Nurse practitioners in primary care. VII. A cohort study of 99 nurses and 79 associated physicians K. SCHERER,* B SC N, MH SC; F. FoRTIN,t BN, M ED, M SC; W.O. SPITZER4 MD, MPH, CCFP[C]; D.J. KERGIN,§ BSN, MPH, PH D
Long-term surveillance of the employment experience and developing roles of 99 nurses and 79 associated physicians who participated in the first 5 years of the McMaster University educational program for family practice nurses was undertaken with a descriptive survey. Data were gathered by mailed questionnaires; a 97.80/o response rate was attained. Sociodemographic profiles of both groups and characteristics of the practice settings where copractitioner teams functioned were determined. Selected noteworthy results show that 92.70/o of the nurses were currently employed, and that 82.50/0 of the graduates continued in their original practice. Nurses' time invested in patient care activities increased by 1050/c; time devoted to clerical and housekeeping duties decreased by 420/0. Changes in roles for both categories of copractitioners were important. The interdisciplinary arrangements resulted in appreciable financial disadvantages to physicians and only modest income incentives to nurses. A series of successes of the model of practice under assessment has been identified; offsetting ongoing difficulties and problems have also been enumerated. The data from this project and preceding studies can facilitate the solution of unresolved problems on the basis of evidence rather than opinion. Au moyen d'une etude descriptive, on a effectue un contrOle au long cours de 'experience d'emploi et de lemer. gence des r6les de 99 infirmieres et de 79 medecins associes qui ont participe aux 5 premieres annees du programme academique de l'Universite McMaster pour les infirmieres en pratique de famille. Les donnees ont ete recueillies par questionnaires expedies par Ia poste; un taux de reponse de 97.80/c a ete obtenu. On a determine les profils sociodemographiques des deux groupes et les caracteristiques des milieux ou les equipes ont realise 9Re.arch associate, school of nursing, McMaster University tAssistant professor of nursing, University of Montreal Wrofessor of family medicine and epidemiology, McGill University §Professor and director, school of nursing, McMaster University Reprint requests to: Dr. WO. Spitzer, Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4
leur pratique. Une liste selective des resultats interessants demontre que 92.70/0 des infirmieres avaient un emploi, et que 82.50/0 des graduees en etaient toujours a leur premier lieu de pratique. Le temps de linfirmiere consacre aux soins du malade a augmente de 1050/ow alors que le temps alloue aux t&ches clericales ou menageres a diminue de 420/c. Pour les deux groupes de praticiens, les changements de r6les ont ete importants. L'abord interdisciplinaire a entraine des pertes financieres appreciables pour les medecins, alors ques les gains pecuniaires des infirmieres ont ete modestes. On a identifie une serie de succes attribuables au type de pratique sous evaluation; en contrepartie, les difficultes et les problemes courants ont aussi ete detailles. Les donnees issues de ce projet et des etudes precedantes peuvent faciliter Ia solution des problemes qui persistent en s'appuyant sur des preuves plut6t que sur des opinions.
dependent team relationships.2 This paper, the last in a series of articles on evaluative studies of the nurse practitioner,2-7 reports the first follow-up survey in long-term surveillance of the graduates of the McMaster program and their associated physicians who were under assessment. The field work of a descriptive survey began in March 1975 and was completed in 2 months. The employment experience, professional activities and current roles of 99 family practice nurses (80 of whom had graduated) who had completed the family nurse practitioner educational program at McMaster University in Hamilton and of 79 associated physicians were surveyed by mailed questionnaires.
Long-term surveillance is the final phase in evaluating new health professionals through pilot studies, controlled trials, economic analyses and consumer surveys. Program developers, practitioners, health care investigators and educators share the responsibility of detecting what might be termed unsuspected or unforeseeable deferred side effects of the introduction of new health professionals to a system of provision of health services. Identification of previously unknown contraindications for their development, scrutiny that reveals deterioration of performance and evidence of high vocational attrition of new professionals could reverse early verdicts that the advantages of new arrangements tested outweigh the disadvantages observed.1 In 1971 McMaster University initiated an educational program for nurse practitioners, sponsored jointly by the schools of medicine and nursing. The program enables registered nurses to extend their responsibility in primary health care. The focus of the curriculum is provision or enhancement of the nurses skills in assessing and managing patients in family practice. A deliberate strategy is to require participation of a physician-sponsor with each nurse in order to sensitize the physician to the enhanced abilities of the nurse and to encourage the development of mutually
General plan The study was designed as a descriptive survey to develop a method of evaluation that would permit subsequent consistent, long-range, periodic assessment of the roles and employment experience of copractitioners. The questionnaire method was adopted rather than observation or work-sampling because of time and budgetary constraints; past performances had demonstrated that the expertise of the McMaster field survey unit would ensure a response rate high enough to overcome the common serious limitations of a questionnaire approach.9 The geographic distances resulting from copractitioners scattered in five provinces and five states accounted for the decision to gather the data by mail.
856 CMA JOURNAL/APRIL 23, 1977/VOL. 116
Methods A detailed account, including results not reported herein, has been provided in a monograph.8 The following is a brief summary of the methods.
Data gathering and development of questionnaires Types of questions: The questionnaires were developed after discussion with consultants in the professional organizations, in the educational program and from copractitioner settings. The consultations helped determine areas of interest and of priority. Separate questionnaires for the nurses and physicians were designed, with two general types of questions: structured questions that would be precoded and open-ended
Table Il-Practice arrangements for 79 physicians Variable Type of practice Solo Group or partnership Hospital based Community health clinic University teaching practice Industrial medicine Other
Table I-Demographic data for 99 nurse practitioners Variable Sex distribution Female Male
95.9 4.1
Age on entry to program (yr) 20-24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50-54 55-59 .60
1.3 26.3 23.7 13.7 18.7 10.0 2.5 2.5 1.3
Marital status(n = 98*) Married Single Divorced Separated
61.6 27.2 5.1 5.1
No. of children 0 or not appropriate 1 2 3 4 5 No answer *One nurse practitioner died.
47.5 11.1 19.2 12.1 6.1 1.0 1.0 2.0
Involvement in clinical practice Full-time Part-time Not appropriate No answer Type of reimbursement Fee-for-service within Ontario Health Insurance Plan (OHIP) Fee-for-service outside OHIP Capitation Global budget Salaried Clinical incentive/grants Fee-for-service within OHIP+ salary Fee-for-service within OHIP + incentive Other No answer
29.1 21.5 3.8 12.7 29.1 1.3 2.5 73.4 22.8 1.3 2.5 43.0 3.8 1.3 11.4 24.0 3.8 5.1 5.1 1.3 1.3
Table Ill-Current employment of 80 gradduate nurse practitioners Current employment Private physician's office Urban 27.5 Rural 8.8 Community health clinic 11.3 Teaching unit or university medical centre 20.0 Victorian Order of Nurses 5.0 Public health 2.5 Emergency room 2.5 Correction centre 1.2 Senior citizens home 1.2 Industrial medicine (occupational health) 1.2 Psychiatric nurse therapist 1.2 Working (not as nurse practitioner) 6.3 Unemployed 11.3
Table V-Arrangement for assignment of new patients as reported by 79 physicians Description Either MD or nurse practitioner (NP) (depending on availability) 46.8 NP only 19.0 Either MD or NP (depending on presenting symptoms)
17.7
MD only Other
8.9 5.1
MD and NP
1.3
No answer
1.3
Table VI-Changes in physicians' net income* Direction First subsequent and year v. baseline magnitude of change, % No. Increase >25 2 15-24 2
Last year reported v. baseline No. 1 3
+14 to -14 20 20 Decrease 15-24 2 5 >25 6 3 *Response rates for changes in income of physicians in private fee-for-service practice were 85% for gross income and 80% for net income.
Table ViI-Changes in practice size Direction First subsequent and year v. baseline magnitude of change, % No. Increase 100-125 0 50-99 0 15-49 3 +14-14 Decrease 15-49 50-99
Last year reported v. baseline No. 2 2 1
21
19
1 1
1 1
Indodd
(indomethacin, MSD Std.) IndIcatIons INDOCID' (indomethacin, MSD Std.) has been found effective in the symptomatic treatment of selected cases of rheumatoid arthritis, ankylosing (rheumatoid) spondylitis, gout, selected cases of severe osteoarthritis including degenerative disease of the hip. INDOCID. should be used in those cases of severe osteoarthritis which do not respond to treatment with other drugs such as the salicylates. In these conditions it may on occasion replace other commonly used agents such as corticosteroids, salicylates, phenylbutazone-like compounds, and colchicine. Dosage Summary For Adults In chronic rheumatoid arthritis and ankylosing (rheumatoid) spondylitis: Start with 25 mg b.i.d. or t.i.d. If response is inadequate, add 25 mg daily each week until an adequate response is obtained or a dosage of 150 to 200 mg is reached. In acute rheumatoid arthritis and acute flares of chronic rheumatoid arthritis: Start with 25mg bid. or tid. If response is inadequate, add 25 mg each day until an adequate response is obtained or until a total daily dose of 150-200 mg is reached. Maintenance corticosteroids can often gradually be reduced 25 to 50 percent and completely discontinued over several weeks or months in some patients. In severe osteoarthritis and degenerative disease of the hip: Start with 25 mg bid. or tid. If response is inadequate, increase the daily dosage by 25 mg at about weekly intervals until an adequate response is obtained or until a dosage of 150 to 200 mg is reached. In acute gout: 50 mg tid. until all signs and symptoms subside. lNDOClD. Suppositories: 100 mg to 200 mg a day. May be administered one at bedtime, and if necessary one the following morning. Also may be used in combined administration with Capsules: 100 mg suppository at bedtime, supplemented the following day by 25 mg capsules as needed up to a total of 150 to 200 mg (capsules and suppositories) of indomethacin. Note: In chronic disorders, it is important to start with low dosage and increase gradually for best results with fewer adverse reactions. Always give INDOCID* with food or immediately after meals or with antacid to reduce gastric irritation. As with all drugs, the lowest possible effective dose should be utilized for each individual patient. ContraIndications Active peptic ulcer, gastritis, regional enteritis, ulcerative colitis, divert iculitis and if there is a recurrent history of GI. lesions. Also contraindicated in patients allergic to asa. or indomethacin. Safety of indomethacin for use in pregnancy or lactation has not been established. Indomethacin suppositories are contraindicated in subjects with a history of recent rectal bleeding. SHOULD NOT BE ADMINISTERED TO PEDIATRIC AGE GROUPS. Warning Patients who experience dizziness, lightheadedness, or feelings of detachment on indomethacin should be cautioned against operating motor vehicles, machinery, climbing ladders, etc. Use cautiously in patients with psychiatric disturbances, epilepsy, or parkinsonism. PrecautIons indomethacin should be used with caution because of the possible occurrence of gastrointestinal reactions, the incidence of which may be decreased by glying the drug immediately after meals, with food or antacids. The risk of continuing therapy with indomethacin in the face of such symptoms must be weighed against the possible benefits to the individual patient. Indomethacin suppositories should be given with caution to patients with any anal or rectal pathology. Discontinue it GI. bleeding occurs. Peptic ulcer has been reported. Hemorrhage and perforation have occurred in patients with history of peptic ulcer (see Contralndlcatlons) or in patients receiving steroids or salicylates concomitantly. In some patients there was no history of peptic ulcer or of other drugs being given. As a result of GI. bleeding some patients may manifest anemia and, for this reason, appropriate blood determinations are recommended periodically. Headache may occur, usually eariy in treatment. Discontinue therapy if headache persists despite dosage reduction. In common with other drugs which have anti-inflamma-
tory, analgesic and antipyretic properties, indomethacin possesses the potential of masking the signs and symptoms which ordinarily accompany infectious disease. The physician must be alert to this possibility to avoid undue delay in initiating appropriate treatment of the infection. Indomethacin should be used with caution in patients with existing, but controlled infections. Where therapy is prolonged, ophthalmological examinations are desirable at periodic intervals (see Eye Reactions). Since advancing years appear to increase the possibility of adverse reactions, indomethacin should be used with greater care in the elderly. As with any drug, patients should be followed carefully to detect unusual manifestations of drug sensitivity. Adverse Reactions Central Nervous System: Commonly seen, headache (usually more severe in morning), dizziness, and lightheadedness. Infrequently observed: mental confusion, syncope, drowsiness, convulsions, coma, depression which may be severe, and other psychic disturbances, such as depersonalization. The severity of these effects may occasionally require cessation of therapy and rarely, admission to hospital. Gastrointestinal: include nausea, anorexia, vomiting, epigastric distress, abdominal pain, and diarrhea, which are not uncommon. Single or multiple ulceration of esophagus, stomach, duodenum orsmall intestine, perforation and hemorrhage have occurred. A few fatalities have been reported. Hemorrhage without obvious ulceration. Increased abdominal pain in patients with ulcerative colitis. Indomethacin has been suspected of precipitating the symptoms of ulcerative colitis or regional ileitis but causal relationship not proven. Rarely reported, intestinal ulceration followed by stenosis and obstruction. Least frequent reactions: ulcerative stomatitis, bleeding from sigmoid colon or diyerticuli, perforation of pre-existing sigmoid lesions, e.g., diverticuli or carcinoma. With the use of indomethacin suppositories, pruritus ani, tenesmus, and irritation of the rectal mucosa reported occasionally; rectal bleeding rarely. However, sigmoidoscopic examination in a number of patients did not reveal any significant changes of rectal mucosa. Hepatic: Toxic hepatitis and jaundice of uncertain etiology, including severe and fatal cases. Cardiovascular-Renal: Infrequently, edema, elevation of blood pressure, and hematuria. Dermatologic-Hypersensitivity: Infrequently, pruritus, urticaria, angioneurotic edema, angiitis, erythema nodosum, skin rashes, loss of hair, and acute respiratory distress including sudden dyspnea and asthma. Hematologic Reactions: Infrequently leukopenia, purpura and thrombocytopenia. Rarely agranulocytosis, hemolytic anemia, but definite relationship to drug not established. Anemia secondary to obvious or occult gastrointestinal bleeding. It is advisable to perform periodic blood counts (including platelet) in patients on long term therapy. If signs or symptoms of above reactions appear, discontinue drug and institute appropriate hematological investigations. Ear Reactions: Tinnitus infrequently, and deafness rarely. Eye Reactions: Retinal disturbances, including those of the macula, and corneal deposits have been observed. Some of these changes regressed after discontinuation of therapy. Infrequently, blurred vision, orbital and penorbital pain. Miscellaneous: Rarely, vaginal bleeding, hyperglycemia, glycosuria and peripheral neuropathy, and epistaxis. DETAILED INFORMATION AVAILABLE ON REQUEST. How Supplied Ca 8662-lNDOClD. Capsules 25 mg each, are opaque, blue and white, imprinted with an MSD trademarkand potency, and are supplied in bottles of 100 and 1000. Ca 8663-lNDOCl0. Capsules 50 mg each, are opaque, blue and white, imprinted with an MSD trademarkand potency, and are supplied in bottles of 100 and 500. Ca 8711-lNDOClD. Suppositories 100 mg each, are white opaque suppositories, supplied in boxes of 12 and 30. Trademark
O MERCK I SHARP I & DOHME CANADA LIMITED POINTE CLAIRE, QUEBEC H9R 4P7
(MC-941 bl
862 CMA JOURNAL/APRIL 23, 1977/VOL. 116
Master University and from comparable programs elsewhere in Canada and the extent of their success as innovators have resulted in arresting challenges to the system for provision of primary health services. The magnitude of the challenge is one that health care planners and decision makers in Canada can no longer ignore. We acknowledge the outstanding contribution of the respondent family practice nurses and their associated physicians. Mrs. Betty Bidgood supervised the data gathering of the McMaster University health sciences field survey unit. Sally Skene and Maria Yan-Ying of the same unit assisted in the data analysis. This study was supported by national health grant no. 606-22-35 from the Health and Welfare Canada research directorate. References 1. SPITZER WO: A strategy for evaluation of new health professionals, in New Health Professionals, vol 1, Fogarty International Center
series on the teaching of preventive medicine, National Institutes of Health, Bethesda, MD, DHEW pubi no 75-875, 1975, pp 83-98 2. SPrrZER WO, KERGIN DJ: Nurse practitioners in primary care. I. The McMaster University educational program. Can Med Assoc .1 108: 991, 1973 3. CHENOY NC, SPIrzaa WO, ANDERSON GD:
Nurse practitioners in primary care. II. Prior attitudes of a rural population. Ibid, p 998 4. Ss'rs-zaR WO, KERGIN DJ, YOSHDA MA, Ct al: Nurse practitioners in primary care. III. The southern Ontario randomized trial. Ibid, p 1005 5. BATCHELOR GM, S.rrzast WO, COMLEY AE, et al: Nurse practitioners in primary care. IV: Impact of an interdisciplinary team on attitudes of a rural population. Can Med Assoc J 112: 1415, 1975 6. SPITZER WO, ROBERTS RS, DELMORE T: Nurse practitioners in primary care. V. Develop-
ment of the Utilization and Financial Index to measure effects of their deployment. Can Med Assoc J 114: 1099, 1976 7. Idem: Nurse practitioners in primary care. VI. Assessment of their deployment with the Utilization and Financial Index. Ibid, p 1103 8. SCHERER K, FORTIN F, S.rrzasi WO, et al: First Survey of Nurse Practitioners and Associated Physicians, Methodological Manual and Final Report, McMaster University, Hamilton, 1976 9. MILLER DC: Handbook of Research Design and Social Measurement, 2nd ed, New York, McKay, 1971, p 76
10. SPsrzaR WO, SACKETr DL, SIBLEY JC, et al:
The Burlington randomized trial of the nurse practitioner. N Engi J Med 290: 251, 1974
11. SPITzER WO, HACKETT BC, RUSSELL WAM:
Changes in income with nurse practitioner. Ontario Med Rev 41: 269, 1974 12. LEwis CE, RESNIK BA: Nurse clinics and progressive ambulatory patient care. N Engl J Med 277: 1236, 1967 13. Laas RE, ANDERSON RM: Patient attitudes
to the expanded role of the nurse in family practice. Can Med Assoc J 105: 1164, 1971 14. SWEENY GP, HAY WI: The Burlington experience: a study of nurse practitioners in family practice. Can Fain Physician 19: 101, 1973 15. CHARRON KC (chmn): The Nurse Practitioner in Primary Care, Ontario Council of Health, Ontario Ministry of Health, Toronto, Queen's Printer, 1975 16. An assistant in the house? (E) Lancet 2: 842, 1975 17. Krankenschwestern als praktische Arzte (E). Frankf Allg zig 27: 27, 1974 18. BREwER C: When nurses turn doctor. The
Guardian, London, England, July 4, 1974, p 15
Long-term surveillance of the employment experience and developing roles of 99 nurses and 79 associated physicians who participated in the first 5 years of the McMaster University educational program for family practice nurses was undertaken with a descriptive survey. Data were gathered by mailed questionnaires; a 97.80/o response rate was attained. Sociodemographic profiles of both groups and characteristics of the practice settings where copractitioner teams functioned were determined. Selected noteworthy results show that 92.70/o of the nurses were currently employed, and that 82.50/0 of the graduates continued in their original practice. Nurses' time invested in patient care activities increased by 1050/c; time devoted to clerical and housekeeping duties decreased by 420/0. Changes in roles for both categories of copractitioners were important. The interdisciplinary arrangements resulted in appreciable financial disadvantages to physicians and only modest income incentives to nurses. A series of successes of the model of practice under assessment has been identified; offsetting ongoing difficulties and problems have also been enumerated. The data from this project and preceding studies can facilitate the solution of unresolved problems on the basis of evidence rather than opinion. Au moyen d'une etude descriptive, on a effectue un contrOle au long cours de 'experience d'emploi et de lemer. gence des r6les de 99 infirmieres et de 79 medecins associes qui ont participe aux 5 premieres annees du programme academique de l'Universite McMaster pour les infirmieres en pratique de famille. Les donnees ont ete recueillies par questionnaires expedies par Ia poste; un taux de reponse de 97.80/c a ete obtenu. On a determine les profils sociodemographiques des deux groupes et les caracteristiques des milieux ou les equipes ont realise 9Re.arch associate, school of nursing, McMaster University tAssistant professor of nursing, University of Montreal Wrofessor of family medicine and epidemiology, McGill University §Professor and director, school of nursing, McMaster University Reprint requests to: Dr. WO. Spitzer, Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4
leur pratique. Une liste selective des resultats interessants demontre que 92.70/0 des infirmieres avaient un emploi, et que 82.50/0 des graduees en etaient toujours a leur premier lieu de pratique. Le temps de linfirmiere consacre aux soins du malade a augmente de 1050/ow alors que le temps alloue aux t&ches clericales ou menageres a diminue de 420/c. Pour les deux groupes de praticiens, les changements de r6les ont ete importants. L'abord interdisciplinaire a entraine des pertes financieres appreciables pour les medecins, alors ques les gains pecuniaires des infirmieres ont ete modestes. On a identifie une serie de succes attribuables au type de pratique sous evaluation; en contrepartie, les difficultes et les problemes courants ont aussi ete detailles. Les donnees issues de ce projet et des etudes precedantes peuvent faciliter Ia solution des problemes qui persistent en s'appuyant sur des preuves plut6t que sur des opinions.
dependent team relationships.2 This paper, the last in a series of articles on evaluative studies of the nurse practitioner,2-7 reports the first follow-up survey in long-term surveillance of the graduates of the McMaster program and their associated physicians who were under assessment. The field work of a descriptive survey began in March 1975 and was completed in 2 months. The employment experience, professional activities and current roles of 99 family practice nurses (80 of whom had graduated) who had completed the family nurse practitioner educational program at McMaster University in Hamilton and of 79 associated physicians were surveyed by mailed questionnaires.
Long-term surveillance is the final phase in evaluating new health professionals through pilot studies, controlled trials, economic analyses and consumer surveys. Program developers, practitioners, health care investigators and educators share the responsibility of detecting what might be termed unsuspected or unforeseeable deferred side effects of the introduction of new health professionals to a system of provision of health services. Identification of previously unknown contraindications for their development, scrutiny that reveals deterioration of performance and evidence of high vocational attrition of new professionals could reverse early verdicts that the advantages of new arrangements tested outweigh the disadvantages observed.1 In 1971 McMaster University initiated an educational program for nurse practitioners, sponsored jointly by the schools of medicine and nursing. The program enables registered nurses to extend their responsibility in primary health care. The focus of the curriculum is provision or enhancement of the nurses skills in assessing and managing patients in family practice. A deliberate strategy is to require participation of a physician-sponsor with each nurse in order to sensitize the physician to the enhanced abilities of the nurse and to encourage the development of mutually
General plan The study was designed as a descriptive survey to develop a method of evaluation that would permit subsequent consistent, long-range, periodic assessment of the roles and employment experience of copractitioners. The questionnaire method was adopted rather than observation or work-sampling because of time and budgetary constraints; past performances had demonstrated that the expertise of the McMaster field survey unit would ensure a response rate high enough to overcome the common serious limitations of a questionnaire approach.9 The geographic distances resulting from copractitioners scattered in five provinces and five states accounted for the decision to gather the data by mail.
856 CMA JOURNAL/APRIL 23, 1977/VOL. 116
Methods A detailed account, including results not reported herein, has been provided in a monograph.8 The following is a brief summary of the methods.
Data gathering and development of questionnaires Types of questions: The questionnaires were developed after discussion with consultants in the professional organizations, in the educational program and from copractitioner settings. The consultations helped determine areas of interest and of priority. Separate questionnaires for the nurses and physicians were designed, with two general types of questions: structured questions that would be precoded and open-ended
Table Il-Practice arrangements for 79 physicians Variable Type of practice Solo Group or partnership Hospital based Community health clinic University teaching practice Industrial medicine Other
Table I-Demographic data for 99 nurse practitioners Variable Sex distribution Female Male
95.9 4.1
Age on entry to program (yr) 20-24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50-54 55-59 .60
1.3 26.3 23.7 13.7 18.7 10.0 2.5 2.5 1.3
Marital status(n = 98*) Married Single Divorced Separated
61.6 27.2 5.1 5.1
No. of children 0 or not appropriate 1 2 3 4 5 No answer *One nurse practitioner died.
47.5 11.1 19.2 12.1 6.1 1.0 1.0 2.0
Involvement in clinical practice Full-time Part-time Not appropriate No answer Type of reimbursement Fee-for-service within Ontario Health Insurance Plan (OHIP) Fee-for-service outside OHIP Capitation Global budget Salaried Clinical incentive/grants Fee-for-service within OHIP+ salary Fee-for-service within OHIP + incentive Other No answer
29.1 21.5 3.8 12.7 29.1 1.3 2.5 73.4 22.8 1.3 2.5 43.0 3.8 1.3 11.4 24.0 3.8 5.1 5.1 1.3 1.3
Table Ill-Current employment of 80 gradduate nurse practitioners Current employment Private physician's office Urban 27.5 Rural 8.8 Community health clinic 11.3 Teaching unit or university medical centre 20.0 Victorian Order of Nurses 5.0 Public health 2.5 Emergency room 2.5 Correction centre 1.2 Senior citizens home 1.2 Industrial medicine (occupational health) 1.2 Psychiatric nurse therapist 1.2 Working (not as nurse practitioner) 6.3 Unemployed 11.3
Table V-Arrangement for assignment of new patients as reported by 79 physicians Description Either MD or nurse practitioner (NP) (depending on availability) 46.8 NP only 19.0 Either MD or NP (depending on presenting symptoms)
17.7
MD only Other
8.9 5.1
MD and NP
1.3
No answer
1.3
Table VI-Changes in physicians' net income* Direction First subsequent and year v. baseline magnitude of change, % No. Increase >25 2 15-24 2
Last year reported v. baseline No. 1 3
+14 to -14 20 20 Decrease 15-24 2 5 >25 6 3 *Response rates for changes in income of physicians in private fee-for-service practice were 85% for gross income and 80% for net income.
Table ViI-Changes in practice size Direction First subsequent and year v. baseline magnitude of change, % No. Increase 100-125 0 50-99 0 15-49 3 +14-14 Decrease 15-49 50-99
Last year reported v. baseline No. 2 2 1
21
19
1 1
1 1
Indodd
(indomethacin, MSD Std.) IndIcatIons INDOCID' (indomethacin, MSD Std.) has been found effective in the symptomatic treatment of selected cases of rheumatoid arthritis, ankylosing (rheumatoid) spondylitis, gout, selected cases of severe osteoarthritis including degenerative disease of the hip. INDOCID. should be used in those cases of severe osteoarthritis which do not respond to treatment with other drugs such as the salicylates. In these conditions it may on occasion replace other commonly used agents such as corticosteroids, salicylates, phenylbutazone-like compounds, and colchicine. Dosage Summary For Adults In chronic rheumatoid arthritis and ankylosing (rheumatoid) spondylitis: Start with 25 mg b.i.d. or t.i.d. If response is inadequate, add 25 mg daily each week until an adequate response is obtained or a dosage of 150 to 200 mg is reached. In acute rheumatoid arthritis and acute flares of chronic rheumatoid arthritis: Start with 25mg bid. or tid. If response is inadequate, add 25 mg each day until an adequate response is obtained or until a total daily dose of 150-200 mg is reached. Maintenance corticosteroids can often gradually be reduced 25 to 50 percent and completely discontinued over several weeks or months in some patients. In severe osteoarthritis and degenerative disease of the hip: Start with 25 mg bid. or tid. If response is inadequate, increase the daily dosage by 25 mg at about weekly intervals until an adequate response is obtained or until a dosage of 150 to 200 mg is reached. In acute gout: 50 mg tid. until all signs and symptoms subside. lNDOClD. Suppositories: 100 mg to 200 mg a day. May be administered one at bedtime, and if necessary one the following morning. Also may be used in combined administration with Capsules: 100 mg suppository at bedtime, supplemented the following day by 25 mg capsules as needed up to a total of 150 to 200 mg (capsules and suppositories) of indomethacin. Note: In chronic disorders, it is important to start with low dosage and increase gradually for best results with fewer adverse reactions. Always give INDOCID* with food or immediately after meals or with antacid to reduce gastric irritation. As with all drugs, the lowest possible effective dose should be utilized for each individual patient. ContraIndications Active peptic ulcer, gastritis, regional enteritis, ulcerative colitis, divert iculitis and if there is a recurrent history of GI. lesions. Also contraindicated in patients allergic to asa. or indomethacin. Safety of indomethacin for use in pregnancy or lactation has not been established. Indomethacin suppositories are contraindicated in subjects with a history of recent rectal bleeding. SHOULD NOT BE ADMINISTERED TO PEDIATRIC AGE GROUPS. Warning Patients who experience dizziness, lightheadedness, or feelings of detachment on indomethacin should be cautioned against operating motor vehicles, machinery, climbing ladders, etc. Use cautiously in patients with psychiatric disturbances, epilepsy, or parkinsonism. PrecautIons indomethacin should be used with caution because of the possible occurrence of gastrointestinal reactions, the incidence of which may be decreased by glying the drug immediately after meals, with food or antacids. The risk of continuing therapy with indomethacin in the face of such symptoms must be weighed against the possible benefits to the individual patient. Indomethacin suppositories should be given with caution to patients with any anal or rectal pathology. Discontinue it GI. bleeding occurs. Peptic ulcer has been reported. Hemorrhage and perforation have occurred in patients with history of peptic ulcer (see Contralndlcatlons) or in patients receiving steroids or salicylates concomitantly. In some patients there was no history of peptic ulcer or of other drugs being given. As a result of GI. bleeding some patients may manifest anemia and, for this reason, appropriate blood determinations are recommended periodically. Headache may occur, usually eariy in treatment. Discontinue therapy if headache persists despite dosage reduction. In common with other drugs which have anti-inflamma-
tory, analgesic and antipyretic properties, indomethacin possesses the potential of masking the signs and symptoms which ordinarily accompany infectious disease. The physician must be alert to this possibility to avoid undue delay in initiating appropriate treatment of the infection. Indomethacin should be used with caution in patients with existing, but controlled infections. Where therapy is prolonged, ophthalmological examinations are desirable at periodic intervals (see Eye Reactions). Since advancing years appear to increase the possibility of adverse reactions, indomethacin should be used with greater care in the elderly. As with any drug, patients should be followed carefully to detect unusual manifestations of drug sensitivity. Adverse Reactions Central Nervous System: Commonly seen, headache (usually more severe in morning), dizziness, and lightheadedness. Infrequently observed: mental confusion, syncope, drowsiness, convulsions, coma, depression which may be severe, and other psychic disturbances, such as depersonalization. The severity of these effects may occasionally require cessation of therapy and rarely, admission to hospital. Gastrointestinal: include nausea, anorexia, vomiting, epigastric distress, abdominal pain, and diarrhea, which are not uncommon. Single or multiple ulceration of esophagus, stomach, duodenum orsmall intestine, perforation and hemorrhage have occurred. A few fatalities have been reported. Hemorrhage without obvious ulceration. Increased abdominal pain in patients with ulcerative colitis. Indomethacin has been suspected of precipitating the symptoms of ulcerative colitis or regional ileitis but causal relationship not proven. Rarely reported, intestinal ulceration followed by stenosis and obstruction. Least frequent reactions: ulcerative stomatitis, bleeding from sigmoid colon or diyerticuli, perforation of pre-existing sigmoid lesions, e.g., diverticuli or carcinoma. With the use of indomethacin suppositories, pruritus ani, tenesmus, and irritation of the rectal mucosa reported occasionally; rectal bleeding rarely. However, sigmoidoscopic examination in a number of patients did not reveal any significant changes of rectal mucosa. Hepatic: Toxic hepatitis and jaundice of uncertain etiology, including severe and fatal cases. Cardiovascular-Renal: Infrequently, edema, elevation of blood pressure, and hematuria. Dermatologic-Hypersensitivity: Infrequently, pruritus, urticaria, angioneurotic edema, angiitis, erythema nodosum, skin rashes, loss of hair, and acute respiratory distress including sudden dyspnea and asthma. Hematologic Reactions: Infrequently leukopenia, purpura and thrombocytopenia. Rarely agranulocytosis, hemolytic anemia, but definite relationship to drug not established. Anemia secondary to obvious or occult gastrointestinal bleeding. It is advisable to perform periodic blood counts (including platelet) in patients on long term therapy. If signs or symptoms of above reactions appear, discontinue drug and institute appropriate hematological investigations. Ear Reactions: Tinnitus infrequently, and deafness rarely. Eye Reactions: Retinal disturbances, including those of the macula, and corneal deposits have been observed. Some of these changes regressed after discontinuation of therapy. Infrequently, blurred vision, orbital and penorbital pain. Miscellaneous: Rarely, vaginal bleeding, hyperglycemia, glycosuria and peripheral neuropathy, and epistaxis. DETAILED INFORMATION AVAILABLE ON REQUEST. How Supplied Ca 8662-lNDOClD. Capsules 25 mg each, are opaque, blue and white, imprinted with an MSD trademarkand potency, and are supplied in bottles of 100 and 1000. Ca 8663-lNDOCl0. Capsules 50 mg each, are opaque, blue and white, imprinted with an MSD trademarkand potency, and are supplied in bottles of 100 and 500. Ca 8711-lNDOClD. Suppositories 100 mg each, are white opaque suppositories, supplied in boxes of 12 and 30. Trademark
O MERCK I SHARP I & DOHME CANADA LIMITED POINTE CLAIRE, QUEBEC H9R 4P7
(MC-941 bl
862 CMA JOURNAL/APRIL 23, 1977/VOL. 116
Master University and from comparable programs elsewhere in Canada and the extent of their success as innovators have resulted in arresting challenges to the system for provision of primary health services. The magnitude of the challenge is one that health care planners and decision makers in Canada can no longer ignore. We acknowledge the outstanding contribution of the respondent family practice nurses and their associated physicians. Mrs. Betty Bidgood supervised the data gathering of the McMaster University health sciences field survey unit. Sally Skene and Maria Yan-Ying of the same unit assisted in the data analysis. This study was supported by national health grant no. 606-22-35 from the Health and Welfare Canada research directorate. References 1. SPITZER WO: A strategy for evaluation of new health professionals, in New Health Professionals, vol 1, Fogarty International Center
series on the teaching of preventive medicine, National Institutes of Health, Bethesda, MD, DHEW pubi no 75-875, 1975, pp 83-98 2. SPrrZER WO, KERGIN DJ: Nurse practitioners in primary care. I. The McMaster University educational program. Can Med Assoc .1 108: 991, 1973 3. CHENOY NC, SPIrzaa WO, ANDERSON GD:
Nurse practitioners in primary care. II. Prior attitudes of a rural population. Ibid, p 998 4. Ss'rs-zaR WO, KERGIN DJ, YOSHDA MA, Ct al: Nurse practitioners in primary care. III. The southern Ontario randomized trial. Ibid, p 1005 5. BATCHELOR GM, S.rrzast WO, COMLEY AE, et al: Nurse practitioners in primary care. IV: Impact of an interdisciplinary team on attitudes of a rural population. Can Med Assoc J 112: 1415, 1975 6. SPITZER WO, ROBERTS RS, DELMORE T: Nurse practitioners in primary care. V. Develop-
ment of the Utilization and Financial Index to measure effects of their deployment. Can Med Assoc J 114: 1099, 1976 7. Idem: Nurse practitioners in primary care. VI. Assessment of their deployment with the Utilization and Financial Index. Ibid, p 1103 8. SCHERER K, FORTIN F, S.rrzasi WO, et al: First Survey of Nurse Practitioners and Associated Physicians, Methodological Manual and Final Report, McMaster University, Hamilton, 1976 9. MILLER DC: Handbook of Research Design and Social Measurement, 2nd ed, New York, McKay, 1971, p 76
10. SPsrzaR WO, SACKETr DL, SIBLEY JC, et al:
The Burlington randomized trial of the nurse practitioner. N Engi J Med 290: 251, 1974
11. SPITzER WO, HACKETT BC, RUSSELL WAM:
Changes in income with nurse practitioner. Ontario Med Rev 41: 269, 1974 12. LEwis CE, RESNIK BA: Nurse clinics and progressive ambulatory patient care. N Engl J Med 277: 1236, 1967 13. Laas RE, ANDERSON RM: Patient attitudes
to the expanded role of the nurse in family practice. Can Med Assoc J 105: 1164, 1971 14. SWEENY GP, HAY WI: The Burlington experience: a study of nurse practitioners in family practice. Can Fain Physician 19: 101, 1973 15. CHARRON KC (chmn): The Nurse Practitioner in Primary Care, Ontario Council of Health, Ontario Ministry of Health, Toronto, Queen's Printer, 1975 16. An assistant in the house? (E) Lancet 2: 842, 1975 17. Krankenschwestern als praktische Arzte (E). Frankf Allg zig 27: 27, 1974 18. BREwER C: When nurses turn doctor. The
Guardian, London, England, July 4, 1974, p 15
