Impact of nurse practitioners in primary care on patients with chronic diseases in rural and underserved areas: A systematic review

Abstract

Background

Ageing, multimorbidity, and workforce shortages increasingly limit access to primary healthcare, especially in rural and underserved areas.

Objectives

To document impact of nurse practitioners (NPs) in primary care on patients with chronic diseases.

Methods

Searches were conducted in Medline, EMBASE, CINAHL, and CENTRAL (March 1978–October 2023). This systematic review followed MECIR and PRISMA guidelines (PRISMA 2020 checklist: EQUATOR Network) with SWiM used as a PRISMA extension due to the lack of meta-analysis. The focus was on NPs’ roles in chronic disease management and primary care in underserved or remote areas, excluding mental health, cancer, and dental care.

Results

Among 3,684 citations, 25 studies were selected, including 10 RCT. NPs may improve access to primary care and chronic disease management, particularly in underserved areas. Although not all studies directly compared NPs to traditional models, they were most often assessed against General Practitioners (GPs) alone. Seven studies also evaluated collaborative NP-GP models versus GP-only care. Patient satisfaction was generally higher with NPs, possibly due to longer consultations and greater patient education. Clinical and biological outcomes were often comparable between NPs and GPs, with the best results in collaborative models, which were also associated with higher costs.

Conclusion

NPs may enhance access to care, particularly for vulnerable populations. Higher patient satisfaction may be linked to longer consultations and patient education. While clinical outcomes were comparable to those of GPs, collaborative models yielded the best results, though potentially at a higher cost.

KEY MESSAGES

• This review examined NPs’ contributions to chronic disease management in primary care, particularly in underserved settings.

• NPs improved access to care and patient satisfaction, with clinical outcomes comparable to GPs, especially in collaboration.

• These findings highlight their potential to strengthen services for underserved populations, while noting that effective collaboration may require greater resources.

Introduction

Access to primary healthcare is a global public health issue linked to ageing populations and rising chronic disease prevalence [1]. Chronic diseases are the leading contributors to morbidity and mortality worldwide [2]. Ageing individuals are more likely to suffer from multiple conditions [3], increasing frailty. Multimorbidity affects 73% of Americans aged 65 + 35% of those 40–64 and 7.9% of those 18–39 [4]. Health needs have also risen due to medical advances and increased life expectancy [4].

Chronic diseases are progressive, long-term conditions affecting daily life, with Europe the most impacted WHO region [1]. They impact daily activities, reduces quality of life, and increases mortality risk [5,6]. In Europe, 86% of deaths and 77% of morbidity result from diabetes, cancers, cardiovascular and chronic respiratory diseases, and mental disorders [2]. Although 80% of premature heart diseases, strokes, and diabetes could be prevented by risk factor management [2]. Patients with chronic diseases frequently use primary care. In Canada, 41% of primary care patients have at least one chronic disease, and primary care use increases with multimorbidity [7].

Primary care provides first-contact, accessible, continuous, comprehensive, and coordinated person-focused care, to optimise population health and reduce disparities [8]. It plays a crucial role in managing and preventing chronic diseases [9,10]. As patients with chronic conditions are frequent and vulnerable users of primary care, improving accessibility directly benefits them, making primary care both central for chronic disease management and a response to accessibility challenges [9].

General practitioners (GPs) are central to prevention and primary care but face significant shortages. One in five Canadians lacks a family doctor [11], and the U.S. projects a shortage of over 120,000 GPs by 2034 [12]. In Europe, 40% of doctors in 13 of 44 reporting countries are aged 55+, posing workforce challenges [13].

Primary care availability also correlates with mortality rates [14]. Given increasing demand, GPs can collaborate with Nurse Practitioners (NPs) to improve access for patients with chronic conditions [15]. The International Council of Nurses (ICN) defines NPs as nurses with advanced theoretical knowledge, decision-making skills, and essential clinical competencies, typically acquired at the master’s level.

Although systematic reviews exist on NPs [16–19], none specifically examine their role in chronic disease management in primary care. Equally, published research on rural primary care across Europe is scarce [20]. As chronic disease patients are the main users of these services, understanding NPs’ impact on access to care is essential, particularly in underserved areas, where healthcare resources are limited or geographically distant, reducing accessibility and continuity of care [21]. Outcomes are more imbalanced where access is limited [22]. This study documents the impact of NP interventions on patients with chronic diseases in primary care settings where access is difficult.

Methods

Study design

This systematic review was conducted according to the Methodological Expectations for Cochrane Intervention Reviews (MECIR) [23] and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [24]. Eligibility criteria were structured using the PICOS framework. Synthesis Without Meta-analysis (SWiM) was used as PRISMA extension because meta-analysis was not feasible [25]. The protocol was registered in PROSPERO (CRD42022358333).

Search strategy

The search strategy was developed from predefined objectives (population, interventions, comparators, outcomes) [23]. Medical Subject Headings (MeSH) terms were identified accordingly (Appendix 1). Research concepts included NPs, medically underserved areas or access to care, and chronic diseases or primary care.

Studies were identified through searches in Medline (PubMed), EMBASE (Ovid), CINAHL, and CENTRAL (Cochrane Library), covering March 1978, the earliest record, to 1 October 2023. Reference lists of retrieved articles were also screened, but all additional citations were already present in the four databases and are included in Figure 1.

Figure 1.

Flowchart illustrating the study selection process.

Electronic search strategies were developed by a project member (AS), reviewed by three others (MB, AB, CP), and assessed by an information specialist (MAG).

Eligibility criteria

According to the PICOS statement (Population, Intervention, Comparator, Outcomes, Study design), the following eligibility criteria were applied.

Population (P) – Studies included patients with chronic conditions in underserved or remote areas [26]. We focused on adults (≥ 18 years old) consulting in general practice, and excluded studies from emergency departments, hospitals, mental health, cancer, and dental care.

Intervention (I) – The intervention had to be performed by health professionals recognised as nurse practitioners in their country [27]. Registered nurses, lacking advanced practice training, were excluded.

Comparator (C) – No predefined comparator was set to include the widest range of studies comparing NP-delivered care with ‘traditional care’. Comparators varied, including GPs alone, collaborative GP–NP teams, or no comparator group, allowing inclusion of diverse care models and healthcare contexts.

Outcomes (O) – Studies had to measure at least one clinical outcome [23], including: access to care (e.g. wait times, travel duration, number of patients seen), satisfaction, patient characteristics, practice patterns (e.g. guideline adherence, therapeutic education, counselling, prescriptions), non-scheduled care use, quality of life, clinical and biological criteria, and costs based on consultation duration or time spent with patients. Outcomes were classified into two categories: impact on the healthcare system and impact on patients.

Study design (S) – Eligible studies examined the impact of NPs in chronic disease management or primary care in medically underserved or remote areas, or where health service accessibility was limited. Prospective or cross-sectional observational and interventional primary studies providing original data were included, covering quantitative and mixed-methods designs. No language restrictions were applied, and studies were not excluded by publication date to ensure a comprehensive understanding of NPs’ impact.

Study records

Data management Search results (titles and abstracts) were uploaded into Zotero^®. Duplicate publications from the same study were identified by comparing author names, study sites, and sample sizes.

Selection process – Following Cochrane recommendations [28], two reviewers (AS, CP) independently and double-blind screened all titles and abstracts using predefined criteria: (1) original research, (2) NP impact, (3) chronic disease or healthcare access issues, and (4) underserved or remote settings.

Full-text articles deemed relevant were evaluated, with exclusion reasons documented. Reviewers were not blind to authors, date, or journal. After an initial consensus, they reassessed remaining articles independently, with a third member (AB) arbitrating if needed.

Data extraction

Two reviewers (AS, CP) extracted data using a pre-tested form refined with team input. Extraction was conducted double-blind, with a third reviewer (AB) contributing to consensus.

Synthesis of results

Study characteristics (author, year, country, design, participants, measurement type) (Table 1) and outcomes (measures, statistics) were extracted into tables (Appendix 2 & 3). Descriptive statistics summarised continuous variables and categorical variables. Due to heterogeneity, a synthesis without meta-analysis was conducted following the ‘European Social Research Council Guidance on Narrative Synthesis in Systematic Reviews’ [29].

Table 1.

Study characteristics.

Author (date)	Design, Country		Participants characteristics
	Evidence type	Country	Conditions	Number patients	Female % patients	Mean age patients	Type of health care professionals	Number of health care professionals	Female % care givers	Mean age care givers
Callaghan et al. [43]	Observational	Canada	NA	NA	NA	NA	NP	43	93	NA
Chatsiri et al. [44]	Observational	Thailand	Type-2 diabetes	300	73	60.7	NP-GP full time, NP-GP partial, NP alone	NA	NA	NA
Coppa et al. [45]	Quasi experimental study	USA	Primary care	82	70	60.6	GP & NP	NA	NA	NA
D’Affliti et al. [46]	Quasi-experimental study	USA	NA	41	NA	NA	GP & NP	NA	NA	NA
Dierick Van Daele et al. [33]	Randomised controlled trial	The Netherlands	Chronic conditions	1501	60.9	44.5	GP & NP	15	NA	NA
Dierick Van Daele et al. [34]	Randomised controlled trial	The Netherlands	Chronic conditions	2747	60.9	44.5	GP & NP	15	NA	NA
Doescher et al. [47]	Observational research	USA	NA	NA	NA	NA	GP & NP	2307	62.3	50
Everett et al. [48]	Observational	USA	Chronic conditions	6803	54.3	64.3	GP & NP	NA	NA	NA
Houweling et al. [35]	Randomised controlled trial	The Netherlands	Diabetes	230	52.4	68.3	GP & NP	NA	NA	NA
Kinnersley et al. [36]	Randomised controlled trial	UK	Chronic conditions	1222	59.5	29.3	GP & NP	NA	NA	NA
Kuo et al. [49]	Observational	USA	Diabetes	345,819	60.1	76.9	GP & NP	NA	NA	NA
Lenz et al. [37]	Randomised controlled trial	USA	Chronic conditions	406	28.3	46.5	GP & NP	NA	NA	NA
Litaker et al. [38])	Randomised controlled trial	USA	Diabetes, high blood pressure	157	58.5	60.6	NP & GP+NP	NA	NA	NA
Neff et al. [50]	Observational	USA	Chronic conditions	NA	NA	NA	GP & NP	262 829	NA	NA
Park et al. [51]	Observational	USA	Chronic conditions	NA	NA	NA	Patient centred medical homes (PCMH: NP-led & GP-led)	11870	NA	NA
Perloff et al. [52]	Observational research	USA	Chronic conditions	558,099	NA	NA	NP & GP + NP	324 321	64.2	72.8
Prasad et al. [53]	Observational research	Canada	Frail elders	2496	NA	NA	GP & NP	NA	NA	NA
Roots et al. [54]	Mixed methods research (3 cases study)	Canada	Chronic conditions	NA	NA	NA	GP & NP	11	NA	NA
Sackett et al. [39]	Randomised controlled trial	Canada	Chronic conditions	954	57.5	NA	GP & NP	NA	NA	NA
Sears et al. [55]	Quasi-experimental study	USA	Primary care	42,533	33.4	37.6	GP & NP	NA	NA	NA
Shum et al. [40]	Randomised controlled trial	UK	Chronic conditions	1792	60.1	27.6*	GP & NP	NA	NA	NA
Van der Biezen et al. [56]	Quasi-experimental study	The Netherlands	Chronic conditions	12092	53	34	GP & NP	143	40**	49.3***
Venning et al. [41]	Randomised controlled trial	UK	Chronic conditions	1292	57.5	NA	GP & NP	NA	NA	NA
Voogdt et al. [42]	Randomised controlled trial	The Netherlands	High risk cardiovascular diseases	695	50	63.5	GP & NP	NA	NA	NA
Young et al. [57]	Observational research	USA, Iowa	Chronic conditions	NA	NA	NA	GP & NP	2941	NA	NA

Notes: * mean of median ages; ** GP, NP not included; *** GP, NP not included; NP: Nurse practitioner GP: General practitioner; NA: Non available.

Critical appraisal

Study quality was assessed double-blind by two reviewers (AS, CP) using the Mixed Methods Appraisal Tool (MMAT) (Table 2) [30,31]. The MMAT, suited for qualitative, quantitative, and mixed-methods studies, is increasingly used in health sciences [32], particularly nursing. It was chosen here due to the inclusion of mixed-methods studies. Each article received a score from 0 to 5, with ≥ 4/5 indicating high quality and < 4/5 considered low quality [30]. Quality was first verified during eligibility screening (see flowchart) before formal MMAT scoring. No studies were discarded on the basis of methodological quality. Discrepancies were resolved by consensus.

Table 2.

Quality of studies using the mixed methods appraisal tool (MMAT).

Author (year)	Number of MMAT category, Design	S1	S2	1	2	3	4	5	Total
Callaghan et al. [43]	4, Quantitatif descriptif	1	1	1	1	1	1	1	7
Chatsiri et al. [44]	4, Quantitatif descriptif	1	1	1	0	1	1	1	6
Coppa et al. [45]	3, Quantitatif non randomisé	1	1	1	1	1	NA	1	6
D’Affliti et al. [46]	4, Quantitatif descriptif	1	NA	NA	1	0	1	1	4
Dierick Van Daele et al. [33]	2, Quantitatif RCT	1	1	1	NA	1	1	1	6
Dierick Van Daele et al. [34]	2, Quantitatif RCT	1	1	1	NA	1	1	1	6
Doescher et al. [47]	4, Quantitatif descriptif	1	1	1	1	1	NA	1	6
Everett et al. [48]	4, Quantitatif descriptif	1	1	NA	1	1	NA	1	5
Houweling et al. [35]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Kinnersley et al. [36]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Kuo et al. [49]	3, Quantitatif non randomisé	1	1	1	1	1	NA	1	6
Lenz et al. [37]	3, Quantitatif non randomisé	1	0	0	1	0	NA	1	2
Litaker et al. [38]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Neff et al. [50]	4, Quantitatif descriptif	1	1	NA	NA	1	NA	1	4
Park et al. [51]	4, Quantitatif descriptif	1	1	1	1	1	NA	1	6
Perloff et al. [52]	3, Quantitatif non randomisé	1	1	1	1	1	NA	1	6
Prasad et al. [53]	4, Quantitatif descriptif	1	NA	NA	1	NA	NA	NA	2
Roots et al. [54]	5, Méthodes mixtes	1	1	1	1	1	NA	NA	5
Sackett et al. [39]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Sears et al. [55]	4, Quantitatif descriptif	1	1	1	1	1	NA	1	6
Shum et al. [40]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Van der Biezen et al. [56]	3, Quantitatif non randomisé	1	1	1	1	1	1	1	7
Venning et al. [41]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Voogdt et al. [42]	2, Quantitatif RCT	1	1	1	1	1	0	1	6
Young et al. [57]	3, Quantitatif non randomisé	1	1	1	1	NA	0	1	5

Notes: NA: Not available; RCT: Randomised controlled trial.

Results

Literature search

A total of 3,684 unique citations were identified through database searches (Figure 1). After removing 91 duplicate records identified from different sources, the titles and abstracts of 3,593 records were screened for eligibility. Of these, 113 references were identified as potentially relevant. After excluding 88 references that did not fulfil the inclusion criteria based on the full-text review, our systematic review included 25 primary studies.

Study characteristics

Ten studies were randomised controlled trials [33–42] (Table 1). Sixteen studies were conducted in North America [37–39,43, 45–55,57] and eight in Europe [33–36,40–42,56]. Nine studies were published before 2010 [33,36–41, 48,55] and sixteen after 2010 [34,35,42–47,49–54,56]. Twelve studies compared the results of NPs with those of GPs [33–37,40–42, 49,51,52,55]. Seven studies compared GPs alone with a team of GPs and NPs [38,39,43,44, 46,56,57], while four studies assessed the impact of NPs before and after the intervention [45,50, 53,54].

We considered that these studies, by adding NPs to traditional care, corresponded to studies that measured the work of an NP+GP team compared with GP-only care (Table 1).

Eighteen studies were longitudinal, with a mean follow-up of 15.7 months. The number of patients included ranged from 82 [45] to 602,249 [52], with a median of 1,292. The number of GPs included ranged from 31 [46] to 241,618 [50] and for NPs, from 318 [54] to 21,211 [50] (Table 3).

Table 3.

General results table: the impact of NPs or the NP+GP team compared with a GP alone, according to the different criteria measured.

First author (year)	Impact on the healthcare system				Impact on the patient
	Access to health care	Modalities of medical care	Cost and/or duration	Type of patient (in care for the vulnerable)	Satisfaction of patients	Patients quality of life	Clinical and biological outcomes	Emergency visits, readmissions and preventable hospitalisations
Callaghan et al. [43]	↑ (team)
Chatsiri et al. [44]		–			↑ (team)	↑ (team)	–
Coppa et al. [45]								↑ (team)
D’Affliti et al. [46]	↑ (team)				↑ (team)
Dierick Van Daele [33]		↑	↑ (time)			–
Dierick Van Daele [34]			↑ ↓ (cost)
Doescher et al. [47]			↓ (time)
Everett et al. [48]				↑
Houweling et al. [35]			↑		↑	–	–
Kinnersley et al. [36]		↑			↑		–
Kuo et al. [49]								↑
Lenz et al. [37]					–	–	–
Litaker et al. [38]			↓ (cost) (team)		↑ (team)	–	-↑(team)
Neff et al. [50]	↑ (team)
Park et al. [51]	↑			↑
Perloff et al. [52]			↑
Prasad et al. [53]	↑ (team)
Roots et al. [54]	↑ (team)		↑		↑ (qualitative)			↑ (team)
Sackett et al. [39]						–	–
Sears et al. [55]		↑		↑
Shum et al. [40]		↑	↑		↑			–
Van der Biezen et al. [56]	↑ (team)
Venning et al. [41]		–	- (cost) ↑ (time)		↑
Voogdt et al. [42]		↑
Young et al. [57]	↑ (team)

Notes: ↑ or ↓ statistically significant positive or negative impact; −: non statistically significant results, (team): NP+GP vs healthcare professional alone, (cost): results about cost only, (time): results about time only, (qualitative): qualitative method used for this results.

Results of the studies

Impact on the health care system

Access to healthcare – The integration of an NP into GP practice has been associated with a reduction in waiting times for non-urgent appointments. Some studies report an average decrease of 21 days [46,54]. Additionally, incorporating NPs as a primary source of care alongside GPs has been linked to a decrease in the proportion of people living in medically underserved areas [57]. (Appendix 2).

In the U.S., states allowing independent NP practice seem to offer better geographical access to primary care providers, with lower odds of a drive exceeding 30 min compared to the most restrictive states [50].

Modalities of medical care – Differences in medical care modalities have been observed between NPs and GPs. Studies suggest that NPs are more likely than GPs to inform and educate patients about their condition [36,42]. However, findings on prescribing patterns vary. Some studies report a slightly higher prescription rate for NPs [40], while others indicate the opposite trend in favour of GPs [41].

Costs and duration – Across several studies, NPs generally conduct longer consultations than GPs [33,40,41,54]. Regarding costs, mixed results have been reported. While teams combining NPs and GPs appear to have higher personnel expenses over a 12-month period compared to GPs alone, direct consultation costs tend to be lower for NPs [34,38, 41,52]. However, when considering productivity costs, this difference is not always significant.

Type of patient – Patient demographics also appear to differ depending on whether they are treated by NPs or GPs. Two studies indicate that NPs and medical assistants treat a higher proportion of female and older patients [48,55]. Additionally, NP-led medical centres are more frequently located in rural or medically underserved areas [51]. NPs also seem to care for a greater proportion of Medicaid-eligible patients compared to GPs [51].

Impact on the patient

Satisfaction – Patient satisfaction, as assessed by standardised questionnaires, appears to be higher for NPs than for GPs in several studies. Reported satisfaction rates ranged from 75.1% for NPs to 67.9% for GPs [35,36,40]. (Appendix 3).

Patients’ quality of life – The impact on patients’ quality of life has been evaluated using various standardised scales. Findings remain mixed. One study reported a 2.3-point higher score on the SF-36 general health criterion in favour of GPs [35]. However, another study with a longer follow-up found a 3.0-point higher score in favour of NPs [37].

Clinical and biological outcomes – Several studies have examined clinical and biological parameters. For instance, one study found a significant reduction in glycated haemoglobin among patients managed by NPs [38], while two others did not observe such a difference [35,37]. Similarly, no significant variation was noted in total cholesterol levels over a 14-month period [35]. Symptom resolution after consultation was comparable between the two groups, with 49% of patients in each reporting ‘much better’ outcomes on the Likert scale [36].

Unscheduled care – The involvement of NPs has been associated with a reduction in emergency admissions, with studies reporting decreases ranging from 23.7% (p < 0.001) [45] to 41.6% (p < 0.05) [54]. Avoidable hospitalisations also appeared less frequent among patients managed by NPs compared to GPs (OR = 0.90; 95% CI = 0.87–0.93, p = 0.001) [49]. Additionally, some studies suggest that NP interventions, particularly in collaboration with GPs, may contribute to lower rehospitalisation rates, with reported reductions between 34.9% (p = 0.001) [45] and 41.6% (p < 0.05) [54].

Discussion

This systematic review confirms that NPs improve access to primary care [43,46, 50,51,54,57] and contribute to greater satisfaction among patients and professionals [35,36,40,41, 44,46,54], in accordance with previous systematic reviews reporting similar findings [16–19].

They are more likely to serve vulnerable populations in underserved areas [48,51,55] and spend more time with patients, offering additional counselling and lifestyle interventions [33,35,36,40–42, 44,47,54]. In collaboration with GPs, they help reduce unscheduled care use [40,45, 49,54]. While NP-provided care is at least equivalent to that of GPs, if not superior in some cases [35–39,44], the cost-effectiveness of NPs remains debated – some studies report lower costs despite longer consultation times, while others find similar or slightly higher costs for NP-GP teams with improved outcomes [34,38, 41,52].

Impact on the healthcare system

Regarding access to healthcare, the eight included studies suggested a potential improvement associated with NPs in line with prior research demonstrating that expanding the NP workforce can alleviate physician shortages and improve service coverage [15]. Adding a provider logically increased the number of individuals receiving care, though the lack of appropriate controls makes isolating NPs’ specific contribution difficult.

Two studies reported shorter wait times with NPs compared to GPs alone, but multidisciplinary collaboration appeared most effective in meeting care demands [58] in accordance with the literature [59–61]. One study also found that GPs perceiving greater team efficiency reported lower burnout levels [62]. Furthermore, collaboration with NPs has been linked to improved healthcare professional satisfaction, partly due to workload redistribution easing GPs’ pressure [46].

These findings align with research on patient populations served by different professionals [48,51]. NPs more often worked in rural or underserved areas and treated elderly patients, women, and Medicaid-eligible individuals; these findings are consistent with previous studies showing a focus on vulnerable populations [63,64].

Some literature also noted a correlation between being female and caring for vulnerable peoples, in accordance with previous research highlighting gendered patterns in caregiving professions and activities [65,66]. This is particularly relevant given that nursing remains predominantly female, with 92% of the Canadian workforce being women [67].

Studies generally reported better outcomes when teams included both NPs and GPs, though it remains unclear whether this was due to NPs specifically or if other health professionals would yield similar benefits.

Cost analyses faced methodological challenges due to variations in study design and healthcare systems. Given the international scope of the included studies, cost estimates were highly context-dependent, reflecting differences in salary structures, reimbursement models, and scope of NP practice [68]. In accordance to prior studies, NPs are not necessarily a less expensive alternative [15,16]. One study found comparable costs between NPs and GPs, attributing this to NPs’ longer consultation times [41].

Overall, the evidence on cost-effectiveness remained inconclusive, with some studies reporting lower consultation costs for NPs and others showing comparable or higher expenses when accounting for productivity and team-related factors [34,38, 41,52]. These findings highlight the heterogeneity of economic evaluations and the difficulty of generalising cost-effectiveness across diverse healthcare systems.

Impact on the patient

Regarding patient satisfaction, findings indicated slightly higher satisfaction levels for NPs than GPs, in accordance with previous studies showing that patients often report greater satisfaction with NP-led care. This may relate to consultation time, often considered key to patient experience. NPs generally spent nearly twice as long with patients as GPs, a finding consistent with prior research suggesting that NPs tend to allow more time for communication and patient education. However, research suggests that actual consultation duration does not always correlate directly with satisfaction [69]. Instead, perceived time with the provider appears to be a stronger predictor [70]. Prior studies [71,72] found that consultations perceived as longer were not necessarily longer in reality, which aligns with person-centred care principles emphasising the quality of interaction, perceived attention, and active listening rather than consultation length itself [73].

Consultation volume also differed, with GPs generally seeing more patients due to higher consultation numbers and longer working hours. This may relate to NP follow-up eligibility and the possibility that NPs refer cases beyond their scope to GPs.

Consultation style differences may also shape patient experience. Female GPs spend more time per patient than male counterparts [74], and as most NPs are women, a similar trend may apply. Longer consultations tend to be more patient-centred, emphasising education and illness comprehension [74]. This aligns with our findings suggesting that NPs provided more information, lifestyle advice, and health education compared to GPs [36,42,44], possibly linked to GPs’ shorter consultation times. Training differences may also play a role, with GPs focusing on clinical-biological foundations and NPs adopting a more holistic approach. Some literature distinguishes ‘care’, emphasising the human aspect of nursing, from ‘cure’, focused on medicine’s technical aspects [75], highlighting their complementary roles.

Regarding quality of life, studies suggested better outcomes for NP-treated patients, though findings varied due to differences in study designs, measurement scales, NP regulations, and patient populations (e.g. chronic diseases) [76].

For clinical and biological outcomes, results were mixed. While mortality and symptom resolution appeared equivalent between NPs and GPs, NPs were generally associated with better outcomes in other parameters. This may stem from their greater emphasis on lifestyle and preventive advice, known to improve chronic disease management [77]. However, the best results consistently emerged when NPs worked with GPs rather than independently.

Finally, regarding unscheduled care, readmissions, and preventable hospitalisations, NP involvement was associated with improved outcomes, especially in collaboration with GPs. These benefits may relate to better or equivalent clinical-biological outcomes with NPs compared to GPs alone, as well as improved patient management through NP-GP collaboration [78,79].

Limitations

The included studies were highly heterogeneous in design and quality, mostly non-randomised, with sample sizes ranging from a few dozen to several thousand. Only four were conducted in Europe, potentially limiting representativeness and the robustness of conclusions. The review covered nearly five decades (1976–2023), during which NP roles and scopes evolved considerably, reflecting the progressive development of advanced practice. This heterogeneity – along with inconsistencies in parameters studied and statistical reporting – made synthesis difficult. As highlighted by Osakwe [19], many studies compared interventions to standard care without clearly defining it, despite major cross-country variations in healthcare systems and NP regulation. Most studies originated from North America, where advanced practice nursing is more established, whereas Europe presents diverse healthcare and socio-political contexts leading to wide differences in NP scope of practice. For this reason, our findings should be generalised with caution. No date restriction was applied, as older studies were included to capture this evolving field and account for countries being at different stages of advanced practice implementation. Nearly one-third of the studies were rated as low quality according to the MMAT, and one-fifth lacked sufficient data for interpretation. These limitations highlight the need for robust, high-quality studies meeting international standards to better assess the impact of NPs.

Conclusion

This systematic review synthesised evidence on NPs’ impact in primary care and for patients with chronic diseases, particularly in underserved or remote areas. Findings suggest NPs may improve access to care, notably through greater representation in rural areas and involvement with vulnerable populations. Studies also indicate slightly higher patient satisfaction with NPs, possibly linked to longer consultations and greater emphasis on education.

Regarding quality of care, results vary, but some studies suggest comparable outcomes between NPs and GPs, particularly in clinical and biological parameters. The best outcomes were generally reported in collaborative settings where NPs worked alongside GPs. While these models may be beneficial, they can also involve higher healthcare costs.

Given the variability in study designs and healthcare contexts, further research is needed to better define NPs’ contributions and optimise care integration.

Funding Statement

Action de Santé Libérale en Equipe (ASALEE).

Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.