Result card

  • ECO5: What are the estimated differences in costs and outcomes between Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS?

What are the estimated differences in costs and outcomes between Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS?

Authors: Neill Booth, Taru Haula and Heidi Stuerzlinger (supported by Ingrid Rosian-Schikuta).

Internal reviewers: Matthias Schwenkglenks, Nadine Berndt and Fabio Trimaglio

Acknowledgments: We would like to thank information specialist Jaana Isojärvi (THL, Finland) for development of systematic literature search strategies for the ECO domain, and for performing those searches in the available databases. We would also like to acknowledge her generous contribution in helping to construct a Refworks database and in sourcing numerous published articles for review.

Two of the articles identified through the systematic literature review present results from the same cost-effectiveness study (Pandor et al (2013) {4}, which is a National Institute for Health Research (NIHR) Health Technology Assessment -report, and Thokala et al (2013) {5}, which is a journal article). Information from both studies are presented when it is possible that it would be useful. In those two pieces of research STS is divided into two different approaches: STS via human to machine (STS HM) interface and STS via human to human (STS HH) contact. The estimations and analyses in this study also include a third intervention, home telemonitoring (TM), in which transmitted data is reviewed by medical staff or medical support is provided during office hours. The cost-effectiveness of each of these three interventions is estimated in relation to usual care, which is defined as usual care for patients discharged in the past 28 days with a heart failure (HF)-related hospitalisation as per the NICE Clinical Guidelines for the Management of Adults with Chronic Heart Failure. It is mentioned in the articles that the actual impact of each intervention is for the first six months after an initial discharge, since after 6 months it is assumed that all the patients receive usual care according to the aforementioned clinical guidelines. Pandor et al. (2013) {4} and Thokala et al. (2013) {5} thus both present results of a study employing a Markov model for a hypothetical cohort of 250 heart-failure patients, using a 30-year (or patient lifetime) horizon, with an annual discount rate of 3.5% for both costs and outcomes. The perspective is that of the NHS in England and Wales. The base-case cost-effectiveness results of each strategy compared to usual care and to the next most effective alternative are presented from this study. The probabilities presented below, of each strategy being the ‘most cost-effective’ at varying levels of willingness to pay per QALY gained, are from Pandor et al. (2013) {4}, since the results of Thokala et al. (2013) {5} are from the same study and quite similar. In the probabilistic sensitivity analysis (PSA) the percentage of model runs in which an intervention was the ‘most cost-effective’ strategy (at a £20 000 per QALY threshold) was 44% for TM (during office hours), 36% for human-to-human STS (STS HH), 18% for human-to-machine STS (STS HM) and 2% for ‘usual care’. When one study, the Home-HF study {14}, was excluded, the probability for TM increased to 73%. In the base-case analyses (including or excluding the Home-HF study) TM was found to be the ‘most cost-effective’ strategy, then STS HH. Results for the different scenarios were also presented: higher usual care cost scenario, lower TM cost scenario, higher TM cost scenario, higher STS HH cost scenario and lower STS HH cost scenario.  The conclusions regarding the relative cost-effectiveness of TM did not substantially change in the analyses using higher usual care cost, lower TM cost and higher STS HH cost. In the scenario with higher TM cost TM was dominated by STS HH, since the difference in expected QALYs between these interventions was small (0.0006), the change in the difference between the costs leads to a sizeable change in the ICER. However, in the same scenario, after exclusion of the Home-HF study, TM was still the most cost-effective strategy. It is stated in both articles that there is substantial uncertainty as to which strategy is the optimal in terms of net benefit, since the CEAC (cost-effectiveness acceptability curve) suggests that the best strategy is cost-effective in less than half of the PSA runs (with base-case costs and Home-HF study included). It was reported that this uncertainty was lower in the analyses that excluded the Home-HF study.

In the study by Miller et al. (2009) {3}, a Markov model was developed to estimate the cost-effectiveness of a telephonic disease management (TDM) program compared to control group without TDM. Both costs and effects were discounted at a rate of 3% per year. Costs are expressed as the difference in total discounted lifetime costs with and without TDM and effectiveness as discounted QALYs saved with TDM. The discounted effect in terms of QALYs was 0.111 and the discounted net TDM cost was $4 850 per patient; costs per QALY saved were estimated to be $43 650.

In the study by Pandor et al (2013) {4} and Thokala et al (2013) {5} uncertainties remain about the assumptions made in the estimation of both costs and effectiveness.

In the study by Miller et al. (2009) {3} the authors concluded that model results indicated both that TDM could be thought of as ‘cost-effective’ in the long term and that short-term results from a clinical trial alone might not reveal long-term cost-effectiveness.

Booth N, . T Result Card ECO5 In: Booth N, . T Costs and economic evaluation In: Jefferson T, Cerbo M, Vicari N [eds.]. Structured telephone support (STS) for adult patients with chronic heart failure [Core HTA], Agenas - Agenzia nazionale per i servizi sanitari regionali ; 2015. [cited 2 December 2022]. Available from: