However , there were no consistent relationships observed between intervention characteristics and the effects of interventions .
Most trials review ed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure .
OBJECTIVE This systematic review of recent r and omized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease ( CAD ) and /or heart failure .
Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community
Context Although evidence indicates that nurse-led care management improves clinical outcomes for patients with heart failure , evidence on the economic benefits of these programs is lacking . Contribution Using data on costs from a r and omized trial of 12 months of care management versus usual care for socioeconomically disadvantaged patients with heart failure , the investigators estimated that the cost-effectiveness of case management is less than $ 20000/QALY . Caution The results might not apply to patients in less socioeconomically disadvantaged setting s. The Editors Health care administrators and policymakers are increasingly turning to nurse-led disease management to lessen the economic and health burden of chronic diseases , such as heart failure . Meta-analyses of r and omized , controlled trials ( RCTs ) suggest that nurse management can be effective at reducing rehospitalization and sometimes at improving functioning ( 1 ) . To our knowledge , however , no previous RCT has included a cost-effectiveness analysis sufficient to inform policymakers as to whether nurse management improves quality of life for patients with heart failure at a reasonable cost to society . Studies have not followed recommended cost-effectiveness guidelines or thoroughly calculated intervention costs ( 2 ) . Establishing the cost-effectiveness of nurse management for heart failure may be especially important in minority communities , which have disproportionate rates of hospitalization for heart failure ( 3 ) and shortfalls in the use of proven effective therapies ( 4 ) and in patients ' underst and ing of heart failure ( 5 ) . We aim ed to estimate the cost-effectiveness of a nurse-led disease management intervention that was conducted alongside a r and omized , controlled effectiveness trial . The trial , conducted in Harlem , New York , from 1999 to 2003 , found that patients in the nurse-managed group maintained better physical functioning , as measured by the Short Form-12 ( SF-12 ) physical component score , and had statistically significantly fewer hospitalizations than did patients in the control group ( 6 ) . Methods For the RCT , we recruited patients from outpatient clinics at the 4 hospitals serving East and Central Harlem in New York City . We r and omly assigned 406 patients to usual care ( 203 patients ) or a nurse-led program ( 203 patients ) in which patients had 1 in-person visit with a trained nurse and periodic follow-up telephone calls over 12 months ( 6 ) . The nurses stressed adherence to a low-salt diet and to medications and worked with the patient 's physician to optimize heart failure medications according to published guidelines . Primary outcomes were total hospitalizations and physical functioning as measured by the SF-12 physical component score . Trained surveyors who were blinded to treatment assignment called patients in both groups every 3 months for 18 months to administer the SF-12 and collect information on health care utilization , amount of informal care received , and patients ' estimates of their time engaged in receiving health care over the past 3 months . We measured cost-effectiveness by using the incremental cost-effectiveness ratio ( ICER ) , which is the difference in average costs between the nurse-managed and usual care groups ( CostNCostUC ) divided by the difference in mean quality -adjusted life-years ( QALYs ) ( QALYNQALYUC ) : ICER = (CostNCostUC)/(QALYNQALYUC ) QALYs We estimated QALYs for the 12-month intervention by translating the SF-12 physical and mental component scores into Health Utility Index Mark 3 ( HUI3 ) and EuroQol-5D ( EQ-5D ) quality -of-life scores by using methods described by Franks and colleagues ( 7 ) . We chose these translations over other published methods ( 810 ) because they were vali date d in African-American patients , and most of the patients in our trial were African American or Hispanic . Patients who died were assigned a quality -of-life score of 0 in subsequent periods . We calculated QALYs by connecting the 5 quality -of-life scores for each patient ( baseline and quarterly through 12 months ) by using straight lines and calculating the area of the result ing 4 trapezoids . We estimated adjusted differences in QALYs by the coefficient on treatment from a linear regression of each patient 's QALY on his or her quality -of-life score at baseline and treatment assignment ( 11 ) . Societal Costs We followed guidelines for cost-effectiveness analysis ( 2 ) to estimate costs from a societal perspective and included intervention , medical , and nonmedical costs ( Appendix Table ) . Intervention costs included all intervention material s ( for example , scales ) , telephone service for 2 patients who did not have it , patients ' transportation costs to the initial nurse meeting , nurses ' salaries and fringe benefits , physician time overseeing the nurse activities , and costs for office space and equipment used by the nurses . Appendix Table . Data Sources and Imputations for Cost Items We derived medical costs for inpatient , outpatient , and emergency department use from administrative records from the 4 hospitals that participated in the trial . For inpatient costs , we converted billed charges to costs by using the cost-to-charge ratio for each hospital ( 2 , 12 ) and converted the costs to 2001 U.S. dollars by using the Producer Price Index for general and surgical hospitals ( 13 ) . For outpatient and emergency department cl aims , we applied the 2001 Medicare fee schedule for the New York City region ( 14 ) to billed procedure codes . For medication costs , we obtained medications prescribed from patients ' charts and prices for those medications from the average prices paid by Medicaid ( 15 ) . We used quarterly patient surveys to collect information on inpatient and outpatient utilization at nonparticipating institutions ( to supplement administrative records from participating hospitals ) and information on nonmedical costs , which included nursing home stays ; patient transportation and time costs associated with medical encounters ; and costs of informal care or assistance with household chores provided by friends , family members , or paid housekeepers . Costs are reported in 2001 U.S. dollars . Because of skewed cost data and a high percentage of patients with zero costs for many cost categories , we evaluated the statistical significance of the difference in costs between nurse-managed and usual care groups by using 2-part gamma models ( 16 ) . In the first part , we estimated the probability of costs being greater than 0 by logistic regression , with treatment assignment ; age ; sex ; race ( non-Hispanic black , non-Hispanic white , or other non-Hispanic ) ; Hispanic ethnicity ; recruitment site ; education ; preference for Spanish interview ; New York Heart Association ( NYHA ) heart failure class ; and indicators for diabetes , chronic pulmonary disease , and ischemic heart disease as explanatory variables . In the second part , for patients with costs greater than zero , we modeled costs as a function of the same explanatory variables by using generalized linear models with a gamma distribution and a logarithmic link function . For nursing home costs , which had a very small probability of being greater than 0 , we calculated unadjusted differences in mean costs and bootstrapped SEs by using 500 replicates stratified by treatment . We replaced missing observations for SF-12 scores and self-reported utilization with 10 imputed values found by using imputation by chained equations ( 17 ) as implemented by the ICE comm and in Stata , version 10.0 ( StataCorp , College Station , TX ) ( 18 ) . The previously listed explanatory variables at baseline and administrative data for hospitalizations and outpatient visits at baseline and quarterly follow-up were regressors in these equations . We estimated the 2-part models described previously on each imputed data set and combined the results by using Rubin 's rules ( 19 ) . Uncertainty in the ICER We created 500 bootstrapped replicates ( 50 from each of the 10 imputations ) and plotted the corresponding cost-effectiveness acceptability curves ( 20 ) . We calculated approximate empirical CIs for the ICER by using the bootstrap percentile method ( 21 ) . To explore whether nurse management is more likely to be cost-effective for patients with varying heart failure severity , we computed separate acceptability curves according to baseline NYHA class . Sensitivity Analysis We estimated costs on the basis of national prices for all cost items . We used the national 2001 Medicare fee schedule to calculate costs for outpatient and emergency department use ( 14 ) , deflated costs for hospitalizations and self-reported medical use by the ratio of the United States to New York metropolitan area Consumer Price Index for medical care , and deflated nonmedical costs by the ratio of the United States to New York metropolitan area Consumer Price Index for urban dwellers ( 22 ) . To characterize the cost implication s from the payer 's perspective , we also calculated costs to the Medicare program on the basis of categories and proportions of societal costs that Medicare typically covers . These included intervention costs but excluded costs for nursing home stays , patient time , telephone consultations , nonphysician office visits , and informal care . We decreased payer costs by the deductible and copayment rates for Medicare beneficiaries in 2001 . We included drug costs because Medicare and most insurers now cover medications . We assumed the deductible and copayment rate of the 2006 Medicare prescription drug plan , but no coverage gap . We investigated the influence of imputing missing survey data on the results by reporting the ICER for the observed data only ( available data analysis ) for patients who responded to every quarterly telephone survey until death or 12 months ( complete case analysis ) and for a data set in which a patient 's missing observations were replaced with the mean value of that patient 's observed responses ( patient-specific imputation ) . We conducted all analyses in Stata , version 10 ( 18 ) . The
However , there were no consistent relationships observed between intervention characteristics and the effects of interventions .
Most trials review ed demonstrated a beneficial impact of nursing interventions for secondary prevention in patients with CAD or heart failure .
OBJECTIVE This systematic review of recent r and omized trials was conducted to determine if cardiovascular nursing interventions improve outcomes in patients with coronary artery disease ( CAD ) and /or heart failure .