Cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme compared with usual care using a CBT manual alone for patients with heart failure: secondary analysis of data from the SEMAPHFOR trial

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Abstract

Objective

To assess the cost-effectiveness of a nurse facilitated, cognitive behavioural self-management programme for patients with heart failure compared with usual care including the un-facilitated access to the same manual, from the perspective of the NHS.

Design

Data were obtained from a pragmatic, multi-centre, randomized controlled ‘open’ trial conducted in seven centres in the UK between 2006 and 2008. Effectiveness was estimated as Quality-Adjusted Life Years. Resource use was measured prospectively on all patients using information provided by patients in postal questionnaires, case-note review, electronic record review and interviews with patients. Unit costs were obtained from the literature and applied to the relevant resource use to estimate total costs. Multiple imputation was used to handle missing data.

Results

There were no substantial differences in the utility scores between treatment groups in all follow-up assessments, in the use of medication or outpatient visits and both groups report a similar frequency of contact with health care professionals. After controlling for baseline utility and using imputed dataset, treatment was associated with a reduction in QALY of 0.004 and a additional cost of £69.49. The probability that the intervention is cost-effective for thresholds between £20,000 and £30,000 is around 45%.

Conclusions

There is little evidence that the addition of the intervention had any effect on costs or outcomes. The uncertainty around both estimates of cost and effectiveness mean that it is not reasonable to make recommendations based on cost-effectiveness alone.

Introduction

Heart failure (HF) is a common condition across the general European population, with a prevalence between 0.4 and 2% that increases rapidly with age (Swedberg et al., 2005). In the UK, around 900,000 people suffer from this condition. Approximately 1 in 35 people aged 64–74 has HF and this figure rises to 1 in 7 for the population older than 85 years (NICE, 2010). In addition to the costs for patients and their families, in terms of reduced quality of life and financial costs, HF imposes a considerable burden on the National Health Service (NHS). HF accounts for 1 million inpatient beds, equivalent to 2% of total capacity, and 2% of the total NHS annual budget (NICE, 2010). Given the high rate of hospitalization in patients with HF (Stewart et al., 2002), it is of great interest to design strategies that contribute to improve patients’ health status and reduce the rate of avoidable admissions and re-admissions.

Several studies have shown that education alone may not always influence patient's behaviour and additional strategies could be worthwhile (Jovicic et al., 2006). One alternative that could be effective in the management of patients with HF is a nurse-led cognitive-behavioural intervention. These programmes, which aim to produce changes in patients’ behaviour by influencing thinking, require patients to set small realistic goals and then move to the next level when they have achieved the previous objective. Cognitive-behavioural interventions have been successful in different clinical trials in areas such as mental and eating disorders, smoking cessation and chronic pain (Hollon and Beck, 2004).

The purpose of this paper is to assess, from the perspective of the NHS, the cost effectiveness of a nurse facilitated manual for patients with heart failure compared with usual care using manual without nurse input.

Section snippets

Trial design

The cost-effectiveness results shown in this paper are a secondary analysis of a pragmatic, multi-centre, randomised controlled ‘open’ trial conducted between 2006 and 2008 in Birmingham and Darlington. Potential participants were identified by General Practitioners with special interest, heart failure nurses, research co-ordinators or consultants from open access heart failure diagnostic clinics, acute and medical wards, following discharge from hospital after an acute event or from GP

Cost-effectiveness based on complete cases

Baseline characteristics are summarized in Table 1. Patients were well balanced between groups in several dimensions that may influence the disease prognosis, such as age, gender, NYHA class, previous admissions to hospital, and medical history (except for previous stroke). There was a considerable number of missing data at each follow-up interview, particularly in primary care, outpatient and medication costs, with no difference between treatment arms (6-month primary care cost: 49.5% and

Discussion

Decisions in health care entail an opportunity cost, to either known or unknown groups of patients, in the form of health benefits foregone (Claxton and Culyer, 2006). Therefore, governments must consider a broad range of related policy questions in order to select an optimal strategy for the management of patients with heart failure. This article tried to address some of these issues using a trial-based economic evaluation.

Is the addition of nurse facilitation to a cognitive-behavioural

Conflict of interest

Robert Lewin and Jill Pattenden received BHF funding as part of salary, and the other authors declare that they have no conflict of interest.

Funding

This work was supported by the British Heart Foundation (BHF Project Grant PG/03/098).

Ethical approval

Yes, Huntingdon Research Ethics Committee on the 20th September 2005.

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