Abstract

Purpose

To bear a systematic review of randomized controlled trials (RCTs) of the condom and effectiveness of primary intendance provided by advanced do nurses (APNs) and evaluate the potential of their deployment to help alleviate primary intendance shortages.

Information sources

PubMed, Medline and the Cumulative Index to Nursing and Centrolineal Health Literature.

Report option

RCTs and their follow-up reports that compared outcomes of care provided to adults by APNs and physicians in equivalent master intendance provider roles were selected for inclusion.

Data extraction

Ten articles (seven RCTs, plus ii economic evaluations and one 2-yr follow-upwards study of included RCTs) met inclusion criteria. Data were extracted regarding report pattern, setting and outcomes across four mutual categories.

Results of data synthesis

The seven RCTs include information for 10 911 patients who presented for ongoing main care (4 RCTs) or same-twenty-four hours consultations for astute weather condition (three RCTs) in the primary care setting. Study follow-up ranged from i day to 2 years. APN groups demonstrated equal or better outcomes than physician groups for physiologic measures, patient satisfaction and cost. APNs generally had longer consultations compared with physicians; however, two studies reported that APN patients required fewer consultations over time.

Conclusion

At that place were few differences in principal care provided by APNs and physicians; for some measures APN intendance was superior. While studies are needed to assess longer term outcomes, these data advise that the APN workforce is well-positioned to provide safe and effective main care.

Introduction

The Proclamation of Alma-Ata (1978) identified universally-attainable chief intendance as a fundamental component of an effective wellness organisation [ane–three]. However, even in resource-rich countries such as the United States (The states), this vision has nonetheless to be realized. With an aging population and expanded admission to insurance coverage under the Affordable Care Human activity, the shortage of primary care providers (PCPs) in the US is increasingly acute. Although estimates of the magnitude of the shortage vary, projections remain consistent that the supply of PCPs will not keep up with the growing need for primary care services [4, v]. The shortage stems largely from the increasing complexity of services provided in the primary care setting, coupled with financial disincentives to enter chief care practice [6]. Compared with most developed nations, access to primary care is more express for Americans. In a 2014 comparison of eleven international healthcare systems, the Commonwealth Fund reported that while the US had one of the shortest wait times for specialist care, only 59% of American adults were able to get a same- or next-day primary care appointment when ill [vii]; a related written report establish that family practise wait times averaged 19.5 days [viii]. I proposed solution to the PCP shortage relies on increasing physician supply through programs and policies offering incentives for entry into primary care. To engagement this arroyo has not been successful, offers no guarantee of success and, even if successful, requires considerable atomic number 82 time and high cost [9].

An alternative approach is to maximize utilization of non-dr. providers, including nurse practitioners (NPs) and other avant-garde practise nurses (APNs), physician administration and midwives in primary care delivery. These provider types receive different grooming with different scopes of practice divers past state legislation. In the US, the supply of NPs is growing quickly [five, 10] with NPs more than probable to specialize in primary intendance than their physician counterparts. Currently more 75% of NPs in the US practice in at least ane master care site [eleven]. Hence, full deployment and expanded utilise of NPs is one promising strategy to alleviate the primary intendance shortage and is consistent with the Institute of Medicine Future of Nursing Report recommendation that nurses should practice to the full extent of their teaching and grooming [12].

Previous systematic reviews examining outcomes of NP and other APN intendance have demonstrated favorable results; however, they are either outdated [13], non limited to the master care setting [14–17], include studies with designs other than randomized controlled trials (RCTs) [xiii–xix], include studies which do not compare outcomes of APNs and physicians in comparable roles [xv, 18, 20] or include studies in which the APN is not in a PCP role [21]. The purpose of this systematic review is to evaluate data from RCTs regarding the cost and quality of care provided by APNs in principal intendance.

Methods

Literature search

The guidelines set forth in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [22] were followed. PubMed, Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were systematically searched with assistance from an data specialist expert in systematic review methods to identify RCTs comparison outcomes of care provided to adults by APNs and physicians in the primary care setting. Initially, wide categories of search terms were selected, including: APN, patient outcomes, principal care and RCT. Specific terms within each category were then identified (for example, the category for APN included the terms 'nurse practitioner,' 'nurse clinicians,' 'advanced practice nursing,' et cetera). Terms were entered more often than not and expanded to include medical subject heading (MeSH) terms where bachelor. Similar search terms were listed using database-specific commands such equally ADJ or * (wildcard) to ensure inclusion of relevant articles (for case: family NPs, patient satisfaction, family health clinic, random* stud*). All possible combinations of the terms from each category were then searched to locate target studies (run across Supplementary Appendix). Boosted search criteria included presence of an abstract and English language publication. No date restriction was employed.

Inclusion criteria included RCTs comparing primary care outcomes of APNs and physicians, every bit well equally whatsoever publications stemming from these RCTs providing longer term follow-up or economic evaluation of the included RCT samples. APNs were defined as nurses who had received additional formal education and preparation that expanded their scope of exercise to include services traditionally considered to fall under the practice of medicine, such equally diagnosis and treatment of medical conditions. Exclusion criteria included review articles, non-RCT design or no original data, studies in which APN care was non the independent variable and studies with entirely pediatric samples (due to the variation in outcomes of interest between adult and pediatric patients, which would impede information assemblage). Additionally, the APN role in the written report had to exist that of a PCP, with an educational groundwork allowing them to manage their own panel of patients.

Afterward removing duplicates, reviewers screened titles to identify articles that met inclusion and exclusion criteria. Side by side, abstracts and full text of identified studies were independently assessed by ii reviewers. Discrepancies regarding whether a study met inclusion criteria and/or whether the role of APNs was equivalent to that of a PCP were discussed among reviewers until consensus was attained. Reference lists of included manufactures equally well as previously-published systematic reviews were manus-searched for any additional RCTs satisfying inclusion and exclusion criteria.

Quality appraisement

The Cochrane Collaboration's tool for assessing risk of bias was used to assess study quality [23]. The instrument contains seven criteria: random sequence generation, allotment concealment, blinding of participants and personnel, blinding of issue assessor, incomplete outcome data, selective outcome reporting and other bias. Each criterion has detailed directions for making judgments about risk of bias and is rated as high, depression or unclear. Two independent reviewers rated the quality of each study and discrepancies were discussed until consensus was reached among all authors.

For studies that included a toll outcome, the Quality of Health Economic Studies (QHES) instrument [24, 25] was also used, including 16 criteria scored equally 'met' or 'not met'. Each criterion receives a weighted score ranging from one to 9 points totaling 0–100 points. Two reviewers (EL, Equally) independently appraised each economical evaluation; where scores differed, agreement was achieved by consensus.

Information extraction and synthesis

Data regarding study sample and setting, pattern and outcomes were extracted including sample size, patient characteristics and compunction rates, number and location of practices and providers, treatment description and elapsing, points of data collection, outcomes measured and statistical techniques. Outcomes assessed in multiple studies were and so synthesized to provide comparison beyond studies.

Results

Literature search

The initial search identified 784 manufactures. Amid these, 109 were duplicates. Upon further screening, 512 articles were removed based on title review and 125 based on abstract review. Thirty were then excluded based on a review of the unabridged article, the most common reason for exclusion beingness that the study examined outcomes of intendance by nurses who were not acting in a PCP role. 1 publication, despite several requests for inter-library loan, could not be located and was excluded [26]. Two additional RCTs were identified during the hand search [27, 28] resulting in a final full of 10 articles: seven RCTs [27–33], a 2-year follow-up of the sample from the Mundinger et al. RCT [34] and two economic evaluations of an included RCT [35, 36]. Effigy1 summarizes the literature search.

Figure one

Flow diagram of literature search. CINAHL, Cumulative Index to Nursing and Allied Health Literature; APN, advanced practice nurse; PCP, primary care provider; RCT, randomized controlled trial.

Menstruum diagram of literature search. CINAHL, Cumulative Alphabetize to Nursing and Centrolineal Wellness Literature; APN, advanced practise nurse; PCP, primary care provider; RCT, randomized controlled trial.

Figure 1

Flow diagram of literature search. CINAHL, Cumulative Index to Nursing and Allied Health Literature; APN, advanced practice nurse; PCP, primary care provider; RCT, randomized controlled trial.

Catamenia diagram of literature search. CINAHL, Cumulative Alphabetize to Nursing and Allied Health Literature; APN, advanced exercise nurse; PCP, main care provider; RCT, randomized controlled trial.

Report characteristics

The ten included studies represent data from 10 911 subjects who participated in seven RCTs (Table1). Five studies were conducted in Europe [27, 29–31, 33]. One study and its 2-yr follow-upwardly were conducted in the US [32, 34]. Subjects were randomized when they presented for a general [28, 32] or diabetes-focused primary care visit [27, xxx], or for same-day consultation for any reason [31, 33] or for a pre-defined list of weather and/or diabetes-related care [29]. One written report limited recruitment to adults without a usual source of care during an emergency room visit and targeted a high proportion with chronic conditions such as asthma, diabetes mellitus and hypertension [32].

Table ane

Characteristics of included studies

Author, year, state Sample, setting Provider type (number), intervention description Data collection time points, attrition rate Chief outcomes
Dierick-van Daele, 2009, 2010a
The netherlands		 APN grouping Northward = 817; physician group N = 684
Historic period (years): 42.viii ± sixteen.v APN grouping, 46.1 ± 16.6 doc grouping
Race/ethnicity: NR
xv general practices		 NP (n = 12) vs. full general practitioner (n = 50)
Unmarried consultation for pre-defined list of problems; any follow-up over 2 week duration

  • Information drove:

    • Baseline

    • Immediately after visit

  • Attrition 32.eight% at 2 weeks for follow-up questionnaire data, 6.9% for medical data

  • Effectiveness of consultation (health status)

  • Patient satisfaction

  • Direct costsa

  • Productivity lossa

  • Healthcare resource utilization

  • Adherence to guidelines
Houweling, 2009
The Netherlands		 APN grouping Due north = 50; medico grouping N = 43
Age (years): 63.1 ± 10.6 APN group,
59.6 ± 10.6 physician grouping
Race/ethnicity: NR
two infirmary associated diabetes outpatient clinics		 Nurse specialized in diabetes (n = NR) vs. internist (north = NR)
All diabetes intendance, including claret force per unit area and lipid direction, over 12 calendar month elapsing

  • Data collection:

    • Baseline

    • half dozen months

    • 12 months

  • Attrition 9.7% at 12 months

  • Physiologic measures (hemoglobin A1c, blood pressure, lipid contour, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Healthcare costs

  • Healthcare resource utilization
Houweling, 2011
The Netherlands		 APN group N = 116; physician group N = 114
Historic period (years): 67.1 ± eleven.0 APN grouping,
69.5 ± x.half dozen physician group
Race/ethnicity: NR
Single group practice		 Practice nurse (n = two) vs. general practitioner (north = two)
All diabetes care, including blood pressure and lipid management, over
14 calendar month duration

  • Information collection:

    • Baseline

    • fourteen months

  • Compunction ten.4% at 14 months

  • Physiologic measures (hemoglobin A1c, blood pressure, lipid contour, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Process indicators (appropriate preventive intendance, therapy intensification)
Kinnersley, 2000
England and Wales		 APN group N = NR; physician group Due north = NR; total N = 1465
Age ≥sixteen years: 62% APN group,
68% md group
Race/ethnicity: NR
10 general practices		 NP (n = ten) vs. general practitioner
(n = NR)
Aforementioned-day consultation; whatsoever follow-upward over 4 calendar week elapsing

  • Data drove:

    • Baseline

    • Immediately after initial visit

    • ii weeks

    • 4 weeks (audit data)

  • Compunction 25% at 2 weeks for questionnaire data, 11% at four weeks for audit information

  • Symptom resolution

  • Patient satisfaction

  • Healthcare resources utilization

  • Patient education

  • Patient intentions for hereafter care
Mundinger, 2000 and Lenz, 2004b
United States		 APN grouping N = 1181 (222b); physician group N = 800 (184b)
Age (years): 45.5 ± NR APN group,
46.7 ± NR md grouping
Race/ethnicity: xc.3% Hispanic
v main intendance clinics at an urban academic medical center		 NP (northward = 7) vs. doc (n = 17)
All primary care services over
1 twelvemonth duration

  • Data collection:

    • Baseline

    • Immediately subsequently initial visit

    • 6 months

    • one year

    • 2 yearsb

  • Attrition 0.05% at 6 months for medical data; 21% at six months for interview data

  • Physiologic measures (glycosylated hemoglobin, blood pressure, peak flow)

  • Wellness status

  • Patient satisfaction

  • Healthcare resource utilization
Spitzer, 1974, 1976a
Canada		 APN group N = 1529; physician grouping
N = 2796 (selected for interview cohort:
APN grouping N = 340; doc group Northward = 614)
Age >xv years: 80%
Race/ethnicity: NR
Big suburban primary care practice		 NP (n = 2) vs. family physician (north = 2)
All primary care services over i year duration

  • Data collection:

    • Baseline

    • 1 year

  • Attrition: NR

  • Physiologic measures (mortality, concrete function, social and emotional office)

  • Patient satisfaction

  • Price of care, financial performancea

  • Healthcare resources utilizationa

  • Quality of care, adherence to guidelines
Venning, 2000
England and Wales		 APN group N = 651; physician group N = 665
Age >xvi years: 67%
Race/ethnicity: NR
twenty general practices		 NP (n = NR) vs. general practitioner (n = NR)
Same-twenty-four hour period consultation plus any follow-up inside 2 calendar week duration

  • Data collection:

    • Baseline

    • 2 weeks

  • Attrition 24% at 2 weeks

  • Health condition

  • Patient satisfaction

  • Cost of intendance

  • Healthcare resource utilization
Author, year, country Sample, setting Provider type (number), intervention description Data collection fourth dimension points, attrition rate Chief outcomes
Dierick-van Daele, 2009, 2010a
The netherlands		 APN group Northward = 817; medico group N = 684
Age (years): 42.8 ± 16.5 APN group, 46.1 ± xvi.6 dr. group
Race/ethnicity: NR
15 general practices		 NP (n = 12) vs. general practitioner (north = l)
Unmarried consultation for pre-defined listing of problems; any follow-upwardly over two week duration

  • Information collection:

    • Baseline

    • Immediately after visit

  • Attrition 32.viii% at 2 weeks for follow-upward questionnaire data, 6.9% for medical data

  • Effectiveness of consultation (wellness status)

  • Patient satisfaction

  • Direct costsa

  • Productivity lossa

  • Healthcare resource utilization

  • Adherence to guidelines
Houweling, 2009
The Netherlands		 APN group N = 50; physician group North = 43
Age (years): 63.1 ± x.6 APN group,
59.half-dozen ± 10.6 physician group
Race/ethnicity: NR
two hospital associated diabetes outpatient clinics		 Nurse specialized in diabetes (n = NR) vs. internist (due north = NR)
All diabetes intendance, including blood pressure and lipid direction, over 12 month elapsing

  • Data collection:

    • Baseline

    • half-dozen months

    • 12 months

  • Attrition nine.7% at 12 months

  • Physiologic measures (hemoglobin A1c, claret pressure, lipid profile, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Healthcare costs

  • Healthcare resource utilization
Houweling, 2011
The Netherlands		 APN group N = 116; physician group N = 114
Historic period (years): 67.1 ± 11.0 APN group,
69.v ± 10.6 md group
Race/ethnicity: NR
Single group practice		 Practice nurse (north = 2) vs. general practitioner (n = ii)
All diabetes care, including blood pressure and lipid management, over
14 calendar month duration

  • Information drove:

    • Baseline

    • 14 months

  • Attrition x.4% at xiv months

  • Physiologic measures (hemoglobin A1c, blood pressure, lipid profile, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Process indicators (appropriate preventive care, therapy intensification)
Kinnersley, 2000
England and Wales		 APN group Northward = NR; doctor group North = NR; total N = 1465
Age ≥xvi years: 62% APN group,
68% dr. group
Race/ethnicity: NR
x general practices		 NP (n = ten) vs. general practitioner
(northward = NR)
Aforementioned-day consultation; any follow-up over 4 week duration

  • Data drove:

    • Baseline

    • Immediately after initial visit

    • 2 weeks

    • four weeks (audit data)

  • Compunction 25% at 2 weeks for questionnaire data, eleven% at iv weeks for audit data

  • Symptom resolution

  • Patient satisfaction

  • Healthcare resource utilization

  • Patient education

  • Patient intentions for future intendance
Mundinger, 2000 and Lenz, 2004b
U.s.a.		 APN grouping Northward = 1181 (222b); md grouping Due north = 800 (184b)
Age (years): 45.five ± NR APN grouping,
46.7 ± NR physician grouping
Race/ethnicity: ninety.3% Hispanic
5 primary intendance clinics at an urban bookish medical centre		 NP (n = seven) vs. doctor (northward = 17)
All master care services over
1 year duration

  • Data collection:

    • Baseline

    • Immediately after initial visit

    • 6 months

    • 1 year

    • 2 yearsb

  • Compunction 0.05% at 6 months for medical data; 21% at vi months for interview information

  • Physiologic measures (glycosylated hemoglobin, blood pressure, meridian catamenia)

  • Health status

  • Patient satisfaction

  • Healthcare resources utilization
Spitzer, 1974, 1976a
Canada		 APN group N = 1529; physician group
N = 2796 (selected for interview cohort:
APN group North = 340; physician group North = 614)
Historic period >fifteen years: fourscore%
Race/ethnicity: NR
Big suburban primary intendance practise		 NP (n = two) vs. family unit doc (northward = 2)
All primary care services over one year duration

  • Information collection:

    • Baseline

    • ane year

  • Compunction: NR

  • Physiologic measures (mortality, physical role, social and emotional function)

  • Patient satisfaction

  • Price of intendance, financial performancea

  • Healthcare resource utilizationa

  • Quality of care, adherence to guidelines
Venning, 2000
England and Wales		 APN group Due north = 651; physician group North = 665
Age >16 years: 67%
Race/ethnicity: NR
twenty general practices		 NP (n = NR) vs. general practitioner (n = NR)
Same-day consultation plus whatsoever follow-up within 2 week duration

  • Information collection:

    • Baseline

    • 2 weeks

  • Attrition 24% at two weeks

  • Wellness status

  • Patient satisfaction

  • Cost of care

  • Healthcare resource utilization

APN, avant-garde practice nurse; NR, not reported; BMI, trunk mass alphabetize.

aEconomic evaluation of randomized control trial.

bTwo-yr follow-up of 406 subjects.

Table 1

Characteristics of included studies

Writer, year, country Sample, setting Provider type (number), intervention description Data collection time points, attrition rate Main outcomes
Dierick-van Daele, 2009, 2010a
Kingdom of the netherlands		 APN group Due north = 817; dr. group N = 684
Age (years): 42.viii ± 16.v APN grouping, 46.ane ± 16.6 doc group
Race/ethnicity: NR
15 general practices		 NP (n = 12) vs. general practitioner (n = 50)
Single consultation for pre-defined listing of problems; whatever follow-up over 2 calendar week elapsing

  • Information drove:

    • Baseline

    • Immediately afterward visit

  • Compunction 32.eight% at two weeks for follow-upward questionnaire information, half dozen.9% for medical data

  • Effectiveness of consultation (health status)

  • Patient satisfaction

  • Direct costsa

  • Productivity lossa

  • Healthcare resource utilization

  • Adherence to guidelines
Houweling, 2009
The netherlands		 APN group Due north = 50; dr. group N = 43
Historic period (years): 63.1 ± ten.half-dozen APN group,
59.6 ± 10.6 dr. group
Race/ethnicity: NR
2 infirmary associated diabetes outpatient clinics		 Nurse specialized in diabetes (northward = NR) vs. internist (northward = NR)
All diabetes care, including blood pressure and lipid management, over 12 month duration

  • Data drove:

    • Baseline

    • 6 months

    • 12 months

  • Attrition 9.7% at 12 months

  • Physiologic measures (hemoglobin A1c, blood pressure level, lipid profile, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Healthcare costs

  • Healthcare resources utilization
Houweling, 2011
The Netherlands		 APN group N = 116; md group N = 114
Historic period (years): 67.1 ± 11.0 APN group,
69.five ± x.six physician group
Race/ethnicity: NR
Unmarried group practice		 Practice nurse (n = 2) vs. general practitioner (n = 2)
All diabetes care, including blood pressure and lipid management, over
14 calendar month elapsing

  • Information collection:

    • Baseline

    • 14 months

  • Attrition 10.iv% at 14 months

  • Physiologic measures (hemoglobin A1c, blood pressure, lipid profile, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Procedure indicators (appropriate preventive care, therapy intensification)
Kinnersley, 2000
England and Wales		 APN grouping North = NR; doc group N = NR; total N = 1465
Age ≥16 years: 62% APN grouping,
68% doctor group
Race/ethnicity: NR
x general practices		 NP (n = x) vs. general practitioner
(n = NR)
Aforementioned-day consultation; whatsoever follow-up over 4 calendar week duration

  • Data collection:

    • Baseline

    • Immediately after initial visit

    • ii weeks

    • 4 weeks (audit data)

  • Attrition 25% at two weeks for questionnaire information, 11% at 4 weeks for audit data

  • Symptom resolution

  • Patient satisfaction

  • Healthcare resources utilization

  • Patient educational activity

  • Patient intentions for future care
Mundinger, 2000 and Lenz, 2004b
Us		 APN group Northward = 1181 (222b); medico grouping N = 800 (184b)
Age (years): 45.v ± NR APN grouping,
46.seven ± NR physician grouping
Race/ethnicity: 90.3% Hispanic
5 primary care clinics at an urban academic medical center		 NP (n = 7) vs. physician (north = 17)
All master care services over
one year elapsing

  • Data collection:

    • Baseline

    • Immediately after initial visit

    • six months

    • 1 year

    • 2 yearsb

  • Attrition 0.05% at half dozen months for medical information; 21% at 6 months for interview data

  • Physiologic measures (glycosylated hemoglobin, blood force per unit area, peak catamenia)

  • Health condition

  • Patient satisfaction

  • Healthcare resource utilization
Spitzer, 1974, 1976a
Canada		 APN group N = 1529; md grouping
Northward = 2796 (selected for interview cohort:
APN grouping N = 340; physician group N = 614)
Age >15 years: 80%
Race/ethnicity: NR
Big suburban chief care do		 NP (n = 2) vs. family dr. (north = 2)
All primary intendance services over 1 year elapsing

  • Data collection:

    • Baseline

    • 1 year

  • Compunction: NR

  • Physiologic measures (bloodshed, physical office, social and emotional function)

  • Patient satisfaction

  • Toll of care, financial performancea

  • Healthcare resource utilizationa

  • Quality of care, adherence to guidelines
Venning, 2000
England and Wales		 APN grouping North = 651; physician grouping N = 665
Age >16 years: 67%
Race/ethnicity: NR
xx general practices		 NP (n = NR) vs. general practitioner (n = NR)
Same-24-hour interval consultation plus whatsoever follow-up within 2 week elapsing

  • Data collection:

    • Baseline

    • ii weeks

  • Attrition 24% at ii weeks

  • Health status

  • Patient satisfaction

  • Price of care

  • Healthcare resource utilization
Writer, twelvemonth, country Sample, setting Provider blazon (number), intervention description Information collection time points, compunction rate Chief outcomes
Dierick-van Daele, 2009, 2010a
The Netherlands		 APN group Northward = 817; physician group Northward = 684
Age (years): 42.8 ± xvi.5 APN group, 46.one ± sixteen.half-dozen physician grouping
Race/ethnicity: NR
fifteen general practices		 NP (north = 12) vs. general practitioner (n = fifty)
Single consultation for pre-defined list of problems; whatever follow-up over 2 week duration

  • Data collection:

    • Baseline

    • Immediately afterwards visit

  • Attrition 32.eight% at two weeks for follow-up questionnaire data, 6.nine% for medical data

  • Effectiveness of consultation (health status)

  • Patient satisfaction

  • Direct costsa

  • Productivity lossa

  • Healthcare resources utilization

  • Adherence to guidelines
Houweling, 2009
The netherlands		 APN group Northward = 50; physician grouping North = 43
Historic period (years): 63.i ± 10.6 APN group,
59.six ± 10.6 physician group
Race/ethnicity: NR
ii hospital associated diabetes outpatient clinics		 Nurse specialized in diabetes (n = NR) vs. internist (northward = NR)
All diabetes care, including blood force per unit area and lipid management, over 12 month duration

  • Data collection:

    • Baseline

    • 6 months

    • 12 months

  • Compunction nine.seven% at 12 months

  • Physiologic measures (hemoglobin A1c, blood pressure, lipid contour, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Healthcare costs

  • Healthcare resource utilization
Houweling, 2011
Holland		 APN group N = 116; md group N = 114
Age (years): 67.1 ± 11.0 APN group,
69.5 ± ten.six physician group
Race/ethnicity: NR
Single group exercise		 Exercise nurse (due north = ii) vs. general practitioner (northward = ii)
All diabetes care, including blood pressure and lipid management, over
14 month duration

  • Data collection:

    • Baseline

    • 14 months

  • Attrition 10.4% at xiv months

  • Physiologic measures (hemoglobin A1c, blood pressure, lipid contour, BMI)

  • Quality of life, symptoms

  • Patient satisfaction

  • Process indicators (appropriate preventive intendance, therapy intensification)
Kinnersley, 2000
England and Wales		 APN grouping N = NR; dr. group N = NR; total N = 1465
Age ≥16 years: 62% APN grouping,
68% medico group
Race/ethnicity: NR
10 general practices		 NP (due north = 10) vs. general practitioner
(n = NR)
Same-day consultation; whatsoever follow-up over 4 calendar week elapsing

  • Data collection:

    • Baseline

    • Immediately after initial visit

    • ii weeks

    • 4 weeks (audit data)

  • Compunction 25% at two weeks for questionnaire information, 11% at 4 weeks for audit data

  • Symptom resolution

  • Patient satisfaction

  • Healthcare resource utilization

  • Patient teaching

  • Patient intentions for hereafter care
Mundinger, 2000 and Lenz, 2004b
United States		 APN group N = 1181 (222b); dr. grouping N = 800 (184b)
Age (years): 45.5 ± NR APN group,
46.seven ± NR physician group
Race/ethnicity: 90.3% Hispanic
5 chief care clinics at an urban academic medical eye		 NP (north = 7) vs. md (n = 17)
All chief intendance services over
1 year duration

  • Information collection:

    • Baseline

    • Immediately after initial visit

    • 6 months

    • ane year

    • ii yearsb

  • Compunction 0.05% at half dozen months for medical information; 21% at 6 months for interview information

  • Physiologic measures (glycosylated hemoglobin, blood pressure, meridian menstruation)

  • Health condition

  • Patient satisfaction

  • Healthcare resource utilization
Spitzer, 1974, 1976a
Canada		 APN group N = 1529; physician group
N = 2796 (selected for interview cohort:
APN group Northward = 340; physician grouping Due north = 614)
Age >15 years: lxxx%
Race/ethnicity: NR
Large suburban main care practice		 NP (n = two) vs. family physician (north = 2)
All primary intendance services over i twelvemonth elapsing

  • Data collection:

    • Baseline

    • 1 yr

  • Attrition: NR

  • Physiologic measures (bloodshed, physical function, social and emotional part)

  • Patient satisfaction

  • Price of care, financial performancea

  • Healthcare resource utilizationa

  • Quality of intendance, adherence to guidelines
Venning, 2000
England and Wales		 APN group N = 651; physician group N = 665
Historic period >16 years: 67%
Race/ethnicity: NR
20 general practices		 NP (due north = NR) vs. full general practitioner (n = NR)
Same-mean solar day consultation plus any follow-up within ii week elapsing

  • Data collection:

    • Baseline

    • two weeks

  • Attrition 24% at ii weeks

  • Health status

  • Patient satisfaction

  • Toll of care

  • Healthcare resource utilization

APN, avant-garde practice nurse; NR, not reported; BMI, trunk mass index.

aEconomic evaluation of randomized control trial.

b2-year follow-upward of 406 subjects.

The number of providers varied by report ranging from two [28, 30] to 12 [29, 31] APNs and ii [28] to 50 [29] physicians. Two studies did not depict the number of providers [27, 33]. In two studies control grouping subjects saw both a dr. and 'standard nurse' who provided patient education, while care to those randomized to the intervention grouping was provided solely by the APN [27, 28]. APN scope of practise and titles used for APNs and physicians varied across studies. Restrictions on APN practice included the requirement for APN prescriptions to be co-signed by the general practitioner [33] and APN apply of a defined treatment protocol for diabetes-related care [27, 30]. One study reported that both APN and md providers had the aforementioned resources, such equally hospital admitting privileges, available to them [32]. Subject follow-up ranged from one day [29] to 2 years [34].

Quality appraisement

Randomized controlled trials

The bulk of studies fell in the low hazard of bias category across five of the seven criteria. For allocation concealment, risk of bias was low or unclear risk, and for random sequence generation the majority of studies demonstrated unclear risk (Fig.2).

Figure two

Summary of quality appraisal of RCTs.

Summary of quality appraisement of RCTs.

Figure 2

Summary of quality appraisal of RCTs.

Summary of quality appraisal of RCTs.

4 studies were unclear regarding the methods used for random sequence generation [28, 30–32], two showed low run a risk [29, 33] and 1 demonstrated loftier take chances of inadequate random sequence generation [27]. Iv studies reported their method of allocation concealment [29, 31–33]. Study personnel [27–29, 32] and outcome assessors [27, 28, 30–33] were blinded in the majority of studies. Four studies had low risk of incomplete outcomes data [27, 28, 30, 32] while three had loftier risk due to loftier compunction rates [29, 31, 33]. Six studies had a depression hazard of selective outcome reporting [27–30, 32, 33]. No significant take chances of bias was identified in the 'other bias' category for any of the RCTs.

Economical evaluations

Two economic evaluations [35, 36] were conducted alongside the RCTs [28, 29] with scores of 51 (9 criteria met) [36] and 86 (13 criteria met) [35]. Both studies provided acceptable clarification of their methodology for measuring and/or estimating cost and clearly described primary result measures. One [35] stated the perspective from which the study was completed, conducted a sensitivity analysis of the cost estimate under varying assumptions and measured wellness outcomes using valid and reliable scales.

Outcomes results

Table2 summarizes select physiologic, patient satisfaction, price and resource use outcomes for each written report. In three studies, outcome monitoring ended no more than 4 weeks from the time of the initial study visit [29, 31, 33]; in one written report subject follow-upwardly was limited to 1 twenty-four hours [29]. A single study reported long-term outcomes of patients retained in care at 2 years [34].

Table 2

Selected outcomes results

Writer, year Outcomes: APN group vs. physician group
Physiologic Patient satisfaction (Instrument) Cost Healthcare resource utilization
Dierick-van Daele, 2009, 2010a N/A 8.2 ± 1.2 vs. 8.two ± 1.3
(Investigator-developed instrument)		 Straight cost per consultation based on salary (euros): 31.9 ± 36.3 vs. 40.2 ± 49.9a**

  • Consultation duration (min): 12.ii vs. nine.2*

  • Referrals (percent of consultations): 12.0 vs. 14.2%

  • Number of prescriptions per consultation:

    • 1: 55.0 vs. 54.2%

    • 2: 16.nine vs. xix.5%

    • ≥three: 8.8 vs. 7.8%
Houweling, 2009

  • Change (95% CI) over 12 months:

    • Systolic BP: −8.6 (−2.6, −fourteen.7) vs. −iv.0 (0.9, −8.nine) mmHg

    • Diastolic BP: −1.iv (ane.iv, −four.1) vs. −2.iv (0.viii, −4.9) mmHg

    • Total cholesterol: −0.iv (−0.2, −0.half-dozen) vs. −0.9 (−0.five, −1.3) mmol/l

    • Cholesterol/HDL ratio: −0.4 (0.one, −0.six) vs. −0.nine (−0.5, −ane.iv)***

    • HbA1c: −1.5 (−one.0, −1.9) vs. −0.ix (−0.5, −1.3)%

 73.9 vs. 53.3%*
 [Patients' Evaluation of the Quality of Diabetes Care (PEQD)]		 Total salary costs over 12 months (euros): 114.6 ± l.iv vs. 138.iii ± 48.3***

  • Consultation elapsing over 12 months (min): 272.0 ± 120.v vs. 249.ii ± 110.7

  • Primary care visits over 12 months: vii.4 ± 3.0 vs. ix.viii ± 3.8**
Houweling, 2011

  • Modify (95% CI) over 14 months:

    • Systolic BP: −vii.4 (−3.8, −10.9) vs. −5.half-dozen (−2.3, −eight.8) mmHg

    • Diastolic BP: −3.2 (−1.iii, −5.two) vs. −i.0 (−0.viii, −two.eight) mmHg

    • Total Cholesterol: −0.1 (−0.3, 0.ane) vs. −0.05 (−0.2, 0.1) mmol/l

    • Cholesterol/HDL ratio: 0.03 (−0.1, 0.2) vs. 0.07 (−0.1, 0.ii)

    • HbA1c: −0.09 (−0.3, 0.1) vs. 0.03 (−0.2, 0.iii)%

 66.4 vs. 51.7%
 (PEQD)		 N/A N/A
Kinnersley, 2000 N/A Hateful score range across exercise sites: 72.9–79.5 vs. 68.7–79.5%
[Consultation Satisfaction Questionnaire (CSQ)]		 N/A

  • Consultation elapsing: ten vs. 6 min (statistically meaning)

  • Referrals (pct of consultations): 5 vs. five%

  • Prescription issued (percent of consultations): 63 vs. 63%
Mundinger, 2000
Lenz, 2004b

  • Value at 6 months:

    • Systolic BP: 137 vs.139 mmHg

    • Diastolic BP: 82 vs. 85 mmHg***

    • Glycosylated hemoglobin: 9.5 vs. 9.iv%

  • Value at 2 years:

    • Systolic BP: 139.0 vs. 141.9 mmHgb

    • Diastolic BP: 85.ix vs. 88.1 mmHgb

    • Glycosylated hemoglobin: eight.9 vs. 10.3%b

Initial consultation: 4.59 vs. iv.60
At 6 months: 4.45 vs. 4.46
 (Investigator-adult instrument based on Medical Outcomes Study)
At two years: hateful score range across categories 65.4–90.8 vs. 67.6–94.4%b
[Patient Care Cess Survey (PCAS)]		 Due north/A

  • Primary care visits at one year:

    • 0: 18.0 vs. xix.1%

    • 1–4: 51.8 vs. 47.1%

    • ≥5 visits: thirty.iv vs. 33.8%

  • Primary care visits (subgroup)

    • Twelvemonth 1: 3.6 vs. 4.2b

    • Twelvemonth 2: 1.8 vs. 2.5b***

  • ≥1 Hospitalization at 1 year: 8.5 vs. nine.viii%

  • ≥i Hospitalization (subgroup):

    • First year: 4.5 vs. 7.half-dozen%b

    • 2d year: iv.5 vs. 8.2%b

  • ≥ane ED/urgent intendance visits at 1 year: 34.2 vs. 33.8%

  • ≥ane ED/urgent care visits (subgroup):

    • First twelvemonth: 28.4 vs. 32.6%b

    • Second year: 30.iii vs. 33.2%b

Spitzer, 1974, 1976a North/A 96 vs. 97%
(Musical instrument not specified)		 Total UF-alphabetize: 297.0 vs. 285.7a N/A
Venning, 2000 N/A iv.forty ± 0.46 vs. four.24 ± 0.52)***
(Medical Interview Satisfaction Calibration (MISS))		 Total salary cost for initial and return consultation (pounds): eighteen.ane ± 33.4 vs. twenty.vii ± 33.four

  • Consultation elapsing (min): 11.6 ± v.8 vs. 7.3 ± 4.eight*

  • Referred to infirmary (percent of consultations): one.7 vs. iii.8%

  • Prescription issued (percent of consultations): 61.0 vs. 64.7%
Author, year Outcomes: APN group vs. physician grouping
Physiologic Patient satisfaction (Instrument) Cost Healthcare resources utilization
Dierick-van Daele, 2009, 2010a Due north/A eight.2 ± i.2 vs. viii.2 ± one.3
(Investigator-developed instrument)		 Directly price per consultation based on salary (euros): 31.9 ± 36.3 vs. 40.2 ± 49.9a**

  • Consultation duration (min): 12.2 vs. 9.2*

  • Referrals (percent of consultations): 12.0 vs. xiv.ii%

  • Number of prescriptions per consultation:

    • 1: 55.0 vs. 54.two%

    • 2: 16.nine vs. 19.5%

    • ≥three: 8.8 vs. 7.8%
Houweling, 2009

  • Alter (95% CI) over 12 months:

    • Systolic BP: −8.6 (−two.six, −14.seven) vs. −4.0 (0.9, −8.9) mmHg

    • Diastolic BP: −1.4 (one.4, −4.1) vs. −2.4 (0.8, −4.9) mmHg

    • Full cholesterol: −0.iv (−0.2, −0.6) vs. −0.9 (−0.5, −1.iii) mmol/l

    • Cholesterol/HDL ratio: −0.4 (0.ane, −0.6) vs. −0.nine (−0.5, −1.4)***

    • HbA1c: −1.5 (−i.0, −i.9) vs. −0.9 (−0.5, −1.3)%

 73.9 vs. 53.3%*
 [Patients' Evaluation of the Quality of Diabetes Intendance (PEQD)]		 Total salary costs over 12 months (euros): 114.6 ± 50.4 vs. 138.iii ± 48.three***

  • Consultation duration over 12 months (min): 272.0 ± 120.5 vs. 249.2 ± 110.seven

  • Main care visits over 12 months: 7.iv ± iii.0 vs. 9.8 ± iii.8**
Houweling, 2011

  • Change (95% CI) over fourteen months:

    • Systolic BP: −7.4 (−3.viii, −10.nine) vs. −5.6 (−2.iii, −8.8) mmHg

    • Diastolic BP: −three.2 (−1.3, −five.two) vs. −one.0 (−0.8, −2.8) mmHg

    • Total Cholesterol: −0.1 (−0.three, 0.1) vs. −0.05 (−0.2, 0.ane) mmol/l

    • Cholesterol/HDL ratio: 0.03 (−0.1, 0.two) vs. 0.07 (−0.i, 0.2)

    • HbA1c: −0.09 (−0.3, 0.1) vs. 0.03 (−0.2, 0.3)%

 66.4 vs. 51.7%
 (PEQD)		 Due north/A N/A
Kinnersley, 2000 Northward/A Mean score range beyond practice sites: 72.9–79.5 vs. 68.7–79.v%
[Consultation Satisfaction Questionnaire (CSQ)]		 N/A

  • Consultation duration: 10 vs. 6 min (statistically significant)

  • Referrals (per centum of consultations): 5 vs. 5%

  • Prescription issued (percent of consultations): 63 vs. 63%
Mundinger, 2000
Lenz, 2004b

  • Value at 6 months:

    • Systolic BP: 137 vs.139 mmHg

    • Diastolic BP: 82 vs. 85 mmHg***

    • Glycosylated hemoglobin: 9.v vs. 9.four%

  • Value at 2 years:

    • Systolic BP: 139.0 vs. 141.9 mmHgb

    • Diastolic BP: 85.nine vs. 88.1 mmHgb

    • Glycosylated hemoglobin: 8.nine vs. 10.3%b

Initial consultation: four.59 vs. 4.60
At 6 months: 4.45 vs. iv.46
 (Investigator-developed instrument based on Medical Outcomes Study)
At 2 years: mean score range beyond categories 65.4–90.8 vs. 67.6–94.4%b
[Patient Care Cess Survey (PCAS)]		 N/A

  • Master care visits at 1 year:

    • 0: 18.0 vs. xix.1%

    • ane–four: 51.8 vs. 47.ane%

    • ≥5 visits: 30.4 vs. 33.eight%

  • Primary care visits (subgroup)

    • Year ane: three.six vs. 4.2b

    • Twelvemonth 2: 1.eight vs. 2.5b***

  • ≥1 Hospitalization at i yr: 8.5 vs. 9.eight%

  • ≥1 Hospitalization (subgroup):

    • Commencement year: 4.5 vs. seven.six%b

    • 2nd year: 4.5 vs. 8.2%b

  • ≥i ED/urgent care visits at 1 year: 34.ii vs. 33.8%

  • ≥1 ED/urgent care visits (subgroup):

    • First year: 28.4 vs. 32.6%b

    • 2nd year: thirty.3 vs. 33.2%b

Spitzer, 1974, 1976a N/A 96 vs. 97%
(Instrument non specified)		 Full UF-index: 297.0 vs. 285.7a N/A
Venning, 2000 N/A 4.xl ± 0.46 vs. four.24 ± 0.52)***
(Medical Interview Satisfaction Calibration (MISS))		 Total bacon cost for initial and render consultation (pounds): xviii.one ± 33.iv vs. 20.7 ± 33.4

  • Consultation elapsing (min): eleven.six ± five.8 vs. seven.3 ± 4.8*

  • Referred to hospital (pct of consultations): one.7 vs. 3.8%

  • Prescription issued (percentage of consultations): 61.0 vs. 64.7%

APN, advanced practice nurse; N/A, not applicative or not measured; BP, claret pressure; HDL, loftier-density lipoprotein; CI, confidence interval; UF-index, utilization-financial index.

aEconomic evaluation of randomized command trial.

bTwo-twelvemonth follow-up of 406 subjects.

*P < 0.001; **P < 0.01; ***P < 0.05.

Table two

Selected outcomes results

Author, year Outcomes: APN group vs. doc group
Physiologic Patient satisfaction (Instrument) Toll Healthcare resource utilization
Dierick-van Daele, 2009, 2010a Due north/A 8.2 ± 1.2 vs. eight.2 ± 1.3
(Investigator-developed musical instrument)		 Direct price per consultation based on bacon (euros): 31.9 ± 36.iii vs. xl.2 ± 49.9a**

  • Consultation duration (min): 12.2 vs. 9.two*

  • Referrals (percent of consultations): 12.0 vs. 14.2%

  • Number of prescriptions per consultation:

    • 1: 55.0 vs. 54.2%

    • 2: 16.nine vs. 19.five%

    • ≥three: 8.8 vs. 7.8%
Houweling, 2009

  • Alter (95% CI) over 12 months:

    • Systolic BP: −8.6 (−ii.6, −14.7) vs. −4.0 (0.9, −8.9) mmHg

    • Diastolic BP: −1.iv (1.4, −four.1) vs. −two.4 (0.8, −iv.nine) mmHg

    • Total cholesterol: −0.four (−0.two, −0.half-dozen) vs. −0.9 (−0.5, −one.iii) mmol/l

    • Cholesterol/HDL ratio: −0.4 (0.1, −0.6) vs. −0.9 (−0.5, −1.4)***

    • HbA1c: −1.v (−1.0, −1.ix) vs. −0.ix (−0.5, −1.3)%

 73.9 vs. 53.3%*
 [Patients' Evaluation of the Quality of Diabetes Care (PEQD)]		 Total bacon costs over 12 months (euros): 114.6 ± 50.4 vs. 138.3 ± 48.iii***

  • Consultation duration over 12 months (min): 272.0 ± 120.5 vs. 249.2 ± 110.7

  • Chief care visits over 12 months: 7.4 ± 3.0 vs. 9.eight ± 3.eight**
Houweling, 2011

  • Change (95% CI) over 14 months:

    • Systolic BP: −7.four (−three.8, −x.9) vs. −5.6 (−2.3, −eight.8) mmHg

    • Diastolic BP: −iii.2 (−i.three, −5.2) vs. −1.0 (−0.viii, −2.8) mmHg

    • Total Cholesterol: −0.ane (−0.iii, 0.1) vs. −0.05 (−0.2, 0.1) mmol/l

    • Cholesterol/HDL ratio: 0.03 (−0.one, 0.two) vs. 0.07 (−0.i, 0.ii)

    • HbA1c: −0.09 (−0.iii, 0.one) vs. 0.03 (−0.2, 0.iii)%

 66.4 vs. 51.7%
 (PEQD)		 North/A Northward/A
Kinnersley, 2000 N/A Mean score range beyond do sites: 72.9–79.5 vs. 68.vii–79.v%
[Consultation Satisfaction Questionnaire (CSQ)]		 N/A

  • Consultation elapsing: 10 vs. 6 min (statistically significant)

  • Referrals (percentage of consultations): 5 vs. five%

  • Prescription issued (percent of consultations): 63 vs. 63%
Mundinger, 2000
Lenz, 2004b

  • Value at 6 months:

    • Systolic BP: 137 vs.139 mmHg

    • Diastolic BP: 82 vs. 85 mmHg***

    • Glycosylated hemoglobin: nine.v vs. 9.four%

  • Value at ii years:

    • Systolic BP: 139.0 vs. 141.9 mmHgb

    • Diastolic BP: 85.9 vs. 88.1 mmHgb

    • Glycosylated hemoglobin: 8.9 vs. ten.three%b

Initial consultation: 4.59 vs. four.60
At 6 months: 4.45 vs. 4.46
 (Investigator-developed instrument based on Medical Outcomes Study)
At two years: mean score range across categories 65.four–90.8 vs. 67.6–94.four%b
[Patient Intendance Assessment Survey (PCAS)]		 North/A

  • Primary intendance visits at ane twelvemonth:

    • 0: xviii.0 vs. xix.i%

    • 1–four: 51.8 vs. 47.1%

    • ≥5 visits: 30.4 vs. 33.eight%

  • Primary care visits (subgroup)

    • Year 1: iii.6 vs. 4.2b

    • Twelvemonth ii: 1.8 vs. 2.vb***

  • ≥1 Hospitalization at ane twelvemonth: 8.5 vs. 9.8%

  • ≥one Hospitalization (subgroup):

    • First twelvemonth: 4.five vs. 7.6%b

    • Second year: iv.v vs. 8.2%b

  • ≥1 ED/urgent care visits at 1 twelvemonth: 34.2 vs. 33.eight%

  • ≥1 ED/urgent care visits (subgroup):

    • Outset twelvemonth: 28.iv vs. 32.6%b

    • Second year: 30.3 vs. 33.ii%b

Spitzer, 1974, 1976a N/A 96 vs. 97%
(Instrument not specified)		 Total UF-index: 297.0 vs. 285.7a N/A
Venning, 2000 N/A 4.40 ± 0.46 vs. 4.24 ± 0.52)***
(Medical Interview Satisfaction Scale (MISS))		 Total salary price for initial and return consultation (pounds): 18.ane ± 33.iv vs. 20.7 ± 33.4

  • Consultation duration (min): 11.half-dozen ± 5.eight vs. 7.3 ± 4.8*

  • Referred to hospital (pct of consultations): ane.7 vs. 3.eight%

  • Prescription issued (percent of consultations): 61.0 vs. 64.7%
Author, twelvemonth Outcomes: APN group vs. doc group
Physiologic Patient satisfaction (Instrument) Price Healthcare resource utilization
Dierick-van Daele, 2009, 2010a Northward/A 8.ii ± 1.2 vs. 8.2 ± i.3
(Investigator-developed musical instrument)		 Directly price per consultation based on salary (euros): 31.9 ± 36.3 vs. 40.2 ± 49.9a**

  • Consultation duration (min): 12.2 vs. 9.2*

  • Referrals (pct of consultations): 12.0 vs. 14.ii%

  • Number of prescriptions per consultation:

    • ane: 55.0 vs. 54.2%

    • 2: 16.9 vs. 19.v%

    • ≥3: 8.eight vs. 7.8%
Houweling, 2009

  • Change (95% CI) over 12 months:

    • Systolic BP: −8.vi (−two.6, −14.7) vs. −4.0 (0.9, −viii.9) mmHg

    • Diastolic BP: −1.4 (1.4, −4.1) vs. −2.four (0.8, −4.9) mmHg

    • Full cholesterol: −0.4 (−0.2, −0.6) vs. −0.9 (−0.5, −ane.3) mmol/l

    • Cholesterol/HDL ratio: −0.four (0.1, −0.6) vs. −0.ix (−0.5, −one.four)***

    • HbA1c: −1.5 (−ane.0, −1.9) vs. −0.9 (−0.5, −ane.iii)%

 73.9 vs. 53.three%*
 [Patients' Evaluation of the Quality of Diabetes Care (PEQD)]		 Total salary costs over 12 months (euros): 114.half dozen ± 50.four vs. 138.iii ± 48.3***

  • Consultation elapsing over 12 months (min): 272.0 ± 120.5 vs. 249.2 ± 110.7

  • Chief care visits over 12 months: 7.4 ± 3.0 vs. 9.8 ± 3.eight**
Houweling, 2011

  • Change (95% CI) over 14 months:

    • Systolic BP: −7.4 (−3.viii, −10.9) vs. −v.six (−2.three, −8.8) mmHg

    • Diastolic BP: −3.2 (−1.three, −v.two) vs. −1.0 (−0.viii, −two.8) mmHg

    • Full Cholesterol: −0.ane (−0.3, 0.1) vs. −0.05 (−0.two, 0.i) mmol/l

    • Cholesterol/HDL ratio: 0.03 (−0.1, 0.ii) vs. 0.07 (−0.1, 0.2)

    • HbA1c: −0.09 (−0.3, 0.1) vs. 0.03 (−0.two, 0.three)%

 66.iv vs. 51.7%
 (PEQD)		 Due north/A N/A
Kinnersley, 2000 N/A Mean score range beyond practise sites: 72.9–79.5 vs. 68.7–79.five%
[Consultation Satisfaction Questionnaire (CSQ)]		 N/A

  • Consultation duration: 10 vs. 6 min (statistically pregnant)

  • Referrals (percent of consultations): 5 vs. v%

  • Prescription issued (percentage of consultations): 63 vs. 63%
Mundinger, 2000
Lenz, 2004b

  • Value at 6 months:

    • Systolic BP: 137 vs.139 mmHg

    • Diastolic BP: 82 vs. 85 mmHg***

    • Glycosylated hemoglobin: 9.5 vs. 9.four%

  • Value at 2 years:

    • Systolic BP: 139.0 vs. 141.9 mmHgb

    • Diastolic BP: 85.9 vs. 88.ane mmHgb

    • Glycosylated hemoglobin: viii.nine vs. 10.iii%b

Initial consultation: 4.59 vs. 4.60
At vi months: 4.45 vs. iv.46
 (Investigator-developed instrument based on Medical Outcomes Written report)
At 2 years: hateful score range across categories 65.four–90.8 vs. 67.6–94.4%b
[Patient Care Cess Survey (PCAS)]		 N/A

  • Chief care visits at 1 year:

    • 0: eighteen.0 vs. 19.1%

    • 1–4: 51.8 vs. 47.i%

    • ≥five visits: xxx.four vs. 33.8%

  • Primary care visits (subgroup)

    • Yr 1: 3.6 vs. 4.2b

    • Year ii: 1.8 vs. 2.5b***

  • ≥1 Hospitalization at 1 yr: 8.5 vs. nine.8%

  • ≥i Hospitalization (subgroup):

    • Offset year: iv.v vs. vii.6%b

    • 2nd year: 4.five vs. 8.2%b

  • ≥one ED/urgent care visits at 1 year: 34.2 vs. 33.8%

  • ≥1 ED/urgent care visits (subgroup):

    • Offset year: 28.4 vs. 32.6%b

    • Second twelvemonth: 30.3 vs. 33.2%b

Spitzer, 1974, 1976a N/A 96 vs. 97%
(Musical instrument not specified)		 Total UF-alphabetize: 297.0 vs. 285.7a N/A
Venning, 2000 N/A iv.40 ± 0.46 vs. 4.24 ± 0.52)***
(Medical Interview Satisfaction Calibration (MISS))		 Full salary cost for initial and return consultation (pounds): eighteen.ane ± 33.four vs. 20.7 ± 33.4

  • Consultation duration (min): eleven.6 ± 5.8 vs. 7.3 ± 4.viii*

  • Referred to hospital (per centum of consultations): ane.7 vs. 3.viii%

  • Prescription issued (percent of consultations): 61.0 vs. 64.vii%

APN, advanced practice nurse; Due north/A, not applicative or not measured; BP, blood pressure; HDL, high-density lipoprotein; CI, confidence interval; UF-index, utilization-financial index.

aEconomic evaluation of randomized command trial.

bTwo-twelvemonth follow-upward of 406 subjects.

*P < 0.001; **P < 0.01; ***P < 0.05.

Physiologic measures

Three RCTs [27, 30, 32] and 1 follow-up written report [34] assessed blood pressure and glucose outcomes, and 2 [27, 30] reported lipid outcomes. Betwixt-group differences were mostly non meaning, with the exception of the cholesterol/high-density lipoprotein (HDL) ratio [27] and the diastolic blood pressure level at 6 months [32] with both favoring the APN group. Additional physiologic measures were investigated in single studies with no differences between APN and physician groups for mortality [28], change in body mass index (BMI) [27, xxx], modify in LDL [27] or top expiratory catamenia rate [32, 34].

All studies investigated subjective health status; instruments used included the Medical Outcomes Short Form 36 (SF-36) [32–34], brunt of illness and the EQ5-D [29], measures of disability or impaired activities of daily living and emotional and social functioning [28] and measures of symptoms and symptom resolution [27, 30, 31] with no differences between groups.

Patient satisfaction

All studies examined patient satisfaction. 4 RCTs [27, xxx, 31, 33] and 1 follow-up report [34] used existing validated instruments, two [29, 32] adapted existing instruments and one [28] did non specify the tool used to mensurate satisfaction. Three studies demonstrated higher patient satisfaction among patients who received intendance from APNs [27, 30, 33], and i written report reported higher satisfaction amidst patients who received care from APNs at iii of their ten report sites [31].

Cost of care

Four studies (two RCTs [27, 33] and two economic evaluations [35, 36]) examined differences in costs of care. Iii studies estimated cost using provider salary; of these, two [27, 35] found that APN care was less expensive compared with physician provided intendance. One study examined almanac laboratory and monthly medication costs; while APN care was less expensive for laboratory services (64.ix ± 34.five versus 91.5 ± 36.seven euros, P = 0.001), there were no differences in monthly medication costs [27]. Spitzer et al., 1976, examined toll of care by developing a Utilization and Financial Alphabetize in which provider salary was aggregated with laboratory, radiology, hospital costs and out of pocket expenditures; no differences were observed betwixt care provided past APNs and physicians [36].

Healthcare resource utilization

All studies reported healthcare resource utilization outcomes. 4 studies [27, 29, 31, 33] examined consultation length; of these, 3 establish that APN consultations were 3.0 [29] to 4.3 [33] minutes longer than those provided by physicians [29, 31, 33]. Two RCTs and one follow-up written report examined total number of primary care visits with conflicting findings at 1 year [27, 32] just fewer visits amongst APN patients at two years [34]. One RCT [32] and its follow-upwards study [34] examined hospitalization and emergency department or urgent care visits with no significant differences betwixt groups.

Three studies [29, 31, 33] examined the number of referrals made and 2 [32, 34] investigated the number of specialty care visits; both found no differences between APNs and physicians. Of iii studies that examined follow-upwardly adherence [29, 31, 33], two [29, 33] reported that APNs more frequently requested a render visit and their patients were more than likely to go on the appointment. Three studies examined the prescription patterns for medications and diagnostic tests [29, 31, 33]; ane [33] reported that APNs more than frequently ordered diagnostic tests with no differences in medication prescriptive practices.

Process measures

Four studies examined other clinical process measures. Three [28–30] assessed clinician guideline adherence; one found that APNs had higher rates of providing disease-appropriate care across v of six indicators examined [30].

Kinnersley et al., reported that patients assigned to the dr. group were less likely to report having been told the cause of their illness (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.44–0.76), how to salvage symptoms (OR 0.32, 95% CI 0.24–0.43) and what to practise if the trouble persisted (OR 0.61, 95% CI 0.41–0.xc) [31]. There were no differences regarding the proportion reporting that they were advised of the likely elapsing of their disease and how to reduce the chances of recurrence.

Discussion

Findings of this systematic review suggest that APNs in primary care settings perform as well as physicians in terms of clinical outcomes and patient satisfaction. Results were mixed across studies regarding whether APNs ordered more diagnostic tests, and some evidence suggested APNs more than oft asked patients to render to the clinic afterwards a consultation. APN consultations took slightly longer than doctor consultations, but did not translate to overall increased costs. In that location was too evidence suggesting that APN patients required fewer total primary care visits, and that APNs demonstrated like guideline adherence to physicians and provided more thorough patient education. Overall, APNs in these studies provided care that was in some means different from care provided by physicians, merely with comparable quality and at equal or lower toll.

Prior systematic reviews take also examined chief care provided by APNs simply had limitations that we attempted to address such as variations in study design. For example, one review of studies published between 1990 and 2008 included information from observational studies and studies conducted in a wide range of settings [sixteen]. Similarly, a review published in 2013 too included observational studies and studies in which the APN and physician were in non-equivalent or squad-based roles [17], and a 2014 review investigated outcomes of nurse prescribing but included non-RCTs and a diversity of care settings and specializations [xiv]. One recent review was limited to RCTs conducted in primary care settings but included a broad multifariousness of nurse roles not specific to APN scope of do [21].

The results of this systematic review are generally consequent with the conclusions of earlier reviews [14, 16, 17, 21]. However by limiting our search to RCTs in which APNs were compared directly to physicians in a PCP role, we take reduced the amount of heterogeneity present in the aggregated data to provide a college level of bear witness.

1 limitation of this systematic review was our decision to limit the search to the English language. The results of the review are further limited by the modest body of rigorous published research; surprisingly, assessment of primary care provided by APNs was the focus of simply seven RCTs. Our conclusion to narrowly focus only on APNs in a PCP role and to aim for a higher level of testify past limiting our review to RCTs led to inclusion of a smaller number of studies than previous reviews. Amid the seven included RCTs, only four assessed outcomes for longer than one calendar month, with one study examining outcomes of but a single consultation. Sample sizes were oft small, resulting in high adventure for blazon Two errors, and issue and procedure measures were assessed in unlike ways. These limitations preclude conclusions well-nigh long-term outcomes of care by APNs. Additionally, only one study was conducted in the US. Rigorous studies with longer observation periods are conspicuously needed.

Hereafter studies should focus on additional outcomes that are absent in the current torso of research. The physiologic outcomes addressed in current research focused on changes in parameters such every bit blood pressure; a more than meaningful outcome would exist the proportion of subjects attaining disease control over fourth dimension. Future studies should also examine rates of preventable hospitalizations and appropriate preventive care, such as vaccines and disease screening. Finally, studies with longer follow-upward periods will permit for assessment of rates of retention in care.

In 2010 the Institute of Medicine recommended that barriers be removed to allow nurses to practice to the full extent of their didactics and training to help meet the needs of a changing health intendance system [12]. This recommendation has been met with some resistance, largely from physician groups that frequently reference concerns over patient safety [9], despite enquiry that suggests improved patient safety when a cooperative team-based approach is implemented [37]. In the U.s. telescopic of practice laws in 30 states even so limit NP autonomy by requiring NPs to have exercise agreements with a collaborating or supervising md [38]. Although studies with longer follow-upwards are needed, the research summarized in this systematic review adds to the body of evidence that there are few differences in primary intendance provided by APNs and physicians, and in some areas APN care may exist superior. Removing barriers that prevent APNs from practicing to the full extent of their training therefore appears to be a safe, logical and effective arroyo to addressing the master care shortage.

Supplementary textile

Supplementary fabric is available at INTQHC online.

Funding

No funding was received in support of this work.

Acknowledgment

Nosotros thank Anca Meret, data specialist, Wellness Sciences Library, Columbia Academy Medical Centre, for her aid in constructing and implementing the literature search.

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© The Writer 2015. Published past Oxford University Press in association with the International Guild for Quality in Health Intendance; all rights reserved

    • Supplementary data