Nursing Research and Practice / 2014 / Article / Tab 2

Review Article

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)ParticipantsIntervention (CNS role)Number of sitesNumber of CNSs experience and training

CNS in outpatient setting ()
Alexander, 1988, USCompare CNS () and usual primary continuity care () of poorly controlled noncompliant asthmatic children21 asthmatic children (15 months to 13 years) from low-income families who used the ED as their primary care sourceCNS promoted self-care based on the Orem Self-Care Nursing Model; permission to prescribe was not described (alternative role) 11 CNS 
Education and experience were not reported

Arts, 2012, NLCompare CNS () and physician () care and cost-effectiveness in the treatment of patients with diabetes337 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 lipidsCNS managed diabetes patients in same way as the physicians, including diabetes-related clinical admissions; referrals to specialist care required a physician (alternative role) 14 CNSs 
Doctoral or Masters prepared with extensive experience in diabetes care

Brandon, 2009, USCompare CNS () and usual care () of patients with HF20 adult patients living with HF for >6 months who were capable of self-careCNS provided education, care management and medication adherence advice, and patient support; permission to prescribe was not reported (complementary role) 11 CNS 
Masters prepared* 
Student practicum under cardiologist supervision plus 10-year experience in intensive and coronary care

Brooten, 2001, USCompare CNS ( mother; 94 infants) and usual care ( mothers; 100 infants) of high-risk pregnant women173 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) 13 CNS 
Masters prepared specializing in high-risk pregnancies and infants 
(experience not reported)

Chien, 2012, ChinaCompare psychiatric CNS () and usual care () of patients with psychiatric symptoms79 referred adult (18–49 yrs) patients with first-episode, moderately severe psychiatric symptoms who were at low risk of self-harm or violenceCNS provided 6 sessions of assessment, support system design, coordination of care, and education in symptom management; permission to prescribe was not reported (complementary role) 11 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) [9699]Compare gerontologic CNS education (), CNS education plus consultation () and neither education nor consultation () in the use of physical restraints in nursing homes643 (463 analyzed) residents (>60 yrs) from 3 nursing homesCNS 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) 31 CNS 
Masters prepared 
(experience not reported)

Faithfull, 2001, UKCompare CNS () and usual care () of men treated with radical radiotherapy for prostate and bladder cancer115 men undergoing radical (>60 Gy) radiotherapy for prostate or bladder cancerCNS made initial assessments, had open access clinics during therapy, and made posttherapy telephone contacts; permission to prescribe was not reported (alternative role) 11 CNS 
Masters prepared with expertise in radiotherapy toxicity management* 
(experience not reported)

Ritz, 2000, USCompare 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 systemCNS provided assessments, information, support, and coordination of care; permission to prescribe was not described (complementary role) 12 CNSs 
Masters prepared* 
(experience not reported)

Ryan, 2006, UKCompare rheumatologic CNS plus usual care () and usual care () of patients with rheumatoid arthritis71 patients with diagnosed rheumatoid arthritis who were beginning new disease modifying antirheumatic drugsCNS provided the same service as the outpatient clinic nurse with addition of assessment and referral responsibilities; permission to prescribe was not reported (complementary role) 11 CNS 
Doctoral preparation with 16-year experience in rheumatology*

Swindle, 2003, USCompare mental health CNS () and physician care () of veterans with depression268 new patients with PRIME-MD depression diagnosisCNS 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) 29 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)[100102]Compare CNS outpatient care (), inpatient care (), and day-patient care () of patients with rheumatoid arthritis210 rheumatoid arthritis patients with increasing functional limitationsCNS provided information, referrals, and hardware prescriptions; CNS did not have permission to prescribe or change drugs (alternative role) 66 CNSs 
Education and experience were not reported

CNS in transition role ()
Brooten, 1986, USCompare perinatal CNS-care ( mothers; 39 infants) and usual care ( mothers; 40 infants) of very-low-birth weight infants72 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) 13 CNSs (1 FTE; 2 PTE)  
Masters prepared in perinatal and neonatal nursing

Brooten, 1994, USCompare CNS plus usual care () and usual care () of high risk postpartum women 122 postpartum women who had received an unplanned caesarean deliveryCNS provided comprehensive in hospital and follow-up care with postdischarge home visits and telephone calls (complementary role) 13 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 patients140 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 units80 consecutive elderly patients (≥75 yrs) admitted to nonintensive care units who were expected to stay ≥72 hoursCNS met patients, family, and care providers in hospital and again just prior to discharge; permission to prescribe was not reported (complementary role) 11 CNS 
Masters prepared with additional geriatric knowledge and skills

Laramee, 2003, USCompare CHF CNS plus usual care () and usual care () in the management of HF patients admitted to hospital287 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 oedemaCNS visited patients daily in hospital and made postdischarge telephone contacts (complementary role) 11 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 homeCNS contacted patients after discharge and made home visits and telephone contacts (complementary role) 17 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 surgery149 (123 analyzed) women (≥21 yrs) with suspected ovarian cancer recovering from gynaecological cancer surgery and undergoing chemotherapyCNS provided tailored specialized care through 18 postdischarge patient contacts (complementary role) 21 CNS and 4 NPs* 
Education and experience were not reported

Naylor, 1990, USCompare CNS plus usual care () and usual care () of elderly patients admitted to hospital40 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) 12 PTE CNSs 
Masters prepared

Naylor, 1994, USCompare gerontologic CNS plus usual care () and usual care () of elderly patients admitted to hospital276 English speaking inpatients (≥70 years) admitted from their homes: medical (CHF and angina/MI) and surgical (CABG and CVR) patientsCNS contacted patient in hospital, made postdischarge visits, and was available 7 days/week during hospitalization and after discharge (complementary role) 12 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 hospital363 hospitalized elderly patients (≥65 yrs) admitted to hospital from home who were at risk of readmissionCNS contacted patient in hospital, made home visits and weekly telephone contacts, and individualized patient management; permission to prescribe was not reported (complementary role) 25 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 HF239 HF patients ( ≥65 years) admitted to study hospitals from their homesCNS contacted patients in hospital and after discharge and provided discharge planning, assessments, education, and development and implementation of care goals (complementary role) 63 CNSs 
Masters prepared with specialized training in managing elderly HF patients

Thompson, 2005, UKCompare CNS plus usual care () and usual care () of patients admitted to hospital for HF106 patients with acute admissions to hospital for CHF and left ventricular ejection fraction ≤45%, who were discharged homeCNS provided clinic and home-based care within 10 days of discharge; permission to prescribe was not reported (complementary role) 22 CNSs 
Postgraduate education with HF management experience

York, 1997, USCompare perinatal CNS-facilitated early discharge plus usual care ( mothers; 42 infants) and usual care ( mothers; 51 infants) of high-risk pregnant women96 high-risk pregnant women with either diabetes or hypertension during pregnancyCNS provided in hospital and postdischarge follow-up care; permission to prescribe was not reported (complementary role) 11 CNS 
Masters prepared

CNS in inpatient setting ()
Talley, 1990, USCompare psychiatric liaison CNS consultation () and no consultation () for nursing care and the use of sitters107 acute care patients who had been assigned lay sitters primarily because of a danger of “harm to self” or “generally unpredictable” behaviourCNS provided individualized consultations to patients, nursing staff, and sitters sometimes on multiple occasions; permission to prescribe was not reported (complementary role) 12 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.