ObjectiveTo determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care.DesignA systematic review of randomised controlled trials reported since 1980.Data sources10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites.Included studiesRandomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes.Results11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: −€6.41; 95% CI −€9.28 to −€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly.ConclusionsNurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.

sangster‐gormley e., martin‐misener r., downe‐wamboldt b. & dicenso a. (2011) Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. Journal of Advanced Nursing67(6), 1178–1190. Abstract Aim.  To review the literature about the Canadian experience with nurse practitioner role implementation and identify influencing factors. Background.  Although nurse practitioners have been in existence for more than 40 years, their integration into healthcare systems has been challenging. While frameworks exist to guide implementation of these roles, clear identification of factors influencing role implementation may inform best practices. Given that Canada has witnessed considerable growth in nurse practitioner positions in the past decade, an exploration of its experience with role implementation is timely. Data sources.  A review of Canadian literature from 1997 to 2010 was conducted. Electronic databases including CINAHL, Cochrane Database of Systematic Reviews, Health Source: Nursing Academic Edition, Medline, Social Science Index, PubMed, Web of Science and PsychINFO and government and professional organization websites were searched. Methods.  An integrative review was performed guided by Whittemore and Knafl’s method. Results.  Ten published studies and two provincial reports were included. Numerous facilitators and barriers to implementation were identified and analysed for themes. Three concepts influencing implementation emerged: involvement, acceptance and intention. Involvement is defined as stakeholders actively participating in the early stages of implementation. Acceptance is recognition and willingness to work with nurse practitioner. Intention relates to how the role is defined. Conclusion.  This integrative review revealed three factors that influence nurse practitioner role implementation in Canada: involvement, acceptance and intention. Strategies to enhance these factors may inform best practice role implementation processes.

( 2 0 1 3 ) A systematic review of the effectiveness of advanced practice nurses in longterm care. Journal of Advanced Nursing 69(10), 2148-2161. doi: 10.1111/ jan.12140 AbstractAim. To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings. Background. Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted. Design. Quantitative systematic review. Data sources. Twelve electronic databases were searched ; leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group. Review methods. Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria. Results. Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services. Conclusion. Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.

There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed.

Objective:to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universal health coverage and universal access to health. Method:we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health. Results:given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universal health coverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation. Conclusions:given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries.