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
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.
References (22)
The irrelevance of inference: a decision-making approach to the stochastic evaluation of health care technologies
Journal of Health Economics
(1999)- et al.
On the Decision Rules of Cost-Effectiveness Analysis
Journal of Health Economics
(1993) - et al.
Bayesian methods for evidence synthesis in cost-effectiveness analysis
Pharmacoeconomics
(2006) - et al.
Measuring and Valuing Health Benefits for Economic Evaluation
(2007) - et al.
Missing… presumed at random: cost-effectiveness of incomplete data
Health Economics
(2003) - et al.
Wickedness or folly? The ethics of NICE's decisions
Journal of Medical Ethics
(2006) Unit Costs of Health and Social Care 2009
(2009)NHS reference costs 2008–2009
(2010)- et al.
A Social Tariff for EuroQol: Results from a UK General Population Survey
(1995) - et al.
Cost effectiveness acceptability curves – facts, fallacies and frequently asked questions
Health Economics
(2004)