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.

( 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.

The purpose of this study is to explore attitudes and beliefs that affect decisions about prescribing and administering pain medications in older adults who live in long-term care (LTC), with a particular emphasis on those with cognitive impairment. At each of the four participating LTC facilities, data were gathered from three separate groups of health care professionals: physicians, registered nurses, and registered practical nurses. Based on grounded theory, a model was developed that highlighted critical decision points for nurses and physicians regarding pain management. The major themes that emerged from the data concerned pain assessment (lack of recognition of pain, uncertainty about the accuracy of pain assessment and diagnosis) and treatment (reluctance to use opioids, working to individualize pain treatments, issues relating to physician trust of the nurse on prescribing patterns). These findings may facilitate the development of innovative approaches to pain management in LTC settings.

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