Long-term cost effectiveness of case-based training of evidence-based clinical practice in primary care patients with coronary heart disease

Abstract

Implementation of evidence-based guidelines in primary health care is a task of great complexity. Secondary prevention in patients with coronary heart disease (CHD) is still far from guide line goals. We performed a successful case-based randomized intervention study in primary care. All-cause mortality was reduced from 44% to 22% in the intervention group (hazard ratio 0.45 CI 0.20-0.95; p=0.02) during follow-up. Our aim was to assess long-term cost-effectiveness. Methods: Direct costs of hospital admissions were assessed by the National Patient Register (NPR) which covers all hospital care and enabled calculation of all costs for inpatient care. The cost of drugs and intervention were added to the direct costs (2012 price level). Net gained life years in the intervention and specialist group as compared to control group were assessed from the life table analysis and discounted by 3%. Finally the gained life years were adjusted for quality of life as assessed by the time trade off method. Cost effectiveness was assessed as net costs divided by net effects. Results: The patients in the intervention group (IG) had a gain of 365 days (one year) as compared to the control group. The patients in the specialist group (SG) had a gain of 361 days. Discounting and quality adjustment resulted in a gain of 0.66 and 0.65 quality adjusted life years (QALY) respectively. This gain paralleled a net increase in health care cost (direct cost) of 4 574 Euro in the IG and 7 786 Euro in the SG respectively a net increase in indirect societal costs of 13 241 Euro in the IG and 18 731 Euro in the SG. Thus the increase in total costs from a societal perspective was 17 861 Euro in the IG and 26 608 Euro in the SG, which implied a cost per QALY gained of 27 062 Euro vs. 40 936 Euro respectively (costs and effectiveness discounted by 3%). To determine whether the intervention is cost-effective the cost-effectiveness ratio has to be compared with the societal value of a QALY. If the value fall below this value, the intervention is defined as cost-effective. In this paper we use a value of 90 000 Euro per QALY gained (corresponding to SEK 800 000 using the average exchange rate during 2012 of 1 Euro=8.7 SEK). The cost per gained QALY is well below that threshold value. This study compares cost effectiveness of case-based training of general practitioners as compared to usual primary care of patients with a very high risk of coronary death. We found that the gain in life expectancy of the patients in the intervention was achieved in a cost effective way.