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BACKGROUND/RATIONALE:
Clinical practice guidelines are designed to translate research into recommendations for practice, and form the basis for many VA performance measures for heart failure care. However, many providers both within and outside the VA are often slow to incorporate guideline recommendations. These delays have important consequences for the health of veterans, particularly if life-prolonging heart failure treatments are delayed. Recently, beta-blockers have been shown to improve survival (1,2), and are now recommended by all major clinical heart failure guidelines that have been published in the last three years. The American College of Cardiology and the American Heart Association has recently listed beta-blocker use as one of 13 recommended performance measures for patients with heart failure. (3) The VA has recently begun tracking beta-blocker use in heart failure patients through the External Peer Review Program (EPRP) in anticipation of a possible VA performance measure.
With the goal of improving the use of beta-blockers in patients with heart failure, we conducted a clinical trial (funded by VA HSR&D) of two interventions to increase the initiation and titration of beta-blockers in patients with heart failure. (4) The trial found that the use of a nurse case manager (supervised by a cardiologist) led to large improvements in beta-blocker use compared to computerized reminders and usual care. Both increased initiation and more appropriate dosing were noted for the nurse-case manager group. No significant differences in beta-blocker use at follow-up were found between the reminder and usual care groups.
If the nurse case-manager for heart failure is to be implemented on a wide scale, the cost-effectiveness of this intervention must be demonstrated. Furthermore, the cost-effectiveness should be demonstrated from the perspective of the VA Hospital Director if a business case for implementation is to be made.(5) The purpose of this study is to evaluate the cost of nurse based initiation and titration of beta-blockers, estimate the long-term benefits (quality adjusted life-years) and determine the cost and cost per quality adjusted life-year gained both from a societal and a local VA center perspective.
OBJECTIVE(S):
Primary Short-Term Aims
1) To determine the economic impact of a nurse-based program designed to implement heart failure guidelines for beta-blocker use (previously shown to be effective in a randomized trial).
2) To determine the cost-effectiveness of the nurse-based program.
3) To develop a business case for a nurse based program that will be used to implement clinical practice guidelines and improve compliance with performance measures.
METHODS:
Economic Analysis We will use a state transition model, previously developed by Dr. Heidenreich (6) to estimate the long-term economic and health outcomes for heart failure patients treated with and without beta-blockers. This model uses data from randomized clinical trials and cohort studies to estimate the impact on resource use and survival with beta-blockers and other heart failure treatments. The model follows a hypothetical cohort of patients with heart failure over their life-time, using a 12 month cycle length and a 3% discount rate.
Perspective: Analyses from several perspectives will be performed. a VA medical center perspective will be used to demonstrate the impact on cost and outcome at one and five years after initiation of the program. In addition, a societal perspective will be used with and without indirect costs due to loss of employment. The VA perspective will use VA costs per resource consumed, while the societal perspective will use average U.S. wholesale costs for medications, and Medicare payments for hospitalization, physician services and laboratory tests.
Intervention : The intervention tested in the randomized trial consisted of a nurse practitioner identifying, initiating, titrating, and stabilizing appropriate heart failure patients on beta-blockers. (4) After reaching the target or the maximum tolerated beta-blocker dose, the patient was returned to his or her primary care provider for all additional care.
Cost and Effectiveness of the Intervention: Data from the completed randomized trial will be used to determine the resources used (space, personnel) by the nurse in identifying patients, initiating and titrating medications. Heart failure related costs are already incorporated into the heart failure state-transition model describe above. The randomized trial that documented the effectiveness of the intervention included only 169 patients, and was not powered to show differences in mortality or hospitalization rates. The effect of beta-blockers on these outcomes will be determined from the state-transition model which incorporates results from meta-analyses of randomized controlled trials. The impact of the program on outcome is assumed to be due solely to increased use of beta-blockers.
FINDINGS/RESULTS:
No results at this time.
IMPACT:
Through an analysis of the cost and outcomes of a program to improve recommended heart failure care we will be able to prepare a business case for the intervention that will facilitate the program’s implementation.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems
DRE:
Resource Use and Cost, Treatment
Keywords:
Cardiovasc’r disease, Clinical practice guidelines, Nursing
MeSH Terms:
none
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