Cost-effectiveness of nurse-based case management versus usual care for elderly patients with myocardial infarction: results from the KORINNA study

Effect of case management based on Omaha system on clinical symptoms and quality of life of coronary heart disease patients after percutaneous coronary intervention

To investigate the effect of case management (CM) based on the Omaha system on clinical symptoms and quality of life (QOL) of coronary heart disease patients after percutaneous coronary intervention (PCI). Patients with coronary heart disease after their first PCI in the People's Hospital of Longhua in Shenzhen were randomly divided into a control group (received CM based on the Omaha system) and an observation group (received routine nursing) using a random number table. Nursing problems and the knowledge-behavior-status (KBS) score of patients were evaluated on the day after surgery, on the day before discharge, at 5 weeks after discharge, and at 12 weeks after discharge. The QOL of patients was evaluated using the coronary intervention coronary revascularization outcome questionnaire (CROQ-PTCA-Post, Chinese version) score on the day after surgery and at 12 weeks after discharge. A total of 104 patients completed the study (51 in the control group, 53 in the observation group). There were no significant differences in baseline data between the 2 groups (P gr.05). The main nursing problems were circulation, mental health, and pain in both groups on the day after surgery, whereas they were circulation, sleep and rest, and mental health after nursing. There were no significant differences in the KBS scores of the co-existing nursing problems on the day after surgery (P Th.05). The KBS scores of the co-existing nursing problems were significantly increased between the 2 groups (P < .01) on the day before discharge and at 5 weeks and 12 weeks after discharge. The KBS scores of the most co-existing nursing problems in the observation group were significantly higher at 12 weeks after discharge than at the day before discharge and at 5 weeks after discharge. Moreover, there were no significant differences in the CROQ-PTCA-Post scores on the first day after surgery between the 2 groups (P gr.05). These scores were significantly increased between the 2 groups at 12 weeks after discharge (P < .01). CM based on the Omaha system for patients after PCI can effectively improve the KBS scores and QOL of PCI patients with postoperative nursing problems, making this approach worthy of clinical promotion.

Use of the visual analogue scale for health state valuation: a scoping review

OBJECTIVES

The visual analogue scale (VAS) has been used in the context of health and healthcare for various purposes, for example, to measure pain and to provide a single-index measure of health-related quality of life (HRQoL). This scoping review aims to describe how the VAS has been used for health state valuation in the published literature.

METHODS

The search was carried out in Medline, Web of Science and PsycInfo. The findings of the included articles were tabulated and presented descriptively using frequencies and proportions.

RESULTS

The database search yielded 4856 unique articles, out of these, 308 were included. In 83% of the articles, the main purpose for using a VAS was to value health states. The two most common perspectives when valuing health states with a VAS were hypothetical (44%) and own health (34%). Some (n = 14) articles used the VAS in the context of economic evaluations, including calculating quality-adjusted life years (QALYs). A large variation in the design of the VAS was found, including the description of the lower and upper anchors. Advantages and disadvantages with using a VAS were mentioned in 14% of the included articles.

CONCLUSION

The VAS has been a common method for valuing health states, both as a stand-alone method and in combination with other valuation methods. Despite its widespread use, the design of the VAS has been inconsistent which makes comparison of results across studies challenging. Further research on the role of using the VAS in economic evaluations is warranted.

Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

BACKGROUND

Chronic ultimorbidity is the most frequent and serious health problem in older adults. Home visiting programmes could be a strategy with potential benefits. However, there are no scoping reviews to date that examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

OBJECTIVE

To examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

METHODS

A scoping review was carried out following PRISMA-ScR reporting guidelines. The search was conducted in six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) between October 2021 and April 2022.

RESULTS

Four RCTs with 560 patients were included. The visits were carried out by nurses, nursing students, volunteers, and other healthcare professionals. The interventions varied in the number of visits, frequency, duration of follow-up, and whether or not they were combined with other strategies such as telephone calls. Discrepancies were found in the effects of the interventions on quality of life, self-efficacy, self-rated health, and use and cost of health and social services.

CONCLUSION

This review shows that home visiting programmes could have potential benefits for older adults with chronic multimorbidity. However, its results have been inconclusive. There is a need for high quality studies involving a larger number of patients, in which home visits are the main intervention.

[Cost-Effectiveness of Case and Care Management in Older Populations in Germany: a Systematic Literature Review]

BACKGROUND

Despite trends toward longer-lasting health, the complexity of older people's health problems is increasing, raising the need for interprofessional care in all settings. A lack of coordination among providers risks fragmented care, leading to a repetition or gaps in services, conflicting treatment recommendations, medication errors and higher costs. Accordingly, new integrated models of care are needed that are based on patient needs. Case and Care Management (CCM) is currently being tested in Germany in a variety of settings to improve care.

AIM OF THE STUDY

The aim of the present study was to analyze the results of health economic evaluations of CCM interventions in Germany in populations over 60 years of age compared to standard care.

MATERIAL AND METHODS

The study is based on a systematic literature review conducted via Pubmed and Livivo and supplemented by a comprehensive hand search. The primary studies included for analysis were assessed using the CHEERS statement and narratively synthesized.

RESULTS

A total of five cost-effectiveness studies were included, predominantly based on randomized controlled trials. Results regarding cost effectiveness were mixed. Individual studies found significant differences on effectiveness and cost endpoints.

CONCLUSIONS

The mixed, small number of studies does not currently provide a clear picture of whether CCM interventions have health economic advantages over standard care. Further research is indicated. Innovation fund projects on the topic area are expected to generate new evidence in the future.

Cost-Effectiveness of Pulmonary Rehabilitation in Patients With Bronchial Asthma: An Analysis of the EPRA Randomized Controlled Trial

OBJECTIVES

At 3 months after the intervention, this study evaluates the cost-effectiveness of a 3-week inpatient pulmonary rehabilitation (PR) in patients with asthma compared with usual care alongside the single-center randomized controlled trial-Effectiveness of Pulmonary Rehabilitation in Patients With Asthma.

METHODS

Adopting a societal perspective, direct medical costs and productivity loss were assessed using the Questionnaire for Health-Related Resource Use-Lung, a modification of the FIM in an Elderly Population. The effect side was operationalized as minimal important differences (MIDs) of the Asthma Control Test (ACT) and the Asthma Quality of Life Questionnaire (AQLQ) and through quality-adjusted life-years (QALYs) gained. Adjusted mean differences in costs (gamma-distributed model) and each effect parameter (Gaussian-distributed model) were simultaneously calculated within 1000 bootstrap replications to determine incremental cost-effectiveness ratios (ICERs) and to subsequently delineate cost-effectiveness acceptability curves.

RESULTS

PR caused mean costs per capita of €3544. Three months after PR, we observed higher mean costs (Δ€3673; 95% confidence interval (CI) €2854-€4783) and improved mean effects (ACT Δ1.59 MIDs, 95% CI 1.37-1.81; AQLQ Δ1.76 MIDs, 95% CI 1.46-2.08; QALYs gained Δ0.01, 95% CI 0.01-0.02) in the intervention group. The ICER was €2278 (95% CI €1653-€3181) per ACT-MID, €1983 (95% CI €1430-€2830) per AQLQ-MID, and €312 401 (95% CI €209 206-€504 562) per QALY gained.

CONCLUSIONS

Contrasting of PR expenditures with ICERs suggests that the intervention, which achieves clinically relevant changes in asthma-relevant parameters, has a high probability to be already cost-effective in the short term. However, in terms of QALYs, extended follow-up periods are likely required to comprehensively judge the added value of a one-time initial investment in PR.

Health-related quality of life 1-3 years post-myocardial infarction: its impact on prognosis

Objective

To assess associations of health-related quality of life (HRQoL) with patient profile, resource use, cardiovascular (CV) events and mortality in stable patients post-myocardial infarction (MI).

Methods

The global, prospective, observational TIGRIS Study enrolled 9126 patients 1–3 years post-MI. HRQoL was assessed at enrolment and 6-month intervals using the patient-reported EuroQol-5 dimension (EQ-5D) questionnaire, with scores anchored at 0 (worst possible) and 1 (perfect health). Resource use, CV events and mortality were recorded during 2-years’ follow-up. Regression models estimated the associations of index score at enrolment with patient characteristics, resource use, CV events and mortality over 2-years’ follow-up.

Results

Among 8978 patients who completed the EQ-5D questionnaire, 52% reported ‘some’ or ‘severe’ problems on one or more health dimensions. Factors associated with a lower index score were: female sex, older age, obesity, smoking, higher heart rate, less formal education, presence of comorbidity (eg, angina, stroke), emergency room visit in the previous 6 months and non-ST-elevation MI as the index event. Compared with an index score of 1 at enrolment, a lower index score was associated with higher risk of all-cause death, with an adjusted rate ratio of 3.09 (95% CI 2.20 to 4.31), and of a CV event, with a rate ratio of 2.31 (95% CI 1.76 to 3.03). Patients with lower index score at enrolment had almost two times as many hospitalisations over 2-years’ follow-up.

Conclusions

Clinicians managing patients post-acute coronary syndrome should recognise that a poorer HRQoL is clearly linked to risk of hospitalisations, major CV events and death.

Trial registration number

ClinicalTrials.gov Registry (NCT01866904) (https://clinicaltrials.gov).

Cost-utility analysis of home-based cardiac rehabilitation as compared to usual post-discharge care: systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Determining cost-utility differences between home-based cardiac rehabilitation (HBCR) on the one hand, and usual post-discharge care (UC) on the other, can improve resource-allocation in healthcare settings.

AREAS COVERED

In June 2019, PubMed, Web of Science, Scopus, and Cochrane library were searched for randomized controlled HBCR trials. Standardized mean differences (SMDs) of cost and quality-adjusted life years (QALYs) between HBCRs and UCs were calculated using random effect models. Heterogeneity was assessed by inconsistency index (I2) and publication bias by funnel plot and Egger's regression test. Thirteen articles, representing 2,992 participants, were deemed representative for final analysis. In the meta-analysis, a significant difference with respect to QALYs favored HBCR, while no significant cost difference was observed between HBCR and UC. However, subgroup-analysis of trials with different follow-up durations revealed somewhat different results, and HBCR was found to be significantly better with regard to both cost and QALYs for patients with heart failure. Cost-utility analysis categorizing interventions as 'dominant', 'effective', 'doubtful', and 'dominated', found HBCRs dominant.

EXPERT OPINION

Although HBCR tended to be superior compared to UC in this review, larger and more robust trials addressing specific patients groups are needed for definitive results.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population

Older people (aged 65 years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80 years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

Cost-effectiveness analysis of case management for optimized antithrombotic treatment in German general practices compared to usual care - results from the PICANT trial

BACKGROUND

By performing case management, general practitioners and health care assistants can provide additional benefits to their chronically ill patients. However, the economic effects of such case management interventions often remain unclear although how to manage the burden of chronic disease is a key question for policy-makers. This analysis aimed to compare the cost-effectiveness of 24 months of primary care case management for patients with a long-term indication for oral anticoagulation therapy with usual care.

METHODS

This analysis is part of the cluster-randomized controlled Primary Care Management for Optimized Antithrombotic Treatment (PICANT) trial. A sample of 680 patients with German statutory health insurance was initially considered for the cost analysis (92% of all participants at baseline). Costs included all disease-related direct health care costs from the payer's perspective (German statutory health insurers) plus case management costs for the intervention group. A-Quality Adjusted Life Year (QALY) measurement (EQ-5D-3 L instrument) was used to evaluate utility, and incremental cost-effectiveness ratio (ICER) to assess cost-effectiveness. Mean differences were calculated and displayed with 95%-confidence intervals (CI) from non-parametric bootstrapping (1000 replicates).

RESULTS

N = 505 patients (505/680, 74%) were included in the cost analysis (complete case analysis with a follow-up after 12 and 24 months as well as information on cost and QALY). After two years, the mean difference of direct health care costs per patient (€115, 95% CI [- 201; 406]) and QALYs (0.03, 95% CI [- 0.04; 0.11]) in the two groups was small and not significant. The costs of case management in the intervention group caused mean total costs per patient in this group to rise significantly (mean difference €503, 95% CI [188; 794]). The ICER was €16,767 per QALY. Regardless of the willingness of insurers to pay per QALY, the probability of the intervention being cost-effective never rose above 70%.

CONCLUSIONS

A primary care case management for patients with a long-term indication for oral anticoagulation therapy improved QALYs compared to usual care, but was more costly. However, the results may help professionals and policy-makers allocate scarce health care resources in such a way that the overall quality of care is improved at moderate costs, particularly for chronically ill patients.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41847489 .

Determinants of adherence and effects on health-related quality of life after myocardial infarction: a prospective cohort study

BACKGROUND

Adherence to recommendations and medication is deemed to be important for effectiveness of case management interventions. Thus, reasons for non-adherence and effects on health-related quality of life (HRQoL) should be fully understood. The objective of this research was to identify determinants of non-adherence to medication and recommendations, and to test whether increased adherence improved HRQoL in patients after myocardial infarction (MI) in a case management intervention.

METHODS

Data were obtained from the intervention group of the KORINNA study, a randomized controlled trail of a nurse-led case management intervention with targeted recommendations in the elderly after MI in Germany. Reasons for non-adherence were described. Logistic mixed effects models and OLS (ordinary least squares) were used to analyze the effect of recommendations on the probability of adherence and the association between adherence and HRQoL.

RESULTS

One hundred and twenty-seven patients with 965 contacts were included. Frequent reasons for non-adherence to medication and recommendations were "forgotten" (22%; 11%), "reluctant" (18%; 18%), "side effects" (38%; 7%), "the problem disappeared" (6%; 13%), and "barriers" (0%; 13%). The probability of adherence was lowest for disease and self-management (38%) and highest for visits to the doctor (61%). Only if patients diverging from prescribed medication because of side effects were also considered as adherent, 3-year medication adherence was associated with a significant gain of 0.34 quality-adjusted life years (QALYs).

CONCLUSIONS

Most important determinants of non-adherence to medication were side effects, and to recommendations reluctance. Recommended improvements in disease and self-management were least likely adhered. Medication adherence was associated with HRQoL.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN02893746 , retrospectively registered, date assigned 27/03/2009.

The 3-Year Cost-Effectiveness of a Nurse-Based Case Management versus Usual Care for Elderly Patients with Myocardial Infarction: Results from the KORINNA Follow-Up Study

OBJECTIVES

To assess the 3-year cost-effectiveness of a nurse-based case management intervention in elderly patients with myocardial infarction from a societal perspective.

METHODS

The intervention consisted of one home visit and quarterly telephone calls in the first year, and semi-annual calls in the following 2 years. The primary effect measures were quality-adjusted life-years (QALYs), on the basis of the EuroQol five-dimensional questionnaire (EQ-5D-3L) and adjusted life-years from patients' self-rated health states according to the visual analogue scale (VAS-ALs). A linear regression model was used for adjusted life-years and a gamma model for costs. Estimation uncertainty was addressed by cost-effectiveness acceptability curves, which indicate the likelihood of cost-effectiveness for a given value of willingness to pay. The secondary objective was to examine EQ-5D-3L utility scores and VAS scores among survivors using linear mixed models.

RESULTS

Primary outcomes regarding QALY gains (+0.0295; P = 0.76) and VAS-AL gains (+0.1332; P = 0.09) in the intervention group were not significant. The overall cost difference was -€2575 (P = 0.30). The probability of cost-effectiveness of the case management at a willingness-to-pay value of €0 per QALY was 84% in the case of QALYs and 81% in the case of VAS-ALs. Secondary outcomes concerning survivors' quality of life were significantly better in the intervention group (EQ-5D-3L utilities: +0.104, P = 0.005; VAS: +8.15, P = 0.001) after 3 years.

CONCLUSIONS

The case management was cost-neutral and led to an important and significant improvement in health status among survivors. It was associated with higher QALYs and lower costs but the differences in costs and QALYs were not statistically significant.

Validity of self-reported hospital admissions in clinical trials depends on recall period length and individual characteristics

RATIONALE, AIMS AND OBJECTIVES

We investigated the validity of self-reported admission data compared to administrative records in a clinical trial.

METHOD

In the randomized KORINNA study (ISRCTN02893746), hospital admission data were collected in telephone interviews with 273 elderly patients quarterly over a 1-year period and thereafter annually over a 2-year period. Data were compared with administrative records and discharge letters. Mixed models were used to investigate if recall period and individual characteristics influence validity.

RESULTS

Specificity (>99%) and sensitivity (94%) of self-reported data did not differ for different recall periods (3 months vs. 12 months). The differences between self-reported and registered inpatient days were not statistically significant. Having regard to all the admissions within the time period of last interview and dropping out, the bias was up to 40% underestimation. The chance of disagreement was significantly smaller [odds ratio (OR) of misremember an admission = 0.596, P = 0.049, confidence interval (CI) = 0.355 to 1.00; OR of misremember length of stay = 0.521, P = 0.002, CI = 0.344 to 0.789] for 3-month periods, but this was primarily driven by number of admissions within the recall period. Individuals with better health and longer stays had a significantly smaller chance of disagreement.

CONCLUSIONS

The bias within one year was not influenced by applying various recall periods, although the probability of correctly self-reported single hospital admission was higher using a recall period of three months. It can be recommended that lengthened recall periods of 12 months are appropriate for gathering self-reported hospital admission data in elderly people with myocardial infarction.