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. Author manuscript; available in PMC: 2026 May 1.
Published in final edited form as: J Clin Nurs. 2024 Dec 9;34(5):1592–1601. doi: 10.1111/jocn.17614

Advanced Practice Nurses in Primary Care and their Impact on Health Service Utilization, Costs, and Access Globally: A Scoping Review

Madison HORTON 1, Justinna DIXON 2, Eleanor TURI 3, Chinmayi BALUSU 4, Rachel PAIKOFF 5, Claudia B MAIER 6, Lusine POGHOSYAN 7
PMCID: PMC12037310  NIHMSID: NIHMS2039498  PMID: 39654015

Abstract

Aim:

Synthesize evidence on advanced practice nurses’ impact on health services utilization, healthcare costs, access and quality of care globally.

Design:

Scoping Review

Methods:

A scoping review guided by the Joanna Briggs Institute Manual for Evidence Synthesis and the PRISMA-ScR checklist.

Data Sources:

PubMed, CINHAL, and Embase for articles between 2016–2023.

Results:

Eighteen studies were included (14 from the United States, two from the Netherlands, and one from Australia and New Zealand each). Outcomes included health services utilization, healthcare costs, access, and quality of care. Most studies reported advanced practice nursing patients had fewer emergency department (9 of 11 studies), fewer hospital (re-)admissions (9 of 10 studies), and primary care visits (3 of 3 studies). Seven (of 8) studies found advanced practice nursing care was associated with significantly lower healthcare costs. For access and quality of care, advanced practice nursing care was associated with lower consultation rates, similar mean number of patients seen, higher protocol adherence, more rural patient care, and lower to similar quality delivery of chronic disease management.

Conclusion:

Majority of the studies reported advanced practice nursing care was associated with lower emergency department visits, hospital readmissions, and costs. Access to care outcomes varied under advanced practice nursing care.

Implications for the Profession and/or Patient Care:

Advanced practice nursing care can improve patient outcomes, reduce costs, and impact access and quality of care. Practices need supportive work environments for advanced practice nurses to deliver high quality, effective care.

Impact:

Addressing the need for a synthesis of up-to-date evidence, this review highlights the importance of advanced practice nurses in primary care. Findings can inform global workforce development strategies to address health inequalities through effective advanced practice nursing integration.

No Patient or Public Contribution.

Keywords: Advanced Practice Nursing, Health Services, Healthcare Costs, Access to Care

Introduction

Globally, health systems face workforce shortages, particularly in rural and socio-economically deprived areas (World Health Organization (WHO), 2020; WHO, 2022). Many countries seek innovative health workforce solutions to meet the increasing demand for care (Maier, 2022). The nursing workforce has undergone major changes in recent decades, including the advancement of nursing education and the introduction of new advanced practice nursing roles (Kilpatrick et al., 2014; Maier & Aiken, 2016; Maier et al., 2017; Wheeler et al., 2022; WHO, 2020). Many definitions of advanced practice nurses (APNs) exist none of which is universally recognized. According to the International Council of Nurses (ICN), APNs are defined as nurses with a minimum master’s degree who possess expert knowledge, complex decision-making skills, and clinical competencies for expanded practice (ICN, 2020). While there are large variations globally in APN roles, education and titles, the most common APN roles internationally are nurse practitioners (NPs) and clinical nurse specialists (CNSs). There are many other roles and titles that are often country and context-specific (ICN, 2020). Increasingly, countries across the globe are making investments to develop the APN workforce. A 2020 report by the World Health Organization (WHO) found that 50 out of 95 countries surveyed (53%) identified the existence of advanced nursing roles (WHO, 2020).

Many countries across the globe are at different levels of APN role development and implementation. The first country to introduce the NP role, the first type of APN, was the United States, followed by Canada, Australia, New Zealand, Ireland, the United Kingdom, and the Netherlands (Maier, 2022; Maier & Aiken, 2016; Maier et al., 2017). In other countries, the APN role development is in the early stages; therefore, the extent of APN integration into healthcare systems and their influence on healthcare delivery varies compared to countries that pioneered the APN role (Maier et al., 2017). An international study found that eleven of 39 countries had considerably expanded the scope of practice of APN from a registered nurse’s practice and included treatment decisions, performing advanced clinical assessments/diagnoses, prescribing medications, ordering tests and examinations, and referrals, among others (Maier et al., 2017). Globally, the uptake of APNs is growing (Maier et al., 2017; Maier et al., 2016; Scanlon et al., 2023; Wheeler et al., 2022), and many policies have been implemented to expand the scope of practice as a strategy to increase primary care capacity (Maier & Aiken, 2016). A 2018 survey in 26 countries found progress in APN implementation, particularly in APN education, yet barriers were reported with regard to advanced practice regulation, title protection, and credentialing (Wheeler et al., 2022).

Despite barriers to APN implementation, evidence on the influence of APNs globally, specifically in primary care settings, has been growing. Several reviews have synthesized the literature on health system outcomes, yet none of these reviews have been conducted recently (Kilpatrick et al., 2014; Martin-Misener et al., 2015; Martínez-González et al., 2014; Morilla-Herrera et al., 2016; Swan et al., 2015). Studies consistently show that APNs impact healthcare costs, access to care, quality of care, health service utilization, and patient outcomes. For example, one review from 2015 identified 11 randomized control trials focused on APNs in ambulatory care and found that, compared to when APNs were added-on to physician care or were substituted for physicians, patients had improved quality of care and lower mean costs per consultation (Martin-Misener et al., 2015). Another meta-analysis published in 2015 based on 2678 patients found that compared with physician-provided care, APN-provided care was associated with lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001); however, it was based on only two trials conducted in the Netherlands and the United Kingdom (Martin-Misener et al., 2015). A systematic review of APNs vs. physician-provided care found similar or reduced healthcare costs as well as similar or improved patient outcomes with care provided by APNs (Swan et al., 2015). Yet, the review also identified average longer consultations provided by APNs, and some limited evidence that patients cared for by APNs required fewer visits over time (Swan et al., 2015). A review by Morilla-Herrera (2016) found that APNs care (versus usual care without APNs) among older people aged 65 years and older was associated with significantly lower hospital readmissions (Morilla-Herrera et al., 2016). Similarly, a systematic review and meta-analysis conducted by Martinez-Gonzalez (2014) found that compared with physician-led care, nurse-led care showed a significant reduction in all-cause hospital admissions (lower relative risk: 0.76, 95% confidence interval [CI]: 0.64 – 0.91), yet it was based on only 5 randomized control trials (Martínez-González et al., 2014).

These reviews were all conducted before 2016 and the findings across the reviews are inconsistent. Some evidence shows that APNs tended to provide longer consultations and more return visits, but a similar number of referrals, pharmaceutical prescriptions, or tests ordered (Kilpatrick et al., 2014; Martin-Misener et al., 2015). Given the growing APN workforce globally, its key role in healthcare service delivery, and its potential to improve access, a robust synthesis of up-to-date evidence is needed. This scoping review aimed to synthesize the recent evidence, from 2016–2023, on the contribution of APNs on health services utilization, access to care, quality of care, and cost.

Methods

Design

We conducted a comprehensive scoping review, guided by the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis (Aromataris E, 2020). We reported our findings following the PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines (Supplementary File 1) (Tricco et al., 2018). A scoping review was chosen as it fits best with our research question, understanding the state of the global literature base focused on outcomes of APNs and their care on health services utilization, healthcare costs, access to care, and quality of care. We included (i) primary care settings, defined as healthcare practices providing “the first level of contact for the population with the healthcare system” and delivering health care “as close as possible to where people live and work” (Rajan et al., 2024) as well as (ii) ambulatory care settings defined as “establishments that are primarily engaged in providing health care services directly to outpatients who do not require in-patient services” (Eurostat & Organization, 2017).

Search Methods

A literature search was conducted, with the guidance of a librarian, in three major databases: PubMed, CINHAL, and Embase. The PubMed search is provided in Appendix 1. Keywords included “advanced practice nursing”, “primary care”, and “health services”. Additionally, the team hand checked the reference lists of identified studies for relevant articles. Resulting articles identified in the search were uploaded to the online review software Covidence, which removed duplicates (Covidence, 2022).

Inclusion and Exclusion Criteria

Included studies focused on populations of adults ages 18 years or older receiving care in primary care or ambulatory care settings (can be a specialty setting if the independent variable is APNs in a primary care setting) and cared for by APNs with at least a master’s level education or undergoing master’s level educational programs. Study designs had to evaluate APN care with a clear counterfactual (i.e., pre/post-APN care or comparing APN care to the care of another clinician). Outcomes were focused on three areas: 1) health service utilization (i.e., emergency department (ED) visits, hospitalization, and readmissions), 2) healthcare costs and, 3) access and quality of care (e.g., wait times, effect on access in underserved areas, number of patients served). Care access and quality of care were defined broadly, covering the quality of accessed care, including whether patient needs are met, and the quality of care received (Penchansky & Thomas, 1981). Quantitative studies, including randomized control trials, quasi-experimental studies, and observational studies, were included. Exclusion criteria included grey literature (e.g., editorials, policy reports), opinion papers, and qualitative manuscripts. Studies were limited to those published in English and peer-reviewed publications from 2016 to 2023 to reflect the most current state of the literature from the previous review in 2016 on the APN workforce internationally (Morilla-Herrera et al., 2016).

Search Outcome

The search yielded 2,607 records. After 271 duplicates were removed by the Covidence software, 2,336 records were screened during the title and abstract review phase. The 4 authors determined that 2,242 records did not meet inclusion criteria (e.g., not focused on APNs, outcome or intervention did not meet a priori inclusion criteria, could not retrieve full text). Figure I displays a flow diagram of the study selection process.

Figure I.

Figure I.

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Flow Diagram of Conducted Literature Search

Data Abstraction and Synthesis

Four authors screened titles and abstracts in Covidence, then full texts to select articles that met a priori inclusion criteria. Informed by the JBI Manual for Evidence Synthesis, data extraction included study design, purpose, patient population characteristics, provider description, model of care, country in which the study was conducted, and measurement methods for outcomes (Aromataris, 2020). Studies were grouped based on the outcome measured into the following categories:1) health services utilization, 2) healthcare costs, and 3) access and quality of care. Disagreements in data collection at any stage were resolved by discussion among four authors until group consensus was met. Authors of studies were not contacted for missing or additional data. All data are reported in a narrative format.

Results

A total of eighteen studies were included in this review, of which fourteen were conducted in the United States, with the remaining being conducted in the Netherlands (2), Australia (1), and New Zealand (1). Most studies (n=17) examined the APN role of NPs, with one study evaluating gerontology nurse specialists (King et al., 2018). All studies were conducted in primary care settings, with one evaluating APN-led mental healthcare (Barraclough et al., 2016), three taking place in the United States Veterans Affairs (VA) primary care settings (i.e., an integrated healthcare system serving veterans of the United States armed forces) (Liu et al., 2020; Morgan et al., 2019; Smith et al., 2020) and four in home-based primary care settings (Coppa et al., 2018; Ernecoff et al., 2021; Jones et al., 2017; Smits et al., 2020). Within the studies conducted in the United States, seven studies involved Medicare/Medicaid patient data, which are public health insurers in the United States (Buerhaus et al., 2018; DesRoches et al., 2017; Loresto et al., 2017; Lutfiyya et al., 2017; Muench et al., 2019; Perloff et al., 2016; Razavi et al., 2021). Medicare covers older Americans ages 65 and older and individuals with disabilities while Medicaid gives health coverage to Americans with low income or limited resources (Services, 2018). A total of ten studies compared APN-delivered care with physician-delivered care (Buerhaus et al., 2018; DesRoches et al., 2017; Liu et al., 2020; Loresto et al., 2017; Lutfiyya et al., 2017; Muench et al., 2019; Perloff et al., 2016; Razavi et al., 2021; Smits et al., 2020; Van Der Biezen et al., 2016), two compared care delivery by APNs to care delivery by physicians and physician assistants (Morgan et al., 2019; Smith et al., 2020), and three studies investigated outcomes pre and post APN care (Barraclough et al., 2016; Coppa et al., 2018; Ernecoff et al., 2021).

Most studies (n=17) had outcomes focused on healthcare service utilization (Barraclough et al., 2016; Buerhaus et al., 2018; Coppa et al., 2018; DesRoches et al., 2017; Ernecoff et al., 2021; Jennings et al., 2020; Jones et al., 2017; King et al., 2018; Liu et al., 2020; Loresto et al., 2017; Lutfiyya et al., 2017; Morgan et al., 2019; Muench et al., 2019; Razavi et al., 2021; Smith et al., 2020; Smits et al., 2020; Van Der Biezen et al., 2016). Eight studies had healthcare cost outcomes (Liu et al., 2020; Lutfiyya et al., 2017; Morgan et al., 2019; Muench et al., 2019; Perloff et al., 2016; Razavi et al., 2021; Smith et al., 2020; Van Der Biezen et al., 2016). Access and quality of care was covered in four studies (Buerhaus et al., 2018; DesRoches et al., 2017; Smits et al., 2020; Van Der Biezen et al., 2016). Details of the results of included studies are included in Appendix 2.

Healthcare Services Utilization

Of the 17 studies covering at least one outcome on healthcare services utilization, 13 were conducted in the United States, and 4 outside of the United States: the Netherlands (2), Australia (1), and New Zealand (1). Below, we present study findings by specific health service utilization outcomes (i.e., ED utilization, hospitalizations, and other health service utilization outcomes).

ED Utilization

Eleven studies focused on ED admissions or visits as outcomes of APN care (United States (8), Australia (1), Netherlands (2)). In a study conducted in the Netherlands, researchers found that compared to physicians, APNs had significantly more ED referrals (24.1% APN patients vs. 15.9% physician patients, (p < 0.001; Smits et al., 2020). A different study in the Netherlands demonstrated that APN care was associated with fewer referrals to the ED compared to physician care (5.1% vs. 11.3% ED referrals, p < 0.001; Van Der Biezen et al., 2016). A study conducted in Australia found that implementation of a full-time psychiatric APN in a public health setting decreased ED admissions (Barraclough et al., 2016). Before APN implementation, there were 152 ED admissions, decreasing to 30 ED admissions, after APN implementation (no p-value provided; Barraclough et al., 2016). This study was subject to bias as the population in the study was highly transient; there were many travelers in the small town, which impacted the data captured throughout the study (Barraclough et al., 2016).

In a United States-based study, Medicare beneficiaries had lower ED visits under the care of APNs ([14.4% - 15.8% for APN patients] vs. [17.5%−19.7% for physician patients], p < 0.01; Muench et al., 2019). DesRoches and colleagues (2017) surveyed three samples of Medicare populations: 1) beneficiaries on Medicare due to receiving disability insurance for longer than 48 months, 2) beneficiaries dually eligible for both Medicare and Medicaid based on age or disability as well as limited income or resources, and 3) beneficiaries who are both disability and dually eligible (DesRoches et al., 2017). Within these surveyed Medicare populations, patients under the care of APNs compared to physicians had decreased risk of ED visits (p <.0001; DesRoches et al., 2017). For Medicare beneficiaries in another study, those who received care from primary care APNs had fewer all-cause ED visits (adjusted odds ratio [AOR] = 0.72, p <0.0001), nonemergent visits (AOR 0.76, p < 0.0001), and emergent primary care sensitive visits (AOR = 0.78, p < 0.0001) compared to patients attributed to primary care physicians (Buerhaus et al., 2018). Coppa and colleagues (2018) found a 23.7% decrease in ED visits among clinically complex patients after the introduction of home-based primary care APNs compared to usual primary care at a Federally Qualified Health Center, a nonprofit health center providing services to underserved areas and populations (p = .001; Coppa et al., 2018). Medically complex diabetes patients of APNs were significantly less likely to visit the ED than patients of physicians (odds ratio [OR] = .90; Morgan et al., 2019). Compared to primary care physician patients, patients of the VA system attributed to primary care APNs had lower odds of any ambulatory care sensitive condition ED visits (AOR = 0.91, 95% CI = 0.83 – 0.99; Smith et al., 2020). Investigating the implementation of an APN-led home-based primary care program, one study showed that patients enrolled in this program had 15.1% higher odds of ED visits at 30 days (95% CI 4.9 – 25.3, p = .004) compared to 27.8% increased odds in ED visits at 90 days (95% CI 16.0–39.6, p <0.001; Ernecoff et al., 2021). In a study focused on the impact of care from an APN dementia care specialist, patients experienced lower odds of ED visits after program implementation (OR = 0.80, 95% CI = 0.66 – 0.97; Jennings et al., 2020).

Hospitalization

Ten studies focused on hospitalization as an outcome, with nine conducted in the United States and one study conducted in New Zealand with nurse specialists undergoing master’s degree training. In the New Zealand study, an intervention of a gerontology APN-led comprehensive assessment and care coordination for high-risk patients was associated with no difference in hospitalization compared to those who received regular physician primary care services (mean difference = 0.08, 95% CI = −0.41 – 0.92, p = 0.63; King et al., 2018). In the United States, one study among Medicare beneficiaries with diabetes found that APN-attributed patients had lower admissions (0.394 physicians vs. 0.066 APNs, p = 0.01) and inpatient days (2.054 physicians vs. 0.286 APNs, p = 0.01) compared to physician-attributed patients (Lutfiyya et al., 2017). A study surveying three samples of Medicare populations found that patients under the care of APNs compared to physicians had a decreased risk of preventable hospitalizations (p <.0001; DesRoches et al., 2017). For Medicare beneficiaries in another study, those who received care from primary care APNs had fewer preventable hospitalizations (overall AOR = 0.78, p <0.0001) compared to patients attributed to primary care physicians (Buerhaus et al., 2018). Coppa and colleagues (2018) found a 34.9 % decrease in rehospitalizations among clinically complex patients after the introduction of home-based primary care APNs (p=.001; Coppa et al., 2018). Medically complex diabetes patients of APNs compared to physicians were significantly less likely to incur all-cause hospitalizations (OR = 0.89) and ambulatory care-sensitive hospitalizations (OR = 0.90; Morgan et al., 2019). Liu et al. measured both inpatient and outpatient healthcare utilization and found that patients assigned to APNs were significantly less likely to have any hospitalization (average marginal effect = −0.86 percentage points; Liu et al., 2020). An APN-led home-based primary care program was associated with an 11.4% decreased likeliness of hospitalizations after 30 days (CI: −17.7 - −5.0; p < .001; Ernecoff et al., 2021). An APN co-management program was associated with fewer average hospitalizations (1.38 vs. 0.74 pre/post, p < 0.001) and fewer readmissions post-implementation (0.37 vs. 0.15 pre/post, p = 0.004; Jones et al., 2017). Finally, in a study focused on the impact of an APN dementia care specialist, patients experienced fewer days hospitalized (incident rate ratio = 0.74; 95% CI = .55 – .99; Jennings et al., 2020).

Other Health Service Utilization Outcomes

Four studies focused on other health service utilization outcomes, three of which were conducted in the United States and one in the Netherlands. Home-based primary care APNs prescribed significantly fewer medications (19.9% APNs vs. 30.6% physicians) compared to physicians in a study conducted in the Netherlands (Smits et al., 2020). Further, in the same study, there were no significant differences in follow-up contact with patients between providers within 72 hours or one month (Smits et al., 2020). In the United States, three studies found that compared to physician patients, APN patients had fewer primary care visits (Liu et al., 2020; Loresto et al., 2017; Lutfiyya et al., 2017). These patients included Medicare beneficiaries (Loresto et al., 2017), VA patients (Liu et al., 2020), and Medicare beneficiaries with diabetes (Lutfiyya et al., 2017). A study of Medicare beneficiaries, where individuals were assigned to primary care physicians or APNs, found that APN beneficiaries had significantly fewer primary care visits (8.5 vs. 15.0; Loresto et al., 2017). In a study investigating inpatient and outpatient utilization trends through VA electronic health records, patients assigned to APNs were found to have a decreased likelihood of having at least one primary care visit (average marginal effect = −1.33 percentage points) compared to those assigned to physicians (Liu et al., 2020). Finally, one study among Medicare beneficiaries with diabetes found that APN-attributed patients had fewer visits (5.74 visits under physicians vs. 3.68 visits under APNs, p = 0.01; Lutfiyya et al., 2017).

Healthcare Costs

Eight studies evaluated healthcare costs as an outcome. Seven were conducted in the United States and one in the Netherlands. Among the studies based in the United States, four used data from Medicare beneficiaries examining the impact of APN care on inpatient, outpatient, and specialty care costs (Lutfiyya et al., 2017; Muench et al., 2019; Perloff et al., 2016; Razavi et al., 2021). Other studies explored the effect of primary care APN assignments on VA patients and medically complex patients (Liu et al., 2020; Morgan et al., 2019; Smith et al., 2020). Six of the seven studies based in the United States found APN care or APN assignment to be significantly associated with lower inpatient, outpatient, pharmacy, or specialty costs (Liu et al., 2020; Lutfiyya et al., 2017; Morgan et al., 2019; Muench et al., 2019; Perloff et al., 2016; Razavi et al., 2021; Smith et al., 2020), whereas one study (Liu et al., 2020) found lower costs, but not statistically significant. Among Medicare beneficiaries, those attributed to primary care APNs had 11% lower inpatient costs than patients attributed to primary care physicians (p < 0.001; Perloff et al., 2016). Another study evaluating costs for Medicare beneficiaries with prescriptions for anti-diabetics, renin-angiotensin system antagonists, or statins found beneficiaries attributed to APNs had significantly lower office-based and non-office-based Medicare part B costs (Muench et al., 2019). For example, APN Medicare patients with prescriptions for antidiabetics had $195 lower office-based costs than physician patients (p <.001; Muench et al., 2019). Also, examining patients at VA facilities, another study found patients receiving care from APNs compared to physicians were associated with lower total care, outpatient, inpatient, and pharmacy costs (Morgan et al., 2019). The estimated mean ratio for the difference in total expenditure for APNs compared to physicians for 0.94 (p <.0001; Morgan et al., 2019). Further, Smith and colleagues (2020) found VA patients receiving primary care from APN compared to physicians were associated with approximately $500-$700 less in healthcare costs per patient per year (p < 0.0001; Smith et al., 2020). Additionally, a study conducted among Medicare beneficiaries with diabetes found significant lower healthcare cost outcomes in various settings including provider, inpatient, outpatient, home health, among patients cared for by APNs compared to physicians (p<0.05; Lutfiyya et al., 2017). While there was a decrease in costs for patients cared for by APNs in skilled nursing facilities, they were not statistically significant (p>0.05; Lutfiyya et al., 2017). Medicare beneficiaries cared for by APNs compared to physicians had 34–21% average lower cost, with APNs using fewer and less expensive resources than physicians (p<0.0001; Razavi et al., 2021). While differences in cost were not statistically significant, one study comparing costs using VA data found total costs for patients cared for by APNs to be lower than patients cared for by physicians (adjusted difference = −$289, 95% CI = −696 – 117) as well as outpatient costs (adjusted difference = −$98, 95% CI = −251 – 55; Liu et al., 2020). In the Netherlands, Van Der Biezen and colleagues (2016) found mean costs per APN consultation to be €7,58 less (95 % CI: €−10,82 - € −4,34, p < .001) compared to the mean cost of physician consultation in a primary care setting (Van Der Biezen et al., 2016). While measures in costs varied between studies, the majority of the included studies demonstrate the statistically significant relationship between APN care and lower healthcare costs. However, one found statistically insignificant effects of APN care being associated with lower healthcare costs (Liu et al., 2020).

Access and Quality of Care

Four studies focused on access to care, including the frequency and number of consultations, quality of accessed care, and the number of healthcare visits in underserved areas. Two studies were conducted in the Netherlands and two in the United States. In the Netherlands, a study that introduced an APN to a care team of all physicians found that the number of consultations with primary care patients per hour was significantly lower for APNs compared to physicians (3.0 for physicians and 2.3 for APNs [p < .001]; Van Der Biezen et al., 2016). Further, the mean number of patients per care provider per hour was the same between APNs and physicians (2.9 consultations per hour; Van Der Biezen et al., 2016). A different study in home-based primary care in the Netherlands evaluated adherence to protocols, finding that protocol adherence was higher for APNs compared to physicians (84.9% APNs vs. 76.2% physicians, p < 0.01; Smits et al., 2020).

In the United States, one study found that Medicare beneficiaries cared for by APNs were more likely to be from rural areas compared to beneficiaries cared for by physicians (Buerhaus et al., 2018). In terms of access to quality care, one study found that beneficiaries cared for by APNs had lower odds of spirometry for chronic obstructive pulmonary disorder (AOR = 0.77, p = 0.002), lipid screening for coronary artery disease (AOR = 0.84, p < 0.0001), comprehensive diabetes measures (e.g., Hemoglobin A1C testing, AOR = 0.95, p = 0.01), and cancer screening (e.g., breast cancer screening, AOR = 0.80, p < 0.0001; Buerhaus et al., 2018). This study controlled for geographical location, rural status, patient demographics, dual eligibility status, and treatment setting (Buerhaus et al., 2018). Another study found that dually eligible Medicare beneficiaries received similar chronic disease management when they were cared for by APNs vs. physicians (lipid screening p = 0.766) but had fewer eye screenings for diabetic patients (p = 0.000; DesRoches et al., 2017).

Discussion

In this scoping review, we synthesized the existing evidence on the contribution of APNs on health services utilization, healthcare costs, access, and quality of care. The review covered 18 studies that were conducted in the United States, the Netherlands, Australia, and New Zealand. Most of the included studies focused on healthcare service utilization, namely ED utilization and hospitalization, as outcomes. Yet, there was a wide variation across studies in terms of health services utilization measures, including hospitalizations, ED admissions, primary care visits, referrals, among others.

Many studies focused on ED utilization and/or hospitalization as outcomes of care by APNs. All eight studies on ED utilization were conducted in the United States and showed that APN-provided care was associated with lower ED utilization. The studies covered a wide range of patient groups with various conditions (patients with complex conditions or multimorbidity, diabetes, dementia, and other conditions), diverse health insurers (e.g., Medicare, Medicaid, etc.) across primary and ambulatory care settings. The findings of the few studies conducted outside of the United States were less consistent: the study from Australia found a decrease in ED admissions, but lacked clarity on statistical significance and studied only one psychiatric APN (Barraclough et al., 2016). In the Netherlands, while one study showed significantly fewer ED referrals by APNs compared to physicians (Van Der Biezen et al., 2016), the other study showed significantly higher ED referrals among patients in the APNs versus to physicians group (Smits et al., 2020).

Compared with previous literature, our findings show that the volume of the evidence base on APNs and ED utilization has considerably increased, particularly from studies conducted in the United States. Previous systematic reviews did not specifically evaluate the contributions of APNs on the outcome of ED utilization. Only one Cochrane review was conducted by Laurant and colleagues (2018) and included all nurses (including APNs and others) evaluated ED utilization (Laurant et al., 2018). The review performed a meta-analysis based on five studies and showed no significant difference between nurse-versus physician-provided care in terms of hospital admissions and emergency room attendance (Laurant et al., 2018). Our review has identified a marked increase in studies, particularly in the United States, which overall suggest reduced ED utilization if care is provided by APNs versus physicians. The study findings are consistent across the studies in the United States but inconsistent across the studies conducted in other countries. For example, the studies conducted in the Netherlands demonstrated different findings: one study showed a significant increase in ED referrals and another study also showed a significant decrease in ED referrals (Smits et al., 2020; Van Der Biezen et al., 2016).

The studies on hospitalizations consistently demonstrated that APN care was associated with lower hospitalization across various patient populations. Several studies conducted among older adults in the United States showed that APN care leads to lower hospitalization rates among these patients (Buerhaus et al., 2018; Coppa et al., 2018; DesRoches et al., 2017; Ernecoff et al., 2021; Jennings et al., 2020; Jones et al., 2017; Liu et al., 2020; Lutfiyya et al., 2017; Morgan et al., 2019). Our hospitalization findings are comparable to those from previous systematic reviews and expand the evidence. For example, the systematic review by Morilla-Herrera (2016), which was based on fifteen randomized control trials, found significantly reduced hospital admissions among patients in long-term care settings if cared for by multidisciplinary healthcare teams with APNs vs. teams without APNs (Morilla-Herrera et al., 2016). The systematic review by Martinez-Gonzalez (2014) showed a significant reduction in all-cause hospital admission among nurse- vs. physician-led care based on a meta-analysis of five randomized control trials (Martínez-González et al., 2014). Furthermore, with effects were more pronounced in the APN-led care models, based on three randomized control trials (Martínez-González et al., 2014). We identified an additional nine United States-focused studies that reported that the care by APNs may reduce hospital admission.

Among eight studies with healthcare cost outcomes, most were conducted in the United States, with only one study being conducted in the Netherlands. Given the variability in the organization of healthcare systems across the countries, it was not surprising that cost as an outcome was a major focus of United States-based studies. Most studies in the United States were conducted among older adults and showed that the care by APNs was associated with lower inpatient, outpatient, pharmacy, and specialty costs. For example, patients attributed to primary care APNs had 11% lower inpatient costs than patients attributed to primary care physicians (p < 0.001) (Perloff et al., 2016). In the Netherlands, the mean costs per APN consultation were also lower than those physician consultations in a primary care setting (Van Der Biezen et al., 2016). Overall, this evidence demonstrates that APN care may be linked to lower healthcare costs for various patients and settings.

Previous reviews on costs show mixed and largely inconclusive results. The systematic review by Swan et al. (2015) found the same or reduced healthcare costs if care was provided by APNs compared with physicians, but also the longer average duration of consultations by APNs (Swan et al., 2015). The review by Martin-Misener found cost savings in the APN- vs. physician-provided care model (acting as alternative providers) based on meta-analysis on two randomized control trials (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<.0001; Martin-Misener et al., 2015). The review by Kilpatrick et al. (2014) suggested some evidence of reduced costs and resource utilization with APNs compared physicians, although this finding is based on limited evidence (Kilpatrick et al., 2014). Martinez-Gonzalez et al. (2014) identified inconclusive results on costs, but their review covered all nurses, not APNs only, substituting for physicians (Martínez-González et al., 2014).

Finally, we have also focused on access and quality of care, covered in four studies. In the Netherlands, the number of consultations with primary care patients per hour was significantly lower for APNs compared to physicians (3.0 for physicians and 2.3 for APNs [p < .001]) while the mean number of patients per care provider per hour was the same for both physicians and APNs (2.9 consultations per hour; Van Der Biezen et al., 2016). A different study in home-based primary care found that protocol adherence as a measure of quality care was higher for APNs compared to physicians (84.9% APNs vs. 76.2% physicians, p < 0.01;Smits et al., 2020). Overall, there is a paucity of research on the contribution of APNs and access to services at country levels as well as from a global perspective.

Implications

Our study findings have implications for policy, practice, and future research. Our review shows that APN care impacts ED utilization, hospitalization, healthcare cost, and access and quality of care. There is increasing evidence suggesting that APN care can reduce ED use and hospitalizations and potentially reduce costs. Thus, supporting APN practice through policy can contribute to these outcomes. Favorable scope-of-practice laws for APNs can ensure that APNs are able to deliver care high quality care to their patients. Similarly, the existing payment models should allow APNs to be properly recognized and reimbursed for their services since their services save costs.

Indeed, policy changes have been recommended to address barriers to APN care internationally. Policy changes that have been encouraged involve a review scope-of-practice laws, payer recognition of APN roles and proper reimbursement for their services, and a need for financial incentives to initiate the new APN role in primary care practices in countries that lack APN workforces in primary care settings (Maier et al., 2017). Such policy changes may support APN practice and subsequently reduce ED use, hospitalizations, and healthcare costs.

Our findings also have implications at the organizational level. Practice implications include support and follow-through by management, which is essential to creating good working environments for APNs in primary care systems (Maier et al., 2017) that will contribute to improving access and quality of care and reduce ED utilization, hospitalizations, and healthcare cost. A good working environment for APNs is important and they are associated with lower hospital and ED utilization (Poghosyan, Liu, et al., 2022). However, scope of practice policies affect work enviornment, with favorable policies for full scope of practice for APNs having better work enviornments (Poghosyan et al., 2022). Therefore, poor work environments and restrictive scope of practice laws are barriers to APN care that can improve ED and hospital use, healthcare costs and impact access and quality of care. By addressing these barriers through policy and practice organizational interventions, the APN workforce can be further developed to improve access to care, quality of care, and reduce healthcare costs (Maier et al., 2017). Based on a report on 37 Organization for Economic Co-operation and Development (OECD) and European Union countries, barriers to APN care include stakeholder opposition, regulatory barriers (e.g., restrictive scope-of-practice laws), payment systems not adequately acknowledging the APN role, or organizational level factors (poor leadership or management strategies) (Maier et al., 2017). Countries and healthcare organizations introducing APNs should invest efforts to effectively utilize the APN role and further identify policy- and practice-related barriers to the APN workforce to maximize their contributions to patient care.

Given the increasing evidence on APN care and the impacts on ED utilization, hospitalizations, healthcare costs, and access and quality of care, findings of these studies have research implications. The evidence is primarily from the United States, and few studies are available from other countries. As the APN workforce grows globally, more research is needed from other countries with differently organized and resourced health systems. The APN workforce is emerging globally, notably in Europe, Africa, Latin America and the Caribbean; however, there are still geographical gaps in research on and implementation of APNs (Kilpatrick et al., 2024). For resource poor countries, implementing the APN workforce can provide a cost-effective solution to expand access to healthcare due to the lower cost of training and compensating APNs (American Association of Nurse Practitioners, 2013; Riley et al., 2016). Investing in APN workforce development can strengthen local healthcare capacity, helping to reduce global health inequities.

Also, the research is inconsistent on the impact of the APN workforce on the outcomes included in this review, and future research is needed. Research on the impact of APNs on these outcomes should involve consistent measures that are reliable and valid. Having evidence from robust, large-scale studies with sufficient sample sizes will help strengthen the impacts of APN care on health service outcomes. Such evidence is critically needed to support the growth and development of the APN workforce.

Limitations

The study has several limitations. The review only included studies published in English. We limited the search to papers published between 2016 and 2023 to build on the synthesis of evidence from previous reviews published before 2016. These restrictions may affect the results. Another limitation is the variation in outcome measures used across the included studies and study designs to evaluate the impact of care by APNs. Further, because of the international scope, the integration of the APN workforce may vary between countries regarding healthcare systems and care delivery. This may impact the extent findings across countries can be synthesized. A quality appraisal of the included literature was not conducted; however, this is consistent with the methodology of scoping reviews (Khalil et al., 2016; Peters et al., 2015; Peters et al., 2020; Pollock et al., 2021; Tricco et al., 2018). Finally, publication bias may have influenced our findings. Studies with null results or negative findings are less likely to be published (Franco et al., 2014). Also, countries with low resources for conducting health research may have been less likely to publish on the APN workforce, limiting the scope of the included literature.

Conclusion

The APN workforce is valuable for delivering care and impacting health service utilization, healthcare costs, access to care and quality of care in primary care settings. ED utilization, hospitalizations, and healthcare costs were lower for primary care patients cared for by APNs in most of the studies included in the review. Access and quality of care outcomes were significantly impacted by APN primary care, measured by frequency of consultations with providers and visits in underserved areas, and quality of care measures. Globally, most of the evidence on primary care APNs is limited to the countries that first developed the role, mainly coming from the United States. More research is needed to better inform how to leverage the APN workforce to promote optimal health outcomes in primary care globally.

Supplementary Material

Appendix2
Appendix1
Supinfo1

Acknowledgements:

National Institute of Nursing Research T32 NR014205, E.T. is funded by the National Institute of Mental Health T32MH109433 and the National Clinician Scholars Program.

Footnotes

Conflicts of Interest: No conflict of interest has been declared by the author(s).

Contributor Information

Madison HORTON, T32 Predoctoral Trainee Columbia University School of Nursing, 560 W 168th St, New York, NY 10032.

Justinna DIXON, T32 Predoctoral Trainee Columbia University School of Nursing, 560 W 168th St, New York, NY 10032.

Eleanor TURI, National Clinician Scholars Program & Center for Mental Health, Perelman School of Medicine, University of Pennsylvania Civic Center Blvd, Philadelphia, PA 19104.

Chinmayi BALUSU, Columbia University School of Nursing, 560 W 168th St, New York, NY 10032.

Rachel PAIKOFF, Columbia University School of Nursing, 560 W 168th St, New York, NY 10032.

Claudia B. MAIER, Bielefeld University School of Public Health, Universitätsstraße 25, 33615 Bielefeld, Germany.

Lusine POGHOSYAN, Stone Foundation and Elise D. Fish Professor of Nursing, Columbia University School of Nursing, and Professor of Health Policy and Management, Mailman School of Public Health, Columbia University, 560 W 168th St, New York, NY 10032.

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Associated Data

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Supplementary Materials

Appendix2
NIHMS2039498-supplement-Appendix2.docx (25.7KB, docx)
Appendix1
NIHMS2039498-supplement-Appendix1.docx (14KB, docx)
Supinfo1
NIHMS2039498-supplement-Supinfo1.docx (107.1KB, docx)

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