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Table 2 Characteristics of the systematic reviews (n = 11)

From: An overview of systematic reviews on the collaboration between physicians and nurses and the impact on patient outcomes: what can we learn in primary care?

Author, country, year Objectives Design Patient population + setting (Patient) Outcomes Results/Conclusions Quality assessment
1. Allen et al., Australia, 2014 To locate and synthesise research using randomized control trial designs on quality of outcomes following transitional care interventions compared with standard hospital discharge for older people with chronic illnesses.
To make recommendations for research and practice.
Systematic review.
12 quantitative studies included:
- 12 randomized controlled trials
- Older patients diagnosed with chronic illnesses
- Transition from acute hospital care to (nursing) home
- Length of hospital stay
- Length of time till re- hospitalization
- Length of re- hospitalization
- Costs
- Functional status
- Depression
- Patient satisfaction
- Quality of life
- General practitioner (GP) satisfaction
Collaboration between nurses and physicians in the ‘Discharge protocol and advanced practice nurse’ intervention:
- Delay in re- hospitalization.
- Fewer days of re- hospitalization.
- Fewer days of hospitalization.
- Lower costs.
- No significant difference in functional status, depression or patient satisfaction.
Collaboration between nurses and physicians in the ‘General practitioner and primary care nurse models’ intervention:
- Mixed results for (re- )hospitalization.
- Higher patient satisfaction.
- Improved referral to community services.
- Higher GP satisfaction.
- Faster discharge communication to GPs.
General practitioner and practice nurse interventions were not effective in the reduction of hospitalization rates or length of stay.
Low response rate of general practitioners makes interpretation of the results difficult.
2. Aubin et al., Canada, 2012 To describe and classify the various interventions studied in the literature to improve continuity of care in the follow- up of patients with cancer.
To determine the effectiveness of interventions aiming to improve continuity of cancer care, on patient, healthcare provider and process outcomes.
Systematic review and meta- analysis.
51 quantitative studies included:
- 49 randomized controlled trials
- 2 controlled clinical trials
(5 studies had a multi- disciplinary approach as intervention)
- Patients (65 years and older) with a cancer diagnosis
- Patients admitted to the hospital with a terminal prognosis of 2 weeks to 6 months
- Patients diagnosed with cancer and receiving Medical oncology outpatient clinic
- Hospital setting
Patient outcomes:
- Quality of life
- Functional status
- Physical performance
- Pain
- Depression
- Anxiety
- Satisfaction
- Survival
- Emotional adjustment
- Cognitive functioning
Informal caregiver outcomes
Process outcomes
Three out of the five studies assessing interdisciplinary team models of care reported significant improvements in one or more classes of patient health- related outcomes during the study follow- up period.
Patients supported by the multidisciplinary specialist
Palliative Care Team had:
- Significant improvements in scores of symptom severity.
- A significantly better mood and were less bothered by emotional problems.
- Significantly better quality of life scores at one and four weeks of follow- up, compared to patients assigned to the control group.
Based on the median effect size estimates and the 95% CI, no significant difference in patient health measures was found. According to the descriptive analysis of single interventions on the improvement of patient health- related outcomes, case management and interdisciplinary teams seemed to be the most favourable models of care to improve one or more classes of patient outcomes.
3. Health Quality Ontario, Ontario, 2013 To determine the effectiveness of specialized nurses who have a clinical role in patient care in optimizing chronic disease management among adults in the primary health care setting. An evidence based analysis.
6 quantitative studies included:
- 6 randomized controlled trials
(8 papers)
- Patients with a chronic disease(s)/type 2 diabetes/asthma/hypertension/dementia/chronic obstructive pulmonary disease (COPD)/cancer/coronary artery disease (CAD)/congestive heart failure (CHF)
- Primary health care setting
- General internal medicine clinic
- Hospitalizations
- Length of stay
- Mortality
- Emergency department visits
- Specialist visits
- Health- related quality of life (HRQOL)
- Patient satisfaction
- Disease- specific measures
- Process measures
- Examination or medication prescribing
- Health- system efficiencies
- Number and length of primary health care visits
- Physician workload
Specialized nurses working with physicians showed a general increase in process measures related to clinical examinations and medication management based on guidelines.
- Significant reduction in HbA1c among diabetes patients.
- Significant increase in the proportion of CAD patients with controlled BP and total cholesterol.
- Significant reduction in hospitalization after 1 year for CAD patients receiving secondary prevention.
- More patient satisfaction with care provided by the nurse plus physician intervention.
- Inconsistency regarding outcomes related to HRQOL.
No outcomes indicated specialized nursing interventions to be more harmful than physicians alone.
Unclear role of the specialized nurse, making it difficult to determine the impact on efficiency. More research is needed to better understand the impact of specialized nurses on primary health care efficiency.
4. Health Quality Ontario, Ontario, 2014 To systematically review team- based models of care for end- of- life service delivery, to determine whether an optimal model exists. Systematic review and meta- analysis.
12 quantitative studies included:
- 2 systematic reviews
- 10 randomized controlled trials
- Patients (adults) with advanced diseases (cancer, dementia, organ failure, stroke, chronic heart failure) receiving end of life care.
- Home care - Hospital care
- Patient quality of life
- Symptom management
- Patient satisfaction
- Informal caregiver satisfaction
- Health care provider satisfaction
- (Nursing) home death
- Advance care planning
- Emergency department visits
- Hospital/ intensive care admission
- Hospital length of stay
The review considered the core model components of team membership, services offered, mode of patient contact, and setting.
Team membership includes at minimum a physician and nurse, one of who is specialized in end- of- life health care.
Team services included: symptom management, psychosocial care, and development of patient care plans, end- of- life care planning, and coordination of care.
Comprehensive team- based model: moderate- quality evidence that a comprehensive team- based model with direct patient contact significantly:
- Improves patient QOL, symptom management and patient and informal caregiver satisfaction.
- Increases the patient’s likelihood of dying at home.
- Decreases the patient’s likelihood of dying in a nursing home.
- Has no impact on hospital admissions or hospital length of stay.
Hospital team- based model: no impact on length of hospital stay, significant reduction of ICU admissions.
Home team- based model: significantly increases patient satisfaction, increases the patient’s likelihood of dying at home and significantly decreases emergency department visits and hospital admissions.
Findings are applicable to deliver care to people with an estimated survival of up to 24 months.
5. Martin et al., Switzerland, 2010 To provide an overview of the evidence base for inter- professional collaboration and new models of care in relation to patient outcomes. A qualitative synthesis.
14 quantitative studies included:
- 14 randomized controlled trials
Elderly with: - acute/chronic diseases - risk factors
- Patients after stroke
- Patients with hip fracture/type 2 diabetes/Alzheimer disease/ chronic heart failure/multi- morbidity/problems in cognition, activities of daily living (ADL)
- Children with asthma
- Patients with bipolar disease/depression
- Primary care
- Hospital setting
- Outpatient clinic
- Mortality
- Clinical outcomes
- Functional outcomes
- Social outcomes
- Utilisation of medical services
- Patient- reported outcomes: QOL, ADL and satisfaction with care.
Mixed results were reported regarding:
- Mortality.
- Physical, emotional and social functioning.
- Utilisation of medical services.
- Hospitalization rates and length of hospital stay.
Patient reported outcomes: significantly higher score of self- perceived health and life satisfaction.
Mixed results regarding activities of daily living.
Four studies showed that participants who experienced collaborative care management models were significantly more satisfied with their care than usual- care recipients.
The evidence base of inter- professional collaboration shows promising results in relation to patient outcomes.
6. Newhouse et al., USA, 2011 Compared to other providers (physicians or teams without advanced practice registered nurses (APRN)), are APRN patient outcomes of care similar? Systematic review.
69 quantitative studies included:
- 20 randomized controlled trials (RCTs)
- 49 observational studies
- Pregnant women
- Neonates
- New- borns
- Children
- Adults
- Elderly
- Community
- Primary care
- Inpatient
- Nursing home
- Ambulatory
- Surgery
- Prenatal- inpatient
- Hospital
- Patient satisfaction
- Self- reported perceived health
- Functional status
- Glucose control
- Lipid control
- Blood pressure (BP)
- Emergency department/urgent care visits
- Hospitalization
- Duration of mechanical ventilation
- Length of stay
- Mortality
- Cost
- Complication
37 studies examined patient outcomes of care by nurse practitioners (NP care group) compared with care management exclusively by physicians.
- High level of evidence to support equivalent levels of patient satisfaction, self- reported perceived health, functional status outcomes, glucose control and BP control.
- High level of evidence to support equivalent rates of emergency department visits, hospitalization and mortality.
- High level of evidence to support better serum lipid levels.
- Moderate level of evidence to support equivalent length of stay.
11 studies examined clinical nurse specialist (CNS) outcomes.
- High level of evidence to support equivalent patient satisfaction scores.
- High level of evidence to support equivalent or lower length of stay for patients cared for in the CNS group.
- High level of evidence to support the CNS group has a lower cost of care
High level of evidence that APRNs provide safe, effective quality care to a number of specific populations in a variety of settings. APRNs have a significant role in the promotion of health in partnership with physicians and other providers,
7. Renders et al., Amsterdam, 2000 To determine the effectiveness of different interventions, targeted at health care professionals or the structure in which health care professionals deliver their care, to improve the care for patients with diabetes in primary care, outpatient and community settings. Systematic review.
41 quantitative studies included:
- 27 randomized controlled trials
- 12 controlled before and after studies
- 2 interrupted time series
- Non- hospitalised patients with Type 1 or Type 2 diabetes mellitus.
- A primary care setting
- Outpatient (ambulatory care) setting - Community setting (managed care organisations, general medical clinics)
- Glycaemic control
- Micro- or macro- vascular complications
- Cardiovascular risk factors
- Hospital admissions
- Mortality
- Well- being
- Perceived health
- Quality of life
- Functional status
- Patient satisfaction
The addition of patient education or a more enhanced role of a nurse to a complex intervention strategy seems to be important to improve patient outcomes besides process outcomes.
Nurses can play an important role in facilitating compliance or giving patient education. They can even replace physicians in delivering many aspects of diabetes care, if detailed management protocols are available, or if they receive training.
The seven studies in which nurses replaced (partly) physicians in providing diabetes care generally demonstrated a positive impact on glycaemic control.
The effectiveness of the implementation of revision of professional roles as a single intervention remains unclear.
8. Shaw et al., USA, 2014 To synthesize the current literature describing the effects of nurse- managed protocols, including medication adjustment, for the outpatient management of adults with common chronic conditions, namely diabetes, hypertension and hyperlipidaemia. Systematic review and meta- analysis.
18 quantitative studies included:
- 16 randomized controlled trials
- 2 controlled before- and- after studies.
(2 companion articles-methods or follow- up)
- Adults with elevated cardiovascular risk
- General medical hospital
- Specialty hospital
- Primary care clinic
- Telephone delivered care
- Haemoglobin A1c level
- BP
- Cholesterol level
- Performance measure
- Behavioural adherence (medication)
- Protocol adherence
The ‘medical home’ is a team approach which may involve nurse- managed protocols.
Nurse- managed protocols were associated with:
- A highly variable mean decrease in HbA1c level.
- A mean decrease in systolic and diastolic BP.
- A mean decrease in total and low- density lipoprotein (LDL) cholesterol levels.
Nurse- managed protocols were statistically significantly more likely to achieve target total cholesterol levels than control protocols.
Effects of lifestyle changes and medication adherence showed an overall pattern of small positive effects associated with nurse- managed protocols.
Adherence to protocol: pharmacologic therapy was started or doses were increased by nurses following treatment protocols more often than in usual care groups.
Team approaches using nurse- managed protocols help improve health outcomes among patients with moderately severe diabetes, hypertension and hyperlipidemia.
9. Smith et al., England, 2014 To review the current literature on the participation and roles of APRNs/ Physician assistants (PAs) in providing cancer screening and prevention recommendations in primary care settings in the USA. Systematic review.
15 quantitative studies included:
- 3 intervention studies
- 12 observational studies
- Adults
- Pregnant women
- Primary care settings
- Private practices
- Primary care health centres
- Study hospitals
- Obstetric clinic
- Hospital ambulatory settings
7 studies reported outcomes on screening for - Cervical cancer (Pap test)
- Breast cancer (Mammogram)
- Colorectal cancer
10 studies reported outcomes on cancer prevention recommendations for
- smoking cessation
- diet
- physical activity
Cervical cancer screening:
- Physicians who work in teams that include NPs and PAs are more supportive of NPs and PAs performing Pap tests than physicians who do not practice in provider teams that include NPs and PAs.
- The annual rate of women screened for cervical cancer by a NP increased significantly at the intervention location.
Breast cancer screening:
- 69- 91% of the patients who see NPs receive mammograms.
- NPs recommend a similar number of mammograms as physicians.
- The annual rate of mammography screening increased more among women seen at the NP screening recommendation site.
Colorectal cancer screening:
- Findings about APRN/PAs involvement in colorectal screening are mixed.
- 2 studies showed physicians reporting more colorectal cancer screening than APRN/PAs.
Smoking cessation recommendations:
- Both physicians and APRN/PAs report frequently providing smoking cessation recommendations.
- Patients are more likely to receive recommendations for smoking cessation during visits with NPs than during visits without NPs.
Diet and physical activity recommendations:
APRN/PAs do not frequently provide recommendations on diet and physical activity (12–52%), they do provide more recommendations than their physician counterparts (3–15%).
10. Snaterse et al., The Netherlands, 2016 To systematically review the available evidence on the efficacy of nurse- coordinated care (NCC) in secondary prevention of coronary heart diseases. Systematic review and meta- analysis.
18 quantitative studies included:
- 18 randomized controlled trials
- Patients with coronary heart diseases (adults)
- Hospital setting
- Outpatient clinics
- Community health clinic
- Secondary prevention unit
- General practices
30 NCC outcomes were measured. Observed outcomes were grouped into four categories:
- Risk factor levels
- Clinical events
- Patient perceived health
- Guideline adherence
NCC programs were grouped into three strategies:
- Risk factor management: education, lipid/BP control, advice on healthy diet and encouraging physical activity, prescription and or titration of drug therapy, enhancing adherence and smoking cessation counselling.
- Multidisciplinary consultation: involvement of multidisciplinary team (>2 disciplines), consultation with general practitioner, referral to specialized disciplines.
- Shared decision- making: personalized action plan, goal setting for cardiac risk factor control and family support.
Effective components regarding behavioural interventions were goal setting for cardiac risk factor control plus identification of barriers.
8 Trials found positive outcomes for NCC compared with usual care:
- Risk factor levels: total cholesterol, LDL cholesterol, triglyceride, pharmacological treatment, BP, diet, SCORE (a comprehensive cardiovascular risk algorithm designed for the primary prevention setting) and smoking cessation.
- Clinical events: all- cause and cardiovascular readmission (days).
- Guideline adherence.
11. Stalpers et al., The Netherlands, 2015 To systematically review the literature and to provide an overview of associations between characteristics of the nurse work environment (e.g., nurse staffing, nurse- physician collaboration) and five nurse- sensitive patient outcomes (i.e., delirium, malnutrition, pain, patient falls and pressure ulcers). Systematic review.
29 quantitative studies included:
- 1 randomized controlled trial
- 28 observational studies
- Hospitalized patients
- Hospital setting: surgical/general/emergency/intensive care/obstetric/cardiology/cardiothoracic surgery/respiratory units.
Nurse- sensitive outcomes:
- 12 studies examined pressure ulcers.
- 11 studies examined patient falls.
- 6 studies analysed both pressure ulcers and patient falls among which one also elaborated on pain management.
Patient falls:
- Collaborative nurse- physician relationships: 2/3 studies reported significant associations. Specifically, positively appreciated communication was associated with fewer adverse events and lower number of patient falls.
Pressure ulcers:
- Collaborative nurse- physician relationships: positively appreciated communication was associated with a lower number of pressure ulcers. Another study did not find significant associations.