Effectiveness of Nurse Practitioners in nursing homes: a systematic review.

Background There are 1.5 million people living in nursing homes in the United States 1. The number of people admitted to nursing homes has increased since 1994, and it is expected that the number of people aged 65 and older living in nursing homes will double by the year 2020 2. Nursing home patients are sicker than they have been in the past 10 years, and the frail, sick patients are more likely to be hospitalized 3. Unnecessary hospitalization of nursing home patients is a costly and critical problem in our healthcare system 3. Hospitalization can cause irreversible decline in function for the elderly patient and can “expose residents to iatrogenic disease and delirium” 4. It has been claimed that nurse practitioners (NPs) can play a valuable role in caring for the long term care patient, reducing unnecessary hospital admissions, and supporting the physician’s practice. A NP on site in the nursing home can provide quick assessment and treatment when a patient has a change of condition. The NP can intervene and treat the patient as needed, instead of transferring the patient to the hospital for assessment. Objectives The objective of this systematic review was to evaluate the effectiveness of having a NP in the nursing home and whether this lead to a decrease in the rate of patient hospitalizations. Inclusion Criteria Types of Participants This systematic review considered studies that include long term care nursing home residents. Types of Interventions The review considered studies that evaluate utilization of a NP (in collaboration with a physician) as a primary care provider for long term care nursing home patients. Types of Outcomes This review considered studies that include the following outcome measures: incidence of hospitalization, types of hospitalization and duration of hospitalization of nursing home patients. Types of Studies Randomized controlled trials (RCTs) were not identified in the search. Therefore, other research designs, such as non-randomized controlled trials and before and after studies, were included. Search Strategy Major databases were searched for English articles written from 1983 to December 2008. Methodological Quality Seven papers were selected for retrieval, and were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Data Collection/Extraction Quantitative data was extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). Data Synthesis Statistical pooling was not possible and the findings are presented in narrative form. Results The review consisted of 12,681 patients in 238 nursing homes. All of the seven included articles found a decrease in hospitalization rates when NPs were utilized as a part of the medical team. Five of the 7 studies found a decrease in ER transfers with the NP group. Garrard, Kane, et al 17 did not measure ER transfers and Kane, Garrard et al 24 found no difference in rate of ER use. Three studies also measured length of hospitalization, and all 3 found that the patients with NPs had shorter lengths of stay. Conclusions This review has demonstrated that nurse practitioners can reduce hospitalization and ER transfers of nursing home patients.