Cost Effectiveness of CNS - 505

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Journal of Evaluation in Clinical Practice ISSN 1365-2753
S Y S T E M AT I C R E V I E W
The clinical effectiveness and cost-effectiveness of clinical

nurse specialist-led hospital to home transitional care:
a systematic review
Denise Bryant-Lukosius RN PhD,1,6 Nancy Carter RN PhD,2,7 Kim Reid MSc,9 Faith Donald NP-PHC
PhD,7,10 Ruth Martin-Misener RN-NP PhD,6,12 Kelley Kilpatrick RN PhD,7,13 Patricia Harbman NP-PHC
PhD,3,7,11 Sharon Kaasalainen RN PhD,4 Deborah Marshall PhD MHSA,14,15 Renee Charbonneau-Smith
RN MSc,8 and Alba DiCenso RN PhD5
1
Associate Professor, School of Nursing and Department of Oncology, 2Assistant Professor, 3Assistant Clinical Professor, 4Associate Professor,
School of Nursing, 5Professor Emeritus, School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, Ontario, Canada
6
Co-Director, 7Affiliate Faculty, 8Knowledge Exchange Specialist, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario,
Canada
9
Director, KJResearch, Rosemere, Quebec, Canada
10
Associate Professor, Daphne Cockwell School of Nursing, 11Postdoctoral Fellow, Health Interventions Research Centre, Ryerson University,
Toronto, Ontario, Canada
12
Associate Professor, School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
13
Assistant Professor, Faculty of Nursing, Université de Montreal, Montréal, Quebec, Canada
14
Canada Research Chair, Health Services and Systems Research, 15Associate Professor, Department of Community Health Sciences, Faculty of
Medicine, University of Calgary, Calgary, Alberta, Canada
Keywords Abstract
advanced practice nursing, clinical nurse
specialist, cost-effectiveness, economic Rationale, aims and objectives Clinical nurse specialists (CNSs) are major providers of
evaluation, health services research, transitional care. This paper describes a systematic review of randomized controlled trials
meta-analysis, randomized controlled trial, (RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional
systematic review, transition care care.
Methods We searched 10 electronic databases, 1980 to July 2013, and hand-searched
Correspondence reference lists and key journals for RCTs that evaluated health system outcomes of CNS
Dr Denise Bryant-Lukosius transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality
School of Nursing of Health Economic Studies tools. The quality of evidence for individual outcomes was
McMaster University assessed using the Grading of Recommendations Assessment, Development and Evalu-
1280 Main Street West ation (GRADE) tool. We pooled data for similar outcomes.
Hamilton, Ontario L8S 4L8 Results Thirteen RCTs of CNS transitional care were identified (n = 2463 participants).
Canada The studies had low (n = 3), moderate (n = 8) and high (n = 2) risk of bias and weak
E-mail: bryantl@mcmaster.ca economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mor-
tality. For patients with heart failure, CNS care delayed time to and reduced death or
Accepted for publication: 14 May 2015
re-hospitalization, improved treatment adherence and patient satisfaction, and reduced
costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care
doi:10.1111/jep.12401
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 mater-
nal 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 evalu-
ation is needed.
Journal of Evaluation in Clinical Practice 21 (2015) 763–781 © 2015 John Wiley & Sons, Ltd. 763
CNS-led transitional care D. Bryant-Lukosius et al.
restrictions based on language, jurisdiction, patient age or practice

Introduction setting, but confirmation that the intervention was delivered by a
Internationally, innovative models of transitional care are being master’s prepared CNS, either in the report or from the authors, was
introduced to improve the quality and safety of care, enhance required. Studies were excluded if outcomes could not be solely
patient and family health care experiences and outcomes, and attributed to the CNS, the control group was exposed to a CNS or
reduce health care costs [1–3]. Transitional care is defined as a they did not include a measure of health system utilization.
comprehensive package of time-limited services tailored to Objective measures of health system utilization including
address health care needs, prevent complications and provide con- health resource use (e.g. length of stay, re-hospitalization) and
tinuous and coordinated care for at-risk populations at key points health care costs (incurred by patients, providers or organiza-
in the care trajectory or when patients are transferred from one tions) were the primary outcomes of interest. Health system uti-
health care setting to another [4]. lization outcomes must be considered in conjunction with patient
Advanced practice nurses are major providers of transitional and provider outcomes and, therefore, additional outcomes
care [4]. The Quality Cost Model of Advanced Practice Nursing included patient/caregiver health status, quality of life and satis-
(APN) Transitional Care was the conceptual foundation for pro- faction with care as well as provider outcomes related to quality
grammes introduced in the 1980s to promote earlier hospital dis- of care and job satisfaction.
charge [5]. This model stresses three elements for evaluating
quality of care: outcomes, patient satisfaction and costs. Clinical
Information sources and search
nurse specialists (CNSs) and nurse practitioners (NPs) are the two
types of advanced practice nurses involved in transitional care. We searched for relevant trials reported from 1980 to July 2012
CNSs have existed since the 1960s [6]. With graduate-level (Fig. 1). We searched 10 electronic bibliographic databases, hand-
education, clinical expertise and experience in a specialized area of searched key journals, reviewed reference lists of relevant papers,
practice, they provide advanced nursing care [7]. Across countries searched websites and contacted authors. We updated the database
there is variability in CNS education and recognition as an search by repeating it for the period of 31 July 2012 to 31 July
advanced practice nursing role [8–10]. Not all countries require 2013. More details about the search strategy can be found else-
CNSs to have a master’s degree in nursing, as recommended for where [20].
advanced practice by the International Council of Nurses [11].
Studies comparing master’s and non-master’s prepared nurses
Study selection and data extraction
indicate that graduate education is important for CNS role enact-
ment consistent with advanced nursing practice [12,13]. Previous Paired reviewers independently screened titles and abstracts of
systematic reviews of specialist nurses indicate that variability in identified citations for relevance. If either reviewer identified a
nurse education may contribute to inconclusive findings and study as relevant, it underwent full-text review by two independent
restrict the generalizability of results [14,15]. reviewers. Study data were extracted by one team member and
Health care administrators and government policy makers reviewed for accuracy and completeness by another. Findings from
report the need for synthesized data about the outcomes of CNS a single study reported in two or more papers were extracted as one
care, especially related to cost-effectiveness, in order to make study. Discrepancies between reviewers were resolved through
evidence-informed decisions about the optimal use of these roles discussion at all stages of the review.
[16,17]. Previous reviews of CNS effectiveness have shown that
the role is associated with improved outcomes [18,19]. However,
Quality assessment
these reviews are limited to studies from one country and have
not focused specifically on CNS transitional care or cost- Modified Cochrane risk of bias criteria were used to assess the
effectiveness of the role. The purpose of this paper is to sum- internal validity of each study [20,23]. Two reviewers (AD and KR)
marize systematic review results specific to the clinical completed the quality assessments independently and authors were
effectiveness and cost-effectiveness of master’s prepared CNSs contacted for any missing information. Eight questions were each
providing transitional care. assigned a high, low or unclear risk of bias and, based on this
assessment, each study received an overall rating of risk of bias as
follows: low (risk in 0–1 category), moderate (risk in 2–3 catego-
Methods ries), high (risk in 4–6 categories) and very high (risk in 7–8
We conducted a systematic review of randomized controlled trials categories).
(RCTs) to evaluate the overall economic impact of CNSs and NPs The 16-item Quality of Health Economic Studies (QHES)
in three situations: inpatient, outpatient and transitional care [20– instrument was used by two reviewers to independently assess
22]. Although this paper reports specifically on CNS transitional each study for the quality of economic analyses [24–26]. Based on
care, the methods have already been described in detail in a com- summary scores ranging from 0 to 100, studies were stratified into
panion paper published in this journal on CNSs in outpatient roles quartiles for extremely poor quality (0–24), poor quality (25–49),
[22]; therefore, the description of methods will be brief. fair quality (50–74) and high quality (75–100). Marshall et al. [27]
report on the details of this assessment.
Where data permitted, we evaluated the quality of the body of
Study eligibility for inclusion
evidence for individual outcomes using the Grading of Recom-
Eligible studies included published and unpublished RCTs compar- mendations Assessment, Development and Evaluation (GRADE)
ing CNS-led transitional care to usual care. There were no study [28] system and GRADEpro software (Cochrane Informatics and
764 © 2015 John Wiley & Sons, Ltd.

D. Bryant-Lukosius et al. CNS-led transitional care
Idenficaon
Records idenfied through electronic Addional records idenfied through other
database searching aer duplicates sources (key journals, author contacts,
removed websites, personal files, reference lists)
(n = 4241) (n = 156)
Inial record review (tle and abstract)

(n = 4397)
Screening
Reasons for exclusion at inial record review
(n = 3981)
Did not meet design criteria: 2468
Did not meet intervenon criteria: 902
Did not meet design and intervenon criteria: 611
Full records retrieved for assessment of

eligibility
Eligibility
(n = 416)
Reasons for exclusion at full record review

(n = 351)
Did not meet design criteria: 35
Did not meet intervenon criteria: 210
Did not meet design and intervenon criteria: 21
Did not meet outcomes criteria: 44
Could not isolate impact of the APN: 38
Study submied for publicaon/in press (author
Included
requested that study be included in future update): 3
Figure 1 Identification and screening of rel- NP and CNS studies included (n = 43) CNS transion studies included (n = 13)
evant studies. Flow diagram adapted from
Moher et al. [29]. APN, advanced practice Constellaons of studies = 15 (37 papers) Constellaon of studies = 6 (12 papers)
nursing; CNS, clinical nurse specialist; NP, Single studies = 28 Single studies = 7
nurse practitioner.
Knowledge Management Department http://tech.cochrane.org/ variables, we calculated a weighted mean difference with a 95%
revman/gradepro). The quality of evidence was considered ‘high confidence interval (CI). For dichotomous outcomes, we calcu-
level’ until downgraded based on potential risk of bias, inconsist- lated an unadjusted pooled risk ratio (RR). A fixed-effects model
ency in results, indirectness of evidence, imprecision and prob- was used because of the small number of studies eligible for
ability of publication bias. pooling. Statistical heterogeneity was examined using the chi-
With each downgrade, the level of confidence in the effect square test for homogeneity and the I2 statistic [23].
estimate decreases and the likelihood that further research may
change the estimate increases. Outcomes were downgraded for
indirectedness if the population, intervention and/or outcome were
Results
not generalizable to real-world situations. The generalizability of Of 4397 unique records, 416 papers underwent full-text review
study results may be limited by the small number of CNSs deliver- with further exclusion of 351 papers (Fig. 1) [29]. Of the 43 RCTs
ing the intervention. To address this issue, we pragmatically estab- included in the overall review, 13 studies reported in 19 papers
lished 10 as the minimum number of CNSs required to generalize evaluated CNS transitional care (Table 1). Twelve studies were
study results to nurses in similar roles. Outcomes with less than 10 conducted in the United States, and one in the United Kingdom.
CNSs were downgraded for indirectedness. More details about how The studies were published in English between 1986 and 2011.
we applied GRADE are provided by Kilpatrick et al. [22]. All 13 studies were superiority trials comparing CNS roles plus
usual care to usual care alone. The Quality Cost Model of APN
Transitional Care [5,30] provided the conceptual basis for most
Data analysis
interventions [31–38]. The studies focused on four populations at
All findings were tabulated separately by outcome with corre- risk for poor health including patients with post cancer surgery
sponding GRADE quality ratings. When studies had comparable [39,40], patients with heart failure [37,41,42], elderly patients
outcomes, the data were combined using the RevMan Analysis [33–36,43] and high-risk pregnant women and low birthweight
statistical package in Review Manager, version 5.1 (Cochrane infants [31,32,38]. Interventions common to most studies included
Collaboration, Copenhagen, Denmark). For continuous outcome discharge planning, care coordination and patient education.
© 2015 John Wiley & Sons, Ltd. 765

Table 1 Characteristics of included studies (N = 13)
766
Author, year, Length of Study
country Study objective Study setting Participants Comparison groups Intervention follow-up quality*
Post-discharge care of patients following surgery for cancer

McCorkle et al. To compare CNS University-affiliated cancer 375 older cancer surgery patients Intervention (n = 190): Oncology CNSs contacted patients within For survival, Low risk of
(2000) [39] post-discharge care to centre in Pennsylvania, discharged home. Newly 7 oncology CNSs (completed 2-year 24 hours of discharge, made three home mean of 24 bias
Jepson et al. usual follow-up care for USA diagnosed with solid tumour programme in oncology) implemented a visits and five telephone contacts over 4 months. QHES: 32
(1999) [50] older post-surgical cancer cancers with ≥6 months predicted standardized nursing intervention weeks. Other outcomes,
CNS-led transitional care
United States patients survival. protocol consisting of standard Responsibilities included patient 6 months
65.6% ≥65 years; 48% male; guidelines, instructional content and assessment and monitoring, management post-discharge.
74.1% white contact schedules. of symptoms and surgical complications,
Control (n = 185): self-care education, counselling, support,
Standard in-hospital post-operative care co-ordination of resources, liaising with
and routine post-discharge follow-up in health care providers.
outpatient surgical clinics. Available on 24-hour basis.
McCorkle et al. To compare CNS Cancer centre-affiliated 123 women ≥21 years undergoing Intervention (n = 63): CNS and NPs provided tailored 6 months Low risk of
(2009) [40] post-discharge care to an teaching hospital in chemotherapy after gynaecological 1 CNS (co-ordinator/lead) + four NPs. A post-discharge care via 18 patient contacts post-surgery bias
McCorkle et al. attention control for Connecticut, USA cancer surgery. Prognosis of ≥6 psychiatric consultation–liaison nurse (eight home visits, seven telephone calls QHES: 45
(2011) [44] post-surgical women with months. also cared for patients in high distress. and three clinic visits) over 6 months.
United States gynaecologic cancers Mean age 60.3 years; 92% white; Control (n = 60): Responsibilities included developing and
19.5% <$29 999 annual income; Post-discharge symptom management maintaining self-management skills,
22.8% $30 000–$59 999; 45.5% by a research assistant (attention facilitating active participation in treatment
≥$60 000; 61.8% with ovarian control) via one home visit and seven decisions, symptom management and
cancer; 73% newly diagnosed; telephone calls over 6 months. monitoring, support, patient education,
66% with late stage. coordination of resources, referrals, direct
nursing care including wound and
medication management.
Post-discharge care of patients with heart failure
Laramee et al. To compare CNS case 550-bed academic medical 287 patients at-risk for early Intervention (n = 141): CNS visited patients daily in-hospital and 12 weeks Moderate
(2003) [41] management to usual centre in Vermont, USA readmission admitted to hospital A single CHF case manager (MSc made telephone contact 1–3 days post-discharge risk of bias
United States care for patients with CHF (serving a largely rural for CHF, left ventricular dysfunction prepared with 18 years of experience in post-discharge and at 1, 2, 3, 4, 6, 8, 10 QHES: 23
area) <40%, or radiologic evidence of critical care and cardiology) provided and 12 weeks.
pulmonary oedema. education plus follow-up care in Responsibilities included early discharge
Mean age 70.7 years; 54.4% male; addition to usual care. planning and care coordination, patient and
43.2% <$15 000 annual income; Control (n = 146): family education, telephone follow-up and
41.8% $15–50 000; 7.7% Usual care that included social service surveillance (e.g. monitoring of symptoms,
>$50 000; 76.3% NYHA Class II or evaluation, dietary consultation, physical laboratory test results, treatment
III therapy/occupational therapy, adherence, appointments, community
medication and CHF education plus resources), promotion of guideline-based
other hospital services. CHF medications.
Naylor et al. To compare CNS Six academic and 239 patients with HF admitted Intervention (n = 118): CNS visited patients daily in hospital and 1 year Moderate
(2004) [37] transitional care to usual community hospitals in from home to hospital. 3 CNSs (MSc prepared with specialized made home visits within 24 hours of post-discharge risk of bias
McCauley et al. post-discharge care for Pennsylvania, USA Mean age 76 years; 42.7% male; training) provided 3-month transitional discharge, weekly for first month, and QHES: 27
(2006) [51] elders with HF 36% black; 64% white; 33.1% care based on the Quality Cost Model bimonthly for next 2 months and was
United States <$10 000 annual income; 26.8% of APN Transitional Care. available by telephone.
$10 000–19 999; 15.9% ≥$20 000 Control (n = 121): Responsibilities included identification of
(24.3% missing income data) Routine hospital discharge care based patient and caregiver goals, individualized
on discharge planning critical paths and care plan developed with physicians,
if referred, standard home care. educational and behavioural strategies to
address patient and caregiver needs, care
coordination, direct patient care and HF
guideline implementation.
© 2015 John Wiley & Sons, Ltd.

D. Bryant-Lukosius et al.
Thompson et al. To compare a CNS-led A district hospital and a Cluster randomization of GP clinics Intervention (n = 58): CNS met patients pre-discharge and made a 6 months Low risk of
(2005) [42] clinic plus home-based general hospital in in area (total number not reported). 2 CNSs (postgraduates experienced in home visit within 10 days post-discharge; post-discharge bias
United Kingdom care to usual Northern England 106 home-discharged patients with HF management) using protocols. patients attended CNS-led HF clinics QHES: 38
post-discharge care for acute admissions to hospital for Control (n = 48): monthly for 6 months.
patients with chronic HF chronic HF and left ventricular Usual care entailing explanation of Hospital responsibilities included education

ejection fraction ≤45%. condition and medications and referral about condition, medications and what to
Mean age 72.5 years; 72.6% male; to post-discharge support as required. expect post-discharge.
74.5% NYHA Class III/IV; 50% with Outpatient appointment 6–8 weeks CNSs were available by telephone during
prior MI. post-discharge. office hours. Home visits involved education
about condition, symptom management and
lifestyle; clinical examination; and history
taking.
CNS-led HF clinic visits involved education,
clinical examination, laboratory tests and
new therapeutic agents. CNSs also referred
to other services.
Post-discharge care of elderly patients
Dellasega et al. To compare CNS and NP Multiple urban hospitals in 140 frail elderly patients discharged Intervention (n = 69 patients and 34 CNS or NP visited patient (and caregiver 6 weeks post- Moderate
(2000) [33] post-discharge care to Pennsylvania, USA home and 65 caregivers. Patients caregivers): where possible) pre-discharge, twice at discharge risk of bias
Dellasega et al. usual care for elderly frail were cognitively and/or functionally Two community health CNSs and two 24–48 hours post-discharge and 2 weeks QHES: 46
(2002) [52] patients and family impaired or medically complex. adult NPs plus RN care (30 patients and post-discharge. Additional telephone calls or
United States caregivers Patients: 17 caregivers had physician-assigned visits initiated as needed.
Mean age 74.4 years; living in rural RN follow-up care). Responsibilities included educating patients
areas Intervention based on the Quality Cost and caregivers about medications, and
Caregivers: Model of APN Transitional Care. illness-related signs and symptoms, health
Mean age 62.4 years. Control (n = 71 patients and 31 promotion and counselling, reviewing
caregivers): discharge instructions.
Standard care involving RN follow-up Specific to caregiver, CNS or NP provided
care if assigned by physician (28 support, taught coping skills and
patients and 11 caregivers had RN encouraged outreach to family and friends
follow-up care). for support.
Mean number of RN visits was two to
three times per week for both groups.
Kennedy et al. To compare CNS 500-bed non-profit acute 80 elderly patients admitted to Intervention (n = 39): CNS met patients, family and care providers 8 weeks Moderate
(1987) [43] discharge planning to care teaching hospital in non-intensive care units and A single gerontological CNS (MSc for about 60 minutes within the first 72 post-discharge risk of bias
Neidlinger et al. usual care for hospitalized Texas, USA expected to stay ≥72 hours. prepared with additional geriatric hours of hospitalization and for 20 minutes QHES: 29
(1987) [45] elderly Reachable by telephone after knowledge and skill) implemented a prior to discharge.
United States discharge. discharge plan in addition to standard Responsibilities included assessment of
Mean age 80.3 years; 47.5% male; discharge care. patient and family needs, identification of
93.8% white; 97.5% had Medicare Control (n = 41): resources and support networks,
coverage; 7.5% had Medicaid Standard discharge planning identification of care needs, coordination of
coverage services, and communication and
clarification of discharge plan to patient and
family.
767
Table 1 Continued
768
Naylor (1990) [34] To compare CNS An urban medical centre, 40 in-patients admitted from home. Intervention (n = 20): CNS made a minimum of two in-patient 12 weeks High risk of
United States discharge planning to USA Mean age 78.8 yrs; 45% male; 2 part-time gerontological CNSs (MSc. visits, evaluated the discharge plan 24 hours post-discharge bias
routine discharge planning 65% white; 35% black; 35% prepared) provided, in addition to before discharge and made two or more QHES: 47
for hospitalized elderly. <$10 000 annual income; angina standard discharge care, discharge telephone calls over 2 weeks
and chronic ischemic heart disease planning based on the protocol tested post-discharge.
most common reasons for by Kennedy et al. [43] and the Brooten Patients had telephone access to CNS
admission. Quality Cost Model of APN Transitional during and following hospitalization.
Care (1988). Responsibilities included patient and
Control (n = 20): caregiver assessment within 24 hours of
Standard discharge care by discharge admission, development and
planning nurse. implementation of discharge plan,
assessment of patient and caregiver
knowledge and skills required
post-discharge.
Naylor et al. To compare CNS Hospital of the University 276 in-patients admitted from Intervention (n = 72 medical; 68 CNS saw patients within 48 hours of 12 weeks High risk of
(1994) [35] discharge planning to of Pennsylvania, USA home, divided into two groups: surgical): admission and every 48 hours in hospital. post-discharge bias
United States routine discharge planning medical and surgical. Two part-time gerontological CNSs Final visit was 24 hours pre-discharge. QHES: 27
for hospitalized elderly Medical group: (MSc prepared with ≥1 year specialist Patients had telephone access to CNS
Mean age 76 years; 49% male; practice) provided, in addition to during hospitalization and 2 weeks
65% white; annual income: 64% standard discharge care, discharge post-discharge.
<$20 000; 36% >$20 000. planning based on the protocol tested CNS made two or more telephone calls
Surgical group: by Kennedy et al. [43] and the Brooten during first 2 weeks post-discharge.
Mean age 75 years; 72% male; Quality Cost Model of APN Transitional Responsibilities included patient and
98% white; annual income: 46% Care (1988). caregiver needs assessment, development
<$20 000; 54% >$20 000. Control (n = 70 medical; 66 surgical): and implementation of discharge plan,
Routine discharge care. patient and caregiver education,
coordination and ongoing evaluation of
discharge plan, communication with primary
care physician and other providers regarding
discharge status.
Naylor et al. To compare CNS A hospital and a medical 363 in-patients admitted from Intervention (n = 177): CNS saw patient within 48 hours of 24 weeks Moderate
(1999a) [36] discharge planning and centre in the University of home with one of eight diagnoses Five part-time gerontological CNSs admission and every 48 hours in-hospital post-discharge risk of bias
(1999b) [53] home follow-up to routine Pennsylvania Health and one or more poor discharge provided in-hospital discharge planning and made at least two home visits (within QHES: 34
United States discharge planning for System in Pennsylvania, outcomes. and post-discharge care (MSc prepared; 48 hours of discharge and 7–10 days
hospitalized elderly USA Mean age 75.4 years; 49.9% male; mean 6.5 years post-degree post-discharge) and at least weekly
55% white; 45% black; 72% with experience). telephone contact.
annual income <$19 000; 28% Intervention was based on the CNS was available by telephone 7 days/
≥$20 000; 30% had CHF. discharge planning protocol tested by week (limited hours).
Kennedy et al. [43] and the Brooten In-hospital responsibilities included
Quality Cost Model of APN Transitional assessment of patient and caregiver
Care (1988). discharge needs, direct clinical care,
Control (n = 186): education and coordination of home
Routine discharge planning. services.
If referred, control group patients Post-discharge responsibilities included
received standard home care. environment assessments; interventions
focusing on medications, symptom
management, diet, activity, sleep, medical
follow-up and emotional status;
collaboration with physicians to adjust
therapies and obtain referrals for services.

Post-discharge care of high-risk pregnant women and infants
Brooten et al. To compare early Neonatal intensive care 72 mothers and 79 very low Intervention (n = 36 mothers and 39 CNS contacted parent(s) shortly after birth 18 months Moderate
(1986) [31] discharge with CNS and intermediate care birthweight infants. infants): and ≥1 per week during infant post-discharge risk of bias
United States follow-up with usual units at the Hospital of Mothers: One full-time and two part-time CNSs hospitalization. QHES: 26
discharge for very low the University of Mean age 23.5 years; 81% black; (MSc prepared in perinatal and neonatal Post-discharge, CNS made home visits at
birthweight infants Pennsylvania, USA 19% white; 65% Medicaid nursing) provided in-hospital and week 1 and month 1, 9, 12 and 18.

(≤1500 g) insurance; 68% annual income post-discharge care for eligible stable Telephone contact three or more times per
<$9999; 21% $10 000–49 000; infants (≤1500 g) and mothers with week for the first 2 weeks and once per
11% >$50 000. satisfactory care-taking skills. week for 8 weeks.
Infants: Control (n = 36 mothers and 40 CNSs were on call for limited hours 7 days
Mean gestational age 30 weeks; infants): per week.
mean birthweight 1167 g. Control infants were discharged In-hospital responsibilities focused on
according to routine nursery practice promoting parent–infant interaction,
when well and weighing about 2200 g. evaluating parent perception and concern,
Parents received support and infant care, infection prevention and
instruction while in hospital but no education.
routine home follow-up care. Prior to discharge, CNS evaluated home
environment and parent’s ability to provide
adequate care.
Post-discharge responsibilities included
physical examination, developmental
screening, confirmation of medical
appointments, assessment of parents’
coping abilities and care-taking skills,
instruction and counselling.
Brooten et al. To compare early Hospital of the University 122 post-partum women with an Intervention (n = 61): CNS provided in-hospital and follow-up care 8 weeks Moderate
(1994) [32] discharge with CNS of Pennsylvania, USA unplanned caesarean delivery. three CNSs provided in-hospital and including two or more home visits and 10 post-partum risk of bias
United States follow-up with usual Mean age 28.5 years; 51.8% black; early post-discharge care (qualifications post-discharge telephone calls (twice a QHES: 33
discharge for women who 43.3% white; 5% other; 36.5% and experience not reported). week for first 2 weeks and weekly for next
had an unplanned Medicaid insurance; 31% <$9999 Intervention mothers met the same 6 weeks). CNSs were on call for limited
caesarean delivery annual income; 25.5% discharge criteria as the control group hours 7 days per week.
$10 000–$24 999; 43.5% ≥$25 000 except for staples and afebrile status. In-hospital responsibilities included
Control (n = 61): discharge planning and evaluation of home
Discharged from hospital at usual time environment and mother’s self-care and
and were afebrile with uncomplicated child care abilities.
wound healing and staples removed. Post-discharge responsibilities included
Control mothers received no routine maternal and infant physical examinations,
follow-up care. assessment of maternal coping abilities and
care-taking skills and arrangement of
medical appointments.
CNSs consulted with physicians, hospital
social services and community groups as
needed.
769
770
Table 1 Continued

York et al. [38] To compare early Hospital setting in United 96 pregnant women with diabetes Intervention (n = 44 mothers and 42 CNS provided in-hospital and post-discharge 8 weeks Moderate
(1997) discharge with CNS States or hypertension during pregnancy. infants): antenatal follow-up care including five or post-partum risk of bias
United States follow-up with usual Telephone access. A single perinatal CNS (MSc prepared) more home visits (within first three QHES: 33
discharge for women Mean age 27.5 years; 81% black; provided in-hospital and early discharge post-discharge days) and 3 weekly phone or
diagnosed with 19% white; 65% public health follow-up care. clinic contacts until delivery.
hypertension or diabetes insurance; 62% below Women had to have met established In-hospital responsibilities included
during pregnancy poverty-level income; 57% criteria before discharge. assessment of ability to assume self and
caesarean section. Control (n = 52 mothers and 51 infant care, knowledge and skills in diabetic
infants): regimen, perceived needs, environment
Discharged routinely from hospital after adequacy for early discharge.
meeting required criteria. There was no Post-natal care included two or more home
routine post-discharge care for control visits and 10 phone contacts during the
patients. 8-week follow-up. Responsibilities included
assessment of mother and infant, support
systems, environmental adequacy,
availability of diabetes-related supplies;
provision of direct care, education and
counselling; and referrals.
CNS consulted with physicians, hospital
social services and community groups as
needed.
*Overall risk of bias was based on a modified version of the Cochrane Risk of Bias [23] tool where studies at risk in one or more category were judged to be at low risk of bias; two to three categories at moderate risk; four to six at high risk;
and seven to eight categories at very high risk of bias. The QHES measured the quality of studies with respect to their health economic analysis. The score ranged from 0 to 100 where studies scoring from 0 to 24 points were judged to be
extremely poor quality, 25 to 49 were poor, 50 to 74 were fair and 75 to 100 were high quality.
APN, advanced practice nursing; CHF, congestive heart failure; CNS, clinical nurse specialist; GP, general practitioner; HF, heart failure; MI, myocardial infarction; MSc, master of science; NP, nurse practitioner; NYHA, New York Heart Association;
QHES, Quality of Health Economic Studies instrument; RN, registered nurse.

Frequent intervention elements were medication review, referrals using a priori subgroup analyses because there were only two
to other providers and services, counselling, emotional support studies; however, it could relate to baseline differences in the 2009
and teaching self-care skills. Other interventions related to car- study [40] with the intervention group reporting more depressive
egiver support, patient safety, wound care, symptom management, symptoms. For health system outcomes, we combined data from
disease monitoring and treatment adherence. the two studies for re-hospitalization at 6 months post-discharge
and found no significant differences.
In summary, two studies evaluated CNS transitional care for 498
Quality assessment
patients following cancer surgery with mixed, low-to-moderate
All but two authors [38,43] responded to our requests to clarify quality findings. CNS care was superior in reducing mortality 2
details about their studies. Three trials were at low, eight at mod- years post-surgery by half, improving uncertainty in illness at 6
erate and two at a high risk of bias. Two trials were at risk of months and reducing primary care visits. Usual care was superior
selection bias, four at risk of detection bias, 10 at risk of attrition in improving functional dependence, physical quality of life,
bias, five at risk of reporting bias and seven at risk of ‘other’ bias depressive symptoms and symptom distress. Neither study
because they had baseline differences for which adjustments were included cost measures. Although the risk of bias for these studies
not made. Details about the specific biases found in these studies was low, when it came to grading each outcome, they were rated
have been reported elsewhere [20]. All the studies compared health down due to imprecision, indirectness (<10 CNSs) and inconsist-
resource use and all but four [33,39,40,42] compared costs. None ency when results were pooled (e.g. for depressive symptoms).
of the studies assessed costs and outcomes jointly resulting in low
QHES scores (23–47 out of 100).
Post-discharge care of patients with
For each of the four patient groups, the studies are described
heart failure
(Table 1) followed by summaries of patient and provider (Table 2)
and health system (Table 3) findings. GRADE was applied to Three studies evaluated early discharge interventions for patients
every outcome for which the required data were available. The with heart failure [37,41,42]. Study participants were 632 men and
outcomes in Tables 2 and 3 are rated as high, moderate, low or women in their early to mid-70s. The interventions were delivered
very low-quality evidence. by one [41], two [42] or three [37] CNSs. They visited patients
while in hospital and had regular post-discharge contact with
patients via telephone [41], home visits [37] or home visits and a
Post-discharge care of patients following
heart failure clinic [42].
surgery for cancer
In the study by Laramee et al. [41], intervention group patients
Two studies evaluated transitional care for patients discharged were more likely to adhere to treatment recommendations includ-
from hospital following surgery for cancer [39,40]. In one study ing weighing themselves daily, checking their ankles and feet for
[39], the participants were 375 men and women (≥60 years of age) swelling, following fluid intake recommendations, following a low
with newly diagnosed solid tumour cancers. Seven oncology CNSs salt diet and taking their medications. There were no group differ-
delivered the 4-week intervention that began within 24 h of hos- ences in the number of patients taking angiotensin-converting
pital discharge and consisted of three home visits and five tele- enzyme inhibitors or angiotensin receptor blockers, taking beta-
phone calls. The second study included 123 women (≥21 years of blockers or achieving target doses of these drugs at 12 weeks.
age) with gynecological cancers [40,44]. A CNS-led team pro- There were no group differences in health resource use or costs.
vided care consisting of eight home visits, seven telephone calls In the study by Naylor et al. [37], the intervention group had a
and three clinic visits over a 6-month period. longer time to death or first re-hospitalization. Quality of life and
In the first study, McCorkle et al. [39] found significantly more functional status at 52 weeks did not differ significantly between
functional dependency in the intervention group at 6 months than groups. For health system outcomes, the intervention group had
the control group. After adjusting for disease stage at diagnosis fewer visiting nurse home visits and lower total costs per patient at
and total length of hospitalization during surgery, the risk of death 52 weeks post-discharge. Other health resource use and cost out-
at 2 years was halved in the intervention group. comes did not differ between groups.
In the second study, the intervention group had lower uncer- In the study by Thompson et al. [42], intervention group
tainty in illness at 6 months signifying an improved ability to patients were more likely to be prescribed a beta-blocker. At 6
determine the meaning of their illness-related events [40]. At 6 months, the groups did not differ significantly in adherence to a
months, there was no group difference in mental quality of life but sodium-restricted diet or in quality of life. Patients in the interven-
the control group had significantly better physical quality of life. tion group had fewer total accumulated re-hospitalization days
McCorkle et al. [44] compared the frequency of primary care (intervention 108 days vs. control 459 days, P < 0.01).
provider visits, emergency room visits and outpatient visits Study results were pooled for patient satisfaction, mortality,
between groups and found a significant reduction in primary care death or re-hospitalization and re-hospitalization outcomes. CNS
visits in the intervention group. Emergency room and outpatient care was associated with improved patient satisfaction at 4 [41]
visits did not differ between groups. and 6 [37] weeks. There were no group differences in mortality at
Data from the two studies [39,40] were combined for depressive 6 months [42] and 52 weeks [37]. CNS care reduced co-end points
symptoms and symptom distress. Usual care was superior to CNS of death or re-hospitalization at 6 months [42] and 52 weeks [37].
care for improving depressive symptoms and symptom distress at Based on all three studies, meta-analysis of re-hospitalization
6 months. There was considerable heterogeneity in the depressive data bordered on significance, in favour of CNS care. Heteroge-
symptom meta-analysis (I2 = 78%) that we could not investigate neity was reduced to I2 = 15% when the study by Thompson et al.

Table 2 Patient and provider outcomes
Intervention effect
size (95% CI) (CNS P-value of GRADE
Outcome (outcome measure) Trial Population n Effect vs. control) effect* quality†

Functional dependence at 6 months (ESDS) McCorkle [39] Cancer surgery 305 MD 1.91 (0.24 to 3.58) 0.03 MOD
Risk of death at 2 years (adjusted) McCorkle [39] Cancer surgery 375 HR 0.49 (0.32 to 0.75) 0.001 NA
Uncertainty in illness at 6 months (MUIS) McCorkle [40] Cancer surgery 123 MD 3.2 (−0.53 to 6.93) 0.0006‡ LOW
Mental quality of life at 6 months (SF-12) McCorkle [40] Cancer surgery 123 MD −3.9 (−7.12 to −0.68) 0.1195‡ MOD
Physical quality of life at 6 months (SF-12) McCorkle [40] Cancer surgery 123 MD −3.8 (−7.92 to 0.32) 0.0019‡ LOW
Depressive symptoms at 6 months (CES-D) McCorkle [39,40] Cancer surgery 430 MD 1.73 (0.28 to 3.18) 0.02 LOW
Symptom distress at 6 months (SDS) McCorkle [39,40] Cancer surgery 428 MD 1.97 (0.73 to 3.21) 0.002 MOD
Adherence: weighed self daily (5-point scale) Laramee [41] Heart failure 287 MD 1.5 (0.62 to 2.38) <0.001 V. LOW
Adherence: checked ankles and feet for swelling (5-point scale) Laramee [41] Heart failure 287 MD 0.2 (0.03 to 0.37) 0.02 LOW
Adherence: fluid recommendations (5-point scale) Laramee [41] Heart failure 287 MD 0.4 (0.14 to 0.66) 0.003 V. LOW
Adherence: low salt diet (5-point scale) Laramee [41] Heart failure 287 MD 0.4 (0.16 to 0.64) <0.001 LOW
Adherence: took medications (5-point scale) Laramee [41] Heart failure 287 MD 0.1 (0.01 to 0.19) 0.04 LOW
Took ACEIs or ARBs at 12 weeks Laramee [41] Heart failure 241 RR 1.06 (0.94 to 1.19) 0.40 MOD
Took BBs at 12 weeks Laramee [41] Heart failure 241 RR 1.12 (0.93 to 1.35) 0.22 LOW
≥ target dose of ACEIs or ARBs at 12 weeks Laramee [41] Heart failure 188 RR 1.28 (0.99 to 1.67) 0.08 LOW
≥ target dose of BBs at 12 weeks Laramee [41] Heart failure 146 RR 1.11 (0.67 to 1.82) 0.72 LOW
Time to death or first rehospitalization Naylor [37] Heart failure 239 Adj IDR 1.65 (1.13 to 2.40) 0.026 NA
Quality of life at 52 weeks (MLWHF quartile) Naylor [37] Heart failure 149 MD 0.2 (−0.36 to 0.76) 0.49 LOW
Functional status at 52 weeks (ESDS quartile) Naylor [37] Heart failure 147 MD 0.2 (−0.3 to 0.7) 0.44 LOW
Prescribed BBs at 6 months Thompson [42] Heart failure 94 RR 3.32 (1.62 to 6.77) <0.001 LOW
Adherence to sodium-restricted diet at 6 months (HBAS) Thompson [42] Heart failure 46 NR NR NS NA
Quality of life at 6 months (MLWHF) Thompson [42] Heart failure 46 MC I – larger mean NS NA
improvement (I −14.2
vs. C −13.7)
Quality of life at 6 months (SF-36 eight subscale dimensions) Thompson [42] Heart failure 41 MC I – larger mean NS NA
improvement for seven
subscales; C – larger
mean improvement for
1 subscale (role
emotional)
Patient satisfaction with care at 4 and 6 weeks (5-point scales Laramee [41]; Heart failure 403 MD 6.09 (3.55 to 8.63) <0.00001 MOD
converted to 100-point scales) Naylor [37]
Mortality at 6 months and 52 weeks of follow-up Naylor [37]; Heart failure 345 RR 0.76 (0.41 to 1.42) 0.40 LOW
Thompson [42]
Death or rehospitalization at 6 months and 52 weeks follow-up Naylor [37]; Heart failure 345 RR 0.73 (0.59 to 0.91) 0.005 LOW
Thompson [42]
Patient medication changes at 1 month Dellasega [33] Elderly patients 140 NR I 0.81 versus C 0.52§ NR NA
Patient cognitive function at 1 month (TICS) Dellasega [33] Elderly patients 140 NR I 34.26 versus 33.52§ NR NA
Patient health status at 1 month (SF-36) Dellasega [33] Elderly patients 140 NR I 3.11 versus C 2.95§ NR NA
Caregiver disability days between weeks 2 and 4 (HDL) Dellasega [52] Elderly patients 32 NR I 0 versus C 122 NS NA
Caregiver physical symptoms between weeks 2 and 4 (HDL) Dellasega [52] Elderly patients 32 NR I 1.50 versus C 2.93 NS NA
Caregiver emotional symptoms between weeks 2 and 4 (HDL) Dellasega [52] Elderly patients 32 NR I 1.19 versus C 1.88 <0.05 NA
Caregiver depression symptoms between weeks 2 and 4 (HDL) Dellasega [52] Elderly patients 32 NR I 5.63 versus C 9.40 <0.05 NA
Caregiver stress between weeks 2 and 4 (Zarit CBI score) Dellasega [52] Elderly patients 32 MD −6.25 (−16.2 to 3.7) 0.22 LOW
Infections during 12 weeks post-discharge Naylor [34] Elderly patients 40 RR 0.7 (0.33 to 1.47) 0.35 LOW
Infections in surgical patients at 2 weeks Naylor [35] Elderly patients 134 RR 2.91 (1.23 to 6.88) 0.004 LOW
Functional status, mental status and perception of health, self-esteem Naylor [35] Elderly patients 276 NR Comparison groups were NR NA
and affect at 6–12 weeks post-discharge ‘similar’
Functional status at 24 weeks (ESDS) Naylor [36] Elderly patients 268 NR NR 0.33 NA
Depressive symptoms at 24 weeks (CES-D) Naylor [36] Elderly patients 268 NR NR 0.20 NA
Patient satisfaction with care at 24 weeks Naylor [36] Elderly patients 268 NR NR 0.92 NA
Mortality during index hospitalization and 6 and 8 weeks Kennedy [43]; Elderly patients 443 RR 1.05 (0.48 to 2.28) 0.90 LOW
post-discharge Naylor [36]
Failure to thrive during 18-month follow-up Brooten [31] VLBW infants 79 RR 0.34 (0.01 to 8.14) 0.51 LOW
Reported abused during 18-month follow-up Brooten [31] VLBW infants 79 RR 0.51 (0.10 to 2.64) 0.42 LOW
In foster care during 18-month follow-up Brooten [31] VLBW infants 79 RR 0.2 (0.01 to 4.14) 0.30 LOW
Poor development during 18-month follow-up (BSDS <80) Brooten [31] VLBW infants 79 RR 1.03 (0.07 to 15.83) 0.99 LOW
Physical growth ≤5th percentile during 18-month follow-up Brooten [31] VLBW infants 79 RR 1.37 (0.33 to 5.72) 0.67 LOW
Infant mortality at 1 year post-discharge Brooten [31] VLBW infants 79 NR I 1 versus C 0 NR NA
Immunized infants at 8 weeks Brooten [32] High-risk pregnancy 123 RR 1.2 (1.01 to 1.43) 0.048 LOW
Maternal anxiety at 8 weeks (MAAC) Brooten [32] High-risk pregnancy 122 NR NR NS NA
Maternal depression at 8 weeks (MAAC) Brooten [32] High-risk pregnancy 122 NR NR NS NA

Table 2 Continued
Intervention effect
size (95% CI) (CNS P-value of GRADE
Outcome (outcome measure) Trial Population n Effect vs. control) effect* quality†
Maternal functional status at 8 weeks (ESDS) Brooten [32]; High-risk pregnancy 122 NR NR NS NA
York [38] 96 NR NS NA
Infant birthweight (g) (women enrolled before delivery) York [38] High-risk pregnancy 54 MD 339 (−40.8 to 718.8) 0.09 LOW
Infant gestational age (weeks) (women enrolled before delivery) York [38] High-risk pregnancy 54 MD 1.0 (−0.34 to 2.34) 0.054 LOW
Infant glucose levels York [38] High-risk pregnancy NR NR NR NS NA
Maternal satisfaction with care at discharge and 8 weeks post-partum Brooten [32]; High-risk pregnancy 218 MD 18.15 (11.9 to 24.4) <0.00001 LOW
(LMOPS) York [38]
5-point scales – patient satisfaction scale (higher score indicates greater satisfaction) and adherence scale (higher score indicates better adherence).
Effect estimate favours intervention: ; effect estimate favours usual care: .
*Reported P-values are in bold font and calculated P-values are in regular font.
†GRADE Working Group grades of evidence: HIGH quality – further research very unlikely to change confidence in the estimate of the effect; MODERATE (MOD) quality – further research
likely to have an important impact on confidence in the estimate of the effect and may change the estimate; LOW quality – further research is very likely to change confidence in the
estimate of the effect and likely to change the estimate; VERY LOW (V. LOW) quality – very uncertain about the estimate of the effect; NA – GRADE was not applied because required
data were not available (e.g. number per group).
‡The calculated 95% confidence intervals were based on raw data, whereas the reported P-values were adjusted for baseline imbalances.
§A weighted average was calculated for the combined intervention groups [registered nurse/advanced practice nursing (RN/APN) + APN only] and control groups (no support + RN only).
ACEI, angiotensin-converting enzyme inhibitor; adj, adjusted; ARB, angiotensin receptor blocker; BB, beta-blocker; BSDS, Bayley Scale Development Score; C, control group; CBI, Caregiver
Burden Interview (higher score indicates greater stress and burden); CES-D, Center for Epidemiological Studies Depression scale (higher score indicates greater number of depressive
symptoms); CI, confidence interval; CNS, clinical nurse specialist; ESDS, Enforced Social Dependency Scale (higher score indicates greater dependency; higher quartile indicates less
dependency); GRADE, Grading of Recommendations Assessment, Development and Evaluation; HBAS, Hill–Bone Adherence Score (higher score indicates greater adherence); HDL,
Health and Daily Living Form (scale range not known); HR, hazard ratio; I, CNS intervention group; IDR, incidence density ratio; LMOPS, LaMonica Oberst Patient Satisfaction scale (higher
score indicates greater satisfaction); MAAC, Maternal Affect Adjective Checklist; MC, mean change from baseline; MD, mean difference between groups; MLWHF, Minnesota Living With
Heart Failure questionnaire (negative change indicates positive improvement in QoL; or divided into quartiles where the higher quartile indicates higher QoL); MUIS, Mishel Uncertainty
in Illness Scale (higher score indicates greater uncertainty); NA, not applicable; NR, not reported; NS, not significant; QoL, quality of life; RR, risk ratio; SDS, Symptom Distress Scale (higher
score indicates greater distress); SF-12, Short Form 12 (higher score indicates better health status); SF-36, short form 36 (positive change denotes improvement in QoL); TICS, Telephone
Interview for Cognition Survey (lower score indicates impairment); VLBW, very low birthweight.
[42] was removed and the meta-analysis of the two remaining and women with mean ages between 75 and 80. The intervention
studies resulted in RR: 0.90, 95% CI 0.73–1.10, P = 0.29 (data not was delivered by one [43], two [34,35] and five [36] CNSs, and two
shown). The study by Thompson et al. [42] found a significant CNSs and two NPs [33]. The CNS visited patients in hospital to
reduction in re-hospitalization in favour of CNS care (RR: 0.51, prepare individualized discharge plans [43] and provided regular
95% CI 0.29–0.91, P = 0.02) (data not shown). Possible explana- post-discharge follow-up home visits [33,36] or telephone calls
tions for the heterogeneity are that, compared with the other two [34,35]. Patients also had telephone access to the CNS as needed.
studies, the study by Thompson et al. [42] was conducted in a In the study by Dellasega and Zerbe [33], there were no signifi-
different country (United Kingdom vs. United States), had a lower cant group differences for patient outcomes but caregivers in the
risk of bias and had a higher QHES score. We pooled data regard- intervention group had better emotional symptom and depression
ing repeat re-hospitalizations for any reason at 90 days [41] and at scores. There were no group differences in health resource use.
52 weeks [37] and found no significant difference between groups. Patient outcomes did not differ significantly between compari-
Finally, based on a meta-analysis of the same two studies, son groups in the study by Kennedy et al. [43] (reported in
CNS care was superior to usual care in reducing length of Neidlinger et al. [45]) and most health system outcomes did not
re-hospitalization stay. differ except for reduced daily hospital costs in the intervention
In summary, three studies, one at low risk and two at moderate group. In the study by Naylor [34], there were no significant
risk of bias, evaluated CNS transitional care in a total of 632 differences in patient (post-discharge infections) or health system
patients with heart failure. There was no instance where usual care (re-hospitalization charges) outcomes at 12 weeks.
performed significantly better than CNS care and a number of Naylor et al. [35] found significantly more infections in surgical
instances where CNS care was superior. CNS care reduced time to patients in the intervention group at 2 weeks. The comparison
death or re-hospitalization and also reduced the combined end groups were described as ‘similar’ in functional status, mental
points of death or re-hospitalization, improved adherence to treat- status, perception of health, self-esteem and affect at 6–12 weeks
ment recommendations and patient satisfaction and reduced costs post-discharge, but P-values were not reported. Number and
and length of re-hospitalization stay (mostly low-quality evidence length of re-hospitalization data are incorporated into meta-
due to imprecision and indirectness). analyses reported below. Time to first re-hospitalization, mean
length of first re-hospitalization stay and mean first re-
hospitalization charges at 12 weeks did not differ between groups
for surgical or medical patients. The 6-week post-discharge health
Five studies evaluated post-discharge interventions for elderly hos- services charge for medical patients was significantly lower in the
pitalized patients [33–36,43]. Study populations included 964 men intervention group.

Table 3 Health system outcomes
Intervention effect size P-value of GRADE

Outcome (outcome measure) Trial n Effect (95% CI) (CNS vs. control) effect* quality†

≥1 re-hospitalization at 6 months post-discharge McCorkle [39,40] 496 RR 1.1 (0.85 to 1.43) 0.46 LOW
Primary care provider visits‡ McCorkle [44] 84 MD −0.84 (−2.35 to 0.67)§ Adj 0.0003 LOW
ER visits‡ McCorkle [44] 28 MD 0.45 (−0.27 to 1.17) 0.22 LOW
Oncology outpatient visits‡ McCorkle [44] 119 MD 0.92 (−0.93 to 2.77) 0.33 LOW
Mean index length of stay (days) Laramee [41] 256 MD −0.9 (−1.99 to 0.19) 0.10 LOW
Outpatient appointments or visits Laramee [41] 251 MD 2.9 (−2.7 to 8.5) 0.28 LOW
ED visits Laramee [41] 251 NR I 0.3 versus C 0.2 NR NA
Cardiologist visits Laramee [41] 251 MD −0.4 (−0.87 to 0.07) 0.09 MOD
Initial admission costs (2000 USD) Laramee [41] 262 MD −$2962 (−$7280 to $1356) 0.18 LOW
Total re-hospitalization costs (2000 USD) Laramee [41] 262 MD $90 (−$3424 to $3604) 0.96 LOW
Total inpatient costs (2000 USD) Laramee [41] 262 MD −$2872 (−$9860 to $4116) 0.31 LOW
Total outpatient costs (2000 USD) Laramee [41] 262 MD $245 (−$199 to $689) 0.28 LOW
Total costs (2000 USD) Laramee [41] 262 MD −$2482 (−$8132 to $3168) 0.39 LOW
CNS intervention cost per patient (2000 USD) Laramee [41] 141 NA $228.52 per patient NA NA
Physician acute care visits Naylor [37] 239 MD 0.0 (−0.39 to 0.39) 0.609 MOD
ER acute care visits Naylor [37] 239 MD −0.2 (−0.43 to 0.03) 0.116 MOD
Visiting nurse home visits Naylor [37] 239 MD −5.2 (−7.71 to −2.69) <0.001 LOW
Physical therapist visits Naylor [37] 239 MD −0.3 (−1.25 to 0.65) 0.703 LOW
Social worker home visits Naylor [37] 239 MD 0.0 (−0.07 to 0.07) 0.678 MOD
Home health aid visits Naylor [37] 239 MD −0.2 (−1.55 to 1.15) 0.286 LOW
Total costs per patient at 52 weeks post-discharge (2001 Naylor [37] 239 NR I $7636 versus C $12 481 0.002§ NA
USD; Lin estimate)
Total accumulated re-hospitalization days among those Thompson [42] 34 NR I 108 versus C 459 days <0.01¶ NA
who were readmitted during 6 months follow-up (total
days)
Re-hospitalization for any reason at 90 days, 6 months Laramee [41]; Naylor 601 RR 0.83 (0.69 to 1.00) 0.06 LOW
and 52 weeks [37]; Thompson [42]
Re-hospitalization more than once for any reason at 90 Laramee [41]; Naylor 495 RR 0.81 (0.57 to 1.13) 0.21 LOW
days and 52 weeks [37]
Length of re-hospitalization stay during 12 and 52 week Laramee [41]; Naylor 215 MD −2.96 (−5.46 to −0.45) 0.02 LOW
follow-up (days) [37]
Informal services for patient at 1 month Dellasega [33] 140 NR I 4.0 versus C 3.6†† NR NA
ER visits for patient at 1 month Dellasega [33] 140 NR I 0.12 versus C 0.12†† NR NA
Hospital visits for patient at 1 month Dellasega [33] 140 NR I 0.21 versus C 0.24†† NR NA
Hospital visits for caregiver between weeks 2 and 4 Dellasega [52] 32 MD 0.19 (−0.01 to 0.39) 0.06 MOD
Physician visits for patient at 1 month Dellasega [33] 140 NR I 2.5 versus C 2.34†† NR NA
Physician visits for caregiver between weeks 2 and 4 Dellasega [52] 32 MD 0 (−0.67 to 0.67) 1.0 LOW
Cost of CNS intervention per patient–caregiver dyad (est. Dellasega [33,52] 69 NA $150 per patient/caregiver NA NA
1998 USD)
Time to re-hospitalization (days) Kennedy [43] 80 NR I 22 versus C 10.8 days NR NA
Post-discharge placement changes at 2 weeks Kennedy [43] 80 NR I ≤ 13% versus C ≤ 13% NS NA
Daily hospital costs (1984 USD) Kennedy [43] 80 NR I $392 versus C $452 0.036 NA
Gross excess hospital revenue per patient (DRG set Kennedy [43] 80 NR I $1194 versus C $283 0.14 NA
payments less costs) (1984 USD)
Mean total hospital costs (1984 USD) Kennedy [43] 80 NR I $3069 versus C $4380 NR NA
Re-hospitalization charge per patient in subgroup of Naylor [34] 11 MD $3805 (−$5351 to $12 961) 0.42 V. LOW
re-hospitalized patients (est. 1989 USD)
Cost for CNS intervention per patient (est. 1989 USD) Naylor [34] 20 NA $43.80 per patient NA NA
Time to first re-hospitalization (days) Naylor [35] 276 MD 10.43 (−1.32 to 22.19) 0.08 LOW
Mean length of stay per first re-hospitalized medical Naylor [35] 142 NR I 7.3 versus C 7.7 days NR NA
diagnostic patient at 12 weeks post-discharge (days)
Mean length of stay per first re-hospitalized surgical Naylor [35] 136 NR I 7.8 versus C 5.2 days NR NA
diagnostic patient at 12 weeks post-discharge (days)
Mean re-hospitalization charges per first re-hospitalized Naylor [35] 142 NR I $32 922 versus C $26 531 NR NA
medical diagnostic patient at 12 weeks post-discharge
(1992 USD)
Mean re-hospitalization charges per first re-hospitalized Naylor [35] 136 NR I $25 847 versus C $17 150 NR NA
surgical diagnostic patient at 12 weeks post-discharge
(1992 USD)
Health services charge for medical DRG patients at 6 Naylor [35] 142 MD −$4293 (−$7515 to −$1071) 0.01 LOW
weeks post-discharge (1992 USD)

Table 3 Continued

Cost of CNS intervention per patient (1992 USD) Naylor [35] 140 NA $93.30 per patient NA NA
Time to re-hospitalization for any reason over 24 weeks Naylor [36] 363 Adj RRR 2.03 (1.34 to 3.08) <0.001 NA
Total aggregate re-hospitalizations for any reason at 24 Naylor [36] 363 NR I 49 versus C 107 <0.001 NA
weeks post-discharge
Multiple re-hospitalizations (≥2) at 24 weeks Naylor [36] 363 RR 0.43 (0.22 to 0.84) 0.01 LOW
Acute care physician visits at 24 weeks Naylor [36] 363 MD −0.1 (−0.55 to 0.35) 0.59 MOD
Acute care ER visits at 24 weeks Naylor [36] 363 MD −0.1 (−0.19 to −0.01) 0.21** LOW
Nurse home visits at 24 weeks (not APN) Naylor [36] 363 MD −4.0 (−6.02 to −1.98) 0.05** LOW
Physiotherapist home visits at 24 weeks Naylor [36] 363 MD 0.4 (−1.36 to 2.16) 0.32 LOW
Occupational therapist home visits at 24 weeks Naylor [36] 363 MD −0.1 (−0.34 to 0.14) 0.95 MOD
Speech therapist home visits at 24 weeks Naylor [36] 363 NR I 0.03 versus C 0 0.31 NA
Social worker home visits at 24 weeks Naylor [36] 363 MD −0.04 (−0.11 to 0.03) 0.23 MOD
Health aid home visits at 24 weeks Naylor [36] 363 MD 0.1 (−2.4 to 2.6) 0.46 LOW
Total aggregate reimbursement costs of any Naylor [36] 363 NR I $427 217 versus C $1 024 218 <0.001 NA
re-hospitalizations at 24 weeks (est. 1998 USD)
Total aggregate reimbursement costs for acute care Naylor [36] 363 NR I $215 378 versus C $214 710 0.72 NA
visits (physician, ED) and home visits (nurses, physical
therapists, occupational therapists, speech therapists,
social workers, health aids) at 24 weeks (est. 1998
USD)
Total reimbursement costs per patient at 24 weeks (est. Naylor [36] 363 MD −$3031 (−$4822 to −$1240) <0.001 LOW
1998 USD)
Length of index hospital stay (days) Kennedy [43]; Naylor 396 MD −0.69 (−1.95 to 0.56) 0.28 LOW
[34,35]
Index hospital charge (1992 USD) Naylor [34,35] 316 MD $1670 (−$2860 to $6210) 0.47 LOW
Any re-hospitalizations shortly after discharge (7 days Kennedy [43]; Naylor 356 RR 0.38 (0.19 to 0.77) 0.007 LOW
and 2 weeks post-discharge) [35]
Any re-hospitalizations 6 and 8 weeks post-discharge Kennedy [43]; Naylor 356 RR 0.63 (0.41 to 0.95) 0.03 LOW
[35]
Any re-hospitalizations 12 and 24 weeks post- discharge Naylor [34–36] 679 RR 0.59 (0.47 to 0.75) <0.0001 LOW
Length of re-hospitalization stay at 12 and 24 weeks Naylor [34,36] 119 MD −2.92 (−5.61 to −0.22) 0.03 LOW
post-discharge (days)
VLBW infant length of hospital stay (days) Brooten [31] 79 MD −11.2 (−17.8 to −4.6) <0.05 LOW
VLBW infant initial hospitalization charge (est. 1985 Brooten [31] 79 MD −$17 420 (−$29 013 to −$5827) 0.003 LOW
USD)
VLBW infant mean physician services charge (est. 1985 Brooten [31] 77 MD −$1716 (−$2925 to −$507) 0.005 LOW
USD)
Mean savings in hospital and physician charge (est. Brooten [31] 77 NR $19 136 per infant NR NA
1985 USD) per VLBW infant
Net savings per VLBW infant (benefit from new Brooten [31] 79 NR $18 560 per infant NR NA
discharge criteria less cost of CNS intervention) (est.
1985 USD)
Total CNS intervention cost per VLBW infant (est. 1985 Brooten [31] 79 NA $576 per infant NA NA
USD)
Maternal re-hospitalizations Brooten [32] 122 RR 0.14 (0.01 to 2.71) 0.19 LOW
Maternal acute care visits Brooten [32] 122 RR 0.46 (0.19 to 1.14) 0.09 LOW
Maternal and infant initial hospitalization charge per Brooten [32] 245 MD −$3233 (−$5831 to −$814) 0.01 LOW
patient (1991 USD)
Maternal and infant re-hospitalization charge per patient Brooten [32] 245 MD −$258 (−$663 to $147) 0.21 LOW
(1991 USD)
Maternal and infant total acute care visit charge per Brooten [32] 245 MD $8 (−$16.80 to $32.80) 0.53 LOW
patient (1991 USD)
Total home caregiver costs per mother–infant dyad Brooten [32] 122 MD −$44 (−$63 to −$25) <0.00001 LOW
(1991 USD)
Maternal and infant total costs and charges per patient Brooten [32] 245 MD −$3326 (−$5836 to −$815) 0.01 LOW
(1991 USD)
Total CNS intervention cost per mother–infant dyad Brooten [32] 122 NA $291 per mother−infant dyad NA NA
(1991 USD) (range $263 to $319)
Infant length of hospital stay (days) York [38] 93 MD −2.7 (−6.67 to 1.27) 0.45 LOW
Maternal re-hospitalizations before delivery York [38] 55 RR 0.7 (0.33 to 1.47) 0.34 LOW
Maternal re-hospitalizations after delivery York [38] 55 NR No difference NS NA
Infant re-hospitalizations York [38] 41 NR No difference NS NA
Maternal acute care visits during pregnancy York [38] 55 RR 0.86 (0.36 to 2.09) 0.76 LOW

Table 3 Continued

Maternal acute care visits after delivery York [38] 55 NR No difference NS NA

Mean total costs and charges per patient (1991 USD) York [38] 97 NR I $17 024 vs. C $30 351 NR NA
Total CNS intervention cost per mother–infant dyad York [38] 44 NA $772 per mother−infant dyad NA NA
(1991 USD)
Maternal post-partum length of hospital stay (days) Brooten [32]; York [38] 215 MD −1.19 (−1.55 to −0.83) <0.00001 MOD
Infant re-hospitalizations at 2 and 8 weeks Brooten [31,32] 202 RR 0.56 (0.21 to 1.44) 0.23 LOW
post-discharge
Infant acute care visits at 8 weeks and 18 months Brooten [31,32] 202 RR 0.82 (0.66 to 1.02) 0.07 LOW
post-discharge
Infant hospital charge (1991 USD) Brooten [32]; York [38] 216 MD −$1111 (−$1543 to −$679) <0.00001 V. LOW
Post-partum maternal hospital charge (1991 USD) Brooten [32]; York [38] 215 MD −$2152 (−$3008 to −$1297) <0.00001 MOD
Effect estimate favours intervention: ; effect estimate favours usual care: .
*Reported P-values are in bold font and calculated P-values are in regular font.
†GRADE Working Group grades of evidence: HIGH quality – further research very unlikely to change confidence in the estimate of the effect; MODERATE (MOD) quality – further research
likely to have an important impact on confidence in the estimate of the effect and may change the estimate; LOW quality – further research is very likely to change confidence in the
estimate of the effect and likely to change the estimate; VERY LOW (V. LOW) quality – very uncertain about the estimate of the effect; NA – GRADE was not applied because required
data were not available (e.g. number per group).
‡Among those who reported at least one visit at 6 months post-discharge.
§
The calculated 95% CIs were based on raw data, whereas the reported P-values were adjusted for baseline imbalances or incomplete follow-up.
¶Adjusted for the number of events per patient per month of follow-up.
**The statistically significant 95% CIs were calculated from the reported means and SDs and contradict the reported non-significant P-values.
††
A weighted average was calculated for the combined intervention groups (RN/APN + APN only) and control groups (no support + RN only). adj, adjusted; APN, advanced practice nurse;
C, control group; CI, confidence interval; CNS, clinical nurse specialist; DRG, diagnosis related group; ED, emergency department; est, estimated; GP, general practitioner; I, CNS
intervention; MD, mean difference; NA, not assessed; NR, not reported; NS, not significant; RR, risk ratio; RRR, relative readmission rate; VLBW, very low birthweight infants.
Finally, Naylor et al. [36] found no significant group differences total and multiple re-hospitalizations; short, moderate and long-
in functional status, depression and patient satisfaction at 24 weeks term re-hospitalizations and re-hospitalization length of stay as
but several statistically significant differences in health system well as a number of cost outcomes (daily hospital costs, health
outcomes, all favouring the intervention group. At 24 weeks, the services charges, total re-hospitalization costs and total reim-
intervention group had a longer time to re-hospitalization for any bursement costs) (low-quality evidence where GRADE could be
reason, fewer total re-hospitalizations for any reason, fewer multi- applied).
ple re-hospitalizations and lower total reimbursement costs for any
re-hospitalizations. All other health system outcomes did not differ
Post-discharge care of high-risk pregnant
significantly.
women and infants
We pooled data for one patient and six health system outcomes.
There were no group differences in the number of deaths at 6 [36] Three trials evaluated an early discharge intervention for high-risk
and 8 weeks [43] post-discharge. A meta-analysis of three studies pregnant women and infants [31,32,38]. Study participants
[34,35,43] found CNS care was equivalent to usual care for length included 72 mothers and 79 very low birthweight infants [31], 122
of index hospital stay. Based on the results of two studies [34,35], post-partum women who had undergone an unplanned caesarean
CNS care was equivalent to usual care in reducing index hospital section [32] and 96 women with pregnancy-related diabetes or
charges. A meta-analysis of two studies found that CNS care hypertension [38]. The intervention was delivered by one [38] or
significantly reduced re-hospitalizations for any reason at 7 days three CNSs [31,32]. The CNSs provided direct care to hospitalized
[43] and 2 weeks [35] after discharge and at 6 [35] and 8 [43] weeks women and infants, assessed their suitability for early discharge
post-discharge. Meta-analysis of three studies found that CNS care and provided post-discharge care via home visits, telephone calls
reduced re-hospitalizations for any reason at 12 [34,35] and 24 [36] and on-call services over several weeks.
weeks post-discharge. CNS care also reduced re-hospitalization Brooten et al. [31] found no group differences for infant out-
length of stay at 12 [34] and 24 weeks [36] post-discharge. comes at 18 months: failure to thrive, reported abuse, foster care,
In summary, five studies, three at moderate risk and two at developmental delay, physical growth and infant mortality at 12
high risk of bias, evaluated CNS transitional care in 899 elderly months. The intervention group had a shorter length of infant
patients and 65 caregivers. There were three significant differ- hospital stay, a lower initial infant hospitalization charge and a
ences in patient outcomes including fewer caregiver emotional lower infant physician services charge. There were no differences
and depression symptoms between 2 and 4 weeks post-discharge in other health system outcomes.
in the intervention group and fewer infections in surgical patients In another study by Brooten et al. [32], CNS care was associ-
at 2 weeks post-discharge in the usual care group. None of the ated, at 8 weeks, with a higher proportion of immunized infants but
health system outcomes significantly favoured usual care. CNS no group difference in maternal anxiety, depression or functional
care was superior to usual care for time to re-hospitalization; status. The intervention group had lower maternal and infant initial

hospitalization charges per patient, lower total home caregiver outcomes, four in studies focused on patients with cancer [39,40]
costs per mother–infant dyad and lower maternal and infant total and one in a study of elderly patients [35]. Of the 93 health system
costs and charges per patient. Other health system outcomes did outcomes, there were no instances when usual care was superior.
not differ between groups. Of the 55 patient outcomes, CNS care was superior for 15
In the study by York et al. [38], there were no group differences outcomes and equivalent for 35 outcomes. CNS care was
in maternal functional status and infant outcomes (birthweight, superior in reducing the risk of death at 2 years by 50% for
gestational age, glucose levels). Health system outcomes did not patients with cancer, increasing the time to death or first
differ significantly except for two of three incorporated into meta- re-hospitalization and reducing the co-end point of death or
analyses reported below. re-hospitalization in patients with heart failure, improving uncer-
Results from two studies were pooled for maternal satisfaction tainty in illness in cancer patients and treatment adherence and
[32,38]. Mothers receiving CNS care were significantly more satisfaction in patients with heart failure, improving emotional
satisfied. There was considerable heterogeneity that could not and depressive symptoms in caregivers of elderly patients, and
be investigated because there were only two studies in the increasing infant immunization rates and maternal satisfaction in
meta-analysis. high-risk pregnant women and infants.
We pooled data for five health system outcomes. A meta- Of the 93 health system outcomes, CNS care was superior for
analysis of two studies [32,38] found that CNS care reduced 25 outcomes and equivalent for 68 outcomes. We did not pool
maternal post-partum length of hospital stay. CNS care was outcomes across groups because we judged the four populations
equivalent in reducing infant re-hospitalization at 2 [31] and 8 [32] to be substantially different from each other. When GRADE was
weeks and infant acute care visits at 8 weeks [32] and 18 months applied to individual patient and health system outcomes, the
[31] post-discharge. Based on two studies [32,38], CNS care was quality of evidence was, for the most part, low (74 low, 15 mod-
superior to usual care in reducing infant hospital charges and erate, 4 very low) which means that further research is very
maternal post-partum hospital charges. likely to change our confidence in the effect estimate and is
In summary, three studies (all moderate risk of bias) evaluated likely to change the estimate. Downgrading was mostly due to
CNS transitional care for 290 high-risk pregnant women and 79 imprecision and indirectness (<10 CNSs) and, when data were
very low birthweight infants. There was no instance where usual pooled, inconsistency (high I2).
care performed better than CNS care. CNS care was superior for Study results across the four population groups provide emerg-
two patient outcomes (immunized infants at 8 weeks and mater- ing data about features of effective CNS-led transitional care. A
nal satisfaction). CNS care was superior in reducing hospital central feature was continuity of care from the hospital to the home
length of stay for very low birthweight infants and post-partum setting including pre-discharge planning and post-discharge
mothers, maternal and infant initial hospitalization charges, follow-up with care coordination, patient education and/or
infant physician charges, home caregiver costs and maternal and ongoing assessment and management of health problems. The
infant total costs and charges. Most outcomes were of low- review of transitional care by Naylor et al. [4] also suggests that
quality evidence due to small number of CNSs (<10) and small the most effective interventions include comprehensive discharge
sample sizes (imprecision). planning and home follow-up or tele-health monitoring post-
discharge. Interventions that reduced readmissions also relied on
nurses as clinical leaders of care and in-person home visits. A
Cost-effectiveness/economic evaluation
Cochrane systematic review of 24 discharge planning studies
None of the 13 studies assessed costs and outcomes jointly and all (three of which were included in our review) found that a dis-
studies scored less than 50 of 100 points on the QHES tool making charge plan tailored to individual patient needs may reduce hos-
it difficult to determine the cost-effectiveness of CNS care. We pital length of stay and readmission rates for older people [46].
created a ‘bottom line’ (Table 4) that integrates patient outcome Our review of transitional care by NPs [21] has also shown
comparisons (clinical effectiveness) with health system outcome reduced re-hospitalizations.
comparisons (resource use and/or costs) based on statistically sig- It is not possible with this set of studies to determine if CNS
nificant findings (Table 2 and Table 3). Only three studies had at transitional care is cost-effective. All 13 studies were given low
least one patient outcome where CNS care was less effective than scores in quality of economic analyses; they were limited to
usual care. In all other instances, they were equivalent or more resource use and cost comparisons and none examined costs and
effective. There is no instance when resource use or costs were outcomes jointly. As a result, the incremental costs and benefits
higher with CNS care but often instances when the CNS reduced of CNS transitional care are unknown. Reported cost differences
resource use and costs, despite the fact that the CNS was an may also be under- or overestimated. Less than half of the
‘add-on’ cost. studies evaluated total costs including inpatient, outpatient and
home care costs, and no study evaluated costs related to medi-
cations, supplies or equipment. Only a few studies considered
Discussion indirect costs related to patient and caregiver expenses and
This systematic review assessed the clinical effectiveness and cost- opportunity costs (e.g. lost wages, leisure time, travel time). The
effectiveness of CNSs delivering transitional care. We identified determination of intervention costs was not comprehensive with
13 trials that evaluated a total of 2463 study participants across many studies failing to include costs for CNS role development,
four population groups. From these trials, 55 patient outcomes and travel time, indirect care and/or overhead. Although the estimates
93 health system outcomes were identified and examined (Table 2 may be incomplete, most intervention costs were fairly low and
and Table 3). Of these, usual care was superior for five patient offset by cost savings.

Table 4 Bottom line, overall risk of bias and quality of health economic analysis
Overall risk QHES

Author, year, country Bottom line of bias* score†

McCorkle et al. (2000) [39]; Jepson et al. (1999) [50] More-to-less effectiveness Low 32
United States Equal resource use
McCorkle et al. (2009) [40]; McCorkle et al. (2011) [44] More-to-less effectiveness Low 45
United States Equal-to-less resource use
Laramee et al. (2003) [41] Equal-to-more effectiveness Moderate 23
Equal costs
Naylor et al. (2004) [37]; McCauley et al. (2006) [51] Equal-to-more effectiveness Moderate 27
Lower costs
Thompson et al. (2005) [42] Equal-to-more effectiveness Low 38
United Kingdom Equal-to-less resource use
Dellasega et al. (2000) [33]; Dellasega et al. (2002) [52] Equal-to-more effectiveness Moderate 46
Kennedy et al. (1987) [43]; Neidlinger et al. (1987) [45] Equal effectiveness Moderate 29
Equal-to-lower costs
Naylor (1990) [34] Equal effectiveness High 47
Equal costs
Naylor et al. (1994) [35] Equal-to-less effectiveness High 27
Naylor et al. (1999) [36]; Naylor et al. (1999) [53] Equal effectiveness Moderate 34
Brooten et al. (1986) [31] Equal effectiveness Moderate 26
Brooten et al. (1994) [32] Equal-to-more effectiveness Moderate 33
York et al. (1997) [38] Equal-to-more effectiveness Moderate 33
*Overall risk of bias was based on a modified version of the Cochrane Risk of Bias tool [23] where studies at risk in ≤1 category were judged to be
at low risk; two to three categories at moderate risk; four to six at high risk; and seven to eight categories at very high risk of bias.
†
The QHES measured the quality of studies with respect to their health economic analysis. The score ranged from 0 to 100 where studies scoring
from 0 to 24 points were judged to be extremely poor quality, 25 to 49 were poor, 50 to 74 were fair and 75 to 100 were high quality.
QHES, Quality of Health Economic Studies instrument.
The intensity of CNS transitional care interventions has impor- found reduced mortality rates. They also noted that the high-
tant implications related to dose effect and impact on outcomes. intensity home visiting intervention evaluated by Naylor et al. [37]
Dose effect encompasses three elements: the amount of care pro- in our review reduced all-cause readmissions at 30 days compared
vided (i.e. frequency and duration of patient contacts); CNS educa- with less intensive interventions. Many factors may have contrib-
tion, expertise and experience; and the patient’s receptivity and uted to the large number of equivalent outcomes in our review but it
response to the intervention [47]. Failure to match the appropriate is also possible that some interventions lacked a sufficient dose.
CNS dose (i.e. amount of care and expertise) with patient needs
(receptivity) can limit the extent to which expected outcomes are
Strengths and limitations
achieved. For example, in contrast to the heart failure group findings
in our review, Feltner et al. [48], in a systematic review of transi- The strengths of this systematic review include the extensive
tional care interventions for adults hospitalized with heart failure, search for published and unpublished trials in any language, inclu-

sion of trials evaluating only master’s-prepared CNSs, use of two

independent reviewers for every stage of the review, quality assess-
Conclusions
ments using established tools, assessment of outcome-specific This systematic review examined the clinical effectiveness and
quality of evidence through application of GRADE and contact cost-effectiveness of CNS transitional care. There is predominantly
with authors for clarification. low-quality evidence that CNS-led transitional care improves
Most study results could not be pooled because the outcome patient health outcomes, including mortality, and reduces hospital
measures differed across studies. Of the few meta-analyses, most length of stay, re-hospitalization rates and costs. Further research is
included only two studies, precluding subgroup analyses to required to refine our understanding of the incremental costs and
investigate heterogeneity. A shortcoming of the review is the benefits of CNS transitional care that is tailored to meet the health
predominance of studies from the United States that may limit care needs of specific at-risk patient populations.
the generalizability of findings to health care systems in other
countries.
Conflict of interest
The authors declare no conflict of interest.
Recommendations for practice and research
Acknowledgements
CNS-led transitional care has the potential to reduce acute care
utilization and costs through shorter hospital lengths of stay and We thank librarians, Laura Banfield and Jo-Anne Petropoulos,
fewer re-hospitalizations, while maintaining or improving health and staff, Sara Kaffashian, R. James McKinlay, Julie Vohra and
outcomes and satisfaction with care for high-risk patient popula- Rose Vonau. An international panel was helpful in determining
tions. As noted in other reviews of transitional care, there was whether studies conducted outside of North America were evalu-
variability in the types and intensity of interventions across studies ating advanced practice nursing roles. This panel included Melanie
[4,48]. As a result the exact combination of effective CNS transi- Rogers (United Kingdom), Petrie Roodbol (The Netherlands),
tional care interventions is not known and is likely dependent on Madrean Schober (Singapore), Barbara Sheer (United States),
the unique health care needs of different patient populations. At a Helen Ward (United Kingdom) and Frances Wong (Hong Kong).
minimum, CNS transitional care should include discharge plan- We thank Brian Hutchison who provided input from a health
ning and follow-up care with careful assessment of the need for policy perspective and Gordon Guyatt who provided methodologi-
home visits or telephone support. cal advice regarding risk of bias and GRADE. We thank the many
To facilitate administrative and clinical decision making about authors of papers included in our review for providing additional
how best to target and tailor CNS transitional care, further research information. This systematic review was made possible through
is needed to discern the types and intensity of pre- and post- funding by the Ontario Ministry of Health and Long-Term Care,
discharge planning interventions required for different at-risk the Office of Nursing Policy in Health Canada and the Canadian
populations. None of the studies in this review included other Foundation for Healthcare Improvement. The views expressed in
types of nursing roles as a comparison group and thus do not this paper are those of the authors and do not necessarily reflect
inform decisions about when to use master’s-prepared CNSs those of the Ontario Ministry of Health and Long-Term Care,
versus specialized but not advanced practice nurses. Future studies Office of Nursing Policy in Health Canada or the Canadian Foun-
of transitional care should examine different patient and health dation for Healthcare Improvement.
care contexts that are best suited for CNS expertise. Further
research is also required to assess the impact of transitional care on References
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Journal of Evaluation in Clinical Practice ISSN 1365-2753

The clinical effectiveness and cost-effectiveness of clinical

restrictions based on language, jurisdiction, patient age or practice

764 © 2015 John Wiley & Sons, Ltd.

Inial record review (tle and abstract)

Full records retrieved for assessment of

Reasons for exclusion at full record review

requested that study be included in future update): 3

© 2015 John Wiley & Sons, Ltd. 765

Post-discharge care of patients following surgery for cancer

© 2015 John Wiley & Sons, Ltd.

© 2015 John Wiley & Sons, Ltd.

© 2015 John Wiley & Sons, Ltd.

© 2015 John Wiley & Sons, Ltd.

Author, year, Length of Study

© 2015 John Wiley & Sons, Ltd.

© 2015 John Wiley & Sons, Ltd. 771

Table 2 Patient and provider outcomes

Post-discharge care of patients following surgery for cancer

772 © 2015 John Wiley & Sons, Ltd.

Effect estimate favours intervention: ; effect estimate favours usual care: .

© 2015 John Wiley & Sons, Ltd. 773

Table 3 Health system outcomes

Intervention effect size P-value of GRADE

Post-discharge care of patients following surgery for cancer

774 © 2015 John Wiley & Sons, Ltd.

Intervention effect size P-value of GRADE

© 2015 John Wiley & Sons, Ltd. 775

Intervention effect size P-value of GRADE

Maternal acute care visits after delivery York [38] 55 NR No difference NS NA

Effect estimate favours intervention: ; effect estimate favours usual care: .

776 © 2015 John Wiley & Sons, Ltd.

© 2015 John Wiley & Sons, Ltd. 777

Overall risk QHES

Post-discharge care of patients following surgery for cancer

778 © 2015 John Wiley & Sons, Ltd.

sion of trials evaluating only master’s-prepared CNSs, use of two

© 2015 John Wiley & Sons, Ltd. 779

780 © 2015 John Wiley & Sons, Ltd.

© 2015 John Wiley & Sons, Ltd. 781

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