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.

Figure 1

Functioning and quality-of-life scores for patients in the nurse management (solid lines) and usual care (dashed lines) groups. A and B. Mean Short Form-12 (SF-12) physical component score (PCS) and mental component score (MCS), by month and treatment group. Vertical bars represent SEs. C and D. Mean quality-of-life scores as measured by translation of SF-12 scores into EuroQol-5D and Health Utility Index Mark 3, by month and treatment group. We assigned deceased patients quality-of-life scores of 0.

Figure 2

Five hundred bootstrapped replicates of incremental costs and incremental quality-adjusted life-years (QALYs) for nurse management versus usual care (top) and the resulting cost-effectiveness acceptability curve (bottom). ICER = incremental cost-effectiveness ratio.

Figure 3

Five hundred bootstrapped replicates of incremental costs and incremental quality-adjusted life-years (QALYs) for nurse management versus usual care (top) and the resulting cost-effectiveness acceptability curve (bottom), by New York Heart Association class at baseline.