title: The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review.
abstract: OBJECTIVE
  Increasing numbers of clinical nurse specialists (CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials (RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles.
  
  
  METHODS
  We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes.
  
  
  RESULTS
  Eleven RCTs, four evaluating alternative provider (n = 683 participants) and seven evaluating complementary provider roles (n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak.
  
  
  CONCLUSIONS
  Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness.
authors.affiliation: Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada; Faculty of Nursing, Université de Montreal, Montreal, Quebec, Canada; Hôpital Maisonneuve-Rosemont Research Centre, Montreal, Quebec, Canada.
authors.forename: Kelley
authors.initials: K
authors.lastname: Kilpatrick
authors.forename: Sharon
authors.initials: S
authors.lastname: Kaasalainen
authors.forename: Faith
authors.initials: F
authors.lastname: Donald
authors.forename: Kim
authors.initials: K
authors.lastname: Reid
authors.forename: Nancy
authors.initials: N
authors.lastname: Carter
authors.forename: Denise
authors.initials: D
authors.lastname: Bryant-Lukosius
authors.forename: Ruth
authors.initials: R
authors.lastname: Martin-Misener
authors.forename: Patricia
authors.initials: P
authors.lastname: Harbman
authors.forename: Deborah Anne
authors.initials: DA
authors.lastname: Marshall
authors.forename: Renee
authors.initials: R
authors.lastname: Charbonneau-Smith
authors.forename: Alba
authors.initials: A
authors.lastname: DiCenso
mesh_terms: D000553:Ambulatory Care / Q000458:organization & administration*; D002170:Canada; D003362:Cost-Benefit Analysis; D019317:Evidence-Based Medicine; D005260:Female; D017048:Health Care Costs; D006801:Humans; D008297:Male; D009720:Nurse Clinicians / Q000191:economics* / Q000706:statistics & numerical data; D024802:Nurse's Role; D010045:Outpatients / Q000706:statistics & numerical data; D011787:Quality of Health Care; D016032:Randomized Controlled Trials as Topic
keywords: ambulatory care; clinical nurse specialist; cost-effectiveness; economic evaluation; health services research; nurse specialist; nursing; outpatient care; systematic reviews