Table 3.

Included Studies, Study Characteristics, and Main Findings

Study, setting, and number of centres	Participants	Intervention	Comparator	Follow-up duration	Main Outcomes
Chan et al. (2009) United Kingdom Multiple (unclear number)	Patients with mild gastro-oesophageal reflux diseaseN  = 175	Nurse Practitioner in Gastroenterology with one outpatient appointment	Care by usual General Practitioner	Six months	Significant symptom (dyspepsia) improvement was noted in the use of Glasgow Dyspepsia Severity Score (mean difference [MD] 2.3: 95% CI 1.4, 3.1) in the GNP group. Health status (140.6; 95% CI –184.8, –96.5) and cost of medication (£39.60; 95% CI 24.2, 55.1) were all in favour of the Nurse Practitioner group (p < 0.001) compared to the General Practitioner group. Although the baseline ulcers healing drug use was similar in both groups, 6 month-follow up reviews showed that the GNP group consumed less full-dose PPI medications (p < 0.0001) and more patients in the group required no treatment (p < 0.001). The study finds variable follow-up management of dyspepsia following gastroscopy, but this can be standardised by involving experienced GNP in the view of empowering patients for effective self-care.
Dierick-van Daele et al. (2009) Netherlands 15	Patients with minor health problems (upper respiratory, ear and nose, musculoskeletal, skin, urinary, gynaecological and geriatric problems) N = 1501	Nurse Practitioner in Primary Care	General Practitioner-led care	Two weeks	Patients perceived of the high-quality care provided by both Nurse Practitioners and General Practitioners, but there were no significant between-group differences in relation to health status (MD 0.82 [SD 0.18] v. 0.80 [SD 0.18], medical resource consumption (composite of prescriptions administered, investigations performed, number of referrals, and invitation to return for review) and adherence to guidelines (79.8% v. 76.2%) (all p > 0.05). However, patients in the Nurse Practitioner group observed significantly longer and more follow-up consultations than those in the General Practitioner group (12.2 [SD 5.7] v. 9.2 [SD 4.8] min, p < 0.05). The study demonstrates the prolonged duration that the nurse practitioners spend on face-to-face consultation (12.2 min on average) in contrast to the GPs (9.20 min (SD 4.8, p < 0.001). Although NP consultation is slightly longer in comparison with GP consultation, it was noted that time in consultation mattered to patients. The study concluded that NPs provided positive and comparable quality of care to GP. The study indicates that there is potential for greater continuity of care while proposing a widespread national and international debate about appropriate skill mix in primary care and evaluate the value of NP role.
Kamps et al. (2003) Netherlands 1	Paediatric patients newly referred from the Primary Care to an outpatient clinic N = 74	Clinical Nurse Specialist in Paediatric Asthma	Usual care delivered by Paediatrician	12 months	No significant differences between groups were observed at 12 months for any of the reported outcomes in terms of percentage of symptom-free days (MD 2.5%; 95% CI –8.8, 13.8), airway hyper-responsiveness (MD 0.06%; 95% CI –0.19, 0.32), functional health status (MD 10.1%; 95% CI –0.3, 19.8), and quality of life (MD 0.08%; 95% CI –0.9, 0.7) (all p > 0.05). However, considerable improvements in the outcomes were observed among both groups at 12 months, with 26% of the children requiring a lower daily dose of inhaled corticosteroids compared to baseline (p = 0.03). Additionally, all parents in the NP group were satisfied with the asthma care they received. There were no emergency room visits or hospital admission in both groups during the study time. This could suggest improved asthma control. The study clearly signaled that in both primary and secondary care settings, asthma nurses can safely provide safe and comparable long term management of mild to moderate childhood asthma without compromising quality of care or control of disease.
Kinnersley et al. (2000) United Kingdom Multiple (unclear number)	Patients seeking a same-day consultation in General Practice. N = 1368	advanced nurse practitioner with a nurse practitioner diploma	General Practitioner care	Two weeks	Generally, patients in the Nurse Practitioner group were more satisfied with the care received, although not for all included primary care trusts (MD ranged from –8.79; 95% CI –13.59, –3.98 to 0.61; 95% CI –4.84, 6.05). There was no significant difference in the resolution of symptoms between groups (OR 0.32; 95% CI 0.23, 0.43), nor were the number of prescriptions issued OR 1.01; 95% CI 0.80, 1.28), investigations ordered (OR 0.83; 95% CI 0.58, 1.16), need for re-attendance (OR 0.91; 95% CI 0.70, 1.17), and referrals to secondary care (OR 0.96; 95% CI 0.58, 1.57) (all p > 0.05). Patients in the NP groups felt that they had received better communication i.e. information about their illnesses and causes. This could reduce chances of recurrence. A higher number of patients would consider future same day consultations with the nurse practitioners. The study findings highlight a wide acceptance of the role of nurse practitioners in the provision of care to patients requesting same day consultations.
Krichbaum (2007) United States 2	Elderly patients discharged from hospital post hip fracture. N = 191	Nurse Practitioner in Gerontology	Usual care protocol	12 months	The results at 12 months follow-up showed that the Nurse Practitioner group observed significant improvements in outcomes related to the need for physical assistance (1.58 [SD 0.76] v. 1.81 [SD 0.90]), mobility (1.24 [SD 0.34] v. 1.42 [SD 0.48]), personal care (1.41 [SD 0.53] v. 1.22 [SD 0.32]), and home chores (1.48 [SD 0.51] v. 1.44 [SD 0.19]), than compared to the comparator (all p < 0.05), although no differences were found for general health status, depression, or living situation (all p > 0.05).
Kuethe et al. (2011) Netherlands 19	Paediatric patients with stable asthma N = 107	Clinical Nurse Specialist in Paediatric Asthma	General Practitioner-led care and care delivered by Paediatrician	Two years	The findings showed that there was a significantly lower number of review visits required among subjects assigned to the General Practitioner group (45.7%) than the Pediatrician group (87.9%) and Nurse Practitioner group (94.3%) at the two-year follow-up (p < 0.0005). However, the study suggests a low follow-up frequency does not detract from maintenance of good disease control in children with stable asthma. The MD between the Nurse Practitioner and the General Practitioner groups was 49.7% (95% CI 39.2, 92.7) and the MD between the Nurse Practitioner and the Pediatrician group was 6.0% (95% CI 0.1, 74.4). There were no significant differences between any of the groups regarding respiratory outcomes and unplanned patient visits, and it was also reported that Nurse Practitioners were able to provide care without consulting a Pediatrician. The specialized asthma nurse can safely provide comparable and equivalent long-term asthma management in both primary care and hospital care settings. The asthma nurse also improves the confidence of parents caring for asthmatic children leading to reduction in exacerbation, school absences and parental leave. The authors suggested that the findings in this study are applicable in secondary as well as in primary care, given that the same criteria of baseline characteristics are met.
Mundinger et al. (2000) United States 5	Patients being followed up in primary care following an Emergency Department or urgent care visit. N = 1316	Nurse Practitioners in Primary Care	General Practitioner-led care	12 months	No significant differences between groups were found for patients’ health status and indices of diabetes and asthma control (p > 0.05). However, patients with hypertension who were assigned to the Nurse Practitioner group observed a significantly lower diastolic blood pressure compared to those assigned to the General Practitioner group (p = 0.04). No other significant findings were observed for health resource utilization. There was no statistically significant difference in “overall patient satisfaction” or “patients’ mean ratings of satisfaction between the two groups. However, the provider attributes in terms of technical skills, communication skills and time spent with patients, the General Practitioners had significantly higher satisfaction ratings compared to Nurse Practitioners (p = 0.05). This finding may be attributable to the fact that the nurse practitioners were transferred to another new site after 2 years before recruitment and data collection were completed whereas the physician practices were not moved during the study period.
Ndosi et al. (2014) United Kingdom 10	Patients with rheumatoid arthritis N = 181	Clinical Nurse Specialist in Rheumatology	Rheumatologist-led care	12 months	Overall, the results showed that the mean change in Disease Activity Score 28 (DAS28) was significant for non-inferiority on both per-protocol and intention-to-treat analyses (–0.31; 95% CI –0.63, 0.02 and –0.15; 95% CI –0.45, 0.14 respectively). In addition, significant intention-to-treat non-inferiority was also found for pain (MD –1.34; 95% CI –7.13, 4.45, p = 0.004), physical functioning (MD 8.91; 95% CI –2.66, 20.5, p = 0.0113), satisfaction (MD –0.92; 95% CI –4.96, 3.12, p = 0.019), and consultation costs (£128; 95% CI –1263, 1006). The study finds that NLC had lower consultation cost and supports that NLC can provide safe and comparable care to manage RA patients. However, evidence on drawing probability of cost effectiveness was inconclusive due to varying disease specific activity and generic outcomes.
Ryden et al. (2000) United States 3	Patients newly admitted to a resident nursing home. N = 319	Nurse Practitioner in Gerontology	Usual care	Six months	Patients assigned to the advanced nurse practitioner group observed significantly greater improvements in outcomes related to incontinence as well as fewer pressure ulcers and episodes of aggressive behavior and higher composite trajectory scores compared to usual care (p < 0.05). Moreover, patients with cognitive impairment were also found to observe a more stable effect, which was statistically significant in favor of the Nurse Practitioner group than the control group. The study suggests that the use of APNs in gerontology care incorporating scientifically based protocols into every day practice was encouraging: improvement in level of continence, pressure ulcer care, enhanced progress of mental health wellbeing among the elders.
Stables et al. (2004) United Kingdom 1	Patients requiring day-case cardiac catheterisation. N = 339	Nurse Practitioner in Cardiothoracic Surgery	Care by junior medical staff	Unclear, but less than one year	There were no significant differences between the groups with regards to major adverse events and the Cardiologists’ acceptance of the patients’ preparation was high for both groups (98.3% and 98.8%). However, patients’ level of satisfaction was significantly greater among those assigned to the Nurse Practitioner (NP) group (p = 0.04) compared to group of Junior Medical Staff (JMS). In addition, the time taken in the clinic visit was lower in the NP group than for JMS group (p = 0.01). The overall event rate including minor adverse clinical events was 4/175 (2.3%) in NP group and 1/161 (0.6%) in JMS group. The calculated absolute risk difference = +1.7%, the upper boundary of the one-sided 95% CI = 6.2%. The study reveals NP role recognition and acceptance among junior medical staff who recommend the NP role should be continued. The study concludes that NPs with appropriate training, education, and support can safely prepare patients for elective cardiac catheterisation.
van Zuilen et al. (2011) Netherlands 9	Patients with diagnosed chronic kidney disease. N = 788	Nurse Practitioner	Usual care by Physician	Five years (median)	At the two-year follow-up, the Nurse Practitioner group had significantly lower systolic (133 [SD 21] v. 135 [SD 19] mmHg p = 0.04) and diastolic blood pressures (77 [SD 10] v. 80 [SD 11] mmHg p = 0.007), LDL cholesterol (2.45 [SD 0.81] v. 2.30 [SD 0.75] mmol/L p = 0.03), and a higher but non-significant use of ACE inhibitors, statins, aspirin, and vitamin D compared to the controls (p > 0.05). Subjects assigned to the Nurse Practitioner group also had no significant improvements in smoking cessation, weight, physical activity levels, or sodium excretion (p > 0.05).
Venning et al. (2000) United Kingdom 20	Patients requesting same-day appointment in Primary Care. N = 1316	Nurse Practitioner	General Practitioner	Two weeks	Nurse Practitioner consultation times were significantly longer (MD 4.2 minutes; 95% CI = 2.98, 5.41), the number of tests ordered were significantly higher (MD 8.7% v. 5.6%; 95% CI 1.04, 2.66), patients were asked to return for review more frequently (MD 37.2% v. 24.8%; 95% CI = 1.36, 2.73), and costs were lower (MD £2.33; 95% CI = 1.62, 6.28) compared to General Practitioners (all p < 0.05). No significant differences were observed between the groups for health status, prescribing patterns, or health service costs (p > 0.05). However, patients were generally more satisfied with Nurse Practitioner consultations, with an adjusted mean difference of 0.18 (95% CI = 0.092, 0.257), but this was not significant (p > 0.05).
Williams et al. (2005) United Kingdom Multiple (unclear number)	Patients with frequent urinary incontinence that affects their quality of life. N = 3748	Nurse Practitioner for Incontinence	Usual General Practitioner-led care and local continence advisory services	Six months	At the three-month follow-up, a significantly higher number of patients in the Nurse Practitioner group found that their incontinence episodes had improved compared to the controls (59% v. 48%, MD 11%; 95% CI 7, 16, p < 0.001). Moreover, a significantly higher proportion of subjects in the Nurse Practitioner group reported that their urinary symptoms had completely resolved compared to the controls (25% v. 15%, MD 10%; 95% CI 6,13, p = 0.001). The associated quality of life between the two groups (74% v. 68%, MD 6%, 95% CI = 2, 10, p = 0.003), patient satisfaction rate with the service provision (52% v. 45%, MD 7%, 95% CI = 3, 12, p = 0.001). These effects were maintained at the six-month follow-up. The study finds that the continence nurse practitioner-led service is both feasible and directly applicable for a wider implementation of continence service which is effective in symptoms reduction associated with incontinence, urinary frequency, urinary urgency and nocturia.