Standard care beats counseling for cost-effective risk management

Standard guideline-directed management of patients’ cardiovascular risk factors is more cost-effective than regular care plus counseling, according to a randomized controlled trial. But results from the Dutch study suggested women might benefit the most from the intervention.

Ans H. Tiessen, MD, of the University Medical Center Groningen in the Netherlands, and colleagues explored the costs and cost-effectiveness of cardiovascular risk management by practice nurses in the SPRING (Self-monitoring and prevention of RIsk factors by nurse practitioners in the region of Groningen) trial, using a societal perspective. The study compared regular care by practice nurses, which consisted of treatment according to Dutch guidelines, with regular care plus counseling that included self-monitoring at home using pedometers, scale weighing and blood pressure devices.

The SPRING trial had enrolled and randomized 179 patients between June 2008 and August 2009 from 20 general practices. The patients were between 50 and 75 years old with an estimated systematic coronary risk evaluation (SCORE) 10-year risk of cardiovascular mortality of 5 percent or greater. The primary outcome was the SCORE cardiovascular risk estimation at one year. The results showed a mean 1.63 percent decrease in SCORE 10-year risk in the control group and a mean 1.79 percent decrease in the intervention group.

In the present study published online Feb. 18 in BMC Public Health, Tiessen et al calculated total direct costs in the SPRING trial. Those costs included medication (2012 prices for generics), time by the medical staff, self-monitoring equipment, transportation and lost productivity. They determined the total cost per patient was $211 (EUR160) for the control group and $442 (EUR335) for the intervention group.

Lost productivity accounted for most of the costs. “The time investment of both medical staff and participants not only caused the main cost driver in both groups, but also the difference between both groups,” they wrote. “The number of visits of intervention group participants was almost twice the number of the control group participants and also the duration per visit was slightly longer in the intervention group.”

The incremental cost-effectiveness ratio was $1,427 (EUR1,082), “which means that for the intervention group approximately 1,100 euros has to be invested extra to obtain a 1 percent decrease of SCORE risk estimation,” they wrote.

A subgroup analysis found that the intervention was more cost-effective in women, patients older than 65 and, to a lesser degree, those with a higher education.  But the authors cautioned that the sample sizes were small and described findings based on those results as preliminary.

They concluded that standard cardiovascular risk management by practice nurses was more cost-effective than care plus counseling based on a self-management approach. They also observed that the annual mortality rate was higher for women compared with men, and that reducing risk factors should influence mortality in women. “A self-monitoring approach may be of interest for subgroups like females, facing a higher case fatality ratio,” they proposed, adding that subgroup and longer-term studies were warranted.