title: A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence?
abstract: Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
authors.affiliation: Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3.
authors.forename: Faith
authors.identifier: 0000-0002-0400-627X
authors.initials: F
authors.lastname: Donald
authors.affiliation: Faculty of Nursing, Université de Montreal and Research Centre of Hôpital Maisonneuve-Rosemont, CSA-RC-Aile Bleue-Room F121, 5415 boulevard l'Assomption, Montréal, QC, Canada H1T 2M4.
authors.forename: Kelley
authors.identifier: 0000-0003-2137-6560
authors.initials: K
authors.lastname: Kilpatrick
authors.affiliation: KJ Research, Rosemere, QC, Canada J7A 4N8.
authors.forename: Kim
authors.identifier: 0000-0001-5484-7205
authors.initials: K
authors.lastname: Reid
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Nancy
authors.identifier: 0000-0002-4506-7167
authors.initials: N
authors.lastname: Carter
authors.affiliation: School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2.
authors.forename: Ruth
authors.initials: R
authors.lastname: Martin-Misener
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8 ; Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, Canada L8S 4L8.
authors.forename: Denise
authors.identifier: 0000-0002-8269-7977
authors.initials: D
authors.lastname: Bryant-Lukosius
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8 ; Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3.
authors.forename: Patricia
authors.identifier: 0000-0001-5626-875X
authors.initials: P
authors.lastname: Harbman
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kaasalainen
authors.affiliation: Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6.
authors.forename: Deborah A
authors.initials: DA
authors.lastname: Marshall
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Renee
authors.identifier: 0000-0002-9775-0718
authors.initials: R
authors.lastname: Charbonneau-Smith
authors.affiliation: Fraser Health Authority, Suite 400-13450 102nd Avenue, Surrey, BC, Canada V3T 0H1.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Donald
authors.affiliation: International Affairs and Best Practice Guidelines Centre, Registered Nurses' Association of Ontario, 158 Pearl Street, Toronto, ON, Canada M5H 1L3.
authors.forename: Monique
authors.identifier: 0000-0001-6240-6127
authors.initials: M
authors.lastname: Lloyd
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Abigail
authors.identifier: 0000-0003-1290-5037
authors.initials: A
authors.lastname: Wickson-Griffiths
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Yost
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Pamela
authors.identifier: 0000-0002-8396-8476
authors.initials: P
authors.lastname: Baxter
authors.affiliation: School of Nursing, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC, Canada V8W 2Y2.
authors.forename: Esther
authors.identifier: 0000-0002-3873-3846
authors.initials: E
authors.lastname: Sangster-Gormley
authors.affiliation: The Hospital for Sick Children, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 555 University Avenue, Toronto, ON, Canada M5G 1X8.
authors.forename: Pamela
authors.initials: P
authors.lastname: Hubley
authors.affiliation: Primary Health Care Nurse Practitioner Program, School of Nursing, University of Ottawa, 600 Peter Morand Crescent, Suite 101, Ottawa, ON, Canada K1G 5Z3.
authors.forename: Célyne
authors.initials: C
authors.lastname: Laflamme
authors.affiliation: School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2 ; School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Marsha
authors.initials: M
authors.lastname: Campbell-Yeo
authors.affiliation: School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2.
authors.forename: Sheri
authors.initials: S
authors.lastname: Price
authors.affiliation: School of Health Studies, Western University, Health Sciences Building, Room 403, London, ON, Canada N6A 5B9.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Boyko
authors.affiliation: School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8 ; Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.
authors.forename: Alba
authors.identifier: 0000-0001-6733-728X
authors.initials: A
authors.lastname: DiCenso