A Systematic Review of the Cost-Effectiveness of Nurse Practitioners and Clinical Nurse Specialists: What Is the Quality of the Evidence?

Table 2

Summary of CNS study characteristics.

Author, year, and country (additional publications)	Study objective (number analyzed)	Participants	Intervention (CNS role)	Number of sites	Number of CNSs experience and training
CNS in outpatient setting ()
Alexander, 1988, US	Compare CNS () and usual primary continuity care () of poorly controlled noncompliant asthmatic children	21 asthmatic children (15 months to 13 years) from low-income families who used the ED as their primary care source	CNS promoted self-care based on the Orem Self-Care Nursing Model; permission to prescribe was not described (alternative role)	1	1 CNS; Education and experience were not reported
Arts, 2012, NL	Compare CNS () and physician () care and cost-effectiveness in the treatment of patients with diabetes	337 patients with diabetes treated in a hospital-based setting. All required insulin treatment or oral blood-glucose medication and had inadequate regulation of blood glucose, blood pressure, or lipids	CNS managed diabetes patients in same way as the physicians, including diabetes-related clinical admissions; referrals to specialist care required a physician (alternative role)	1	4 CNSs; Doctoral or Masters prepared with extensive experience in diabetes care
Brandon, 2009, US	Compare CNS () and usual care () of patients with HF	20 adult patients living with HF for >6 months who were capable of self-care	CNS provided education, care management and medication adherence advice, and patient support; permission to prescribe was not reported (complementary role)	1	1 CNS; Masters prepared*; Student practicum under cardiologist supervision plus 10-year experience in intensive and coronary care
Brooten, 2001, US	Compare CNS ( mother; 94 infants) and usual care ( mothers; 100 infants) of high-risk pregnant women	173 pregnant women at high risk due to gestational or pregestational diabetes mellitus, chronic hypertension, or preterm labour with 194 infants	CNS provided prenatal monitoring, assessment, education, counseling, and community referrals; medication regimens were adjusted after physician consultation (complementary role)	1	3 CNS; Masters prepared specializing in high-risk pregnancies and infants; (experience not reported)
Chien, 2012, China	Compare psychiatric CNS () and usual care () of patients with psychiatric symptoms	79 referred adult (18–49 yrs) patients with first-episode, moderately severe psychiatric symptoms who were at low risk of self-harm or violence	CNS provided 6 sessions of assessment, support system design, coordination of care, and education in symptom management; permission to prescribe was not reported (complementary role)	1	1 CNS; Masters prepared* with training in psychosocial interventions for patients with mental health problems; (experience not reported)
Evans, 1997, US (Strumpf et al., 1992; Patterson et al., 1995; Siegler et al., 1997; Capezuti et al., 1998) [96–99]	Compare gerontologic CNS education (), CNS education plus consultation () and neither education nor consultation () in the use of physical restraints in nursing homes	643 (463 analyzed) residents (>60 yrs) from 3 nursing homes	CNS education involved ten 30-minute sessions addressing issues surrounding restraint use; CNS consultation involved 12 hours/week of unit-based consultation for residents with clinically challenging behaviour (complementary role)	3	1 CNS; Masters prepared; (experience not reported)
Faithfull, 2001, UK	Compare CNS () and usual care () of men treated with radical radiotherapy for prostate and bladder cancer	115 men undergoing radical (>60 Gy) radiotherapy for prostate or bladder cancer	CNS made initial assessments, had open access clinics during therapy, and made posttherapy telephone contacts; permission to prescribe was not reported (alternative role)	1	1 CNS; Masters prepared with expertise in radiotherapy toxicity management*; (experience not reported)
Ritz, 2000, US	Compare CNS () and usual care () of breast cancer patients	210 women with newly diagnosed breast cancer (30–85 years) who were referred by their physician and were cared for within the system	CNS provided assessments, information, support, and coordination of care; permission to prescribe was not described (complementary role)	1	2 CNSs; Masters prepared*; (experience not reported)
Ryan, 2006, UK	Compare rheumatologic CNS plus usual care () and usual care () of patients with rheumatoid arthritis	71 patients with diagnosed rheumatoid arthritis who were beginning new disease modifying antirheumatic drugs	CNS provided the same service as the outpatient clinic nurse with addition of assessment and referral responsibilities; permission to prescribe was not reported (complementary role)	1	1 CNS; Doctoral preparation with 16-year experience in rheumatology*
Swindle, 2003, US	Compare mental health CNS () and physician care () of veterans with depression	268 new patients with PRIME-MD depression diagnosis	CNS contacted patients by telephone or visits, while the CNS recommended antidepressant medication and changes to type and dose; permission to prescribe was not reported (complementary role)	2	9 CNSs; 5 had cognitive behavioral treatment training; 9–23-year experience treating depression
Tijhuis, 2002, NL (Tijhuis et al., 2003; Tijhuis et al., 2003; van Den Hout et al., 2003)[100–102]	Compare CNS outpatient care (), inpatient care (), and day-patient care () of patients with rheumatoid arthritis	210 rheumatoid arthritis patients with increasing functional limitations	CNS provided information, referrals, and hardware prescriptions; CNS did not have permission to prescribe or change drugs (alternative role)	6	6 CNSs; Education and experience were not reported
CNS in transition role ()
Brooten, 1986, US	Compare perinatal CNS-care ( mothers; 39 infants) and usual care ( mothers; 40 infants) of very-low-birth weight infants	72 mothers and 79 very-low-birth weight infants (≤1500 g)	CNS contacted parent(s) during infant hospitalization and made home visits and telephone contact; permission to prescribe was not reported (complementary role)	1	3 CNSs (1 FTE; 2 PTE); Masters prepared in perinatal and neonatal nursing
Brooten, 1994, US	Compare CNS plus usual care () and usual care () of high risk postpartum women	122 postpartum women who had received an unplanned caesarean delivery	CNS provided comprehensive in hospital and follow-up care with postdischarge home visits and telephone calls (complementary role)	1	3 CNSs*; Education and experience were not reported
Dellasega, 2000, US (Dellasega and Zerbe, 2002) [103]	Compare CNS plus usual care ( patients; 34 caregivers) and usual care ( patients; 31 caregivers) of elderly frail discharged patients	140 elderly patients who were scheduled to be discharged home, were cognitively frail and/or functionally impaired, or were a complex case (plus 65 caregivers)	CNS or NP visited patient before discharge and after discharge; additional telephone calls or visits were initiated as needed (complementary role)	3*	2 CNSs and 2 NPs; Education and experience were not reported
Kennedy, 1987, US (Neidlinger et al., 1987) [104]	Compare gerontologic CNS plus usual care () and usual care ) of elderly patients admitted to nonintensive care units	80 consecutive elderly patients (≥75 yrs) admitted to nonintensive care units who were expected to stay ≥72 hours	CNS met patients, family, and care providers in hospital and again just prior to discharge; permission to prescribe was not reported (complementary role)	1	1 CNS; Masters prepared with additional geriatric knowledge and skills
Laramee, 2003, US	Compare CHF CNS plus usual care () and usual care () in the management of HF patients admitted to hospital	287 patients at risk of early readmission who had been admitted to hospital for primary or secondary CHF, left ventricular dysfunction <40%, or radiologic evidence of pulmonary oedema	CNS visited patients daily in hospital and made postdischarge telephone contacts (complementary role)	1	1 CNS; Masters prepared with 18-year experience in critical care and cardiology
McCorkle, 2000, US (Jepson et al., 1999) [105]	Compare CNS plus usual care () and usual care () of older postsurgical cancer patients	375 older (60–92 yrs) newly diagnosed solid-tumor cancer patients discharged after surgery to their home	CNS contacted patients after discharge and made home visits and telephone contacts (complementary role)	1	7 CNSs*; Completed 2-year program in oncology
McCorkle, 2009, US (McCorkle et al., 2011) [106]	Compare oncology CNS plus usual care () and usual care () of women recovering from gynecological cancer surgery	149 (123 analyzed) women (≥21 yrs) with suspected ovarian cancer recovering from gynaecological cancer surgery and undergoing chemotherapy	CNS provided tailored specialized care through 18 postdischarge patient contacts (complementary role)	2	1 CNS and 4 NPs*; Education and experience were not reported
Naylor, 1990, US	Compare CNS plus usual care () and usual care () of elderly patients admitted to hospital	40 English speaking inpatients (≥70 years) who had been admitted to hospital from home.	CNS contacted patients in hospital, implemented the discharge plan, and contacted patients after discharge while coordinating with PCP and providing telephone outreach (complementary role)	1	2 PTE CNSs; Masters prepared
Naylor, 1994, US	Compare gerontologic CNS plus usual care () and usual care () of elderly patients admitted to hospital	276 English speaking inpatients (≥70 years) admitted from their homes: medical (CHF and angina/MI) and surgical (CABG and CVR) patients	CNS contacted patient in hospital, made postdischarge visits, and was available 7 days/week during hospitalization and after discharge (complementary role)	1	2 PTE CNSs; Masters prepared with at least one year experience as a specialist
Naylor, 1999, US (Naylor and McCauley, 1999) [107]	Compare gerontologic CNS plus usual care () and usual care () of elderly patients admitted to hospital	363 hospitalized elderly patients (≥65 yrs) admitted to hospital from home who were at risk of readmission	CNS contacted patient in hospital, made home visits and weekly telephone contacts, and individualized patient management; permission to prescribe was not reported (complementary role)	2	5 PTE CNSs; Masters prepared with a mean of 6.5 years postdegree experience
Naylor, 2004, US (McCauley et al., 2006) [108]	Compare CNS plus usual care () and usual care () of elderly patients hospitalized with HF	239 HF patients ( ≥65 years) admitted to study hospitals from their homes	CNS contacted patients in hospital and after discharge and provided discharge planning, assessments, education, and development and implementation of care goals (complementary role)	6	3 CNSs; Masters prepared with specialized training in managing elderly HF patients
Thompson, 2005, UK	Compare CNS plus usual care () and usual care () of patients admitted to hospital for HF	106 patients with acute admissions to hospital for CHF and left ventricular ejection fraction ≤45%, who were discharged home	CNS provided clinic and home-based care within 10 days of discharge; permission to prescribe was not reported (complementary role)	2	2 CNSs; Postgraduate education with HF management experience
York, 1997, US	Compare perinatal CNS-facilitated early discharge plus usual care ( mothers; 42 infants) and usual care ( mothers; 51 infants) of high-risk pregnant women	96 high-risk pregnant women with either diabetes or hypertension during pregnancy	CNS provided in hospital and postdischarge follow-up care; permission to prescribe was not reported (complementary role)	1	1 CNS; Masters prepared
CNS in inpatient setting ()
Talley, 1990, US	Compare psychiatric liaison CNS consultation () and no consultation () for nursing care and the use of sitters	107 acute care patients who had been assigned lay sitters primarily because of a danger of “harm to self” or “generally unpredictable” behaviour	CNS provided individualized consultations to patients, nursing staff, and sitters sometimes on multiple occasions; permission to prescribe was not reported (complementary role)	1	2 CNSs; Education and experience were not reported

ANP: advanced nurse practitioner; CABG: coronary artery bypass graft; CHF: congestive heart failure; CNS: clinical nurse specialist; CVR: cardiovascular recovery; GP: general practitioner; ED: emergency department; HF: heart failure; FTE: full-time equivalent; Gy: gray (unit of absorbed radiation); MI: myocardial infarction; MSc: Master of Science; NL: The Netherlands; NP: nurse practitioner; PCP: primary care provider; PRIME-MD: primary care evaluation of mental disorders; PTE: part time equivalent; UK: United Kingdom; US: United States.
*Data provided by author.