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.

The clinical effectiveness and cost‐effectiveness of clinical nurse specialist‐led hospital to home transitional care: a systematic review

“…We updated the database search by repeating it for the period of 31 July 2012 to 31 July 2013. More details about the search strategy can be found elsewhere [20].…”

Framework for Evaluating the Impact of Advanced Practice Nursing Roles

“…Multiple systematic reviews have demonstrated the effectiveness of APN roles for improving patient health and quality of care and reducing healthcare utilization and costs (Bryant‐Lukosius et al., ; Donald et al., ; Newhouse et al., ). These studies also indicated a need for conceptually stronger evaluation designs to improve the quality of research and to address knowledge gaps about cost effectiveness and how APN roles contribute to improved patient, provider, and health system outcomes (Donald et al., ; Marshall et al., ). There is also a need for research to evaluate the impact of nonclinical APN role activities (e.g., leadership, research; Bryant‐Lukosius, DiCenso, Israr, & Charbonneau‐Smith, ).…”

The Demand for Healthcare Services and Resources: Patterns, Trends and Challenges in Healthcare Delivery

“…However, in the context of this work, where the main focus is on the implementation of the clinical nurse specialist role, the existent reviews present some limitations. Most of them do not differentiate between different types of APNs (NPs and CNSs) (Donald et al;Tsiachristas and de Bont, 2015) or are specifically focused on NPs (Martínez-González et al, 2014a;Newhouse and Heindel, 2011). Additionally, some are outdated (Fulton and Baldwin, 2004) or strictly focused on a specific type of care (such as primary care), on a specific type of ef-fects (such as health outcomes or economic effects), or only dedicated to a specific type of CNSs (certified nurses, for example) (Martínez-González et al, 2014b;Whitehead, 2019).…”