Advanced Practice Nurse Outcomes 1990–2008

A Systematic Review

Robin P. Newhouse, PhD, RN, NEA-BC; Julie Stanik-Hutt, PhD, ACNP, CCNS, FAAN; Kathleen M. White, PhD, RN, NEA-BC, FAAN; Meg Johantgen, PhD, RN; Eric B. Bass, MD, MPH; George Zangaro, PhD, RN; Renee F. Wilson, MS; Lily Fountain, MS, CNM, RN; Donald M. Steinwachs, PhD; Lou Heindel, DNP, CRNA; Jonathan P. Weiner, PhD


Nurs Econ. 2011;29(5):230-250. 

In This Article


This systematic review of published literature between 1990 and 2008 on care provided by APRNs indicates patient outcomes of care provided by NPs and CNMs in collaboration with physicians are similar to and in some ways better than care provided by physicians alone for the populations and in the settings included. Use of CNSs in acute care settings can reduce length of stay and cost of care for hospitalized patients.

These results extend what is known about APRN outcomes from previous reviews by assessing all types of APRNs over a span of 18 years, using a systematic process with intentionally broad inclusion of outcomes, patient populations, and settings. The results indicate APRNs provide effective and high-quality patient care, have an important role in improving the quality of patient care in the United States, and could help address concerns about whether care provided by APRNs can safely augment the physician supply to support reform efforts aimed at expanding access to care.

The results of this systematic review should be interpreted while considering limitations in the bodies of research reviewed. Limitations include the heterogeneity of study designs and measures, multiple time points for measuring outcomes, the limited number of randomized designs, inadequate statistical data for calculating effect sizes, failure to describe the nature of the APRN and physician roles and the responsibilities or relationships of team members, including collaboration with physicians. Attribution of the APRN to specific outcomes was often difficult because of the complexity of the intervention, which sometimes included several components and multiple providers. In addition, attribution was also clouded by the fact APRNs often practice as part of a team or in collaboration with other providers. Despite these limitations, the aim of the review was to summarize the evidence for a broad range of outcomes. The quality assessment and score included transparent, systematic methods to strengthen the process, including assessment of differences in comparison groups, settings, participants, and attribution to address some of these limitations.

The results of this systematic review indicate APRNs can have an expanded role in health care systems, and should be incorporated to the fullest extent possible. One major professional organization, the American College of Physicians (2009), supports appropriate use of NPs as part of its commitment to promote teams of care. APRNs and other providers can use these results to spark interdisciplinary conversations to better understand one another's roles and capabilities. A collaborative effort will ultimately lead to higher quality health care and better health care systems.

There are many policy implications to these results (Newhouse, 2011). Research to test models of care involving APRNs should be expanded to additional settings and populations based on the needs of priority populations and health policy goals. Restrictions on APRN practice and reimbursement must be modified to allow new models of care to be tested. Health care reform initiatives should include APRNs as providers who are used to the full extent of their scope of practice. Billing data need to indicate the actual provider of care (NP, CNM, CNS, CRNA, or physician). Pay-for-performance initiatives should make provision for incorporating APRNs and other health care providers in the development of initiatives, indicators, and participation for direct and equitable reimbursement.


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