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

Paul L. Hebert, PhD; Jane E. Sisk, PhD; Jason J. Wang, PhD; Leah Tuzzio, MPH; Jodi M. Casabianca, MS; Mark R. Chassin, MD, MPP, MPH; Carol Horowitz, MD, MPH; and Mary Ann McLaughlin, MD, MPH
[+] Article, Author, and Disclosure Information

From the Veterans Administration Puget Sound Health Care System, University of Washington School of Public Health and Community Medicine, and Center for Health Studies, Group Health Cooperative, Seattle, Washington; Mount Sinai School of Medicine, New York, New York; Fordham University, Bronx, New York; and The Joint Commission, Oakbrook Terrace, Illinois.

Grant Support: Dr. Sisk was supported by a grant from the Agency for Healthcare Research and Quality (R01 HS10402-01).

Potential Financial Conflicts of Interest:Grants received: C. Horowitz (National Institutes of Health).

Reproducible Research Statement:Study protocol and statistical code: Available from Dr. Hebert (e-mail, Paul.Hebert2@va.gov). Data set: Not available.

Requests for Single Reprints: Paul L. Hebert, PhD, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101.

Current Author Addresses: Dr. Hebert: Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101.

Drs. Sisk, Wang, Horowitz, and McLaughlin: Mount Sinai School of Medicine, Department of Health Policy, One Gustave L Levy Plaza Box 1077, New York, NY 10029-6574.

Ms. Tuzzio: Group Health Center for Health Studies, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.

Ms. Casabianca: Department of Psychology, Fordham University, Dealy Hall, Room 226, 441 East Fordham Road, Bronx, NY 10458.

Dr. Chassin: The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181.

Author Contributions: Conception and design: P.L. Hebert, J.E. Sisk, M.R. Chassin, C. Horowitz, M.A. McLaughlin.

Analysis and interpretation of the data: P.L. Hebert, J.E. Sisk, J.J. Wang, J.M. Casabianca, M.R. Chassin, C. Horowitz, M.A. McLaughlin.

Drafting of the article: P.L. Hebert, J.E. Sisk.

Critical revision of the article for important intellectual content: J.E. Sisk, M.R. Chassin, C. Horowitz, M.A. McLaughlin

Final approval of the article: P.L. Hebert, J.E. Sisk, C. Horowitz, M.A. McLaughlin.

Provision of study materials or patients: L. Tuzzio, C. Horowitz.

Statistical expertise: P.L. Hebert, J.J. Wang, J.M. Casabianca.

Obtaining of funding: J.E. Sisk.

Administrative, technical, or logistic support: L. Tuzzio, J.M. Casabianca, M.R. Chassin.

Collection and assembly of data: J.E. Sisk, J.J. Wang, L. Tuzzio, J.M. Casabianca, M.A. McLaughlin.

Ann Intern Med. 2008;149(8):540-548. doi:10.7326/0003-4819-149-8-200810210-00006
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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.


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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.

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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.

Grahic Jump Location
Grahic Jump Location
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.
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