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Bulto LN, Roseleur J, Noonan S, Pinero de Plaza MA, Champion S, Dafny HA, Pearson V, Nesbitt K, Gebremichael LG, Beleigoli A, Gulyani A, Schultz T, Hines S, Clark RA, Hendriks JM. Effectiveness of nurse-led interventions versus usual care to manage hypertension and lifestyle behaviour: a systematic review and meta-analysis. Eur J Cardiovasc Nurs 2024; 23:21-32. [PMID: 37130339 DOI: 10.1093/eurjcn/zvad040] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/04/2023]
Abstract
AIMS This review aimed to investigate the effectiveness of nurse-led interventions vs. usual care on hypertension management, lifestyle behaviour, and patients' knowledge of hypertension and associated risk factors. METHODS A systematic review with meta-analysis was conducted following Joanna Briggs Institute (JBI) guidelines. MEDLINE (Ovid), EmCare (Ovid), CINAHL (EBSCO), Cochrane library, and ProQuest (Ovid) were searched from inception to 15 February 2022. Randomized controlled trials (RCTs) examining the effect of nurse-led interventions on hypertension management were identified. Title and abstract, full text screening, assessment of methodological quality, and data extraction were conducted by two independent reviewers using JBI tools. A statistical meta-analysis was conducted using STATA version 17.0. RESULTS A total of 37 RCTs and 9731 participants were included. The overall pooled data demonstrated that nurse-led interventions may reduce systolic blood pressure (mean difference -4.66; 95% CI -6.69, -2.64; I2 = 83.32; 31 RCTs; low certainty evidence) and diastolic blood pressure (mean difference -1.91; 95% CI -3.06, -0.76; I2 = 79.35; 29 RCTs; low certainty evidence) compared with usual care. The duration of interventions contributed to the magnitude of blood pressure reduction. Nurse-led interventions had a positive impact on lifestyle behaviour and effectively modified diet and physical activity, but the effect on smoking and alcohol consumption was inconsistent. CONCLUSION This review revealed the beneficial effects of nurse-led interventions in hypertension management compared with usual care. Integration of nurse-led interventions in routine hypertension treatment and prevention services could play an important role in alleviating the rising global burden of hypertension. REGISTRATION PROSPERO: CRD42021274900.
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Affiliation(s)
- Lemma N Bulto
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
| | - Jacqueline Roseleur
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
| | - Sara Noonan
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
| | - Maria Alejandra Pinero de Plaza
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
- National Health and Medical Research Council, Transdisciplinary Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, 5005, SA, Australia
| | - Stephanie Champion
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
| | - Hila Ariela Dafny
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
| | - Vincent Pearson
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
| | - Katie Nesbitt
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
| | - Lemlem G Gebremichael
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
| | - Alline Beleigoli
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
| | - Aarti Gulyani
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
| | - Timothy Schultz
- Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- National Health and Medical Research Council, Transdisciplinary Centre of Research Excellence in Frailty and Healthy Ageing, Adelaide, 5005, SA, Australia
| | - Sonia Hines
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
- Flinders Rural and Remote Health, NT. College of Medicine and Public Health, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
| | - Robyn A Clark
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
| | - Jeroen M Hendriks
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Sturt Rd, Bedford Park, 5042, SA, Australia
- Mparntwe Centre for Evidence in Health, A JBI Centre of Excellence, Flinders University, 5 Skinner Street, East Wing, 4066, Alice Springs, Northern Territory, Australia
- Centre for Heart Rhythm Disorders, University of Adelaide and Royal Adelaide Hospital, Adelaide, 5001, SA, Australia
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Pouresmail Z, Heshmati Nabavi F, Valizadeh Zare N. Outcomes of Patient Education in Nurse-led Clinics: A Systematic Review. J Caring Sci 2023; 12:188-200. [PMID: 38020736 PMCID: PMC10663435 DOI: 10.34172/jcs.2023.31891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 07/13/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Patient education is an independent role of nurses performed in nurse-led clinics (NLCs). The measurement of patient education outcomes validates whether nursing educational interventions have a positive effect on patients, which helps determine whether changes in care are needed. Standardized nursing terminologies facilitate the evaluation of educational outcomes. We aimed to explore the outcomes of patient education in NLCs based on the Nursing Outcome Classification (NOC) system. Methods The review was conducted according to PRISMA guidelines. We searched "Medline", "Embase", "Web of Science", and "Scopus" databases for articles published between 2000 and 2022. Based on the search strategy, 1157 articles were retrieved from PubMed, Scopus, Web of Science, and Embase databases. After excluding the duplicates, 978 articles were appraised. 133 articles remained after reading the titles and abstracts of the articles. In the next step, the articles were evaluated regarding methodology, research population, and exclusion criteria, after which 112 articles were omitted, and finally, 21 articles were included in the full-text review. We assessed all included studies using the Quality Assessment of Controlled Intervention Studies checklist. Results A total of 21 randomized controlled trials met the inclusion criteria. "Physiologic health", "functional health", "psychosocial health", "health knowledge and behavior", and "perceived health" were the domains of nursing outcomes investigated as Patient Education Outcomes in NLCs. Conclusion Most of the outcomes were linked to lifestyle-related chronic diseases and, further studies are needed to determine the effects of patient education provided in NLCs in terms of family/society health outcomes.
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Affiliation(s)
- Zohre Pouresmail
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Heshmati Nabavi
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Community Health and Psychiatric Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Najmeh Valizadeh Zare
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Operating Room, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
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Vay-Demouy J, Cinaud A, Malka N, Mion B, Kretz S, Lelong H, Blacher J. Advanced practice nurse intervention versus usual care for hypertension control: study protocol for an open-label randomized controlled trial. Trials 2023; 24:438. [PMID: 37400867 DOI: 10.1186/s13063-023-07437-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 06/07/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Hypertension is the most frequent chronic pathology in France and in the world. It is one of the main modifiable cardiovascular risk factors. In France, 50% of treated hypertensives are uncontrolled and only 30% of treated patients are fully adherent to their antihypertensive treatment. Poor adherence to drug treatments is considered as one of the main causes of non-control of hypertension. Since 2018, a new profession has entered the French healthcare system: advanced practice nurses (APN). They have many broad-based skills, at the interface of nursing and medical exercises. The purpose of this study is to assess the impact of an APN intervention versus usual care on hypertension control. METHODS The study will take place at the Hôtel-Dieu University Hospital, Paris, France, as prospective, open-label, controlled, randomized 1-to-1, monocentric, and superiority trial. The participants will be recruited during day hospitalization for cardiovascular assessment in the context of their hypertension management. Patients will be divided into two groups: a "usual care" group which will continue traditional follow-up (day hospitalization followed by consultation with a medical doctor (MD) within approximately 2-12 months) and an "intervention" group which will meet an APN between the day hospitalization and the MD consultation. Participants will be monitored until 12 months after the day hospitalization, depending on their last follow-up study appointment (MD consultation). The primary outcome is the rate of controlled BP (BP < 140/90 mmHg in office BP measurement) in each group. The hypothesis formulated is that an individual APN intervention, included in usual hypertension management, improves hypertension control. DISCUSSION This innovative study will be the first in France where APNs are beginning to be established in the healthcare system. It will provide an objective look at this new profession and the impact it can have in the framework of global management of hypertension. TRIAL REGISTRATION ClinicalTrials.gov NCT0448249. Registered on June 24, 2020.
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Affiliation(s)
- Juliette Vay-Demouy
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France
| | - Alexandre Cinaud
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France
| | - Nathan Malka
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France
| | - Baptiste Mion
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France
| | - Sandrine Kretz
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France
| | - Hélène Lelong
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France
| | - Jacques Blacher
- Diagnosis and Therapeutic Center, Hôtel-Dieu University Hospital, Assistance Publique-Hôpitaux de Paris, Paris Cité University, Paris, 75004, France.
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Freeley S, Broughan J, McCombe G, Casey M, Fitzpatrick P, Frawley T, Morrisey J, Treanor JT, Collins T, Cullen W. Promoting nurse-led behaviour change interventions to prevent cardiovascular disease in disadvantaged communities: A scoping review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:2071-2095. [PMID: 35695081 PMCID: PMC10084375 DOI: 10.1111/hsc.13867] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/07/2022] [Accepted: 05/28/2022] [Indexed: 06/15/2023]
Abstract
Cardiovascular diseases (CVD) are the leading cause of death worldwide and they disproportionally affect people living in disadvantaged communities. Nurse-led behaviour change interventions have shown great promise in preventing CVD. However, knowledge regarding the impact and nature of such interventions in disadvantaged communities is limited. This review aimed to address this knowledge gap. A six-stage scoping review framework developed by Arksey and O'Malley, with revisions by Levac et al., was used. The search process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Extension for Scoping Reviews (PRISMA-ScR). Three electronic databases were searched (PUBMED/MEDLINE, CINAHL Plus, and Cochrane CENTRAL), and included studies were analysed using Braun and Clarke's 'Thematic Analysis' approach. Initial searches yielded 952 papers and 30 studies were included in the review following duplicate, title/abstract, and full-text screening. The included studies indicate that nurse-led behaviour change primary prevention interventions in disadvantaged areas are largely effective; albeit the considerable variety of intervention approaches, study populations and outcome measures used to date make it difficult to ascertain this. Other identified key areas in the promotion of nurse-led behaviour change included tailoring interventions to specific populations, providing adequate training for nurses, overcoming patient access difficulties and encouraging patient engagement. Overall, the findings indicate that nurse-led behaviour change interventions for high-risk CVD patients in disadvantaged areas show much promise, although there is considerable variety in the interventions employed and studied to date. Further research is needed to examine the unique barriers and facilitators of interventions for specific disadvantaged groups.
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Affiliation(s)
- Sarah Freeley
- School of MedicineHealth Sciences Centre, University College DublinDublinIreland
| | - John Broughan
- School of MedicineHealth Sciences Centre, University College DublinDublinIreland
| | - Geoff McCombe
- School of MedicineHealth Sciences Centre, University College DublinDublinIreland
| | - Mary Casey
- School of Nursing, Midwifery, and Health SystemsHealth Sciences Centre, University College DublinDublinIreland
| | - Patricia Fitzpatrick
- School of Public Health, Physiotherapy and Sports Science, University College DublinHealth Sciences CentreDublinIreland
- St. Vincent's University HospitalDublinIreland
| | - Timothy Frawley
- School of Nursing, Midwifery, and Health SystemsHealth Sciences Centre, University College DublinDublinIreland
- Ireland East Hospital GroupDublinIreland
| | | | | | | | - Walter Cullen
- School of MedicineHealth Sciences Centre, University College DublinDublinIreland
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Simonetti V, Comparcini D, Tomietto M, Pavone D, Flacco ME, Cicolini G. Effectiveness of a family nurse-led programme on accuracy of blood pressure self-measurement: A randomised controlled trial. J Clin Nurs 2021; 30:2409-2419. [PMID: 33872417 DOI: 10.1111/jocn.15784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 01/01/2023]
Abstract
AIMS AND OBJECTIVES To evaluate the effectiveness of a Family Nurse Practitioner (FNP)-led programme on the degree of adherence of current recommendations on home blood pressure self-measurement (HBPM) as compared to routine care and management. BACKGROUND HBPM plays an important role for monitoring hypertensive patients; however, patients' adherence to current guidelines is unsatisfactory. A nurse-led training programme in the community setting could be an effective strategy to achieve high level of patients' adherence to recommendations. DESIGN A multicentre randomised controlled trial was carried out from September 2016 to September 2017. METHODS In total, 170 patients were randomly allocated into the intervention group (n = 83) and the usual care (n = 87). All participants received usual care (written and verbal information on HBPM recommendations); subjects in the intervention group also received 1-hour training session on how to correctly self-measure BP. Clinical trial registration was done (ClinicalTrials.gov.: NCT04681703). The CONSORT checklist for randomised controlled trials was used in this study. RESULTS At baseline, the level of adherence to the recommendation was similar in the two groups (p < .05). After 1 month, the adherence significantly increased in the intervention group, where patients were more likely to measure BP at the same hour and from the same arm, in a quiet environment, with the back and uncovered arm supported and the legs uncrossed; recording BP more than once in each measurement session; keeping a diary of blood pressure measurements; use of the appropriate cuff and proper placement of the cuff; and resting for >5 min before performing the measurement (all p < .05). CONCLUSIONS The FNP-led programme is effective in improving patients' adherence to guidelines on the correct technique to self-measure BP at home. RELEVANCE TO CLINICAL PRACTICE This programme may be added to the existing interventions in the community setting or considered into specifically nurse-led hypertension management models.
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Affiliation(s)
| | - Dania Comparcini
- Azienda Ospedaliera Universitaria "Ospedali Riuniti" di Ancona, Ancona, Italy
| | - Marco Tomietto
- Regional Taskforce for Healthcare System Assessment, Direzione Centrale Salute, Politiche Sociali e Disabilità, Trieste, Italy.,Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
| | | | | | - Giancarlo Cicolini
- Department of Biomedical Science and Human Oncology, University of Bari "Aldo Moro", Bari, Italy
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Chambers D, Cantrell A, Booth A. Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BackgroundIn 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.ObjectivesTo map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.MethodsFor the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).ResultsA total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.LimitationsThe research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.ConclusionsOverall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.Future workResearch should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev 2016; 11:CD011227. [PMID: 27873322 PMCID: PMC6464275 DOI: 10.1002/14651858.cd011227.pub2] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. OBJECTIVES To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). SEARCH METHODS We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. SELECTION CRITERIA Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. MAIN RESULTS We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. AUTHORS' CONCLUSIONS The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.
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Affiliation(s)
- Greg Weeks
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
- Barwon HealthPharmacy DepartmentGeelongVictoriaAustralia
| | - Johnson George
- Monash UniversityCentre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical SciencesParkvilleVICAustralia3052
| | - Katie Maclure
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
| | - Derek Stewart
- Robert Gordon UniversitySchool of PharmacyRiverside EastGarthdee RoadAberdeenUKAB10 7GJ
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Parro-Moreno A, Serrano-Gallardo P, Díaz-Holgado A, Aréjula-Torres JL, Abraira V, Santiago-Pérez IM, Morales-Asencio JM. Impact of primary care nursing workforce characteristics on the control of high-blood pressure: a multilevel analysis. BMJ Open 2015; 5:e009126. [PMID: 26644122 PMCID: PMC4679997 DOI: 10.1136/bmjopen-2015-009126] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine the impact of Primary Health Care (PHC) nursing workforce characteristics and of the clinical practice environment (CPE) perceived by nurses on the control of high-blood pressure (HBP). DESIGN Cross-sectional analytical study. SETTING Administrative and clinical registries of hypertensive patients from PHC information systems and questionnaire from PHC nurses. PARTICIPANTS 76,797 hypertensive patients in two health zones within the Community of Madrid, North-West Zone (NWZ) with a higher socioeconomic situation and South-West Zone (SWZ) with a lower socioeconomic situation, and 442 reference nurses. Segmented analyses by area were made due to their different socioeconomic characteristics. PRIMARY OUTCOME MEASURE Poor HBP control (adequate figures below the value 140/90 mm Hg) associated with the characteristics of the nursing workforce and self-perceived CPE. RESULTS The prevalence of poor HBP control, estimated by an empty multilevel model, was 33.5% (95% CI 31.5% to 35.6%). In the multilevel multivariate regression models, the perception of a more favourable CPE was associated with a reduction in poor control in NWZ men and SWZ women (OR=0.99 (95% CI 0.98 to 0.99)); the economic immigration conditions increased poor control in NWZ women (OR=1.53 (95% CI 1.24 to 1.89)) and in SWZ, both men (OR=1.89 (95% CI 1.43 to 2.51)) and women (OR=1.39 (95% CI 1.09 to 1.76)). In all four models, increasing the annual number of patient consultations was associated with a reduction in poor control (NWZ women: OR=0.98 (95% CI0.98 to 0.99); NWZ men: OR=0.98 (95% CI 0.97 to 0.99); SWZ women: OR=0.98 (95% CI 0.97 to 0.99); SWZ men: OR=0.99 (95% CI 0.97 to 0.99). CONCLUSIONS A CPE, perceived by PHC nurses as more favourable, and more patient-nurse consultations, contribute to better HBP control. Economic immigration condition is a risk factor for poor HBP control. Health policies oriented towards promoting positive environments for nursing practice are needed.
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Affiliation(s)
- Ana Parro-Moreno
- Department of Nursing, Department of Preventive Medicine and Public Health, Department of Surgery, School of Medicine, Universidad Autónoma de Madrid/IISPHM, Madrid, Spain
| | - Pilar Serrano-Gallardo
- Department of Nursing, School of Medicine, Universidad Autónoma de Madrid/IDIPHIM/INAECU, Madrid, Spain
| | - Antonio Díaz-Holgado
- Information System Unit, Directorate for Public Health, Health Service of Madrid, Spain
| | - Jose L Aréjula-Torres
- Information System Unit, Directorate for Public Health, Health Service of Madrid, Spain
| | - Victor Abraira
- Clinical Biostatistics of Ramón y Cajal University Hospital/IRYCIS/Centre for Biomedical Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Isolina M Santiago-Pérez
- Epidemiology Unit, Galician Directorate for Public Health, Galician Health Authority, Santiago de Compostela, Spain/IBIMA, A Coruña, Santiago de Compostela, Spain
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