Clinical and economic outcomes of nurse-led services in the ambulatory care setting: A systematic review

https://doi.org/10.1016/j.ijnurstu.2018.02.002Get rights and content

Abstract

Background

With the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led services have been suggested as one solution to manage increasing demand on the health system as they aim to reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction.

Objectives

The aims of this review were to assess the clinical effectiveness, economic outcomes and key implementation characteristics of nurse-led services in the ambulatory care setting.

Design

A systematic review was conducted using the standard Cochrane Collaboration methodology and was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Data sources

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library, MEDLINE EBSCO, CINAHL EBSCO, and PsycINFO Ovid (from inception to April 2016).

Review methods

Data were extracted and appraisal undertaken. We included randomised controlled trials; quasi-randomised controlled trials; controlled and non-controlled before-and-after studies that compared the effects of nurse-led services in the ambulatory or community care setting with an alternative model of care or standard care.

Results

Twenty-five studies of 180,308 participants were included in this review. Of the 16 studies that measured and reported on health-related quality of life outcomes, the majority of studies (n = 13) reported equivocal outcomes; with three studies demonstrating superior outcomes and one demonstrating inferior outcomes in comparison with physician-led and standard care. Nurse-led care demonstrated either equivalent or better outcomes for a number of outcomes including symptom burden, self-management and behavioural outcomes, disease-specific indicators, satisfaction and perception of quality of life, and health service use. Benefits of nurse-led services remain inconclusive in terms of economic outcomes.

Conclusions

Nurse-led care is a safe and feasible model of care for consideration across a number of ambulatory care settings. With appropriate training and support provided, nurse-led care is able to produce at least equivocal outcomes or at times better outcomes in terms of health-related quality of life compared to physician-led care or standard care for managing chronic conditions. There is a lack of high quality economic evaluations for nurse-led services, which is essential for guiding the decision making of health policy makers. Key factors such as education and qualification of the nurse; self-management support; resources available for the nurse; prescribing capabilities; and evaluation using appropriate outcome should be carefully considered for future planning of nurse-led services.

Section snippets

What is already known about the topic?

  • Previous systematic reviews showed the effects of nurse-led care were comparable to physician-led care in several settings.

  • However, majority of these systematic reviews focussed on single specialty settings, were conducted over 10 years ago, and did not provide a detailed synthesis of economic and process outcomes.

What this paper adds

  • This paper provides an updated systematic review of the literature, confirming that nurse-led care produce equivalent or better outcomes compared to physician-led/standard care in managing chronic conditions in the ambulatory care setting.

  • This paper also suggests a number of important process outcomes such as education and qualification of the nurse; self-management support; resources available for the nurse; and prescribing capabilities. These factors should be carefully considered for future

Background

With the increasing burden of chronic and age-related diseases, and the rapidly increasing number of patients receiving ambulatory or outpatient-based care, nurse-led clinics or services have been suggested as one solution to manage increasing demand on the health system as they may reduce waiting times, resources, and costs while maintaining patient safety and enhancing satisfaction (Barkauskas et al., 2011, Bergman et al., 2013). Nurse-led services developed as an advanced practice role for

Aims

The primary aim of this review was to assess the clinical effectiveness of nurse-led services in the ambulatory or community care setting. The secondary aims of this review were to examine the economic outcomes and to characterize the nurse-led services by describing (i) the training and qualification requirements of the nurses; (ii) whether self-management support was a component of the nurse-led intervention; (iii) whether the interventions were delivered by nurse practitioners. These three

Methods

This systematic review was prepared in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was prospectively registered in PROSPERO (ID 42016036924).

Search results

A total of 2863 titles were identified from the initial search. After removing duplicates and screening titles and abstracts, 60 full text articles were retrieved and assessed for eligibility. Of these 60 articles, 25 studies met the inclusion criteria and were included in this review (Fig. 1, PRISMA flow diagram).

Characteristics of the included studies

The 25 included studies involved 180,308 participants and examined nurse-led services in a wide range of conditions and care settings caring for adult patients with heart failure and

Discussion

To the best of our knowledge, this systematic review is the largest review examining the effects of a nurse-led model of care in the ambulatory setting, including 25 original research studies of 180,308 participants. While several reviews exist in the literature (Schadewaldt and Schultz, 2011, Laurant et al., 2005, Latour et al., 2007), this review specifically focussed on studies that examined models of care where registered nurses have the primary responsibilities of care over the patient’s

Conclusions

Nurse-led care is a safe and feasible model of care for consideration across a number of settings. With appropriate training and support provided, nurse-led care is able to produce at least equivocal outcomes in terms of patient HRQoL, symptom burden, self-management and disease-specific clinical targets compared to physician-led care for managing chronic conditions. The strategic expansion of community-based nurse-led services has the potential to transform chronic illness care, creating a

Acknowledgements

The Office of the Chief Nursing and Midwifery Officer, Division of Clinical Excellence, Queensland Health, Australia provided funding for this project.

References (50)

  • K. Bergman et al.

    Patients’ satisfaction with the care offered by advanced practice nurses: a new role in Swedish primary care

    Int. J. Nurs. Pract.

    (2013)
  • M.B. Blank et al.

    A randomized trial of a nursing intervention for HIV disease management among persons with serious mental illness

    Psychiatric Serv. (Washington, DC)

    (2011)
  • S. Borbasi et al.

    Report of an evaluation of a nurse-led dementia outreach service for people with the behavioural and psychological symptoms of dementia living in residential aged care facilities

    Persp. Pub. Health

    (2011)
  • M. Buszewicz et al.

    Practice nurse-led proactive care for chronic depression in primary care: a randomised controlled trial

    Br. J. Psychiatry

    (2016)
  • D. Chan et al.

    A randomised controlled trial of structured nurse-led outpatient clinic follow-up for dyspeptic patients after direct access gastroscopy

    BMC Gastroenterol.

    (2009)
  • M. Chiarella

    Discussion Paper: New and Emerging Nurse-Led Models of Primary Healthcare

    (2008)
  • S.K.Y. Chow et al.

    Health-related quality of life in patients undergoing peritoneal dialysis: effects of a nurse-led case management programme

    J. Adv. Nurs.

    (2010)
  • P. Craig et al.

    Developing and evaluating complex interventions: the new Medical Research Council guidance

    BMJ

    (2008)
  • S. Craig

    Does nurse-led pre-operative assessment reduce the cancellation rate of elective surgical in-patient procedures? A systematic review of the research literature

    Br. J. Anaesth. Recov. Nurs.

    (2005)
  • B.H. Cuthbertson et al.

    The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

    BMJ

    (2009)
  • A.T.M. Dierick-van Daele et al.

    Nurse practitioners substituting for general practitioners: randomized controlled trial

    J. Adv. Nurs.

    (2009)
  • J. Fong et al.

    Nurse practitioner prescribing: an international perspective

    Nurs. Res. Rev.

    (2015)
  • D.M. Foreman et al.

    Nurse-delivered and doctor-delivered care in an attention deficit hyperactivity disorder follow-up clinic: a comparative study using propensity score matching

    J. Adv. Nurs.

    (2011)
  • R. Hatchett

    Nurse-led clinics: 10 essential steps to setting up a service

    Nurs. Times

    (2008)
  • R.A. Hernández et al.

    Economic evaluation of nurse-led intensive care follow-up programmes compared with standard care: the PRaCTICaL trial

    Eur. J. Health Econ.: HEPAC: Health Econ. Prev. Care

    (2014)
  • Cited by (38)

    • Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery

      2023, Seminars in Arthritis and Rheumatism
      Citation Excerpt :

      It was suggested that patients followed in NLC might use more visits to specialists, general practice physicians (GPs), and the emergency department (ED), and have more hospitalizations if this model of healthcare delivery did not address patients’ needs for care [19,21,22]. While in randomized control trial settings, NLC for patients with RA was not associated with increases in healthcare resource utilization; published literature lacks reports on the resource utilization observed in these types of models of care delivery in routine practice [23,24]. To address this gap, we assessed the observed resource utilization and the associated direct healthcare costs in stable patients with RA followed in the NLC and RLC models.

    • Patient Satisfaction With a Nurse Practitioner–Led Heart Failure Clinic

      2023, Journal for Nurse Practitioners
      Citation Excerpt :

      Evaluations of patient satisfaction with care provided by NPs show consistently high ratings of patient satisfaction (9 or higher on a 10-point scale), often exceeding the ratings given for care delivered by physicians.4,5 Most studies have reported satisfaction in primary care settings6-8 with fewer satisfaction ratings reported in specialty practices such as HF clinics.9 HF is a complex and time-consuming disease process to manage for health care providers.

    • Nursing Leaders as Visionaries and Enablers of Action

      2023, Seminars in Oncology Nursing
      Citation Excerpt :

      Next to direct patient care, nurses are daily demonstrating leadership in their own personal development,42 building and maintaining relationships in professional and patient networks, planning and managing resources, critically thinking and evaluating, applying knowledge and evidence to drive innovation in cancer care, involved in critical decision-making, ensuring occupational and patient safety, and improving the overall quality of cancer care delivery. Clinical nurses can, through their leadership, promote best practice and facilitate the incorporation of evidence-based guidelines and standards into policies and procedures,38 facilitate process improvement initiatives to improve economic outcomes, and affect quality metrics and the patient experience.43 In the current and future decade of increasingly complex cancer care, we need to move forward to connect clinical leadership with all leadership and management disciplines.

    View all citing articles on Scopus
    View full text