Table 3 Literature Review Table – Description of Patient Outcomes and Study Results
From: Effectiveness of registered nurses on patient outcomes in primary care: a systematic review
Author, Year, Country | Description of Outcome | Results |
|---|---|---|
Biomarkers | ||
Aubert et al., 1998 [43] USA | Changes in HbA1c value and other clinical markers related to diabetes management (fasting blood glucose, medication type and dose, body weight, blood pressure, lipid levels) after 12 months | The intervention group had a greater decrease in HbA1c values than did the usual care group. The average change in HbA1c value was -1.7 percentage points in the intervention group and -0.6 percentage points in the usual care group (difference -1.1, 95% CI: -1.62 to 0.58; p < 0.001). Patients in the intervention group had a greater decrease in fasting blood glucose than the usual care group (-48.3 mg/dL v. -14.5 mg/dL; difference -33.8, 95% CI: -56.12 to 11.48; p = 0.003); however, other measures were not significant The results show that a RN case manager, in association with primary care physicians and an endocrinologist, can help improve glycemic control in diabetic patients in a group-model health maintenance organization |
Bellary et al., 2008 [44] UK | Changes in type 2 diabetes health markers (blood pressure, total cholesterol, HbA1c) after 2 years Changes in waist circumference, BMI, microalbuminuria, plasma creatinine, Framingham CHD risk after 2 years | The study produced only modest clinical outcomes when comparing the two groups in diastolic blood pressure (-1.91, 95% CI: -2.88 to -0.94 mm Hg; p = 0.0001) and mean arterial pressure (1.36, 95% CI: -2.49 to -0.23 mm Hg; p = 0.018); other outcomes (total cholesterol, systolic blood pressure, HbA1c) were not significant across the two groups. Across both arms of the study over the 2-year period, systolic and diastolic blood pressure decreased significantly and there was a small, but non-significant, reduction in HbA1c (-0.04%, 95% CI: -0.04 to -0.13; p = 0.29). There were no significant differences between groups for waist circumference, microalbuminuria, plasma creatinine or CHD risk score. BMI was significantly increased in the intervention group (p < 0.0001) Evidence suggests that intensive PN-led management can improve outcomes in type 2 diabetes, although this requires further development |
Coppell et al., 2017 [50] New Zealand | Between-group changes to diabetes health markers (weight, HbA1c, waist circumference, BMI, blood pressure, lipids, urate, liver enzymes) after 6 months | The intervention group lost a mean 1.3 kg, while the control group gained 0.8 kg (2.2 kg difference; p < 0.001). Mean HbA1c, BMI, and waist circumference decreased in the intervention group and increased in the control group at 6 months, but differences were not statistically significant after 2 years. Implementation fidelity was high and the intervention was considered feasible to implement in busy general practice settings |
Harris et al., 2015 [59] UK | Changes in patient BMI and fat mass at 3-month follow-up | There were no between-group differences in change to BMI (0.001 kg/m2, 95% CI: -0.17 to 0.18, p = 0.98) or fat mass (0.39 kg, 95% CI: -0.85 to 0.07; p = 0.10) at 3 months |
Harris et al., 2017 [60] UK | Changes in patient fat mass, BMI and waist circumference at 3- and 12-month follow-up | Fat mass was slightly reduced at 12 months in both intervention groups, but these differences did not differ significantly when the nurse group was compared to both postal intervention (p = 0.54) and usual care (p = 0.30). There was no change in BMI or waist circumference |
Karnon et al., 2013 [47] Australia | Weight loss as defined by changes in BMI and weight, as well as reduction of obesity-related complications | Relative to low level involvement of practice nurses in the provision of clinical-based activities to obese patients, high level involvement was associated with significantly larger mean reductions in BMI (mean difference -1.10, CI: -0.45 to -1.75; p = 0.001) after 1 year, and non-significant improvements with respect to patients losing any, 5 and 10% of their baseline weight (p = 0.259) |
Marshall et al., 2011 [51] New Zealand | Changes to blood pressure, weight, BMI, HbA1c, waist circumference, and cardiovascular risk between patient’s first and last visit | No significant changes in average blood pressure, weight, BMI, HbA1c, waist circumference and cardiovascular risk assessment were detected between baseline and follow-up visits |
O’Neill et al., 2014 [48] USA | Changes in blood pressure between index and next consecutive visit | Patients receiving CPS-directed RN case management had greater decreases in systolic blood pressure (-14 mm Hg) than those receiving physician-directed RN management (-10 mm Hg) (p = 0.04). After adjusting for time between visits, blood pressure, and prior stroke, there was no significant effect for provider type on systolic blood pressure change (p=0.24). There were no significant changes in diastolic blood pressure between groups. CPS-directed and physician-directed RN case management for hypertension demonstrated similar effects on blood pressure reduction, supporting an expanded role for CPS-RN teams |
Pine et al., 1997 [49] USA | Changes in total cholesterol levels from first to final nurse visit (pre-post study) | Mean total cholesterol level decreased by 0.29 mmol/L (11.2 mg/dL) (4.3%) from the physician visit to the first nurse visit (p < 0.001) and 0.14 mmol/L (5.4 mg/dL) (2.1%) from the first nurse visit to the final nurse visit (p = 0.4). |
Differences in total cholesterol levels between intervention and comparison groups (matching study) | The mean total cholesterol level of all patients improved significantly (p = 0.002). However, the improvement in intervention patients was no better than that of comparison patients | |
Waterfield et al., 2021 [58] UK | Strength of pelvic floor muscle contraction | After 3 months, there was an increase in strength in both intervention groups compared with controls, with a median difference of 3.0 cmH20 higher for the primary care nurse group compared to the control group (95% CI: 0.3 to 6.0; p = 0.02), and 4.3 cmH20 for the urogynecology specialist group compared to the control group (95% CI: 1.0 to 7.3; p < 0.01). There was no difference between the primary care nurse and urogynecology nurse specialist groups (1.3; 95% CI: -2.0 to 4.7; p = 0.70) |
Endurance of pelvic floor muscle contraction | There was an overall significant difference in endurance over the three groups at the end of the study (p < 0.001). Endurance of contraction for both of the intervention groups increased, while there was a slight decline for the controls from baseline endurance levels. Both the primary care nurse group and the urogynecology nurse specialist group had a significant increase in endurance compared to the control group at 3 months (p = 0.009 and p = 0.008, respectively) | |
Patient-Reported Experience Measures (PREMs) | ||
Caldow et al., 2006 [64] UK | Patient satisfaction with, opinion of, and preference for PN v. doctor consultation in primary care derived from questionnaire responses | Women, younger people, and those who had a lower level of education were significantly less satisfied with the time spent if they had seen a GP compared with a PN (p < 0.05). Patients reported more satisfaction in this area in practices where the PN had an extended role (p < 0.001) Women and younger people had a significantly higher positive attitude towards, and perception of, PNs than did men and older people, respectively (p < 0001), and thought that a PN would know their family history as well as a GP would (p < 0.05). Younger and less well educated people perceived that a PN would know their medical condition (p < 0.001) as well as a GP would. The main perceived differences between GPs and PNs was academic ability and qualifications. This suggests that if PNs take on more roles that were previously only within GP scope of practice, patients would accept them, particularly if they receive information about nurse capabilities |
Cherkin et al., 1996 [57] USA | Patient satisfaction evaluated based on 5 dimensions of subjects’ perceptions: perceived knowledge, worry, control, symptoms, and evaluation of care | The nurse intervention resulted in higher patient satisfaction than usual care (p < 0.05) and higher perceived knowledge (p < 0.001). There were no significant differences among the three groups in worry or symptoms at any follow-up interval and differences in knowledge were no longer significant at the 52-week follow-up |
Desborough et al., 2016 [62] Australia | Patient scores on the Patient Enablement and Satisfaction Survey regarding nurse-led consultations | The median total satisfaction score was 63, indicating that patients were either satisfied or very satisfied with nursing care. The median total patient enablement score was 2.25, indicating enablement levels of the same or less than the average, or that the questions were not applicable. Patients who had longer consultations were more satisfied (OR = 2.50, 95% CI: 1.43 to 4.35; p < 0.01) and more enabled (OR = 2.55, 95% CI: 1.45 to 4.50; p < 0.01) than those who had shorter consultations. Patients who had continuity of care (6 or more appointments) with the same nurse were more satisfied (OR = 2.31, 95% CI: 1.33 to 4.00; p = 0.01). Patients who attended practices where nurses worked with broad scopes of practice and high levels of autonomy were more satisfied (OR = 1.76, 95% CI: 1.09 to 2.82; p = 0.04) and more enabled (OR = 2.56, 95% CI: 1.40 to 4.68; p < 0.01). Patients who received care for the management of chronic conditions (OR = 2.64, 95% CI: 1.32 to 5.30; p < 0.01) were more enabled than those receiving preventive health care These results provide evidence of the importance of continuity of nursing care, adequate consultation time, and broad scopes of nursing practice and autonomy for patient satisfaction and enablement |
Faulkner et al., 2016 [55] UK | Patient satisfaction with initial consultations (how clear they found the advice received on pharmacotherapies, the usefulness of cessation advice received, and satisfaction with consultation as a whole) as assessed by self-report questionnaire | Patients in both groups gave positive evaluations of the support they received; 93.2% of patients who saw HCAs and 91.2% who saw nurses said they were ‘happy’ or ‘extremely happy’ with the consultations, and 89.5% and 84.5% of patients who saw HCAs and nurses, respectively, reported finding the advice they received ‘useful’ or ‘extremely useful’. There were no statistically significant differences in any aspect of patient satisfaction by provider type |
Gallagher et al., 1998 [65] UK | Patient satisfaction with nurse-led telephone advice as measured by a postal questionnaire | Most (n = 154; 88%) patients were very or fairly satisfied with nurse telephone advice. Only n = 10 (6%) were fairly or very dissatisfied |
Halcomb, Davies, & Salamonson, 2015 [63] New Zealand | Patient perceptions of PNs based on responses to a 64-item self-report survey tool containing the General Practice Nurse Satisfaction scale | Participants over 60 years and those of European descent were significantly less satisfied with the PN (p = 0.001); however, controlling for these characteristics, participants who had made < 4 visits to the PN were 1.34 times (95% CI: 1.06–1.70) more satisfied than the comparison group. The study also revealed a high level of satisfaction with PNs overall, with increased satisfaction associated with an increased number of visits Findings suggests that age, ethnicity and employment status were significant predictors of satisfaction levels, and that greater continuity with the PN (i.e., number of visits) strongly influences patient satisfaction with nursing services |
Halcomb, Salamonson, & Cook, 2015 [45] Australia | Patient satisfaction and comfort levels of chronic disease services, based on survey data measuring patient satisfaction with nurse encounters and comfort with nurse roles in general practice | Patient satisfaction with PN services was very high, with nearly two-thirds (n = 51; 63%) of consumers giving the maximum score. However, no statistically significant group differences were detected between patient characteristics, number of visits to the nurse and satisfaction ratings Patient self-reported comfort was also high (median: 72, range: 18–90). Patients who consulted PNs for diabetes-related conditions were almost three times more comfortable (38% v. 14%, p = 0.016) with their encounter than those who consulted for other chronic health conditions |
Marshall et al., 2011 [51] New Zealand | Patient satisfaction with health and treatment as measured by a consultation satisfaction survey | Of the 424 patients who completed a survey, 91% indicated they agreed or strongly agreed with the questions that stated a positive aspect of their care. Questions 3–5 specifically asked if health had improved as a result of attending clinics; 92% indicated that they agreed or strongly agreed. Ninety-four percent of patients had a better understanding of their diagnosis, medication and treatment plan, and were more motivated to self-manage |
Zwar et al., 2010 [56] Australia | Patient feedback on their satisfaction with the quality of smoking cessation support they received during a 6-month follow-up questionnaire | Of the 391 participants who responded to the patient satisfaction questionnaire, 385 (98%) rated the support provided as ‘helpful’ (19%) or ‘very helpful’ (79%). Less than 2% commented that the program could have been improved and all comments indicated that they may have been more successful if they had been able to have more sessions with the RN |
Patient-Reported Outcome Measures (PROMs) | ||
Aubert et al., 1998 [43] | Episodes of severe hypoglycemia; emergency room and hospital admissions | There were no statistically significant differences between nurse case management groups and usual care for adverse events |
Patient health-related quality of life as assessed by a questionnaire developed across four domains: 1) patient-perceived general health status, 2) patient-perceived physical dysfunction during the previous 30 days, 3) patient-perceived mental dysfunction during the pervious 30 days, and 4) patient-perceived functional incapacity during the previous 30 days for either mental or physical reasons | Both groups reported an improved perception of health status after 12 months, but patients in the nurse case management group were more than twice as likely to report improvement in health status score (mean change = 0.47) than the usual care group (mean change = 0.20) (difference=0.27; 95% CI: -0.03 to 0.57;p = 0.02) | |
Cherkin et al., 1996 [57] USA | Physical and social function as measured by a modified version of the Roland Disability Questionnaire, including questions that pertained to back and leg pain Disability as measured by an adaptation to the National Health and Interview Survey, which was implemented at 1, 3 and 7 weeks | There was no statistically significant increase in function or decreases in disability. The proportion of subjects reporting any days of limited activity, bed rest, or work loss resulting from their back pain was similar in all groups at each follow-up interval |
Harris et al., 2015 [59] UK | Changes to patient self-reported levels of depression, anxiety, and pain as measured by questionnaire responses at 3 and 12 months | There were no statistically significant between-group differences in mean scores of depression, anxiety, or pain at 3 or 12 months |
Falls, fractures, sprains, injuries, or any deterioration of health problems already present at 3 and 12 months | There were no between-group differences in number of adverse events at 3 or 12 months | |
Harris et al., 2017 [60] UK | Changes in patient self-report outcomes of anxiety, depression and pain at 3 and 12 months | The interventions had no significant effects on anxiety, depression, or pain scores |
Falls, injuries, fractures, cardiovascular events, and deaths at 3 and 12 months | Total adverse events did not differ between groups at 3 or 12 months, however, cardiovascular events over 12 months were lower in the intervention groups than in controls (p = 0.04) | |
Changes in patient-reported outcomes of exercise self-efficacy and quality of life at 3 and 12 months | Exercise self-efficacy significantly increased in both intervention groups at 3 months for postal group v. control group (ES = 1.1, 95% CI: 0.2 to 2.0; p = 0.01), nurse group versus control (ES = 2.3, 95% CI: 1.4 to 3.2; p < 0.001) and there was a greater effect in the nurse group compared with postal (ES = 1.2, 95% CI: 0.3 to 2.1; p = 0.01). By 12 months, there was a difference between only the nurse and control groups (ES = 1.2, 95% CI: 0.3 to 2.2, p = 0.01). The interventions had no significant effects on quality of life scores | |
Iles et al., 2014 [46] Australia | Patient quality of life measured by patient questionnaires at baseline (pre-intervention) and at 2 years, including a quality of life score using the EuroQol 5-Dimensions, scored with the Australian algorithm | Patient quality of life scores did not differ at baseline between RN-led groups (0.81 ± 0.18) and GP-led groups (0.81 ± 0.18). The quality of life score was inversely associated with MBS item charges (p < 0.001). On average, a 1% increase in the quality of life score resulted in a 44.5% decrease in MBS item charges |
Marshall et al., 2011 [51] New Zealand | Patient physical fitness, daily activity, social activity, social support, feelings, and quality of life, derived from the Dartmouth Primary Care and Cooperative charts and patient self-report survey data | Significant improvements were shown in survey results for social activity (mean difference = -0.20; p = 0.049), change in health (mean difference = -0.42; p = 0.001), and overall health (mean difference = -0.21; p = 0.025); there no changes were reported for quality of life |
Moher et al., 2001 [52] UK | Patient self-report quality of life, as measured by the Dartmouth Primary care and Cooperative charts and the EuroQol questionnaire | The study found no significant or clinically important difference between groups for any dimension of the Dartmouth Primary Care and Cooperative charts or for EuroQol scores |
Pearson et al., 2003 [61] USA | Changes in patient level of depression, overall physical and mental health, and the impact of depression on their work and productivity from baseline to 6-month follow-up | Significant differences between baseline and six months were seen in the major subscales of the Work Limitations Questionnaire: time demands: 66.5 to 84.2, physical demands: 84.1 to 91.3, mental demands: 63.7 to 83.6, interpersonal demands: 77.2 to 90.5, and work output: 67.7 to 85.3. Paired t-test results for the difference in mean scores at baseline and 6-month follow-up for the SF-12 (mean = 29.9 to 48.2), Hamilton Depression Rating Scale (mean = 14.6 to 6.5) and Work Limitations Questionnaire (mean = 70.4 to 87.2) were statistically significant at the 0.0001 level These results show a significant reduction in depression severity for patients treated by the nurse telecare program, with 63% experiencing at least 50% reduction in their score at the 6-month follow-up |
Health Behaviours | ||
Aveyard et al., 2007 [53] New Zealand | Confirmed sustained abstinence from smoking at 4, 12, 26, and 52 weeks after quit day | Of the participants in the basic and weekly arms, the quit % and the percentage difference was 22.4% v. 22.4% at 4 weeks (OR = 1.00; 95% CI: 0.74 to 1.37), 14.1% v. 11.4% at 12 weeks (OR = 0.79; 95% CI: 0.54 to 1.17), 10.7% v. 8.8% at 26 weeks (OR = 0.81; 95% CI: 0.52 to 1.25), and 7.7% v. 6.6% at 52 weeks (OR = 0.85; 95% CI: 0.51 to 1.41). There was no evidence that those in the weekly contact arm were more likely to quit, with point estimate of the quit rates favoring the basic support arm Absolute quit rates achieved are those expected from nicotine replacement therapy alone; neither of the support types were considered effective. PNs have a key role in providing support for smoking cessation, however, providing basic medication support is an adequate approach to achieve positive outcomes |
Patient reported use of nicotine replacement therapies at first telephone call and at each follow-up contact | Rates of nicotine replacement therapy use were high and did not differ between arms | |
Byers et al., 2018 [54] USA | Smoking status changes (i.e., whether patients reported themselves as smokers or non-smokers [former, quit, etc.]) at their last visit compared to their first visit | In GP-led visits, 18.2% (14 out of 77) patients who were reported as smokers during their first visit were reported as nonsmokers at their last visit, compared with 29.1% (41 out of 141) patients who attended RN-led visits. This difference was not statistically significant (p = 0.077); however, the findings suggest that smoking cessation is at least equivalent in patients who attend nurse-led visits compared with physician-led visits, and may be higher |
Cherkin et al., 1996 [57] USA | Changes to patient self-reported participation in regular aerobic exercise between baseline and follow-up | Self-reported exercise was higher in the nurse intervention group after a 1-week follow-up (p < 0.001), however, there was no significant difference after 7 weeks |
Faulkner et al., 2016 [55] UK | Self-reported 2-week point prevalence smoking abstinence at the 8-week follow-up Self-reported 6-month prolonged smoking abstinence at 6 months follow-up CO2 verified 2-week point-prevalence smoking abstinence at 4 weeks following quit date | No statistically significant differences between the two groups in the primary outcome measure of 2-week point prevalence abstinence at 8 weeks follow-up in both the unadjusted (OR = 1.01, 95% CI: 0.73 to 1.40) and adjusted models (OR = 1.07, 95% CI: 0.76 to 1.51) (adjusted for patients’ occupational category, initial CO reading and trial intervention arm) There were also no statistically significant differences in abstinence for support delivered by HCAs v. nurses at 4 weeks (unadjusted OR = 1.15, 95% CI: 0.80 to 1.66; adjusted OR = 0.86, 95% CI: 0.52–1.40) or 6 months follow-up (unadjusted OR = 0.86, 95% CI: 0.52 to 1.40; adjusted OR = 0.93; 95% CI: 0.55 to 1.56). Nurses and HCAs appear to be equally effective at supporting smoking cessation, however, nurses appear to be able to provide equivalent care with less patient contact |
Harris et al., 2015 [59] UK | Daily physical activity as defined by change in average daily step-counts between baseline and 3 months, and between baseline and 12 months, assessed by accelerometry | At 3 months, changes in average daily step-counts were significantly higher in the intervention than control group by 1,037 (95% CI: 513 to 1,560; p < 0.001) steps/day. At 12 months, corresponding differences were 609 (95% CI: 104 to 1,115; p = 0.018) steps/day |
Weekly physical activity as defined by change in average weekly time spent in MVPA; MVPA in > 10-min bouts; accelerometer counts and counts per minute of wear-time between baseline and 3 months | The intervention increased objectively measured physical activity levels in older people at 3 months, with a sustained effect at 12 months. At 3 months, changes in weekly MVPA in ≥ 10-min bouts were significantly higher in the intervention than control group by 63 (95% CI: 40 to 87; p < 0.001) minutes/week, respectively. At 12 months corresponding differences were 40 (95% CI: 17 to 63; p = 0.001) minutes/week. Counts and counts/minute showed similar effects to steps and MVPA | |
Harris et al., 2017 [60] UK | Changes to physical activity as defined by average daily step counts, changes in step counts between baseline and 3 months, changes in time spent weekly in MVPA in > 10-min bouts, and time spent sedentary between baseline, 3 months and 12 months | Both intervention groups increased their step counts at 12 months compared with control (p < 0.001), with no statistically significant difference between nurse and postal delivery groups There were significant differences for change in step counts at the 3-month follow-up between intervention groups and the control group (nurse-supported group v. control 1,172 steps, 95% CI: 844 to 1,501; p < 0.001; postal group v. control 692 steps, 95% CI: 363 to 1,020; p < 0.001), however, the difference between the intervention groups was statistically significant (481 steps 95% CI: 153 to 809; p = 0.004). The two intervention groups had significantly increased step counts at 12 months, as compared to the control, but the two intervention groups did not significantly differ from each other on this outcome at 12 months. Findings for MVPA showed a similar pattern. The intervention had no significant impact on sedentary time |
Changes in patient-reported outcomes of exercise self-efficacy and quality of life at 3 and 12 months | Exercise self-efficacy significantly increased in both intervention groups at 3 months for postal group v. control group (ES = 1.1, 95% CI: 0.2 to 2.0; p = 0.01), nurse group versus control (ES = 2.3, 95% CI: 1.4 to 3.2; p < 0.001) and there was a greater effect in the nurse group compared with postal (ES = 1.2, 95% CI: 0.3 to 2.1; p = 0.01). By 12 months, there was a difference between only the nurse and control groups (ES = 1.2, 95% CI: 0.3 to 2.2, p = 0.01). The interventions had no significant effects on quality of life scores | |
Marshall et al., 2011 [51] New Zealand | Changes in smoking status (including both smoking cessation as well as smoking reduction) between first and last clinic attended | Although the percentage of adults who reported smoking remained the same between the first and last clinic data, there was a change in number of cigarettes smoked, in that the percentage of people who smoked between 0 and 10/day increased and those who smoked ≥ 11/day decreased |
Patient physical fitness, daily activity, social activity, social support, feelings, and quality of life, derived from the Dartmouth Primary Care Cooperative Information charts and patient self-report survey | Significant improvements were shown in survey results for social activity (p = 0.049), change in health (p = 0.001), and overall health (p = 0.025); there no changes were reported for quality of life. Ninety-four percent of patients reported having a better understanding of their diagnosis, medication and treatment plan, and that they were more motivated to self-manage their health needs. | |
Pine et al., 1997 [49] USA | Changes to patient dietary intake as measured by the EPAT from first to final nurse visit | Mean EPAT scores at baseline in both studies demonstrated that intervention patients were already following a diet consistent with the National Cholesterol Education Program Step 1 Diet. However, the mean Section 1 EPAT score improved from 23.4 at the first nurse visit to 20.4 at the final nurse visit (p< 0.001) |
Zwar et al., 2010 [56] Australia | Smoking status, defined as “point prevalence” (no smoking in seven days preceding the assessment) and “continuous abstinence” (no smoking from quit date to assessment at 4- and 6-month follow-up) | At 6-month follow-up, the point-prevalence abstinence rate was 21.7% (108 out of 498 participants at baseline) and the continuous abstinence rate was 15.9% (79 out of 498 participants at baseline). Participants with very low to medium nicotine dependence (0–5 Fagerström Score) had significantly higher point prevalence cessation rates than those with high to very high dependence (score > 5) (p < 0.001). Continuous abstinence rate was not significantly different between these groups. Patients who had attended four or more counseling visits with the RN were significantly more likely to quit at 6 months than patients who attended less than four times (point prevalence abstinence 32% v. 9%, p < 0.001; continuous abstinence 25% v. 3%, p <0.001) |