Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community

Abstract

Background Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. Less is known about the cost-effectiveness of these interventions. Objective To estimate the cost-effectiveness of a nurse-led disease management intervention over 12 months, implemented in a randomized, controlled effectiveness trial. Design Cost-effectiveness analysis conducted alongside a randomized trial. Data Sources Medical costs from administrative records, and self-reported quality of life and nonmedical costs from patient surveys. Participants Patients with systolic dysfunction recruited from ambulatory clinics in Harlem, New York. Time Horizon 12 months. Perspective Societal and payer. Intervention 12-month program that involved 1 face-to-face encounter with a nurse and regular telephone follow-up. Outcome Measures Quality of life as measured by the Health Utilities Index Mark 3 and EuroQol-5D and cost-effectiveness as measured by the incremental cost-effectiveness ratio (ICER). Results of Base-Case Analysis Costs and quality of life were higher in the nurse-managed group than the usual care group. The ICERs over 12 months were $17 543 per EuroQol-5D–based quality-adjusted life-year (QALY) and $15 169 per Health Utilities Index Mark 3–based QALY (in 2001 U.S. dollars). Results of Sensitivity Analysis From a payer perspective, the ICER ranged from $3673 to $4495 per QALY. Applying national prices in place of New York City prices yielded a societal ICER of $13 460 to $15 556 per QALY. Cost-effectiveness acceptability curves suggest that the intervention was most likely cost-effective for patients with less severe (New York Heart Association classes I to II) heart failure. Limitation The trial was conducted in an ethnically diverse, inner-city neighborhood; thus, results may not be generalizable to other communities. Conclusion Over 12 months, the nurse-led disease management program was a reasonably cost-effective way to reduce the burden of heart failure in this community.

Impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or chronic obstructive pulmonary disease: A systematic review of the literature

“…Direct healthcare costs, such as costs of hospitalization, emergency room (ER) visits, medication and healthcare staff were always included in the economic evaluations. Three studies also included direct non-healthcare costs such as travel costs to the healthcare facility [34,45,46]. Three studies additionally incorporated indirect non-healthcare costs such as productivity loss, lost wages, and income lost by family caregivers [36,47,48].…”

“…telephone calls) by care managers/nurse specialists to monitor and improve antidepressant adherence [37,46,57] • Pocket reminder cards for practice teams to enable patient assessment, education and activation of treatment [46] Heart failure • Standardized detailed educational program received at discharge with information on low-salt diet, self-monitoring of blood pressure and symptoms, daily weight, smoking cessation, etc. [32,49] • Nurse led program with home visit and regular telephonic follow-up to stress treatment adherence [45] • Telemanagement system stimulating patients to daily call in and answer a short health questionnaire. Information was stored and automatically analyzed by decision support tools [33,60] • Pharmacists studied guidelines, key concepts in pharmaceutical care [58] • Teaching patients better self-management skills by instructing and encouraging them to monitor their health [49] • Home visits by specialist nurse from HF clinic who provided hospital care, followed by short consultation nurse and physician after each visit [59] • Alerts were set in telemanagement system for abnormalities requiring immediate intervention by nurse [33] • Icons used for medication containers matching with icons on written instruction about medication [58] • Cardiologists were care managers and documented treatment plan [32] • General education about disease and treatment, individualized physical training program, recognizing early triggers of exacerbation, importance of smoking cessation [61,62] • Multidisciplinary care team plus home visits by nurse providing hospital care at home [43] • Pulse oximeter with modem system which is able to transmit information on arterial oxygen saturation through telephone line to a receiving station where tele-assistance nurse is available for tele-consultation [34] • NA…”

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

“…Whether a DMP is a cost-effective way to manage these patients is not well established. The studies suggest a DMP may be cost effective or the extra cost associated with a DMP is acceptable (131,(139)(140)(141)(142). In a recent analysis by Whellan et al (143), an interesting concept based on the American system of reimbursement is presented.…”

Home Monitoring Should Be the Central Element in an Effective Program of Heart Failure Disease Management

“…Importantly, even programs with a net positive impact on direct costs will likely prove to be substantially cost-effective, given the achievable improvements in HF-related morbidity and mortality. Within a randomized, controlled investigation of a 12-month nursetelephone intervention 26 with an average interventional cost of $2177 per patient, Herbert et al 27 observed an incremental overall societal cost (including such costs as telephone and transportation) ranging between $15 000 and $18 000 per quality-adjusted life year (QALY) gained. From the more usual perspective of payer cost, the incremental cost per QALY was between $3100 and $3700.…”