Development and Testing of a Nurse Practitioner Secondary Prevention Intervention for Patients after Acute Myocardial Infarction

Patients with acute myocardial infarction (AMI) are at high risk for reinfarction and death, with the highest rate of death and reinfarction occurring within 30 days of AMI. Therapies that have been shown to reduce these risks (secondary prevention) continue to be underutilized. Nurse practitioners are well positioned to provide secondary prevention during and following hospitalization. The purpose of this pilot study was to examine the feasibility, acceptability, and preliminary effects of an NP delivered secondary prevention intervention. The specific objectives were: 1) to describe NP activities when delivering the secondary prevention intervention; 2) to evaluate the effect of the NP intervention on the rate of implementation of evidence-based secondary prevention treatment strategies and the patients’ achievement of secondary prevention target goals; and, 3) to examine the relationship between the NP activities delivering the intervention and secondary prevention goal achievement by patients. A prospective cohort design was used, in which patients’ achievement of target goals were compared between patients who received secondary prevention care from an NP and those who received usual care. The sample of convenience consisted of 65 patients with AMI. Data on practice activities and implementation of secondary prevention by the NP were collected before discharge from hospital and one week, two weeks, six weeks and 3 months after discharge. Data on patients’ achievement of goals were obtained before discharge from hospital and 3 months after discharge from both groups. This study’s results provide preliminary evidence that an NP delivered secondary prevention intervention, beginning prior to discharge and continuing for three months post myocardial infarction, significantly improves the implementation and uptake of guideline based secondary prevention treatments and risk factor reduction strategies. NP-led interventions such as this warrant replication. The unique contribution of the NP with this patient population is the training and skills needed to deliver all aspects of secondary prevention, including pharmacological and nonpharmacological therapies, without the immediate availability of a physician.Ph

Assessing the quality of economic evaluations of clinical nurse specialists and nurse practitioners: A systematic review of cost-effectiveness

A limited number of randomized controlled trials (RCTs) including economic analysis have supported the cost-effectiveness of nurse practitioners and clinical nurse specialists delivering care in a variety of settings. Our objective was to examine the quality of economic evaluations in this body of literature using the Quality of Health Economic Studies (QHES) tool, and highlight which questions of the quality assessment tool are being addressed adequately or require further attention within this body of literature. Of 43 RCTs included in our systematic review, the majority (77%) fell in the poor study quality quartile with an average total QHES score of 39 (out of 100). Only three studies (7%) were evaluated as high quality. Inter-rater agreement (prior to consensus process) was high (83% agreement). Four criteria for the quality of economic evaluations were consistently addressed: specification of clear, measurable objectives; pre-specification of subgroups for subgroup analyses; justified conclusions based on study results; and disclosure of study funding source. A clear statement of the primary outcome measures, incremental analysis, and assessment of uncertainty were often unclear or missing. Due to poor methodological quality, we currently lack a solid evidence base to draw clear conclusions about the cost-effectiveness of nurse practitioners and clinical nurse specialists. Higher quality economic evaluations are required to inform these questions. Keywords: Clinical nurse specialists, Cost-effectiveness, Economic evaluation, Nurse practitioners, Review, systematic, Quality assessmen

A Systematic Review of the Cost-Effectiveness of Nurse Practitioners and Clinical Nurse Specialists: What Is the Quality of the Evidence?

Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (), NP-transition (), NP-inpatient (), CNS-outpatient (), CNS-transition (), and CNS-inpatient (). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.Peer Reviewe