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.

Nurse practitioner-staffed clinic at Virginia Mason improves care and lowers costs for women with benign breast conditions.

The implementation of a breast clinic based on the use of an advanced registered nurse practitioner at Virginia Mason Medical Center in Seattle, Washington, substantially improved care timeliness and efficiency for women with symptomatic benign breast conditions. Women received their final benign diagnosis in an average of four rather than sixteen days, with fewer imaging studies and physician visits, when compared to a control group. Savings to the employer were estimated at $316 per woman, primarily from increased work productivity. Direct care costs decreased an estimated 19 percent, to $213 per woman. By decreasing both direct medical costs and indirect costs such as work absenteeism and presenteeism, the Virginia Mason Breast Clinic has created substantial savings for providers and employers while delivering care that patients rate highly. This model demonstrates the feasibility of achieving higher quality at lower cost through integrated care.

[Development of a resource-based relative value scale and its conversion factor for advanced nursing practices in the national health insurance].

PURPOSE: The purpose of this study was to develop a resource-based relative value scale (RBRVS) and its conversion factor for advanced nursing practices carried out by critical care nurse practitioners (CCNP) in intensive care units. METHODS: The methodology was developed by calculating CCNP's RBRVS for 32 advanced nursing services based on CCNP's workload and time spent in the context of national health insurance. A cost analysis was performed to estimate the conversion factor of CCNP's RBRVS. The share of CCNP's contribution to fee-for-service in intensive care units was also analyzed. RESULTS: Calculation of the RBRVS of 32 advanced nursing practices showed a range of points from 100.0 to 1,181.4 and an average of 296.1 points. The relevant conversion factor for advanced nursing practices in CCNP were estimated at 37.3-48.4 won. The contribution rate of CCNP's advanced nursing practices in the relative value scale of the national health insurance was estimated at 0.1-31.3%. CONCLUSION: Measuring the economic value of advanced nursing services will be a basis for esta-blishing a reimbursement system for CCNP's practices and thus encourage a social demand for advanced nurse practitioners.

Integrated primary and mental health care: evaluating a nurse-managed center for clients with serious and persistent mental illness.

Nurse-managed centers have been at the forefront of providing ambulatory care alternatives for underserved populations lacking access to care. Following this model, the Center for Integrated Health Care of the College of Nursing at the University of Illinois in Chicago delivers primary and mental health care services to a population of people with serious and persistent mental illness. The authors' experience illustrates the many rewards and challenges that nurse-managed centers face. This article describes their center's model of integrated care, examines selected performance indicators, and discusses the implications, opportunities, and challenges ahead.

Asthma nurse practice improves outcomes and reduces costs in primary health care.

OBJECTIVE: The aim of this study was to elucidate the care of patients with asthma in primary health care from medical, patient self-management, health, quality of life, and health economic perspectives. METHODS: Asthma nurse practice (ANP), an alternative asthma self-management strategy, was compared with traditional asthma care in primary health care in southern Sweden regarding medical history, lifestyle, self-management, symptoms caused by asthma, effects on sick leave, state of health, quality of life and health care costs. The first part of the investigation comprised a retrospective study of a randomly selected sample of patient records of asthmatics (n=152). The second part, lasting 3 months, was prospective and included consecutive patients visits (n=347). RESULTS: The ANP approach showed better results in most of the evaluated outcomes such as asthma quality documentation and self-management and the number of asthma symptoms was significantly lower. From a health economic perspective the results were encouraging with respect to ANP. CONCLUSION: This alternative asthma strategy, ANP, improved asthma care in primary health care and resulted in economic advantages in the health care sector. However the result may only be generalized to other practices working with asthma nurses in the same way.

Integration, capitation, and managed care: transformation of nursing for 21st century health care.

Market-driven reforms and the growth of managed care will transform the nursing profession in the next 5 to 10 years. Managed care will pressure RN-level nursing to justify its costs and advanced training. New roles for nursing will include (a) advanced practice nurses substituting for physicians, (b) nurse case managers coordinating care and aggressively managing patients along care paths, and (c) nurse team leaders organizing patient care and delegating less complex nurse tasks to less trained workers.