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Evidence-Based Nursing Online First, published on April 8, 2015 as 10.1136/eb-2014-102009
Nursing issues
Randomised controlled trial
A nurse-facilitated cognitive behavioural self-management programme for heart failure is no more cost effective than usual CBT care
using the EQ-5D patient questionnaire. Data on healthcare utilisation were collected prospectively from patients and/or patient records. Costs for the delivery of the intervention included nurse training and contact time from nurses. Cost-effectiveness was calculated by dividing the mean difference in costs by the mean difference in QALYs by arm over 12 months. The probability that the intervention is more cost-effective than control was evaluated using a range of threshold values per additional QALY.
Findings
10.1136/eb-2014-102009 Peter A Coventry,1 Nicola Small1,2 1
NIHR Collaboration for Leadership in Applied Health Research and Care and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK; 2Centre for Primary Care, University of Manchester, Manchester, UK Correspondence to: Dr Peter Coventry, University of Manchester, NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, Manchester M13 9PL, UK;
[email protected]
Commentary on: Mejía A, Richardson G, Pattenden J, et al. 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. Int J Nurs Stud 2014;51:1214–20.
Implications for practice and research ▪ Using nurses to facilitate a cognitive behavioural therapy (CBT) based self-management intervention for heart failure patients is no more cost-effective than a CBT manual alone. ▪ CBT self-management for heart failure patients may be more effectively delivered as part of collaborative care but this needs to be confirmed in future trials.
The intervention was associated with a reduction in QALY of 0.004 and an additional cost of £69.49. This means that the intervention cost more than the control and led to fewer QALY gains than using the CBT manual alone. There is, however, considerable uncertainty about the estimates for treatment effectiveness and costs and whether the intervention would be adopted. Based on a threshold of between £20 000 and £30 000 the probability that the intervention is cost-effective was 45%.
Commentary Nurse facilitated self-management using a CBT manual was no more costeffective than a CBT manual alone. Sensitivity analysis returned a similar pattern of results—using updated costs for 2011 and 2012 showed that the intervention would still be more expensive than the control. By convention, treatments are judged by National Institute of Health and Care Excellence (NICE) to be cost-effective if the incremental cost is less than £20 000 per QALY gained.3 Where the incremental cost is higher the evidence needs to be more robust and this study had a number of limitations. First, the trial did not recruit to target and was underpowered to detect prespecified differences in primary and secondary outcomes. Second, the control group was exposed to the core intervention component (ie, the CBT manual), limiting opportunities to compare the intervention with usual care. Third, using an individually randomised and not cluster randomised design meant patients in the control group were supported by the same nurses who facilitated the CBT manual, potentially contaminating results between intervention and control. By contrast, collaborative care that builds in supervision of nonmedical staff to deliver CBT based self-management interventions are cost-effective for treatment of depression in primary care and have proven cost-effectiveness in patients with depression and long-term conditions.4 5 There is scope to extend such collaborative models to support self-management of heart failure and to reduce hospital admissions.
Context Heart failure is a common long-term condition affecting many people in the UK.1 It is a leading cause of hospital admissions which are associated with significant costs in the National Health Service (NHS) and poor quality of life among patients. Self-management is increasingly seen as critical to the delivery of effective and efficient care for long-term conditions, but evidence of effectiveness is mixed for heart failure. Supported self-management interventions based on CBT have proven efficacy in the treatment of depression in adults,2 but clinical utility and costeffectiveness has not been demonstrated among patients with heart failure.
Methods The purpose of the trial was to look at the economic evaluation of the cost-effectiveness of a nurse facilitated manualised self-management intervention versus usual care plus the manual only. The measure of effectiveness was the quality-adjusted life year (QALY), which is a composite measure of health status and time spent in that health state. Health states were assessed at three, 6 and 12 months after randomisation
Competing interests None declared References 1. Mozaffarian D, Benjamin EJ, Go AS, et al, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics— 2015 update: a report from the American Heart Association. Circulation 2015;131: e29–322. 2. Gellatly J, Bower P, Hennessy S, et al. What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. Psychol Med 2007;37:1217–28. 3. National Institute for Health and Care Excellence. Process and methods guides. Guide to the methods of technology appraisal. London: NICE, 2013. http:// publications.nice.org.uk/pmg9 4. Green C, Richards DA, Hill JJ, et al. Cost-effectiveness of collaborative care for depression in UK primary care: economic evaluation of a randomised controlled trial (CADET). PLoS ONE 2014;9:e104225. 5. Katon W, Russo J, Lin EH, et al. Cost-effectiveness of a multicondition collaborative care intervention: a randomized controlled trial. Arch Gen Psychiatry 2012;69:506–14.
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A nurse-facilitated cognitive behavioural self-management programme for heart failure is no more cost effective than usual CBT care Peter A Coventry and Nicola Small Evid Based Nurs published online April 8, 2015
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