• Kelley Kilpatrick, Sharon Kaasalainen, Faith Donald, Kim Reid, Nancy Carter, Denise Bryant-Lukosius, Ruth Martin-Misener, Patricia Harbman, Deborah Anne Marshall, Renee Charbonneau-Smith, and Alba DiCenso.
• Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada; Faculty of Nursing, Université de Montreal, Montreal, Quebec, Canada; Hôpital Maisonneuve-Rosemont Research Centre, Montreal, Quebec, Canada.
• J Eval Clin Pract. 2014 Dec 1; 20 (6): 1106-23.

Rationale, Aims And ObjectivesIncreasing 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.MethodsWe 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.ResultsEleven 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.ConclusionsLow-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.© 2014 John Wiley & Sons, Ltd.

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