: 185-90. 6. Mitchell H, Medley G. Longitudinal study of women with negative cervical smears according to endocervical status. Lancet 1991; 337: 265-7. 7. Boon ME, Beck S. Improving cervical screening by involving general practitioners. Lancef 1991; 338: 699 8. Rosenblatt R. Specialists or generalists: o n whom should we base the American health care system? J A M A 1992; 267: 1665-6 9. Spitzer W. The nurse practitioner revisited: slow death o f a good idea. N m Engl J Med 1984; 3 10: 1049-5 1 .

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Measuring the cost of nurse practitioners.

EDITORIAL Measuring the cost of nurse practitioners This edition of the journal publishes an economic evaluation of women’s health nurses as cervical...
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