Effectiveness of advanced practice nursing interventions on diabetic patients: a systematic review

Academic Edi o : Je zy Słowi´nski
Recei ed: 4 Feb ua y 2025
Re ised: 18 Ma ch 2025
Accep ed: 25 Ma ch 2025
Published: 26 Ma ch 2025
Ci a ion: Rod íguez-Ga cía, A.;
Bo allo-Riego, Á.; Magni, E.;
Gue a-Ma ín, M.D. E ec i eness o
Ad anced P ac ice Nu sing
In e en ions on Diabe ic Pa ien s: A
Sys ema ic Re iew. Heal hca e 2025,13,
738. h ps://doi.o g/10.3390/
heal hca e13070738
Copy igh : © 2025 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license
(h ps://c ea i ecommons.o g/
licenses/by/4.0/).
Sys ema ic Re iew
E ec i eness o Ad anced P ac ice Nu sing In e en ions on
Diabe ic Pa ien s: A Sys ema ic Re iew
Ana Rod íguez-Ga cía 1, Ál a o Bo allo-Riego 2,3,*, Eleono a Magni 2,3,* and Ma ía Dolo es Gue a-Ma ín 2,3
1Andalusian Heal h Se ice, Vi gen Maca ena Hospi al, 41009 Se ille, Spain; [email p o ec ed]
2Nu sing Depa men , Facul y o Nu sing, Physio he apy and Podia y, Uni e si y o Se ille,
41009 Se ille, Spain; [email p o ec ed]
3Ins i u e o Biomedicine o Se ille (IBiS), 41013 Se ille, Spain
*Co espondence: [email p o ec ed] (Á.B.-R.); [email p o ec ed] (E.M.)
Abs ac : Backg ound: Diabe es melli us is a complex ch onic condi ion equi ing con in-
uous heal hca e. Consequen ly, a ious o ganisa ions ecommend he apeu ic educa ion
o enhance ea men adhe ence. This is o en acili a ed by Ad anced P ac ice Nu ses,
who p o ide a ange o ad anced in e en ions ha impac clinical heal h ou comes and
deli e heal hca e se ices o hese pa ien s. Objec i e: To analyse he e ec i eness o
in e en ions pe o med by Ad anced P ac ice Nu ses in pa ien s wi h diabe es. Me hod:
A pee - e iewed sys ema ic e iew was conduc ed and egis e ed in PROSPERO. The
da abases consul ed included PubMed, Scopus, Web o Science, and CINAHL. Inclusion
c i e ia comp ised s udies published be ween 2014 and 2024 on he e ec i eness o in e -
en ions by Ad anced P ac ice Nu ses in diabe ic pa ien s. The e iew included quali a i e,
quan i a i e, and mixed me hods designs. Va ious sc eenings we e ca ied ou , including
he assessmen o me hodological quali y. Resul s: A o al o 600 s udies we e iden i ied,
o which 17 we e selec ed o inal e iew. Among hese, 12 s udies ocused on diabe ic
educa ion. In e en ions we e p edominan ly deli e ed in pe son in p ima y ca e se ings,
p i a e clinics, and hospi als. Repo ed ou comes included educ ions in HbA1c le els,
imp o ed pa ien sel -knowledge and sel -e icacy, and dec eased a es o eadmission and
mo ali y. Conclusions: The sample consis ed p edominan ly o women o e 60 yea s o
age. Diabe ic educa ion eme ged as he mos common in e en ion, p ima ily deli e ed
in pe son by Ad anced P ac ice Nu ses ac oss di e se se ings. Nea ly all in e en ions
p o ed e ec i e in imp o ing heal h ou comes o diabe ic pa ien s.
Keywo ds: ad anced p ac ice nu sing; nu se p ac i ione s; clinical nu ses; p ac ice pa e ns;
nu ses; diabe es melli us
1. In oduc ion
Th oughou ime, Nu sing has p og essi ely e ol ed in he en i e wo ld, wi h he
eme gence o he Ad anced P ac ice Nu se (APN) igu e, which was de ined by he In-
e na ional Nu sing Council as a nu se who, h ough addi ional aining, has acqui ed
expe knowledge, complex decision-making skills, and clinical compe ences o expand
hei p ac ice. All his exe s a di ec in luence on clinical heal h ou comes and on he
p o ision o di ec se ices o indi iduals, amilies, and communi ies. The cha ac e is ics o
an APN can a y acco ding o he con ex o he coun y whe e hey de elop hei ac i i ies,
as a ia ions can be no iced in heal h sys ems, in he egula o y mechanisms o his igu e,
and in nu sing aining sys ems [1].
Heal hca e 2025,13, 738 h ps://doi.o g/10.3390/heal hca e13070738
Heal hca e 2025,13, 738 2 o 21
I is o be aken in o accoun ha he igu e o APN was bo n in he Uni ed S a es
a he beginning o he 20 h cen u y in he o m o wo oles: Clinical Nu se Specialis s
(CNSs) and Nu se P ac i ione s (NPs). Clinical Nu se Specialis s usually concen a e in
mo e indi ec ca e, mo e linked o non-clinical ac i i ies such as suppo ing he sys em,
educa ion, leade ship, and esea ch, om a sys emic app oach mo e connec ed o in-
hospi al en i onmen s [
1
–
3
]. Nu se P ac i ione s concen a e mo e on di ec ca e, mo e on
clinical ac i i ies such as diagnosis, ea men , and p esc ip ions o he pa ien s in di e en
clinical en i onmen s; hey a e mo e au onomous p o essionals and a e linked o P ima y
Heal h Ca e [
1
,
2
,
4
,
5
]. Ne e heless, he e a e o he e ms iden i ied wi h APNs, such as
expe nu ses, midwi e y nu ses, nu se anaes he is s, ou pa ien ca e nu ses, eme gency
nu ses, and liaison nu ses o case-managemen nu ses, among o he s [5–8].
Following he Uni ed S a es, he igu e o he APN was de eloped in Canada and
in o he coun ies such as he Uni ed Kingdom, Aus alia, New Zealand, Ne he lands,
Sweden, and I eland. I did no each Spain un il he beginning o he 21s cen u y, when
he e was a change in he o ganiza ional models o adap heal h se ices o he popula ion’s
needs. This change was implemen ed in he o m o di e en igu es ac oss di e en heal h
se ices, mos ly as Case-Managemen Nu se [
9
,
10
]. In ac , in Spain, his igu e poses a
majo poli ical, legisla i e, and educa ional challenge, wi h he manda o y equi emen
o de ise laws ha egula e i , de ine i s p o ile, and egula e i s p ocess and in eg a ion
in o he Spanish heal h sys em, as well as o de elop uled uni e si y eaching s a egies
ha a ou sound de elopmen o clinical skills, knowledge, and ision o pe o m i s
du ies [2].
Wi h i s a ied denomina ions, he APN is an impo an igu e in e ms o suppo o
gene alis nu ses due o he di icul ies hey ace in hei e e yday p ac ice, as he pa ien s’
condi ions a e inc easingly complex and demanding, which equi es high ca e quali y
s anda ds [
9
]. I is o u mos impo ance o highligh ha he ca e p o ided o ch onic
pa ien s cons i u es one o he main challenges o mos heal h sys ems [10].
In some cases, li ing wi h ch onic disease can u n ou o be di icul , e en mo e
so when he equi ed and sel -adminis e ed ea men and con ol a e complex. In ac ,
he apeu ic non-adhe ence is one o he main p oblems o ch onici y ca e o be e ec i e.
In his ega d, he APN plays a undamen al ole in imp o ing his ca e [11].
Se e al o ganiza ions speak abou inco po a ing an APN p o ile o he diabe es
app oach, in o de o p omo e complex case esolu ion and ac i e educa ion in he pa-
ien s [
11
,
12
]. Diabe es Melli us (DM) is a complex ch onic disease ha a ec s people o all
ages and social s a uses and equi es con inuing heal h ca e in cha ge o a mul idisciplina y
eam, wi h mul i- ac o ial s a egies o isk educ ion beyond glycaemic con ol. Va ious
in e na ional consensuses ecommend eso ing o he apeu ic educa ion in DM by means
o eam comp ising expe p o essionals wi h gua an eed knowledge; his is c ucial o
achie ing good esul s in he pa ien s, as i will help p omo e quali y o li e imp o emen s,
be e ea men adhe ence, and educ ions in he numbe o complica ions [11].
Based on he abo e, he objec i e p oposed is o analyse he e ec i eness o in e en-
ions ca ied ou by Ad anced P ac ice Nu ses in pa ien s wi h diabe es.
2. Ma e ials and Me hods
2.1. S udy Design
A pee sys ema ic e iew was ca ied ou , ollowing he P e e ed Repo ing I ems o
Sys ema ic Re iews and Me a-Analyses (PRISMA) s a emen and he Coch ane manual o
in e en ion sys ema ic e iews, which ensu e he conduc ion o comple e and igo ous
e iews [
13
,
14
]. The s udy p o ocol was egis e ed in PROSPERO (CRD42023407829) be o e
selec ion and da a ex ac ion.
Heal hca e 2025,13, 738 3 o 21
2.2. Sea ch S a egies and Selec ion C i e ia
The ollowing da abases we e consul ed o iden i y ele an s udies: PubMed, Web
o Science, Scopus, and CINAHL. Two e iewe s conduc ed he sea ches independen ly
om he keywo ds iden i ied on he heme. The sea ch s a egy was: (“Nu se P ac i ione ”
OR “Clinical Nu se Specialis ” OR “APN” OR “Ad anced P ac ice Nu sing” OR “P ac ice
Pa e ns, Nu ses’”) AND “Diabe es Melli us” NOT “Re iew”.
The s udy selec ion c i e ia we e as ollows: (1) published s udies on he e ec i eness
o ad anced p ac ice nu se in e en ions in pa ien s wi h diabe es; (2) s udies employing
quali a i e, quan i a i e, and mixed me hods designs published be ween 2014 and 2024.
The s udies (including p o ocols and p ojec s) in which ou comes o in e es we e nei he
measu ed no epo ed we e no eligible.
2.3. Da a Analysis and Assessmen o A icle Quali y
Two e iewe s selec ed he s udies independen ly acco ding o hei i les and ab-
s ac s and, subsequen ly, as pe he p e-es ablished eligibili y c i e ia. All disag eemen s
ega ding s udy selec ion we e esol ed by consensus wi h a hi d au ho . Subsequen ly,
wo e iewe s sepa a ely ex ac ed he da a om he selec ed a icles, and all au ho s pa -
icipa ed in he discussion and syn hesis o he esul s. A egis a ion o m was designed
ollowing he indica ions se o h in he Coch ane Manual [
14
], de ailing (a) au ho ship
and yea ; (b) s udy design, pe iod, and coun y; (c) he ages and sexes o pa icipan s,
as well as whe he hey belonged o a con ol g oup (CG) o an in e en ion g oup (IG),
i speci ied in he s udy design. Addi ionally, he ou comes measu ed in each s udy, he
ins umen s used o measu emen (whe e applicable), he in e en ions pe o med by he
APN, and hei e ec i eness we e eco ded.
The me hodological quali y o he included s udies was assessed by he wo indepen-
den e iewe s using he ollowing ins umen s (in case o disag eemen , a hi d au ho
was consul ed):
1.
In quali a i e s udies, hose sco ing below 50% on he S anda ds o Repo ing Quali-
a i e Resea ch (SRQR) we e excluded. This ins umen consis s o 21 i ems di ided
in o i e dimensions, p o iding a amewo k and ecommenda ions o epo ing
his ype o esea ch. The ollowing ca ego iza ion, based on he pe cen age o i ems
mee ing he e alua ion c i e ia, was applied: Excellen (80–100%), Good (50–80%),
Fai (30–50%), and Poo (<30%) [15];
2.
In obse a ional s udies, hose sco ing below 12 on he S eng hening he Repo ing o
Obse a ional S udies in Epidemiology (STROBE) checklis we e excluded. This ins u-
men consis s o 22 i ems, wi h a maximum possible sco e o 22. S udies wi h sco es
<12 we e deemed o be o insu icien quali y [16];
3.
In Randomised Con olled T ials (RCTs), s udies sco ing below 4 on he Physio he apy
E idence Da abase (PED o) scale we e excluded. This ins umen comp ises 11 i ems,
each wi h a bina y esponse (“Yes” o “No”), whe e each a i ma i e esponse sco es 1
poin . The maximum sco e is 10, as he i s i em is no conside ed due o i s ele ance
o he ex e nal alidi y o he s udies. The me hodological quali y was ca ego ized as
ollows: Excellen (9–10 poin s), Good (8–6 poin s), Accep able (5–4 poin s), and Poo
(<4 poin s). S udies sco ing below 4 we e o insu icien quali y [17–19];
4.
In mixed-me hod s udies, hose sco ing below 4 on he Good Repo ing o a Mixed
Me hods S udy (GRAMMS) scale we e excluded. This ins umen consis s o six i ems,
wi h a maximum possible sco e o 6. S udies sco ing <4 we e classi ied as being o
insu icien quali y [16,20];
5.
In quasi-expe imen al s udies, hose sco ing below 12 on he T anspa en Repo ing
o E alua ions wi h Non andomised Designs (TREND) checklis we e excluded. This
Heal hca e 2025,13, 738 4 o 21
ins umen comp ises 22 i ems g ouped in o i e domains: i le and abs ac , in o-
duc ion, me hodology, esul s, and discussion [
21
,
22
]. The same sco ing c i e ia as
he STROBE checklis we e applied, gi en he iden ical numbe o i ems and he lack
o e idence o a speci ic cu -o sco e. Acco dingly, s udies wi h sco es <12 we e o
insu icien quali y.
2.4. Risk o Bias Analysis
The Coch ane Risk o Bias (ROB-2) ool (V.2) was employed o assess he isk o bias
in RCTs [
23
–
25
], while he JBI c i ical app aisal ool was u ilised o quasi-expe imen al
s udies [26,27].
3. Resul s
3.1. P esen a ion o he S udies
A o al o se en een s udies me he inclusion c i e ia and we e included (Figu e 1).
The cha ac e is ics o he s udies a e p esen ed in Table S1.
Heal hca e2025,13,xFORPEERREVIEW4o 21


5. Inquasi-expe imen als udies, hosesco ingbelow12on heT anspa en Repo ingo 
E alua ionswi hNon andomisedDesigns(TREND)checklis we eexcluded.Thisin-
s umen comp ises22i emsg oupedin o i edomains: i leandabs ac ,in oduc-
ion,me hodology, esul s,anddiscussion[21,22].Thesamesco ingc i e iaas he
STROBEchecklis we eapplied,gi en heiden icalnumbe o i emsand helacko 
e idence o aspeci iccu -offsco e.Acco dingly,s udieswi hsco es<12we eo in-
sufficien quali y.
2.4.Risko BiasAnalysis
TheCoch aneRisko Bias(ROB-2) ool(V.2)wasemployed oassess he isko bias
inRCTs[23–25],while heJBIc i icalapp aisal oolwasu ilised o quasi-expe imen al
s udies[26,27].
3. Resul s
3.1.P esen a iono  heS udies
A o alo se en eens udiesme  heinclusionc i e iaandwe eincluded(Figu e1).
Thecha ac e is icso  hes udiesa ep esen edinTableS1.

Figu e 1. PRISMA lowdiag amo s udy.
Figu e 1. PRISMA low diag am o s udy.
3.2. Quali y Assessmen and Risk o Bias
Table S2 p esen s he esul s ob ained in he hi d sc eening, ollowing he applica ion
o a ious ools o assess he me hodological quali y o he 28 s udies selec ed a e he
second sc eening. A he end o he hi d sc eening, 17 s udies we e inally selec ed, as
depic ed in he low cha .
Heal hca e 2025,13, 738 5 o 21
Table S3 and Figu e S1 display he esul s o applying he Coch ane Risk o Bias
(ROB-2) ool o RCTs. Table S4 p esen s he esul s o using he JBI c i ical app aisal ool
o quasi-expe imen al s udies.
3.3. Thema ic Analysis
3.3.1. Cha ac e is ics o he Diabe ic Pa ien s Subjec ed o APN In e en ions
Table 1shows he di e en cha ac e is ics o he sample comp ising diabe ic pa ien s
subjec ed o APN in e en ions. The samples o he s udies consis ed bo h o women
and o men [
28
–
43
]. In 50% o hem, he e was a highe pe cen age o women in he
sample [
28
,
29
,
31
,
33
,
34
,
36
,
39
,
41
]; 43.75% had a highe pe cen age o men [
32
,
35
,
37
,
38
,
40
,
42
,
43
];
and he pe cen age o men and women was he same in 6.25% [
30
]. In ela ion o gende ,
one s udy made no e e ence o his aspec [44].
Table 1. Cha ac e is ics o he samples o diabe ic pa ien s wi h in e en ion by he APN.
Au ho s Sample (Age and Sex)
Allen e al. [28]
A o al o 525 pa ien s diagnosed wi h CVD, DM2, HT, and hype choles e olemia.
IG: 261 pa ien s—187 women (71.7%) and 74 men. Mean age: 54 ±12 yea s.
CG: 264 pa ien s—187 women (70.8%) and 77 men. Mean age: 55 ±11.5 yea s.
Mackey e al. [29]
A o al o 714 hospi alised diabe ic pa ien s.
IG: 171 diabe ic pa ien s wi h 222 hospi alisa ions—108 women (63.15%) and 63 men.
Mean age: 61 ±13 yea s.
CG: 543 diabe ic pa ien s wi h 665 hospi alisa ions—483 women (88.95%) and 60 men.
Mean age: 68 ±13 yea s.
Richa dson e al. [30]
26 pa ien s wi h DM2, wi h a mean age o 58 yea s. The sample consis ed o 13 women and
13 men. Only one pa ien had DM2 alone, while he emaining 25 combined DM2 wi h
ano he ch onic condi ion (HT and/o hype lipidaemia).
Kuo e al. [31]
A o al o 64,354 pa ien s wi h DM2:
G oup 1: 14,811 pa ien s, 67.8% o whom we e women. The mean age was 76 ±6.2 yea s.
G oup 2: 49,543 pa ien s, 66.1% o whom we e women. The mean age was 78 ±6.5 yea s.
B umm e al. [32]
IG: 40 diabe ic pa ien s, 95% o whom had DM2. Women accoun ed o 12.5% (n = 5). The
mean age was 64 ±11.4 yea s.
CG: Pa ien s we e compiled om his o ical agg ega ed da a om he in e nal pa ien
e alua ion cen e ega ding diabe es- ela ed eadmissions in 2014.
Ga g e al. [33]
A o al o 151 pa ien s wi h DM2:
IG: 77 pa ien s, 58% (n = 45) we e women. The mean age was 65 ±9.4 yea s.
CG: 74 pa ien s, 59% (n = 44) we e women. The mean age was 63 ±10.5 yea s.
Kuo e al. [34]
A o al o 241 diabe ic pa ien s: 53.11% (n = 128) we e women. The mean age was
56 ±11 yea s. The sample was di ided in o wo g oups:
IG: 162 pa ien s, 53.70% (n = 87) we e women. The mean age was 58 ±11 yea s.
CG: 79 pa ien s, 51.89% (n = 41) we e women. The mean age was 52 ±10 yea s.
Ga dine e al. [35]
A o al o 67 diabe ic pa ien s e e ed a discha ge o he hospi al’s diabe es se ice due o
a his o y o uncon olled diabe es. Women accoun ed o 47.76% (n = 32). The mean age
was 67 yea s.
Ma in e al. [36]
A o al o 269 pa ien s wi h DM2 we e di ided in o wo g oups:
IG: 93 pa ien s, 66.7% (n = 62) we e women. The mean age was 62 ±11.6 yea s.
CG: 176 pa ien s, 65.3% (n = 115) we e women. The mean age was 63 ±10.9 yea s.
Akiboye e al. [37]
In o al, 16,102 pa ien s om he p e-in e en ion s udy, o whom 2337 had diabe es.
Among hese, 43.33% (n = 1106) we e women. The mean age was 71 yea s.
A 6 mon hs pos -in e en ion, 17,353 pa ien s we e assessed, o whom 2433 had diabe es.
Among hese, 45.5% (n = 1107) we e women. The mean age was 71 yea s.

Heal hca e 2025,13, 738 6 o 21
Table 1. Con .
Au ho s Sample (Age and Sex)
Knee e al. [44]
A o al o 979 diabe ic pa ien s we e di ided in o wo g oups:
P e-in e en ion g oup: 443 pa ien s wi h a mean age o 59 yea s. O hese, 46.3% had DM1,
48.5% had DM2, and 5.2% had ano he ype o diabe es.
Pos -in e en ion g oup: 536 pa ien s wi h a mean age o 62 yea s. O hese, 40.1% had
DM1, 53.5% had DM2, and 6.3% had ano he ype o diabe es.
McGloin e al. [38] A o al o 40 diabe ic pa ien s: 42.5% (n = 17) we e women. The mean age was 62 yea s.
Kulsick e al. [39]
A o al o 39 pa ien s wi h diabe es:
P e-in e en ion: 23 pa ien s, 78.26% we e women. Age anged om 65 o >85 yea s.
Pos -in e en ion: 16 pa ien s, 68.75% we e women. Age anged om 65 o >85 yea s.
Yago-Es eban e al. [40]
Diabe ic pa ien s:
Phase 1: 101 pa ien s, 30% o whom we e women. The mean age was 71 ±11 yea s.
Phase 2: 685 pa ien s, 29% o whom we e women. The mean age was 69 ±12 yea s.
Phase 3: 73 pa ien s, 22% o whom we e women. The mean age was 63 ±12 yea s.
Ma sh e al. [41]A o al o 16 pa ien s wi h diabe es: 75% (n = 9) we e women. The mean age was
68 ±3.5 yea s.
Dimond [42] 81 pa ien s wi h DM2, 42% (n = 34) o whom we e women. The mean age was 76 yea s.
Ju e al. [43]A o al o 39 diabe ic pa ien s, 36% o whom we e women. The age ange was om 30 o
o e 60 yea s, wi h 51% o pa ien s aged be ween 50–59 yea s.
DM: Diabe es Melli us; CVD: ce eb o ascula disease; HT: hype ension; IG: in e en ion g oup; CG: con-
ol g oup.
As o he diabe ic pa ien s’ age, he o e all mean ound in he s udies was 64.5 yea s
old. I is o be no ed ha 23.53% o he s udies had samples comp ising people aged
be ween 30 and 50 yea s old [
28
,
30
,
34
,
44
], whe eas 76.5% included pa icipan s aged a
leas 60 yea s old [29,31–33,35–43].
Rega ding he DM diagnosis in he samples om he s udies, 35.3% o he pa ien s had
Type 2 DM (DM2) [
32
,
33
,
36
,
39
,
40
,
42
]. One s udy di e en ia ed i s sample be ween Type 1
DM (DM1) and DM2 [
44
]. Ano he one made a dis inc ion be ween he pa ien s wi h DM2
and hose wi hou [
37
]. Ne e heless, he ype o diabe es p esen ed by he pa ien s was
no speci ied in 41.18% [
29
,
31
,
34
,
35
,
38
,
41
,
43
]. In addi ion, he pa ien s had DM (wi hou
speci ying i s ype) along wi h o he ch onic diseases in wo s udies [28,30].
3.3.2. APN In e en ions in Diabe ic Pa ien s and Thei E ec i eness
Table 2p esen s he a iables and/o ins umen s used in he s udies, as well as he
APN in e en ions ca ied ou and hei e ec i eness.
As o he in e en ions, 70.59% o he s udies ocused on diabe ic
educa ion [
28
,
29
,
32
–
39
,
43
,
44
]. In 35.29% o hem, he in e en ions we e a ge ed a
li es yle changes, ea men adhe ence, p e en ion o complica ions, and d ug p esc ip-
ion [28,33,36,37,39,43]. Diabe ic educa ion was implemen ed in combina ion wi h insulin
he apy aining in wo s udies [
29
,
32
]. Finally, in o he cases, diabe ic educa ion was
combined wi h elemoni o ing suppo [
38
] o wi h insulin sel -injec ion simula ions, in
u n p omo ing ewe ea s, conce ns, and my hs [
34
]. One s udy combined educa ion wi h
suppo and mo i a ion-imp o ing measu es [
35
]. Ano he one included supe ision by
means o a de ice called he Abbo F eeS yle P ecision P o and changing he ea men [
44
].
Two s udies make e e ence o he need o ain, supe ise, and wo k as a eam wi h o he
p o essionals when i comes o implemen ing and p omo ing in e en ions ca ied ou by
APNs [40,41].
Heal hca e 2025,13, 738 7 o 21
Table 2. Va iables and/o ins umen s, in e en ions ca ied ou by APNs, and hei e ec i eness.
Au ho s Va iables and/o
Ins umen s In e en ions E ec i eness
Allen
e al. [28]
HbA1c, BP, and
choles e ol. They we e
measu ed om he ini ial
e alua ion o he
ollow-up one.
The cos s we e assessed
a e one yea .
Leng h o he in e en ion in ime: 1 yea .
IG: An NP and a communi y heal h wo ke we e in
cha ge o implemen ing a p og am o educe he
BVD isks. The NP ca ied ou e idence-based
educa ional and beha iou al in e en ions o
li es yle changes and ea men adhe ence, d ug
p esc ip ion, supe ision o he o he heal h
p o essionals, and consul a ions wi h a physician.
Telephone ollow-up was implemen ed be ween he
isi s. The o he p o essional was in cha ge o
ein o cing he NP’s indica ions.
CG: a physician p o ided eedback on he BVD isks.
A 12 mon hs o he
in e en ion, he IG imp o ed
signi ican ly in e ms o he
LDL, AP, and HbA1c clinical
ou comes when compa ed o
he Cg. These indings we e
also obse ed du ing he
12-mon h ollow-up.
The o al cos a e one yea o
in e en ion was highe in he
IG han in he CG.
Mackey
e al. [29]
NP–PA ela ionship in
diabe es ca e and in using
basal-bolus insulin
he apy (GEE me hod)
The ca e p o ided by
NPs/PAs was associa ed
o lowe glucose alues. I
was measu ed in he i s
and las
24 hospi aliza ion hou s.
The ca e p o ided by
NPs/PAs was associa ed
o lowe glucose alues. I
was measu ed in he i s
and las
24 hospi aliza ion hou s.
Leng h o he in e en ion in ime: he pa ien s’
hospi aliza ion ime.
IG: Diabe es con ol and diabe ic educa ion in
hospi alized diabe ic pa ien s in cha ge o an NP and
an assis an physician, along wi h an
endoc inologis . Each p o essional welcomes he
pa ien , pe o ms baseline e alua ion, and ini ia es a
p elimina y ea men plan, which includes insulin
he apy wi h dose adjus men s, discha ge
ecommenda ions abou diabe es, and ollow-up
wi h an endoc inologis , i necessa y. The p ocess
was e iewed by an endoc inologis .
CG: pa ien s no ecei ing ca e om an NP, assis an
physician, o endoc inologis , bu om ano he
p o essional.
A la ge educ ion in he
HbA1c le els was obse ed
be ween he i s and las 24 h
in he IG pa ien s, when
compa ed o he CG.
Basal-bolus insulin he apy
was adminis e ed o 80% o
he IG pa ien s and o 34% o
he CG ones.
As o diabe es join
managemen , he IG educed
he mean HbA1c le el by
6.96 uni s in he las 24 h
when compa ed o he CG.
Richa dson
e al. [30]
HbA1c, BP, choles e ol,
and body weigh .
Dep ession (PHQ-9) and
sel -e icacy (DES-SF).
E e y hing was measu ed
a he beginning and end
o he in e en ion.
Leng h o he in e en ion in ime: no speci ied.
The Heal hca e E ec i eness Da a and In o ma ion
Se (HEDIS) p ima y ca e ool was used, which
measu es and e alua es da a and in o ma ion abou
he e icacy o he heal h ca e p o ided by NPs. As a
i s s ep, he pa ien s’ medical his o ies we e
e iewed; subsequen ly, an indi idualized ea men
plan was de ined o each pa ien acco ding o hei
medical his o y, clinical da a, medica ions in use,
and social ac o s. Va ious da a we e collec ed o m
he pa ien s be o e and a e he in e en ion o
compa ison pu poses. A e he in e en ion, he
pa ien s we e ollowed-up e e y 2–5 weeks o
5 mon hs. In-pe son and elec onic isi s we e
combined wi h phone calls. The ca e equency was
based on each pa ien ’s needs. I necessa y, o he
p o essionals we e consul ed due o he pa ien s’
complex heal h si ua ion.
A la ge pa o he NP’s
con ac wi h he pa ien s in
he in e en ions was ia
phone calls.
Sel -e icacy imp o ed a e
he in e en ion. Albei
sligh ly, he dep ession sco es
we e educed.
A o al o 50% o he pa ien s
eached he HbA1c le els
de ined as a ge in he s udy
(<8%), as was he case wi h
he BP and choles e ol le els.
Heal hca e 2025,13, 738 8 o 21
Table 2. Con .
Au ho s Va iables and/o
Ins umen s In e en ions E ec i eness
Kuo
e al. [31]
Numbe o
oph halmologic exams,
choles e ol, HbA1c, and
neph opa hy moni o ing.
Ca e con inui y (MMCI).
Leng h o he in e en ion in ime: no speci ied.
The HEDIS p ima y ca e ool was used, which
measu es and e alua es he se o and in o ma ion
abou he e icacy o he heal h ca e p o ided.
IG: he HEDIS p og am was employed o selec
hose pa ien s comp ehensi ely ca ed o by an APN
o assess hei unde going o es s and exams ela ed
o choles e ol, e inog aphies, HbA1c, neph opa hy,
and ea men adhe ence.
CG: he HEDIS p og am was employed o selec
hose pa ien s comp ehensi ely ca ed o by a
physician o assess hei unde going o es s and
exams ela ed o choles e ol, e inog aphies, HbA1c,
neph opa hy, and ea men adhe ence.
The IG p esen ed ewe
como bidi ies, DM
complica ions,
hospi aliza ions, and isi s o
p o essionals he p e ious
yea han he CG.
A lowe p obabili y o
unde going e inog aphies o
HbA1c es s was obse ed in
he IG.
The IG p esen ed less
con inuing ca e and mo e
isi s o specialis s han
he CG.
The IG had lowe DM
ea men adhe ence han
he CG.
The expenses we e simila in
bo h g oups.
B umm
e al. [32]
Rehospi alisa ion a es a
30 days, measu ing hem
du ing a one-yea pe iod.
HbA1c, measu ed du ing
a 3–8-mon h pe iod.
Leng h o he in e en ion in ime: 19 mon hs.
IG: in cha ge o an APN specialised din diabe es; he
pa icipan s we e o e ed a diabe es ansi ion
p og am whe e hey we e ins uc ed abou su i al
skills (p e en ion, ecogni ion, hypoglycaemia
ea men , heal hy habi s, insulin adminis a ion,
oo ca e, e c.). They ecei ed ace- o- ace isi s, an
in o ma ion bookle be o e discha ge, and weekly
ollow-up calls o 30 days.
CG: in cha ge o a PHC nu se; he pa icipan s we e
p o ided s anda d ca e be o e discha ge, p o iding
hem wi h educa ion on diabe es sel -con ol. On
ce ain occasions, he pa ien s ecei ed a ollow-up
call a e discha ge.
A o al o 20% o he pa ien s
had in-pe son isi s and none
o hem was eadmi ed in he
30 days a e discha ge.
A o al o 33 pa ien s had hei
HbA1c le els collec ed be o e
and a e he in e en ion
These le els we e signi ican ly
educed; om 11.3% o 9.1%.
A o al o 11 pa ien s we e no
adminis e ed insulin; 10 had
hei HbA1c le els collec ed
be o e and a e he
in e en ion. A educ ion in
hese le els ( om 11.6% o
7.8%) was obse ed in
hese pa ien s.
The eadmission a e a
30 days was lowe in he IG
agains he CG.
Ga g
e al. [33]
HbA1c, measu ed a
baseline, a 3 mon hs, and
1 yea a e discha ge.
BMI, BP, lipids, enal
unc ion, and u ine
albumin.
Leng h o he in e en ion in ime: 1 yea .
IG: Ca e p o ided by an NP specialised in diabe es
in collabo a ion wi h an endoc inologis , ia weekly
o mon hly phone calls o e iew he HbA1c le els.
Ad ice on die , physical exe cise, and medica ions
was p o ided.
CG: Follow-up in cha ge o a PHC physician.
The e we e no signi ican
di e ences be ween he
pa ien s discha ged wi h
con inuing insulin (IG: 3;
CG: 8) and wi hou insulin
(IG: 4; CG 26) in ei he o he
wo g oups.
The e we e no signi ican
di e ences be ween bo h
g oups in e ms o HbA1c
educ ion a 3 mon hs and
1 yea a e discha ge. The e
was also no associa ion
be ween HbA1c educ ion and
mo e success ul o o al phone
calls made by he NP.
Heal hca e 2025,13, 738 9 o 21
Table 2. Con .
Au ho s Va iables and/o
Ins umen s In e en ions E ec i eness
Kuo
e al. [34]
HbA1c, measu ed be o e
and a e he in e en ion.
Numbe o people who
unde wen he
sel -injec ion simula ion; i
was measu ed a e he
in e en ion.
Leng h o he in e en ion in ime: 1 day.
IG: Diabe es p og am implemen ed by a hospi al
whe e a 2 h g oup isi was ca ied ou in a gi en
mon h wi h g oup o wo–eigh pa ien s in cha ge o
h ee NPs and one CSN specialised in diabe es. The
i s hou was ocused on ea s, conce ns, my hs,
e oneous concep s, glycaemic sel -con ol,
p e en ing complica ions, e c. In u n, he second
hou was ocused on he p ac ice. A e he g oup
isi , he pa ien s could e u n o hei PHC
physician, unde go elephone o in-pe son ollow-up
wi h hei NP, o a end a ollow-up g oup.
CG: S anda d ca e in cha ge o ano he p o essional.
A o al o 54.7% o he IG
pa ien s ini ia ed insulin
ea men , agains 39.4% om
he CG.
92% o he IG pa ien s we e
success ul in hei
sel -injec ion simula ions.
The HbA1c le el was educed
by 13.7% in he IG, 15.3% in
hose who ini ia ed insulin,
and 16% in hose who
pe o med an injec ion
simula ion and s a ed using
insulin he ea e . I only
p esen ed a 0.56% educ ion
in he CG du ing he same
ime pe iod.
By 2–6 mon hs a e he
in e en ion, 54.8% o he IG
pa ien s managed o educe
hei HbA1c le els.
Ga dine
e al. [35]
HbA1c, measu ed a
baseline and 3 mon hs
a e he in e en ion.
Leng h o he in e en ion in ime: no speci ied.
Educa ion in diabe es o diabe ic pa ien s augh by
an NP specialised in he disease and a pa - ime
educa o in diabe es. An a emp was made o
empowe he pa ien s by p o iding hem wi h
knowledge, mo i a ion, and suppo o help hem
p e en complica ions in diabe es.
The e we e signi ican
di e ences in he HbA1c
le els be o e and a e he
in e en ion: om
13.3 mmol/L (be o e) o
11.2 mmol/L (a e ).
The e was a signi ican
educ ion in he HbA1c al
le els when compa ing he
esul s a he discha ge
momen o hose ob ained
3 mon hs a e discha ge.
Ma in
e al. [36]
HbA1c was measu ed a
baseline and a 6, 12, and
24 mon hs
pos -in e en ion.
Du a ion o he in e en ion: no speci ied. A baseline, he IG had highe
HbA1c le els han he CG,
and his di e ence pe sis ed
ac oss he h ee ollow-up
poin s. Howe e , a educ ion
in HbA1c alues was
obse ed in he IG compa ed
o p e-in e en ion le els. In
he CG, HbA1c alues
emained simila a baseline
and ac oss all
ollow-up poin s.
IG: The APN implemen ed he in e en ion using
he ch onic ca e model. The APN p o ided pa ien s
wi h counselling and educa ion on li es yle changes,
including physical ac i i y, and discussions on
ba ie s o achie ing goals. P io o he in e en ion,
an assessmen o ca dio ascula isk ac o s and
physical examina ions was conduc ed.
CG: The physician also implemen ed he
in e en ion using he ch onic ca e model.
Pa ien s who ecei ed ca e
om an APN con inued wi h
his ca e o e ime, whe eas
some pa ien s ini ially
a ended by a physician
e en ually sough ca e om
an APN.
A e each isi wi h he APN, a copy o he pa ien ’s
p og ess was sen o he physician.
Heal hca e 2025,13, 738 16 o 21
ha imp o e he in e ac ion among indi iduals wi h he same pa hology. This, in u n,
os e s expe ience sha ing, cla i ies doub s, acili a es he acquisi ion o new knowledge,
and educes he impac o he pa hology on a pe son’s quali y o li e [53].
Ano he o he in e en ions p oposed is especially linked o wo king as a mul idis-
ciplina y eam, whe e APNs should os e hei aining and supe ision [
40
,
41
]. In ac ,
some au ho s s ess he impo ance o APNs o wo k in an in e disciplina y way, ollowing
s uc u ed coo dina ion o he ca e p o ided in o de o imp o e and ensu e he pa ien s’
quali y o li e [54]. This aspec is also c ucial o imp o e comp ehensi e ca e [31,55].
As o he modali y o he in e en ions (in-pe son, emo e, o mixed), i was in-pe son
in mos o he s udies selec ed [
28
–
32
,
34
–
37
,
39
,
40
,
42
,
44
]. This coincides wi h a ious s udies
al eady conduc ed on he heme [
39
,
45
,
52
,
56
]. O he s udies included he emo e modali y
by eso ing o ideocon e ences o phone calls. Some au ho s ha e pu o wa d he
sui abili y o inco po a ing in e en ions h ough mobile apps o o he emo e de ices [
57
].
The mixed modali y has also been desc ibed in s udies om he cu en e iew [
38
,
41
],
which inds a numbe o au ho s who men ion he use ulness o inco po a ing he in-pe son
modali y o in e en ion along wi h emo e ones, such as phone calls [57].
In ela ion o he p o essional igu e ha was in cha ge o he in e en ions, hey
we e ca ied ou independen ly by APNs in mos o he s udies [
30
–
32
,
34
,
36
–
39
,
42
–
44
],
as al eady desc ibed in o he s udies alien o his e iew [
45
,
55
]. In o he s ud-
ies included, he APNs wo ked along wi h o he p o essionals in implemen ing he
in e en ions [
28
,
29
,
33
,
35
,
40
,
41
]. These indings a e in line wi h o he au ho s who s ess
in e disciplina y wo k coo dina ed wi h o he p o essionals o imp o e he ca e p o ided
and ensu e pa ien ca e quali y [54].
Rega ding he e ec i eness o in e en ions led by APNs, i should be conside ed ha
nea ly all s udies ha e designed hei in e en ions o subsequen ly analyse changes in
pa ien s’ clinical ou comes, especially hose ocused on he HbA1c le els. In gene al, i was
possible o educe hese le els in almos all he s udies [
28
–
30
,
32
,
34
–
36
,
38
–
42
], app oaching
he ecommended alues. This coincides wi h he pos ula es se o h by a ious au ho s
who, when de eloping APN he apeu ic educa ion p og ams wi h pa ien s on insulin,
obse ed a educ ion in he HbA1c le els [45].
Ano he o he aspec s assessed in he s udies selec ed was de e mining how
he in e en ions in luenced he sel -knowledge and sel -e icacy le els a ained by
he pa ien s. In his case, hey we e imp o ed and inc eased in a la ge pa o he
s udies [
30
,
34
,
38
,
39
,
41
,
43
]. This is consis en wi h o he au ho s, who indica e ha hese
aspec s also lead o an imp o emen in ea men adhe ence and, in many cases, o insulin
injec ions, i necessa y [45].
The eadmission a es, hospi alisa ion ime, mo ali y a e, and cos s we e equally
add essed in some o he s udies selec ed, showing educ ions in gene al [
28
,
31
,
32
,
37
,
44
].
In his sense, o he au ho s ha e s a ed how APN in e en ions in a hospi al eme gency
se ice ha e allowed educing he eadmission a es, as well as he pa ien s’ hospi alisa ion
imes [
55
]. In he s udy conduc ed by O doñez-Pied a e al. [
58
], i was possible o educe
he eadmission and mo ali y a es, as well as he cos s. In ela ion o he cos s, a ious
au ho s indica e ha coo dina ion be ween APNs and case-managemen nu ses no only
imp o es he ca e p o ided o he pa ien s and eases hei access o hese heal h se ices bu
also helps educes he economic impac on he consump ion o hospi al supplies and he
cos s associa ed wi h non-e iciencies. APNs manage o educe heal hca e cos s by being
well p epa ed o add ess he challenges o ca e ocused on heal h p omo ion and p e en ion
ac ions, while also s anda dising heal h educa ion [
59
]. Rega ding cos -e ec i eness, some
au ho s indica e ha APNs a e gene ally cos -e icien p o ide s. Howe e , as hei ole,
scope o p ac ice, and paymen mechanisms a y by coun y, u he esea ch wi h clea ly

Heal hca e 2025,13, 738 17 o 21
de ined cos measu es is needed o be e unde s and he po en ial o APNs o educe he
high cos o heal hca e se ices [60].
4.3. Imp o emen S a egies in Rela ion o APNs
Some o he s udies selec ed indica e he need o inc ease he numbe o APN p o-
essionals as an imp o emen s a egy ega ding he ca e p o ided o diabe ic pa ien s,
as hese p o essionals help imp o e he heal h ou comes [
28
,
31
,
32
,
36
]. This inding co-
incides wi h he pos ula es se o h by o he au ho s, who highligh his p o essional
igu e because i has specialised knowledge and skills ha help p o ide e ec i e and
good quali y ca e [
61
]. To inc ease he numbe o APNs and achie e g ea e in eg a ion
in diabe es managemen , i is necessa y o con ince key decision-make s o hei alue,
p omo e educa ional p og ammes o hei aining, and imp o e egula o y amewo ks
and policies [62,63].
The ollowing ha e also been desc ibed as imp o emen s a egies: APNs inco -
po a ing inno a i e me hods o imp o e he esul s, such as pe o ming sel -injec ion
simula ions, glucose con inuous moni o ing, o inco po a ing new echnologies like ideo-
con e ence sessions [
30
,
34
,
42
,
43
]. Va ious au ho s ha e also made e e ence o he sui abili y
o in oducing new me hods, including eso ing o eleheal h op ions o heal h ca e, which
helped imp o e diabe es sel -con ol [
64
]. Ne e heless, when e e ing o eleheal h as
an al e na i e ca e me hod du ing he COVID-19 pandemic, wo sened diabe es quali y
measu es we e obse ed in ano he s udy al eady ca ied ou [65].
Ano he o he imp o emen s a egies p oposed in he s udies was o os e diabe ic
educa ion du ing hospi alisa ion, no limi ing i exclusi ely o p ima y ca e se ices. This
will os e be e ea men adhe ence a e he pa ien s’ discha ge [
39
,
44
]. In ano he s udy,
i is desc ibed how he ca e p o ided by APNs du ing hospi alisa ion imp o ed ea men
adhe ence and inc eased he knowledge le els. This helped educe he HbA1c le els, he
hospi aliza ion imes, and he numbe o eadmissions a e discha ge [66].
The ollowing is also p oposed among he imp o emen s a egies: aining and
quali ying o he p o essionals in diabe es managemen o suppo he specialised eam and
inc ease p o i abili y [
29
,
41
]. This coincides wi h o he au ho s alien o he e iew, who
men ion how aining and quali ica ion o o he p o essionals by APNs (such as heal h
suppo wo ke s) helps educe APNs’ wo kload and imp o e he esul s ob ained [67].
4.4. Limi a ions
The p esen s udy has ce ain limi a ions, which a e as ollows: 1. He e ogenei y in
he design and me hodology o he selec ed s udies. Howe e , se e al au ho s conside
his aspec a sou ce o aluable in o ma ion o esea ch when conduc ed me hodically [
14
].
2. Rega ding he quali y and alidi y o he s udies, i should be no ed ha he majo i y
we e ei he obse a ional o quasi-expe imen al in design, which en ails a highe isk
o bias compa ed o he RCTs included in he e iew. In his ega d, i should also be
conside ed ha o quasi-expe imen al s udies, due o he lack o e idence o es ablish a
cu -o poin o dis inguishing be ween good o poo quali y, he same e e ence h eshold
was applied as o pu ely obse a ional s udies, using he STROBE checklis . 3. Res ic ing
he sea ch s a egy o he las 10 yea s.
5. Conclusions
Rega ding he cha ac e is ics o he sample, mos o he s udies included pa ien s
diagnosed wi h DM2, o e he age o 60, and wi h a highe pe cen age o women.
As o he in e en ions ca ied ou by APNs, signi ican di e si y was obse ed in
e ms o in e en ion ype, as well as in hei numbe , leng h in ime, modali y, and he
Heal hca e 2025,13, 738 18 o 21
p o essional igu e in cha ge o he sessions conduc ed. The in e en ion mos equen ly
desc ibed was diabe ic educa ion, exclusi ely implemen ed by APNs in mos o he cases,
and in he in-pe son modali y, bo h in p ima y ca e en i onmen s and in in-hospi al ones.
Re e ing o e ec i eness, he mos e ec i e in e en ions a e hose ocused on he apeu ic
educa ion, in which APNs coo dina e wi h he es o he heal hca e eam and amilies. This
equi es a high le el o aining o add ess he challenges o diabe es managemen . The APN
in e en ions we e able o imp o e he clinical ou comes in gene al, especially hose ela ed
o he HbA1c le els. Likewise, he pa ien s’ sel -knowledge and sel -e icacy in diabe es
managemen a e imp o ed, which a ou s ea men adhe ence and educing possible
u u e complica ions. In addi ion, i has been desc ibed how APN in e en ions in hese
pa ien s helps educe eadmission and mo ali y a es, hospi alisa ion imes, and cos s.
In ela ion o he imp o emen s a egies, i becomes necessa y o inc ease he numbe
o APNs in he di e en heal h scopes o enhance ca e quali y and he pa ien s’ quali y
o li e. Likewise, p omo ing diabe ic educa ion (bo h in p ima y ca e and in in-hospi al
se ings), os e ing he in oduc ion o new ca e me hods, and encou aging aining and
quali ica ion o o he p o essionals in diabe es managemen as suppo o APNs.
Supplemen a y Ma e ials: The ollowing suppo ing in o ma ion can be downloaded a : h ps:
//www.mdpi.com/a icle/10.3390/heal hca e13070738/s1, Table S1: S udy Cha ac e is ics; Table S2:
Resul s ob ained om assessing he me hodological quali y o he s udies; Table S3: Resul s o
applying he Coch ane Risk o Bias (ROB-2) ool o RCTs; Table S4: Resul s o using he JBI c i ical
app aisal ool o quasi-expe imen al s udies; Figu e S1: Resul s o applying he Coch ane Risk o
Bias (ROB-2) ool o RCTs.
Au ho Con ibu ions: Concep ualiza ion, M.D.G.-M. and A.R.-G.; me hodology, M.D.G.-M., A.R.-G.,
Á.B.-R. and E.M.; o mal analysis, M.D.G.-M., A.R.-G. and E.M.; in es iga ion, M.D.G.-M., A.R.-G.,
Á.B.-R. and E.M.; da a cu a ion, M.D.G.-M., A.R.-G. and E.M.; w i ing—o iginal d a p epa a ion,
M.D.G.-M. and Á.B.-R.; w i ing— e iew and edi ing, M.D.G.-M. and Á.B.-R.; supe ision, M.D.G.-M.
All au ho s ha e ead and ag eed o he published e sion o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen : No applicable.
In o med Consen S a emen : No applicable.
Da a A ailabili y S a emen : No addi ional da a a e a ailable.
Con lic s o In e es : The au ho s decla e no con lic s o in e es .
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