The clinical effectiveness of a nurse practitioner versus a non-nurse practitioner on hospital admissions of older adults residing in skilled or long-term care nursing facilities: a systematic review protocol

Review question/objective The objective of this review is to identify the clinical effectiveness of a nurse practitioner versus a non-nurse practitioner on rates of hospital admissions of older adults residing in skilled or long-term care nursing facilities. Background Healthcare systems are currently being faced with the challenge of changing traditional delivery systems in order to provide improved quality health outcomes for patients with chronic diseases living in nursing facilities. The United States (US) faces an increasingly aging population who have multiple chronic conditions without a sufficient number of healthcare providers to deliver medical care.1 Australia also faces similar concerns with the challenge of providing a sufficient number of healthcare providers for its aging population with co-morbidities.2 The World Health Organization anticipates that by 2050 the number of persons aged 80 years and over will approach 395 million.3 During this same period, the need for long-term care in developing countries is expected to quadruple.3 The demand for healthcare services, coupled with current healthcare provider shortages, creates a situation of increased utilization and costs for acute care services. Older adults residing in nursing facilities often face a shortage of physicians to provide essential medical care. This shortage creates an increase in emergency department (ED) visits and hospital admissions that consume a major percentage of healthcare dollars. Findings of a population-based study in Canada evaluating the use of EDs for patients in long-term care facilities revealed that almost 25% of long-term care patients had an ED visit during a six-month period.4 In the US, a study examining hospital readmissions of 6809 Medicare insurance beneficiaries found that of the approximately 32% who discharged to a nursing facility, 15% were re-hospitalized within 30 days.5 In 2005, more than 1.6 million nursing facility patients made up 72% of all hospitalizations in the US.6 In 2011 and 2012, the cost for admitting 247,290 Australian residents in residential aged care was nearly nine billion Australian dollars.7 During 2004, 972 million US dollars were spent on hospitalizations for long-term care residents from 690 nursing facilities in New York State.8 Approximately 23% of these hospitalizations were considered potentially avoidable with conditions that could possibly have been treated at the nursing facilities.8 Effectively managing non-critical illnesses and chronic diseases at nursing facilities avoids not only unnecessary hospitalization costs but also, more importantly, the potential decline of older adults during hospitalization. Studies show that 30% to 60% of older adults have a functional decline in activities of daily living, such as mobility, after a hospital stay.10,11 Chronic disease management and non-critical illness treatment of patients living in nursing facilities may decrease risks of complications associated with hospitalization. In a study of nursing facility residents who died in 2007, over half were hospitalized within six months to a year prior to their death.9 Heart failure, urinary tract infections and pneumonia made up 37% of the diagnoses, which potentially could have been treated in the nursing facility and avoided hospitalization.9 The inadequate supply of geriatric-trained clinicians to provide medical management of patients living in nursing facilities often leads to increased hospital admissions, with associated functional decline post-hospitalization. Efforts to address the shortage of clinical providers in nursing homes can be accomplished with an increased utilization of nurse practitioners (NPs). Nurse practitioners are registered nurses who have completed graduate education, achieved board certification and obtained licensure to provide nursing and clinical interventions to patient populations in their specialty practice areas.12 Nurse practitioners provide health promotion and chronic disease management, with the ability to: 1) perform complete health assessments of patients; 2) order and interpret diagnostic and laboratory tests; and 3) prescribe medications and non-pharmacological therapies.12 Increased utilization of NPs in the nursing facilities has the potential to: 1) deliver healthcare and improve patient outcomes; 2) avoid debility associated with hospitalization; and 3) decrease the additional costs associated with hospital admissions and readmissions. Studies indicate that NPs can provide quality care to older adults residing in nursing facilities and being about a reduction of hospitalizations and ED visits.13–16 Economic studies indicate that utilizing NPs for patient health management will provide cost efficient, improved patient health outcomes.17 The initial search of literature indicates that NPs who practice in nursing homes can function effectively with positive patient outcomes in several practice models to include: 1) a healthcare delivery system or managed care program;18 2) an educational and quality improvement consultant;19,20 3) clinical care consultant;21 4) a primary healthcare provider;14 and 5) physician-NP collaboration teams.13 A systematic review by Christian and Baker evaluated seven studies using physician and NP collaboration models.13 Findings in these studies indicate that clinical interventions carried out by NPs: 1) decreased hospitalizations rates; 2) decreased ED transfers and visits; and 3) led to a reduced length of hospital stay.13 Bakerjian conducted a literature review of 38 studies of NPs providing clinical management of chronic illnesses for patients residing in nursing facilities.22 The results of the review reflected that NPs can serve in various practice models and have a positive effect on decreasing hospitalization rates, ED transfers and visits, healthcare costs and mortality rates.22 Currently, there is a gap in literature that specifically addresses NP healthcare management of nursing facility residents and the potential impact it may have on decreasing rates of hospitalizations. Limitations related to regulation and the fear of infringing professional boundaries still hinder full implementation of NPs as healthcare providers, thus preventing the opportunity to increase clinician presence in underserved healthcare environments.23 Additionally, utilization of NPs' clinical skills in nursing facilities has the potential to: 1) impact healthcare quality outcomes of older adults residing in nursing facilities; 2) help with containment of healthcare costs related to chronic disease management; and 3) decrease the shortage of clinical providers. The current shortage of physician services in long-term care is a contributor to costly hospitalizations that is associated with a high risk of patient debility. There is an immediate need to identify and implement options for providing healthcare provider support and improve patient outcomes for nursing facility residents. Based on this need, a quantitative systematic review will be conducted on the clinical effectiveness of NPs compared to non-NP providers on hospital admissions of older adults residing in skilled or long-term care facilities. Inclusion criteria Types of participants This review will consider studies that include older adults aged 65 years and over, who reside in long-term care facilities or skilled nursing facilities. Types of intervention(s) This review will consider studies that evaluate the clinical effectiveness of nurse practitioners managing chronic disease states and acute illnesses of patients at the nursing facilities. The NP's practice requirements must include: 1) completion of a graduate-level educational program; 2) board certification; and 3) professional licensure as a nurse practitioner. Two interventions, the nurse practitioner practicing either autonomously or as a physician-nurse practitioner collaborating team, will be compared to non-nurse practitioners (physicians and physicians in residency) who provide medical interventions when managing the healthcare of older adults residing in nursing facilities. Types of outcomes This review will consider studies that include the following outcome measure: rates of hospital admissions for acute illnesses or chronic disease exacerbation that could be potentially treated at the nursing facility. Types of studies This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe articles. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in or translated into the English language for this author's clarity of the study will be considered for inclusion in this review. Studies published from 1965, when the first NP program was developed, until December 2014 will be considered for inclusion in this review.24 The databases to be searched include: MEDLINE, CINAHL, EMBASE,, Web of Science, American Health Research and Quality, National Institute for Health and Care Excellence, Centers for Medicare and Medicaid Innovation Projects, and Nursing Academic Edition. The search for gray literature will include: ProQuest Dissertations and Theses and Mednar for dissertations and theses. Initial keywords to be used will be: nurse practitioners, physicians, physician assistants, hospital admissions, hospital readmissions, hospitalizations, outcomes, nursing care facilities, aged, elderly, and older adults. Assessment of methodological quality Papers selected for retrieval will be 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). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data extraction Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Where necessary, authors of primary studies will be contacted for missing information or to clarify unclear data. Data synthesis Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest The primary reviewer is a nurse practitioner who works with older adults residing in skilled or long-term care facilities. The rigorous process of the JBI methodology for a quantitative review and a second reviewer not working in nursing facilities should alleviate any bias in the results of this systematic review. Acknowledgements Kathy A Baker, PhD, RN, ACNS-BC, FAAN Associate Professor Director, Division of Nursing Graduate Studies and Scholarship Deputy Director, The Texas Christian University Center for Evidenced Based Practice and Research: a Collaborating Center of the Joanna Briggs Institute Texas Christian University, Harris College of Nursing and Health Sciences

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