Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, Sevilla, Spain.
Centro Universitario de Enfermería de Cruz Roja, Universidad de Sevilla, Sevilla, Spain.
Nurs Open. 2021 Jul;8(4):1879-1891. doi: 10.1002/nop2.847. Epub 2021 Mar 10.
Advanced Practice Nurse (APN) is a specialist who has acquired clinical skills to make complex decisions for a better professional practice. In the United States, this figure has been developed in different ways, but in some European countries, it is not yet fully developed, although it may imply a significant advance in terms of continuity and quality of care in patients with chronic or multiple pathologies, including cardiac ones and, more specifically, heart failure (HF). The follow-up of HF patients in many countries has focused on the medical management of the process, neglecting all the other comprehensive health aspects that contribute to decompensation of HF, worsening quality indicators or patient satisfaction, and there are not updated reviews to clarify the relevance of APN in HF, comparing the results of APN interventions with doctors clinical practice, since the complexity of care that HF patients need makes it difficult to control the disease through regular treatment. For this reason, this systematic review was proposed in order to update the available knowledge on the effectiveness of APN interventions in HF patients, analysing four PICO questions (Patients, Interventions, Comparison and Outcomes): whether APN implies a reduction in the number of hospital readmissions, if it reduces mortality, if it has a positive cost-benefit relationship and if it implies any improvement in the quality of life of HF patients.
A systematic review was performed based on the PRISMA statement, searching at four databases: PubMed, CINAHL, Scopus and Cuiden. Articles were selected based on the following criteria: English/Spanish language, up to 6 years since publication, and original quantitative studies of experimental, quasi-experimental or observational character. Papers were excluded if they do not comply with CONSORT or STROBE checklists, and if they had not been published in journals indexed in JCR and/or SJR. For the analysis, two separate researchers used the Cochrane Handbook form for systematic reviews of intervention, collecting authorship variables, study methods, risks of bias, intervention and comparison groups, results obtained, PICO question or questions answered, and the main conclusions.
A total of 43,754 patients participated in the 11 included studies for the development of this review, mostly from United States and non-European countries, with a clearly visible lack of European publications. Regarding the results related to first PICO question, researches reviewed proved that APN implied a reduction in the number of hospital readmissions in patients with heart failure (up to 33%). Regarding the second question, mortality was always lower in groups assisted by APN versus in control groups (up to 7.8% vs. 17.7%). Regarding the third question, APN was cost-effective in this type of patient as the cost reduction was eventually calculated in 1.9 million euros. Regarding the last question, quality of life of patients who have been cared for by an APN had notoriously improved, although one of the papers concluded that no significant differences were found. All the questions addressed obtained a positive answer; therefore, APN is a practice that reduced hospital readmissions and mortality in HF patients. The cost-effectiveness is much better with APN than with usual care, and although the quality of life of HF patients seems to improve with APN, more studies are needed to support this focused on this.
高级实践护士（APN）是一位具有临床技能的专家，可以做出更复杂的决策，以提高专业实践水平。在美国，这种角色以不同的方式发展，但在一些欧洲国家，它尚未得到充分发展，尽管它可能在连续性和慢性病患者（包括心脏病患者）的护理质量方面带来显著的进步，更具体地说，心力衰竭（HF）。许多国家对 HF 患者的随访主要集中在对该疾病过程的医疗管理上，而忽略了所有其他有助于 HF 恶化、降低质量指标或患者满意度的综合健康方面，也没有最新的综述来明确 APN 在 HF 中的相关性，比较 APN 干预与医生临床实践的结果，因为 HF 患者所需的护理复杂性使得难以通过常规治疗来控制疾病。出于这个原因，提出了这项系统综述，以更新有关 APN 干预 HF 患者有效性的现有知识，分析了四个 PICO 问题（患者、干预、比较和结果）：APN 是否会减少住院人数、是否会降低死亡率、是否具有成本效益关系以及是否会提高 HF 患者的生活质量。
基于 PRISMA 声明进行了系统综述，在四个数据库中进行了检索：PubMed、CINAHL、Scopus 和 Cuiden。根据以下标准选择文章：英语/西班牙语、发表时间不超过 6 年，以及具有实验、准实验或观察性质的原始定量研究。如果文章不符合 CONSORT 或 STROBE 检查表，或者没有发表在 JCR 和/或 SJR 索引的期刊上，则将其排除在外。为了进行分析，两位独立的研究人员使用 Cochrane 手册对干预措施进行系统评价，收集作者、研究方法、偏倚风险、干预和对照组、获得的结果、回答的 PICO 问题或问题以及主要结论。
这项综述共纳入了 11 项研究，共有 43754 名患者参与了研究，这些研究主要来自美国和非欧洲国家，明显缺乏欧洲的研究结果。关于第一个 PICO 问题的结果，研究证明 APN 可减少心力衰竭患者的住院人数（最多减少 33%）。关于第二个问题，APN 辅助组的死亡率始终低于对照组（最多降低 7.8%比 17.7%）。关于第三个问题，APN 在这种类型的患者中具有成本效益，因为最终计算出的成本降低了 190 万欧元。关于最后一个问题，由 APN 护理的患者的生活质量明显改善，尽管有一篇文章得出结论，认为没有发现显著差异。所有提出的问题都得到了肯定的答案；因此，APN 是一种可以减少 HF 患者住院人数和死亡率的治疗方法。APN 的成本效益明显优于常规护理，尽管 HF 患者的生活质量似乎随着 APN 而改善，但还需要更多的研究来支持这一点。
