Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review.

BACKGROUND: Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness. OBJECTIVE: To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles. METHODS: Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel. RESULTS: The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles. CONCLUSION: Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.

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

RATIONALE, AIMS AND OBJECTIVES: 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.

Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review.

OBJECTIVE: To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care. DESIGN: A systematic review of randomised controlled trials reported since 1980. DATA SOURCES: 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites. INCLUDED STUDIES: Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes. RESULTS: 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: -€6.41; 95% CI -€9.28 to -€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly. CONCLUSIONS: Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.

A Systematic Review of the Cost-Effectiveness of Clinical Nurse Specialists and Nurse Practitioners in Inpatient Roles.

The objective of this systematic review was to synthesize the evidence of the effectiveness and cost-effectiveness of clinical nurse specialists (CNSs) and nurse practitioners (NPs) working in alternative or complementary roles in inpatient settings. Those in alternative roles substitute for another provider and deliver similar services. Those in complementary roles deliver additional services to meet patient health needs. We searched 10 electronic databases, reference lists, pertinent journals and websites from 1980 to July 2012 with no language, publication or geographical restrictions. Study identification and assessment were completed independently by two-member teams. Internal validity was assessed using the Cochrane Risk of Bias tool. The quality of the economic analysis was evaluated using the Quality of Health Economic Studies (QHES) instrument. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess outcome-specific quality of evidence. Three dated trials evaluated CNS and NP inpatient roles; they were conducted in North America and included 488 adults and 821 neonates. In one study, CNSs in complementary provider roles, when compared with usual care, were equally effective with equal resource use (very low-quality evidence). In two studies, NPs in alternative roles, when compared with physicians, were equally effective with equal-to-more resource use and equal costs (low- to moderate-quality evidence). The quality of the economic analyses was poor. Only three dated studies were identified. More research is needed to determine cost-effectiveness and inform policies and decisions related to the implementation of CNSs and NPs working exclusively in inpatient roles.

Hospital to community transitional care by nurse practitioners: a systematic review of cost-effectiveness.

OBJECTIVES: To determine the cost-effectiveness of nurse practitioners delivering transitional care. DESIGN: Systematic review of randomised controlled trials. DATA SOURCES: Ten electronic databases, bibliographies, hand-searches, study authors, and websites. REVIEW METHODS: We included randomised controlled trials that compared formally trained nurse practitioners to usual care and measured health system outcomes. Two reviewers independently screened articles and assessed study quality using the Cochrane Risk of Bias and the Quality of Health Economic Studies tools. We pooled data for similar outcomes and applied the Grading of Recommendations Assessment, Development and Evaluation tool to rate the quality of evidence for each outcome. RESULTS: Five trials met the inclusion criteria. One evaluated one alternative provider nurse practitioner (154 patients) and four evaluated six complementary provider nurse practitioners (1017 patients). Two were at low and three at high risk of bias and all had weak economic analyses. The alternative provider nurse practitioner had similar patient outcomes and resource use to the physician (low quality). Complementary provider nurse practitioners scored similarly to the control group in patient outcomes except for anxiety in rehabilitation patients (MD: -15.7, 95%CI: -20.73 to -10.67, p<0.001) (very low quality) and patient satisfaction after an abdominal hysterectomy (MD: 14, 95%CI: 3.5-24.5, p<0.01) (low quality), both favouring nurse practitioner care. Meta-analyses of index re-hospitalisation up to 42 days (n=766, pooled relative risk (RR): 0.69, 95%CI: 0.34-1.43, I(2)=0%) and any re-hospitalisation up to 180 days (n=800, pooled RR: 0.87, 95%CI: 0.69-1.09, I(2)=32%) were inconclusive (low quality). Complementary provider nurse practitioners significantly reduced index re-hospitalisation over 90 days (RR: 0.55, 95%CI: 0.32-0.94, p=0.03) and 180 days (RR: 0.62, 95%CI: 0.40-0.95, p=0.03) in complex care patients (both low quality) and they significantly reduced the number and duration of rehabilitation patient-to-staff consultation calls (p<0.05). CONCLUSIONS: Given the low quality evidence, weak economic analyses, small sample sizes, and small number of nurse practitioners evaluated in each study, evidence of the cost-effectiveness of nurse practitioner-transitional care is inconclusive and further research is needed.

A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence?

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 effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review.

RATIONALE, AIMS AND OBJECTIVES: 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.

Speciated arsenic in air: measurement methodology and risk assessment considerations.

Accurate measurement of arsenic (As) in air is critical to providing a more robust understanding of arsenic exposures and associated human health risks. Although there is extensive information available on total arsenic in air, less is known on the relative contribution of each arsenic species. To address this data gap, the authors conducted an in-depth review of available information on speciated arsenic in air. The evaluation included the type of species measured and the relative abundance, as well as an analysis of the limitations of current analytical methods. Despite inherent differences in the procedures, most techniques effectively separated arsenic species in the air samples. Common analytical techniques such as inductively coupled plasma mass spectrometry (ICP-MS) and/or hydride generation (HG)- or quartz furnace (GF)-atomic absorption spectrometry (AAS) were used for arsenic measurement in the extracts, and provided some of the most sensitive detection limits. The current analysis demonstrated that, despite limited comparability among studies due to differences in seasonal factors, study duration, sample collection methods, and analytical methods, research conducted to date is adequate to show that arsenic in air is mainly in the inorganic form. Reported average concentrations of As(III) and As(V) ranged up to 7.4 and 10.4 ng/m3, respectively, with As(V) being more prevalent than As(III) in most studies. Concentrations of the organic methylated arsenic compounds are negligible (in the pg/m3 range). However because of the variability in study methods and measurement methodology, the authors were unable to determine the variation in arsenic composition as a function of source or particulate matter (PM) fraction. In this work, the authors include the implications of arsenic speciation in air on potential exposure and risks. The authors conclude that it is important to synchronize sample collection, preparation, and analytical techniques in order to generate data more useful for arsenic inhalation risk assessment, and a more robust documentation of quality assurance/quality control (QA/QC) protocols is necessary to ensure accuracy, precision, representativeness, and comparability.

Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.

BACKGROUND: Estimates on the epidemiology of chronic non-cancer pain vary widely throughout Europe. It is unclear whether this variation reflects true population differences or methodological factors. Such epidemiological information supports European decision makers in allocating healthcare resources. OBJECTIVE: Pan-Europe epidemiological data about chronic non-cancer pain was obtained using systematic review principles in searching and summarising results. METHODS: Multiple databases (MEDLINE, EMBASE, Cochrane Library, CRD Databases, and GIN) were systematically searched for primary studies containing epidemiological data on chronic non-cancer pain in Europe excluding studies that solely concerned migraines, headaches and pain associated with specific disease conditions. The studies were prioritised according to quality, recency and validity. MAIN OUTCOMES: Eighteen research questions concerning aspects of chronic pain included: prevalence; incidence; pain treatments, control and compliance; treatment satisfaction; and quality of life and economic impacts. RESULTS: The search yielded 16 619 references and 45 were relevant to Europe. Studies for each question were selected that provided the most recent, representative and valid data. There was a clear lack of studies concerning chronic non-cancer pain in Europe as a whole. The 1-month prevalence of moderate-to-severe non-cancer chronic pain was 19%. Chronic pain significantly impacted on patient-perceived health status, affected everyday activities including economic pursuits and personal relationships, and was significantly associated with depressive symptoms. The majority relied on drugs for pain control and NSAIDs were the most frequent drug choice. Despite pain medications, a large proportion had inadequate pain control. CONCLUSION: To the authors' knowledge this is the most comprehensive literature review on epidemiological data in this field. It is clear that chronic pain has a dramatic impact on European society. Since chronic non-cancer pain is treated differently from cancer-related pain, the lack of data in this area clearly underlines the need for decision makers in healthcare to gather further epidemiological data.