title: The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review.
abstract: OBJECTIVE
  Clinical nurse specialists (CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials (RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care.
  
  
  METHODS
  We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. We pooled data for similar outcomes.
  
  
  RESULTS
  Thirteen RCTs of CNS transitional care were identified (n = 2463 participants). The studies had low (n = 3), moderate (n = 8) and high (n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs.
  
  
  CONCLUSIONS
  There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed.
authors.affiliation: School of Nursing and Department of Oncology, McMaster University, Hamilton, Ontario, Canada.|Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.
authors.forename: Denise
authors.initials: D
authors.lastname: Bryant-Lukosius
authors.affiliation: School of Nursing, McMaster University, Hamilton, Ontario, Canada.|Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.
authors.forename: Nancy
authors.initials: N
authors.lastname: Carter
authors.affiliation: KJResearch, Rosemere, Quebec, Canada.
authors.forename: Kim
authors.initials: K
authors.lastname: Reid
authors.affiliation: Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.|Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada.
authors.forename: Faith
authors.initials: F
authors.lastname: Donald
authors.affiliation: Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.|School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Ruth
authors.initials: R
authors.lastname: Martin-Misener
authors.affiliation: Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.|Faculty of Nursing, Université de Montreal, Montréal, Quebec, Canada.
authors.forename: Kelley
authors.initials: K
authors.lastname: Kilpatrick
authors.affiliation: School of Nursing, McMaster University, Hamilton, Ontario, Canada.|Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.|Health Interventions Research Centre, Ryerson University, Toronto, Ontario, Canada.
authors.forename: Patricia
authors.initials: P
authors.lastname: Harbman
authors.affiliation: School of Nursing, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kaasalainen
authors.affiliation: Health Services and Systems Research, University of Calgary, Calgary, Alberta, Canada.|Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
authors.forename: Deborah
authors.initials: D
authors.lastname: Marshall
authors.affiliation: Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.
authors.forename: Renee
authors.initials: R
authors.lastname: Charbonneau-Smith
authors.affiliation: School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Alba
authors.initials: A
authors.lastname: DiCenso
mesh_terms: D000367:Age Factors; D017028:Caregivers / Q000523:psychology; D003362:Cost-Benefit Analysis; D005260:Female; D006333:Heart Failure / Q000401:mortality / Q000628:therapy; D006699:Home Care Services / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D009369:Neoplasms / Q000401:mortality / Q000628:therapy; D009720:Nurse Clinicians / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data*; D010351:Patient Discharge / Q000706:statistics & numerical data; D017060:Patient Satisfaction; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D013997:Time Factors; D000069341:Transitional Care / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data*; D016896:Treatment Outcome
keywords: advanced practice nursing; clinical nurse specialist; cost-effectiveness; economic evaluation; health services research; meta-analysis; randomized controlled trial; systematic review; transition care