Decision-analytic evaluation of the clinical effectiveness and cost-effectiveness of management programmes in chronic heart failure

The cost-effectiveness of B-type natriuretic peptide-guided care in compared to standard clinical assessment in outpatients with heart failure in Tehran, Iran

BACKGROUND

B-type natriuretic peptide (BNP) is commonly used as a diagnostic method for patients with heart failure. This study was designed to evaluate the cost-effectiveness of BNP compared to standard clinical assessment in outpatients with heart failure with reduced ejection fraction (HFrEF) in Tehran, Iran.

METHODS

This study was a cost-effectiveness analysis carried on 400 HFrEF outpatients > 45 years who were admitted to Rasoul Akram General Hospital of Tehran, Iran. A Markov model with a lifetime horizon was developed to evaluate economic and clinical outcomes for BNP and standard clinical assessment. Quality-adjusted life-years (QALYs), direct, and indirect costs collected from the patients.

RESULTS

The results of this study indicated that mean QALYs and cost were estimated to be 2.18 QALYs and $1835 for BNP and 2.07 and $2376 for standard clinical assessment, respectively. In terms of reducing costs and increasing QALYs, BNP was dominant compared to standard clinical assessment. Also, BNP had an 85% probability of being cost-effective versus standard clinical assessment if the willingness to pay threshold is higher than $20,800/QALY gained.

CONCLUSION

Based on the results of the present study, measuring BNP levels represents good value for money, decreasing costs and increasing QALYs compared to standard clinical assessment. It is suggested that the costs of the BNP test be covered by insurance in Iran. The result of the current study has important implications for policymakers in developing clinical guidelines for the diagnosis of heart failure.

Long-term cost-effectiveness of a disease management program for patients with atrial fibrillation compared to standard care - a multi-state survival model based on a randomized controlled trial

AIM

To assess the long-term cost-effectiveness of an atrial fibrillation disease management program (i.e. the SAFETY program) from the Australian healthcare system perspective.

METHODS

A multistate Markov model was developed based on patient-level data from the SAFETY randomized controlled trial. Predicted long-term survival, dependent on hospital admission history, was estimated by extrapolating parametric survival models. Quality-adjusted life years (QALY) and life years (LY) were the primary and secondary outcome measures used to estimate the incremental cost-utility/effectiveness ratio (ICUR/ICER). Both deterministic and probabilistic sensitivity analyses (PSA) were undertaken.

RESULTS

The SAFETY program was associated with both higher costs ($94,953 vs. $78,433) and benefits [QALY (3.99 vs 3.60); LY (5.86 vs 5.24)], with an ICUR of $42,513/QALY or ICER of $26,356/LY, compared to standard care. Due to the extended survival, the SAFETY was associated with a greater number of hospitalizations (14.85 vs 11.65) and higher costs for medications ($25,084 vs $22,402) and outpatient care ($12,904 vs $11,524). The cost per hospitalization for an average length of stay, analytical time horizon, and cost of medication are key determinants of ICUR. The PSA showed that the intervention has a 70.4% probability of being cost-effective at a threshold of $50,000/QALY.

CONCLUSIONS

The SAFETY program has a high probability of being cost-effective for patients with atrial fibrillation. It is associated with uncertainty that further research could potentially eliminate; implementation with further evidence collection is recommended.

Cost-Effectiveness of Transitional Care Services After Hospitalization With Heart Failure

BACKGROUND

Patients with heart failure (HF) discharged from the hospital are at high risk for death and rehospitalization. Transitional care service interventions attempt to mitigate these risks.

OBJECTIVE

To assess the cost-effectiveness of 3 types of postdischarge HF transitional care services and standard care.

DESIGN

Decision analytic microsimulation model.

DATA SOURCES

Randomized controlled trials, clinical registries, cohort studies, Centers for Disease Control and Prevention life tables, Centers for Medicare & Medicaid Services data, and National Inpatient Sample (Healthcare Cost and Utilization Project) data.

TARGET POPULATION

Patients with HF who were aged 75 years at hospital discharge.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

Disease management clinics, nurse home visits (NHVs), and nurse case management.

OUTCOME MEASURES

Quality-adjusted life-years (QALYs), costs, net monetary benefits, and incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

All 3 transitional care interventions examined were more costly and effective than standard care, with NHVs dominating the other 2 interventions. Compared with standard care, NHVs increased QALYs (2.49 vs. 2.25) and costs ($81 327 vs. $76 705), resulting in an ICER of $19 570 per QALY gained.

RESULTS OF SENSITIVITY ANALYSIS

Results were largely insensitive to variations in in-hospital mortality, age at baseline, or costs of rehospitalization. Probabilistic sensitivity analysis confirmed that transitional care services were preferred over standard care in nearly all 10 000 samples, at willingness-to-pay thresholds of $50 000 or more per QALY gained.

LIMITATION

Transitional care service designs and implementations are heterogeneous, leading to uncertainty about intervention effectiveness and costs when applied in particular settings.

CONCLUSION

In older patients with HF, transitional care services are economically attractive, with NHVs being the most cost-effective strategy in many situations. Transitional care services should become the standard of care for postdischarge management of patients with HF.

PRIMARY FUNDING SOURCE

Swiss National Science Foundation, Research Council of Norway, and an Intermountain-Stanford collaboration.

Stratified treatment recommendation or one-size-fits-all? A health economic insight based on graphical exploration

OBJECTIVES

We sought to explore to what extent the use of Subpopulation Treatment Effect Pattern Plot (STEPP) may help to identify efficient treatment allocation strategy.

METHODS

The analysis was based on data from the COACH study, in which 1023 patients with heart failure were randomly assigned to three treatments: care-as-usual, basic support, and intensive support. First, using predicted 18-month mortality risk as the stratification basis, a suitable strategy for assigning different treatments to different risk groups of patients was developed. To that end, a graphical exploration of the difference in net monetary benefit (NMB) across treatment regimens and baseline risk was used. Next, the efficiency gains resulting from this proposed subgroup strategy were quantified by computing the difference in NMB between our stratified approach and the best performing population-wide strategy.

RESULTS

The analysis using STEPPs suggested that a differentiated approach, based on offering intensive support to low-risk patients (18-month mortality risk ≤ 0.16) and basic support to intermediate- to high-risk patients (18-month mortality risk > 0.16) would be an economically efficient treatment allocation strategy. This was confirmed in the subsequent cost-effectiveness analysis, where the average gain in NMB resulting from the proposed stratified approach compared to basic support for all was found to be €1312 (95% CI €390-€2346) per patient.

CONCLUSIONS

STEPP provides a systematic approach to assess the interaction between baseline risk and the difference in NMB between competing interventions and to identify cutoffs to stratify patients in a health economically optimal manner.

Cost-effectiveness of a follow-up program for older patients with heart failure: a randomized controlled trial

PURPOSE

To assess the cost-utility of adding a disease management program (DMP) delivered by geriatric day hospital (GDH) for older patients with heart failure (HF) after hospital discharge.

METHODS

117 older HF patients discharged by a geriatric service were randomly assigned to DMP (n = 59) and usual care (UC) (n = 58) groups. The DMP group received health education, therapeutic control and monitoring through both telephone contacts and face-to-face visits at the GDH for 12 months. The UC group received standard health care. The main outcome measures were the costs from the health-care system and societal perspectives and quality-adjusted life-years (QALYs) using EuroQol (EQ-5D-3L). The cost-effectiveness analysis used the package ICEinfer in R 2.13.0.

RESULTS

The mean age was 85 years, and 73% of the patients were women. The mean values of QALYs after 12 months were - 0.083 in DMP and - 0.154 in UC. Each extra QALY gained by the DMP relative to usual care cost was €38,274 and €25,390 from health-care or societal perspective, respectively. An investment of €44,000/QALY (Spanish Health System Threshold) showed a 91 and 85% of probability to be cost-effective from health-care and societal perspectives.

CONCLUSION

The intervention was moderately cost-effective in delaying deaths and preserving the loss of health-related quality of life in older patients with HF. The study was internationally registered with the ISRCTN10823032.

Influenza vaccination in acute coronary syndromes patients in Thailand: the cost-effectiveness analysis of the prevention for cardiovascular events and pneumonia

BACKGROUND

Influenza vaccination has been clinically shown to reduce adverse cardiovascular outcomes in acute coronary syndrome (ACS) patients, but the economic perspectives can provide important data to make informed decisions. This study aimed to perform the economic evaluation of lifelong annual influenza vaccination for cardiovascular events and well-established pneumonia prevention.

METHODS

Lifetime costs, life-expectancy, and quality-adjusted live years (QALYs) were estimated beyond one-year cycle length of a six-health states Markov model condition on whether a hospitalization for ACS, stroke, heart failure, pneumonia, no hospitalizations occurred, or death. The comparison of three age-groups of 40-49, 50-65, and > 65 years scenario was performed. Incremental cost-effectiveness ratio (ICER) and net monetary benefit (NMB) were presented as a societal perspective in 2016. The model robustness was determined by one-way and probabilistic sensitivity analyses.

RESULTS

The influenza vaccination was cost-effective in all age-groups, by dominant ICERs (lower cost with higher effectiveness) which was completely lower than acceptable willingness-to-pay threshold of Thailand [160,000 THB (4,466.8 USD) per QALYs], with a great incremental value of NMB. Especially, the 50-year-old-and-above scenario was shown as the most benefit at 129,092 THB (3,603.9 USD) for each patient.

CONCLUSIONS

The annually additional influenza vaccination to standard treatment in ACS was cost-effective in all age-groups, which should be considered in clinical practice and health-policy making process.

Long-term cost-effectiveness of home versus clinic-based management of chronic heart failure: the WHICH? study

BACKGROUND

The cost-effectiveness of a heart failure management intervention can be further informed by incorporating the expected benefits and costs of future survival.

METHODS

This study compared the long-term costs per quality-adjusted life year (QALY) gained from home-based (HBI) vs specialist clinic-based intervention (CBI) among elderly patients (mean age = 71 years) with heart failure discharged home (mean intervention duration = 12 months). Cost-utility analysis was conducted from a government-funded health system perspective. A Markov cohort model was used to simulate disease progression over 15 years based on initial data from a randomized clinical trial (the WHICH? study). Time-dependent hazard functions were modeled using the Weibull function, and this was compared against an alternative model where the hazard was assumed to be constant over time. Deterministic and probabilistic sensitivity analyses were conducted to identify the key drivers of cost-effectiveness and quantify uncertainty in the results.

RESULTS

During the trial, mortality was the highest within 30 days of discharge and decreased thereafter in both groups, although the declining rate of mortality was slower in CBI than HBI. At 15 years (extrapolated), HBI was associated with slightly better health outcomes (mean of 0.59 QALYs gained) and mean additional costs of AU$13,876 per patient. The incremental cost-utility ratio and the incremental net monetary benefit (vs CBI) were AU$23,352 per QALY gained and AU$15,835, respectively. The uncertainty was driven by variability in the costs and probabilities of readmissions. Probabilistic sensitivity analysis showed HBI had a 68% probability of being cost-effective at a willingness-to-pay threshold of AU$50,000 per QALY.

CONCLUSION

Compared with CBI (outpatient specialized HF clinic-based intervention), HBI (home-based predominantly, but not exclusively) could potentially be cost-effective over the long-term in elderly patients with heart failure at a willingness-to-pay threshold of AU$50,000/QALY, albeit with large uncertainty.

Economic Evaluations of Multicomponent Disease Management Programs with Markov Models: A Systematic Review

BACKGROUND

Disease management programs (DMPs) for chronic diseases are being increasingly implemented worldwide.

OBJECTIVES

To present a systematic overview of the economic effects of DMPs with Markov models. The quality of the models is assessed, the method by which the DMP intervention is incorporated into the model is examined, and the differences in the structure and data used in the models are considered.

METHODS

A literature search was conducted; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed to ensure systematic selection of the articles. Study characteristics e.g. results, the intensity of the DMP and usual care, model design, time horizon, discount rates, utility measures, and cost-of-illness were extracted from the reviewed studies. Model quality was assessed by two researchers with two different appraisals: one proposed by Philips et al. (Good practice guidelines for decision-analytic modelling in health technology assessment: a review and consolidation of quality asessment. Pharmacoeconomics 2006;24:355-71) and the other proposed by Caro et al. (Questionnaire to assess relevance and credibility of modeling studies for informing health care decision making: an ISPOR-AMCP-NPC Good Practice Task Force report. Value Health 2014;17:174-82).

RESULTS

A total of 16 studies (9 on chronic heart disease, 2 on asthma, and 5 on diabetes) met the inclusion criteria. Five studies reported cost savings and 11 studies reported additional costs. In the quality, the overall score of the models ranged from 39% to 65%, it ranged from 34% to 52%. Eleven models integrated effectiveness derived from a clinical trial or a meta-analysis of complete DMPs and only five models combined intervention effects from different sources into a DMP. The main limitations of the models are bad reporting practice and the variation in the selection of input parameters.

CONCLUSIONS

Eleven of the 14 studies reported cost-effectiveness results of less than $30,000 per quality-adjusted life-year and the remaining two studies less than $30,000 per life-year gained. Nevertheless, if the reporting and selection of data problems are addressed, then Markov models should provide more reliable information for decision makers, because understanding under what circumstances a DMP is cost-effective is an important determinant of efficient resource allocation.

Economic Modeling of Heart Failure Telehealth Programs: When Do They Become Cost Saving?

Telehealth programs for congestive heart failure have been shown to be clinically effective. This study assesses clinical and economic consequences of providing telehealth programs for CHF patients. A Markov model was developed and presented in the context of a home-based telehealth program on CHF. Incremental life expectancy, hospital admissions, and total healthcare costs were examined at periods ranging up to five years. One-way and two-way sensitivity analyses were also conducted on clinical performance parameters. The base case analysis yielded cost savings ranging from $2832 to $5499 and 0.03 to 0.04 life year gain per patient over a 1-year period. Applying telehealth solution to a low-risk cohort with no prior admission history would result in $2502 cost increase per person over the 1-year time frame with 0.01 life year gain. Sensitivity analyses demonstrated that the cost savings were most sensitive to patient risk, baseline cost of hospital admission, and the length-of-stay reduction ratio affected by the telehealth programs. In sum, telehealth programs can be cost saving for intermediate and high risk patients over a 1- to 5-year window. The results suggested the economic viability of telehealth programs for managing CHF patients and illustrated the importance of risk stratification in such programs.

MitraClip therapy in mitral regurgitation: a Markov model for the cost-effectiveness of a new therapeutic option

Introduction Mitral regurgitation is a heart condition resulting from blood flowing from the left ventricle towards the left atrium, increasing the risk of heart failure and mortality. While surgery can greatly reduce these risks, some patients are not eligible, resulting in medication being their only therapeutic alternative. The MitraClip (Abbot Vascular) is a medical device that is percutaneously implanted and designed to eliminate leaking of the mitral valve. Methods The efficacy of the MitraClip strategy vs medical management was assessed using a 4-state Markov model based on the mitral regurgitation grade (mitral regurgitation grade 0, I/II, and III/IV, and death). At each 1-month cycle, patients were or were not hospitalized. The model analyzed a fictional population of 1000 patients over a 5-year period from a national Health Insurance perspective. The primary end-point was the number of deaths avoided. Data from the EVEREST II High Risk Study patients were used along with a literature review. Results At 5 years, among the 1000 patients, 276 deaths were found to be avoidable with the MitraClip strategy. The incremental cost-effectiveness ratio (ICER) was €93,363 per death avoided. The annual ICER was calculated to take into consideration excess costs resulting from the MitraClip over the first year (€29,984 vs €8557 for the reference strategy) and the reduction of costs in following years (€3122 for MitraClip vs €8557 for reference strategy). Thus, the mean ICER was calculated to be €20,720 per death avoided. Conclusion The MitraClip is a novel alternative therapy for mitral insufficiency in patients ineligible for surgery that may offer a medico-economic advantage.

Cost-effectiveness and cost-utility of a structured collaborative disease management in the Interdisciplinary Network for Heart Failure (INH) study

BACKGROUND

Non-pharmacological treatment programmes are being developed, in which specialised nurses take care of heart failure (HF) patients. Such disease management programmes might increase survival and quality of life in HF patients, but evidence on their cost-effectiveness remains limited.

METHODS AND RESULTS

A prospective economic evaluation piggy-backed onto the randomised controlled Interdisciplinary Network for Heart Failure (INH) Study weighted costs of the intervention HeartNetCare -HF™ (HNC) regarding effectiveness, mortality and quality-adjusted life years (QALYs). To consider uncertainty sensitivity analyses were performed. Compared to usual care (UC), HNC revealed 8,284 <euro> per death avoided within the 6 month study follow-up period. The cost-utility analysis showed additional costs of 49,335 <euro> per QALY.

CONCLUSION

Although HNC did not reduce short-term re-admission rates of HF patients hospitalised for cardiac decompensation within the first 180 days after discharge, HNC might reduce mortality and increase quality of life in these patients at reasonable costs. Therefore, long-term HNC-effects deserve further evaluation.

Are all outcomes in chronic heart failure rated equally? An argument for a patient-centred approach to outcome assessment

Chronic heart failure (CHF) is a multi-dimensional and complex syndrome. Outcome measures are important for determining both the efficacy and quality of care and capturing the patient's perspective in evaluating the outcomes of health care delivery. Capturing the patient's perspective via patient-reported outcomes is increasingly important; however, including objective measures such as mortality would provide more complete account of outcomes important to patients. Currently, no single measure for CHF outcomes captures all dimensions of the quality of care from the patient's perspective. To describe the role of outcome measures in CHF from the perspective of patients, a structured literature review was undertaken. This review discusses the concepts and methodological issues related to measurement of CHF outcomes. Outcome assessment at the level of the patient, provider and health care system were identified as being important. The perspectives of all stakeholders should be considered when developing an outcomes measurement suite to inform CHF health care. This paper recommends that choice of outcome measures should depend on their ability to provide a comprehensive, comparable, meaningful and accurate assessment that are important to patient.

Resource use and cost implications of implementing a heart failure program for patients with systolic heart failure in Swedish primary health care

AIM

Heart failure (HF) is a common but serious condition which involves a significant economic burden on the health care economy. The purpose of this study was to evaluate cost and quality of life (QoL) implications of implementing a HF management program (HFMP) in primary health care (PHC).

METHODS AND RESULTS

This was a prospective randomized open-label study including 160 patients with a diagnosis of HF from five PHC centers in south-eastern Sweden. Patients randomized to the intervention group received information about HF from HF nurses and from a validated computer-based awareness program. HF nurses and physicians followed the patients intensely in order to optimize HF treatment according to current guidelines. The patients in the control group were followed by their regular general practitioner (GP) and received standard treatment according to local management routines. No significant changes were observed in NYHA class and quality-adjusted life years (QALY), implying that functional class and QoL were preserved. However, costs for hospital care (HC) and PHC were reduced by EUR 2167, or 33%. The total cost was EUR 4471 in the intervention group and EUR 6638 in the control group.

CONCLUSIONS

Introducing HFMP in Swedish PHC in patients with HF entails a significant reduction in resource utilization and costs, and maintains QoL. Based on these results, a broader implementation of HFMP in PHC may be recommended. However, results should be confirmed with extended follow-up to verify long-term effects.

Associations between Seattle Heart Failure Model scores and health utilities: findings from HF-ACTION

BACKGROUND

The Seattle Heart Failure Model (SHFM) is a well validated prediction model of all-cause mortality in patients with heart failure, but its relationship with generic health status measures has not been evaluated. We sought to investigate relationships between SHFM scores and health utility weights, which are necessary to estimate quality-adjusted life-years in cost-effectiveness analyses.

METHODS AND RESULTS

We applied mixed linear regression to examine relationships between baseline SHFM scores and EQ-5D-derived health utilities collected longitudinally in a large clinical trial. A 1-unit increase in SHFM score (higher predicted mortality) was associated with a 0.030 decrease in utility (P < .001) and an additional 0.006 decrease per year (P < .001). With SHFM score modeled as a categorical variable, EQ-5D utilities for patients with rounded SHFM scores of 1 or 2 were significantly lower (-0.041 and -0.053, respectively; both P < .001) and declined more rapidly over time (-0.011 and -0.020, respectively; both P ≤ .004) than for patients with scores of -1.

CONCLUSIONS

Patients with higher SHFM-predicted mortality had significantly lower health utilities at baseline and greater rates of decline over time, compared with patients with lower SHFM-predicted mortality. These relationships can be applied when examining the cost-effectiveness of heart failure interventions.

Cost-effectiveness of heart failure therapies

Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Management of HF involves accurate diagnosis and implementation of evidence-based treatment strategies. Costs related to the care of patients with HF have increased substantially over the past 2 decades, partly owing to new medications and diagnostic tests, increased rates of hospitalization, implantation of costly novel devices and, as the disease progresses, consideration for heart transplantation, mechanical circulatory support, and end-of-life care. Not surprisingly, HF places a huge burden on health-care systems, and widespread implementation of all potentially beneficial therapies for HF could prove unrealistic for many, if not all, nations. Cost-effectiveness analyses can help to quantify the relationship between clinical outcomes and the economic implications of available therapies. This Review is a critical overview of cost-effectiveness studies on key areas of HF management, involving pharmacological and nonpharmacological clinical therapies, including device-based and surgical therapeutic strategies.

COST-UTILITY ANALYSIS OF NT-PROBNP-GUIDED MULTIDISCIPLINARY CARE IN CHRONIC HEART FAILURE

Objectives: A recent randomized, controlled trial in chronic heart failure patients showed that NT-proBNP-guided, intensive patient management (BMC) on top of multidisciplinary care reduced all-cause mortality and heart failure hospitalizations compared with multidisciplinary care (MC) or usual care (UC). We now performed a cost-utility analysis of these interventions from a payer's perspective.

Methods: Costs related to hospitalizations, ambulatory physician and nurse visits, and NT-proBNP testing for the three management strategies were acquired for both Austria (€) and Canada ($) and combined with the survival and quality of life data from the clinical trial for cost-effectiveness analysis. Data on long-term survival, costs, and quality-adjusted life-years (QALY) were extrapolated for a 20-year time horizon using a Markov model, which simulated the progression of disease through beta-blocker use, hospitalizations, and mortality.

Results: BMC was the most cost-effective strategy as it was dominant (cost-saving with improved health outcome) over both MC and UC based on both Austrian and Canadian costs. Incremental cost-effectiveness ratios for MC relative to UC were €3,746 and $5,554 per QALY gained for Austrian and Canadian costs, respectively. The probabilities for BMC being the most cost-effective strategy were 92 percent at a threshold value of Austrian €40,000 and 93 percent at a threshold value of Canadian $50,000.

Conclusions: NT-proBNP-guided, intensive HF patient management in addition to multidisciplinary care not only reduces death and hospitalization but also proves to be cost-effective.

Decision-analytic models to simulate health outcomes and costs in heart failure: a systematic review

Chronic heart failure (CHF) is a critical public health issue with increasing effect on the healthcare budgets of developed countries. Various decision-analytic modelling approaches exist to estimate the cost effectiveness of health technologies for CHF. We sought to systematically identify these models and describe their structures. We performed a systematic literature review in MEDLINE/PreMEDLINE, EMBASE, EconLit and the Cost-Effectiveness Analysis Registry using a combination of search terms for CHF and decision-analytic models. The inclusion criterion required 'use of a mathematical model evaluating both costs and health consequences for CHF management strategies'. Studies that were only economic evaluations alongside a clinical trial or that were purely descriptive studies were excluded. We identified 34 modelling studies investigating different interventions including screening (n = 1), diagnostics (n = 1), pharmaceuticals (n = 15), devices (n = 13), disease management programmes (n = 3) and cardiac transplantation (n = 1) in CHF. The identified models primarily focused on middle-aged to elderly patients with stable but progressed heart failure with systolic left ventricular dysfunction. Modelling approaches varied substantially and included 27 Markov models, three discrete-event simulation models and four mathematical equation sets models; 19 studies reported QALYs. Three models were externally validated. In addition to a detailed description of study characteristics, the model structure and output, the manuscript also contains a synthesis and critical appraisal for each of the modelling approaches. Well designed decision models are available for the evaluation of different CHF health technologies. Most models depend on New York Heart Association (NYHA) classes or number of hospitalizations as proxy for disease severity and progression. As the diagnostics and biomarkers evolve, there is the hope for better intermediate endpoints for modelling disease progression as those that are currently in use all have limitations.

Self care in patients with chronic heart failure

'Heart failure self care' refers to the practices in which patients engage to maintain their own health, and to the decisions that they make about managing signs or symptoms. In this article, we base our discussion of self care in chronic heart failure on the classification of patients as being 'expert', inconsistent', or 'novice' in heart failure self-care behaviors. The available literature on factors predicting heart failure self care and its outcomes are reviewed within this context. Factors known to influence heart failure self care include experience with the illness, physical functioning, depression and anxiety, social support, daytime sleepiness, and attitudes such as confidence. Further research is needed to understand the contributions of comorbidities, patient sex, and health disparities on heart failure self care. The evidence to support a link between heart failure self care and health outcomes is limited, but early evidence suggests that adequate self care is associated with an improvement in health status, a decrease in the number and duration of hospitalizations, and a decline in levels of biomarkers of stress and inflammation, and in intrathoracic impedance. Implications of heart failure self care for clinical practice, policy, and public health are also described.