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Lacny S, Zarrabi M, Martin-Misener R, Donald F, Sketris I, Murphy AL, DiCenso A, Marshall DA. Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study. J Adv Nurs 2016; 72:2138-52. [PMID: 27119440 DOI: 10.1111/jan.12989] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
AIMS To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home. BACKGROUND As demand for long-term care increases, alternative care models including nurse practitioners are being explored. DESIGN Cost-effectiveness analysis using a controlled before-after design. METHODS The study included an 18-month 'before' period (2005-2006) and a 21-month 'after' time period (2007-2009). Data were abstracted from charts from 2008-2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves. RESULTS Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%. CONCLUSION Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.
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Affiliation(s)
- Sarah Lacny
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mahmood Zarrabi
- Health Technology Assessment and Innovation Department, Alberta Health Services, Alberta, Canada
| | | | - Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, Ontario, Canada
| | - Ingrid Sketris
- College of Pharmacy, Dalhousie University, Nova Scotia, Canada
| | - Andrea L Murphy
- College of Pharmacy, Dalhousie University, Nova Scotia, Canada
| | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Ontario, Canada
| | - Deborah A Marshall
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Coyne I, Comiskey CM, Lalor JG, Higgins A, Elliott N, Begley C. An exploration of clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners, in Ireland. BMC Health Serv Res 2016; 16:151. [PMID: 27117714 PMCID: PMC4847185 DOI: 10.1186/s12913-016-1412-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 04/19/2016] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Clinical specialist (CS) and advanced practitioner (AP) roles have increased in nursing and midwifery internationally. This study explored clinical practice in sites with and without clinical nurse or midwife specialists or advanced nurse practitioners in Ireland. METHODS Using a case study design, interview, observational and documentary data from postholding sites (CSs or APs employed) were compared with data from non-postholding sites (no CSs or APs employed). Interviews and observations were conducted with postholders (n = 23), and compared with data from healthcare professionals (nurses or midwives, doctors) (n = 23) in matched services. Interviews were held with Directors of Nursing and Midwifery (n = 23), healthcare professionals (n = 41), service users (n = 41) with experience of receiving care or working with postholders, and non-postholders in matched services. The data were analysed using Nvivo (Version 8). RESULTS The findings suggest that postholders' practice appeared to differ from non-postholders' in relation to case management and service provision. Postholders were seen as having an impact on readmission rates, waiting lists/times, collaborative decision-making, continuity of care and workload management. Postholders' autonomy to manage caseloads was perceived to lead to smoother transition of patients/clients through the healthcare system. Service-users' self-reports appeared to appreciate the individualised holistic care provided by postholders. Postholders' role in facilitating person-centred care and promoting interprofessional team working, are essential elements in quality care provision and in global healthcare workforce planning. CONCLUSIONS To meet changing healthcare demands, promote person-centred care, and improve service delivery, more specialist and advanced practice posts in nursing and midwifery should be developed and supported within healthcare.
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Affiliation(s)
- Imelda Coyne
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.
| | - Catherine M Comiskey
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland
| | - Joan G Lalor
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland
| | - Agnes Higgins
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland
| | - Naomi Elliott
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland
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Kilpatrick K, Tchouaket E, Carter N, Bryant-Lukosius D, DiCenso A. Structural and Process Factors That Influence Clinical Nurse Specialist Role Implementation. CLIN NURSE SPEC 2016; 30:89-100. [DOI: 10.1097/nur.0000000000000182] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bryant-Lukosius D, Spichiger E, Martin J, Stoll H, Kellerhals SD, Fliedner M, Grossmann F, Henry M, Herrmann L, Koller A, Schwendimann R, Ulrich A, Weibel L, Callens B, De Geest S. Framework for Evaluating the Impact of Advanced Practice Nursing Roles. J Nurs Scholarsh 2016; 48:201-9. [PMID: 26869323 DOI: 10.1111/jnu.12199] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To address the gap in evidence-based information required to support the development of advanced practice nursing (APN) roles in Switzerland, stakeholders identified the need for guidance to generate strategic evaluation data. This article describes an evaluation framework developed to inform decisions about the effective utilization of APN roles across the country. APPROACH A participatory approach was used by an international group of stakeholders. Published literature and an evidenced-based framework for introducing APN roles were analyzed and applied to define the purpose, target audiences, and essential elements of the evaluation framework. Through subsequent meetings and review by an expert panel, the framework was developed and refined. FINDINGS A framework to evaluate different types of APN roles as they evolve to meet dynamic population health, practice setting, and health system needs was created. It includes a matrix of key concepts to guide evaluations across three stages of APN role development: introduction, implementation, and long-term sustainability. For each stage, evaluation objectives and questions examining APN role structures, processes, and outcomes from different perspectives (e.g., patients, providers, managers, policy-makers) were identified. CONCLUSIONS A practical, robust framework based on well-established evaluation concepts and current understanding of APN roles can be used to conduct systematic evaluations. CLINICAL RELEVANCE The evaluation framework is sufficiently generic to allow application in developed countries globally, both for evaluation as well as research purposes.
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Affiliation(s)
- Denise Bryant-Lukosius
- Associate Professor, School of Nursing and Department of Oncology, Co-Director, Canadian Centre for Advanced Practice Nursing Research, McMaster University, Canada
| | - Elisabeth Spichiger
- Scientific Collaborator, Department of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutical Areas, Bern University Hospital and Lecturer, Institute of Nursing Science, University Basel, Switzerland
| | - Jacqueline Martin
- Executive Head, Department of Nursing and Allied Health Professions, University Hospital Basel, Basel, Switzerland
| | - Hansruedi Stoll
- Clinical Nurse Specialist, Cancer Care, University Hospital Basel, Basel, Switzerland
| | | | - Monica Fliedner
- Advanced Practice Nurse, Palliative Care, Co-Director of the University Centre for Palliative Care and Scientific Collaborator, Department of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutical Areas, Inselspital Bern University Hospital, Bern, Switzerland
| | - Florian Grossmann
- Clinical Nurse Specialist, Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Morag Henry
- Nurse Practitioner, Program Leader, Institute of Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Luzia Herrmann
- Head of Nursing Development, Directorate of Nursing, Medical-Technical and Medical-Therapeutical Areas, Inselspital Bern University Hospital, Basel, Switzerland
| | - Antje Koller
- Advanced Practice Nurse, Departments of Internal Medicine and Palliative Care, Medical Center, University of Freiburg, Freiburg, Germany
| | - René Schwendimann
- Director of Education, Institute of Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Anja Ulrich
- Clinical Nurse Specialist, Geriatric Care, Head of Nursing, Department of Medicine, University Hospital Basel, Basel, Switzerland
| | - Lukas Weibel
- Clinical Nurse Specialist, Cardiology Care, University Hospital Basel, Basel, Switzerland
| | - Betty Callens
- Nurse Practitioner, Family Medicine Center at California Hospital, Los Angeles, CA, USA
| | - Sabina De Geest
- Professor and Director of the Institute of Nursing Science, Faculty of Medicine, University of Basel, Basel, Switzerland and Professor, Academic Centre for Nursing and Midwifery, Faculty of Medicine, KU Leuven, Leuven, Belgium
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Maier CB. The role of governance in implementing task-shifting from physicians to nurses in advanced roles in Europe, U.S., Canada, New Zealand and Australia. Health Policy 2015; 119:1627-35. [DOI: 10.1016/j.healthpol.2015.09.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 09/09/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
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Bryant-Lukosius D, Carter N, Reid K, Donald F, Martin-Misener R, Kilpatrick K, Harbman P, Kaasalainen S, Marshall D, Charbonneau-Smith R, DiCenso A. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract 2015; 21:763-81. [PMID: 26135524 DOI: 10.1111/jep.12401] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2015] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Denise Bryant-Lukosius
- School of Nursing and Department of Oncology, McMaster University, Hamilton, Ontario, Canada.,Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, Ontario, Canada.,Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada
| | - Kim Reid
- KJResearch, Rosemere, Quebec, Canada
| | - Faith Donald
- Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.,Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada
| | - Ruth Martin-Misener
- Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.,School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kelley Kilpatrick
- Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada.,Faculty of Nursing, Université de Montreal, Montréal, Quebec, Canada
| | - Patricia Harbman
- 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
| | | | - Deborah Marshall
- 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
| | | | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Klemenc-Ketis Z, Terbovc A, Gomiscek B, Kersnik J. Role of nurse practitioners in reducing cardiovascular risk factors: a retrospective cohort study. J Clin Nurs 2015; 24:3077-83. [DOI: 10.1111/jocn.12889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Zalika Klemenc-Ketis
- Department of Family Medicine; Medical Faculty; University of Maribor; Maribor Slovenia
- Department of Family Medicine; Medical Faculty; University of Ljubljana; Ljubljana Slovenia
| | - Alenka Terbovc
- Zdravstveni dom Kranj; Osnovno zdravstvo Gorenjske; Kranj Slovenia
| | - Bostjan Gomiscek
- Faculty of Business; University of Wollongong in Dubai; Dubai UAE
- Faculty of Organizational Sciences; University of Maribor; Kranj Slovenia
| | - Janko Kersnik
- Department of Family Medicine; Medical Faculty; University of Maribor; Maribor Slovenia
- Department of Family Medicine; Medical Faculty; University of Ljubljana; Ljubljana Slovenia
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Donald F, Kilpatrick K, Reid K, Carter N, Bryant-Lukosius D, Martin-Misener R, Kaasalainen S, Harbman P, Marshall D, DiCenso A. Hospital to community transitional care by nurse practitioners: a systematic review of cost-effectiveness. Int J Nurs Stud 2015; 52:436-51. [PMID: 25443307 DOI: 10.1016/j.ijnurstu.2014.07.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2014] [Revised: 07/16/2014] [Accepted: 07/20/2014] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada.
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montreal, Research Centre Hôpital Maisonneuve-Rosemont, CSA - RC - Aile bleue - Room F121, 5415 boul. l'Assomption, Montréal, QC H1T 2M4, Canada.
| | - Kim Reid
- KJResearch, Rosemere, QC, Canada.
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28H, Hamilton, ON L8S 4L8, Canada.
| | - Denise Bryant-Lukosius
- School of Nursing and Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON L8S 4L8, Canada.
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS B3H 4R2, Canada.
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, HSC-3N25F, Hamilton, ON L8S 4L8, Canada.
| | - Patricia Harbman
- Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3, Canada; School of Nursing, McMaster University, 1280 Main Street West, HSC-3N28, Hamilton, ON L8S 4L8, Canada.
| | - Deborah Marshall
- Canada Research Chair, Health Services and Systems Research, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada.
| | - Alba DiCenso
- School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8, Canada.
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Marshall DA, Donald F, Lacny S, Reid K, Bryant-Lukosius D, Carter N, Charbonneau-Smith R, Harbman P, Kaasalainen S, Kilpatrick K, Martin-Misener R, DiCenso A. Assessing the quality of economic evaluations of clinical nurse specialists and nurse practitioners: A systematic review of cost-effectiveness. NURSINGPLUS OPEN 2015. [DOI: 10.1016/j.npls.2015.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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