Cost-effectiveness of Advanced Practice Nurses Compared to Physician-led Care for Chronic Diseases

A Systematic Review

Cilgy M. Abraham, BS, RN, PhD; Allison A. Norful, PhD, RN, ANP-BC; Patricia W. Stone, PhD, RN, FAAN; Lusine Poghosyan, PhD, MPH, RN, FAAN


Nurs Econ. 2019;37(6):293-305. 

In This Article

Abstract and Introduction


Globally, advanced practice nurses (APNs) provide high-quality chronic disease care to patients, yet the cost-effectiveness of their services is minimally explored. This review aims to determine the cost-effectiveness of chronic disease care provided by APNs compared to physicians globally.


Chronic diseases are the primary cause of death and disability worldwide (World Health Organization, 2018). The global economic impact of chronic diseases could reach $47 trillion by 2030 (Kelland, 2011). In 2015, the United States spent $3.2 trillion on health care with nearly 86% of annual healthcare costs expended on chronic diseases (Centers for Disease Control and Prevention, 2015, 2017). As a result, the high cost of healthcare services has led researchers, clinicians, and policymakers to call for innovative cost-effective care delivery models to reduce spending (Reynolds et al., 2018).

While chronic disease care has traditionally been delivered by physicians, the current demand for primary care services exceeds the available supply of physicians (Yarnall et al., 2009). For example, less than 10% of the overall physician workforce practices in rural areas where 21% of the U.S. population resides, which limits access to care for patients in rural communities (Bodenheimer & Pham, 2010). Accordingly, physician-centric models cannot effectively meet the demand for patient care and primary care providers from other disciplines, such as advanced practice nurses (APNs), are needed to optimize chronic disease care delivery.

APNs are registered nurses with advanced training at the master's or doctoral level and can diagnose and manage patient conditions by performing assessments, ordering and interpreting diagnostic tests, prescribing medications and treatments, and providing patient education (Kleinpell et al., 2014; National Council of State Boards of Nursing, 2008). Globally, the growth rate of the APN workforce is high. For example, in the past 10 years, the Netherlands experienced a 27.8% increase in its APN workforce (Maier, Barnes, Aiken, & Busse, 2016). From 2013 to 2025, the APN workforce is projected to increase by 93% in the United States (U.S. Department of Health and Human Services, 2016). Furthermore, 39 countries have developed policies to shift primary care tasks from physicians to APNs to meet the demand for patient care (Maier & Aiken, 2016). This shift is supported by evidence that APNs in primary care have led to improved care quality, optimal patient outcomes, lower risk for hospitalizations and readmissions (Jennings, Clifford, Fox, O'Connell, & Gardner, 2015; Kuo, Chen, Baillargeon, Raji, & Goodwin, 2015; Swan, Ferguson, Chang, Larson, & Smaldone, 2015), higher patient satisfaction and improved measures in patient follow-up, counseling, and screening (Cassidy, 2012; Klemenc?Ketis, Terbovc, Gomiscek, & Kersnik, 2015; Van Dijk, Crone, van Empelen, Assendelft, & Middelkoop, 2017; Peeters et al., 2014).

Despite the evidence on the effectiveness of APN-led care, professional organizations such as the American Medical Association, American Osteopathic Association, American Academy of Pediatrics, and American Academy of Family Physicians continue to debate whether APNs should be able to practice independently (Fairman, Rowe, Hassmiller, & Shalala, 2011). One concern stemming from this debate is whether APNs are more expensive to the healthcare system compared to physicians (Hughes, Jiang, & Duszak, 2015; Roblin et al., 2017). Since more chronic disease care management of patients is being shifted to APNs, it is crucial to understand the differences in cost of care between APNs and physicians. Recognizing the cost of different care delivery models will provide insights to the most optimal means of delivering chronic disease care that can reduce healthcare spending without compromising high-quality patient care. The purpose of this systematic review is to determine the cost-effectiveness of chronic disease care management delivered by APNs compared to physicians.