Article Text

Download PDFPDF

A randomised trial comparing the cost effectiveness of different emergency department healthcare professionals in soft tissue injury management
  1. Carey Middleton McClellan1,
  2. Fiona Cramp2,
  3. Jane Powell2,
  4. Jonathan Richard Benger1,2
  1. 1Academic Department of Emergency Care, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
  2. 2University of the West of England, Bristol, UK
  1. Correspondence to Dr Carey Middleton McClellan; carey.mcclellan{at}


Objectives To evaluate the cost effectiveness of soft tissue injury management by emergency nurse practitioners (ENPs) and extended scope physiotherapists (ESPs) compared with the routine care provided by doctors in an emergency department (ED).

Design Randomised, pragmatic trial of equivalence.

Setting A single ED in England.

Participants 372 patients were randomised, 126 to the ESP group, 123 to the ENP group and 123 to the doctor group. Participants were adults (16 years and older) presenting to the ED with a peripheral soft tissue injury eligible for management by any of the three professional groups.

Interventions Patients were randomised to treatment by an ESP, ENP or routine care provided by doctors (of all grades).

Main outcome measures Economic cost-minimisation evaluation from a funder perspective of the National Health Service, England incorporating analysis of the direct, indirect and tangible costs of care in primary and secondary settings.

Results From a funder perspective in primary and secondary care, ESPs and ENPs are at best equivalent and could not cost less than routine care. Uncertainty in cost arises from ESPs and ENPs incurring greater indirect costs, such as those associated with follow-up appointments and subsequent primary care visits. Comparison from a funder perspective in secondary care, that is, considering those costs incurred in secondary care alone, demonstrates that ENPs are equivalent in cost to routine care, while ESPs are either equivalent or possibly cheaper than routine care.

Conclusions These results question the notion that training the healthcare workforce to undertake extensions of their role is generally cost effective. While the randomised trial indicated that the three professional groups have equivalent clinical outcomes, this economic analysis suggests that substitution of routine care with a predominantly ESP or ENP workforce could prove more expensive. Further research is required to understand the underlying reasons for this. The trial has been registered with ISRCTN-ISRCTN 70891354.

  • Accident & Emergency Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.