Impact of the Advanced Practice Provider in Adult Critical Care

A Systematic Review and Meta-analysis

Herman G. Kreeftenberg, MD; Sjaak Pouwels, MD, PhD; Alexander J. G. H. Bindels, MD, PhD; Ashley de Bie, MD; Peter H. J. van der Voort, MD, PhD, MSc


Crit Care Med. 2019;47(5):722-730. 

In This Article

Abstract and Introduction


Objectives: To evaluate the effects on quality and efficiency of implementation of the advanced practice provider in critical care.

Data Sources: PubMed, Embase, The Cochrane Library, and CINAHL were used to extract articles regarding advanced practice providers in critical care.

Study Selection: Articles were selected when reporting a comparison between advanced practice providers and physician resident/fellows regarding the outcome measures of mortality, length of stay, or specific tasks. Descriptive studies without comparison were excluded. The methodological quality of the included studies was rated using the Newcastle-Ottawa scale. The agreement between the reviewers was assessed with Cohen's kappa. A meta-analysis was constructed on mortality and length of stay.

Data Extraction and Synthesis: One-hundred fifty-six studies were assessed by full text. Thirty comparative cohort studies were selected and analyzed. These compared advanced practice providers with physician resident/fellows. All studies comprised adult intensive care. Most of the included studies showed a moderate to good quality. Over time, the study designs advanced from retrospective designs to include prospective and comparative designs.

Data Synthesis: Four random effects meta-analyses on length of stay and mortality were constructed from the available studies. These meta-analyses showed no significant difference between performance of advanced practice providers on the ICU and physician residents/fellows on the ICU, suggesting the quality of care of both groups was equal. Mean difference for length of stay on the ICU was 0.34 (95% CI, −0.31 to 1.00; I 2 = 99%) and for in hospital length of stay 0.02 (95% CI, −0.85 to 0.89; I 2 = 91%); whereas the odds ratio for ICU mortality was 0.98 (95% CI, 0.81–1.19; I 2 = 37.3%) and for hospital mortality 0.92 (95% CI, 0.79–1.07; I 2 = 28%).

Conclusions: This review and meta-analysis shows no differences between acute care given by advanced practice providers compared with physician resident/fellows measured as length of stay or mortality. However, advanced practice providers might add value to care in several other ways, but this needs further study.


For more than 2 decades, acute care nurse practitioners (ACNPs) and physician assistants (PAs) are increasingly embedded in ICUs, particularly in the United States.[1,2] However, in the rest of the world, this concept remains relatively unknown, despite the fact that research about the additional value of this concept continues to emerge. This systematic review and meta-analysis established an overview about the current available evidence in this area.

Nowadays, hospital care is challenged by several trends such as an increasing demand in efficiency and quality of healthcare, a rising proportion of patients with chronic diseases and ongoing specialization in medical disciplines. This often coincides with increasing physician shortages in several regions in the world.[3–6] In light of these developments, one of the applied solutions has been to reallocate patient care to PA and nurse practitioners (NPs) also called "advanced practice provider" (APP). An APP is a nonphysician with an independent license to practice as APP. APPs, in collaboration with healthcare professionals and other individuals, provide a full range of primary, acute, and specialty healthcare services.

This staffing model shows beneficial outcomes and has gained popularity within various medical disciplines, like surgical and trauma teams, but also in pediatric and adult ICUs.[1,2,7–9] Except for the United States where APPs were already legalized during the 1960s,[10–12] they are currently increasingly recognized and adapted by other countries in the world and in the critical care processes of these countries.[3,4] In the last years, several reviews were undertaken to assess the added value of the critical care APP to clinical teams and the exact role of this APP.[7,13–16] The review of Woo et al[16] highlighted that APPs can increase patients' access to emergency and critical care and showed that APPs improve patient outcomes. The review of Fry[15] also demonstrated that the available evidence about APPs showed a contribution to positive patient, service, and nursing outcomes. In addition, organizational models with APPs seem to be cost-effective, appropriate, and efficient in delivery of critical care services. It was recognized that health systems and the role of APPs differs between countries and studies in specific local situations are needed.[15] The reviews of Edkins et al,[14] Gershengorn et al,[13] and Kleinpell et al[7] showed promising results regarding embedding of APPs in critical care. However, all review articles came to the same conclusion that the literature was mainly descriptive and not solid enough for definite conclusions.

The objective of this systematic review and meta-analysis is to gain insight in the place and additional value of the APPs in critical care and to investigate the quality and efficiency of care provided by APPs compared with physicians.