title: A risk adjusted cost-effectiveness analysis of alternative models of nurse involvement in obesity management in primary care.
abstract: OBJECTIVE
  Controlled evaluations are subject to uncertainty regarding their replication in the real world, particularly around systems of service provision. Using routinely collected data, we undertook a risk adjusted cost-effectiveness (RAC-E) analysis of alternative applied models of primary health care for the management of obese adult patients. Models were based on the reported level of involvement of practice nurses (registered or enrolled nurses working in general practice) in the provision of clinical-based activities.
  
  
  METHODS
  Linked, routinely collected clinical data describing clinical outcomes (weight, BMI, and obesity-related complications) and resource use (primary care, pharmaceutical, and hospital resource use) were collected. Potential confounders were controlled for using propensity weighted regression analyses.
  
  
  RESULTS
  Relative to low level involvement of practice nurses in the provision of clinical-based activities to obese patients, high level involvement was associated with lower costs and better outcomes (more patients losing weight, and larger mean reductions in BMI). Excluding hospital costs, high level practice nurse involvement was associated with slightly higher costs. Incrementally, the high level model gets one additional obese patient to lose weight at an additional cost of $6,741, and reduces mean BMI by an additional one point at an additional cost of $563 (upper 95% confidence interval $1,547).
  
  
  CONCLUSIONS
  Converted to quality adjusted life year (QALY) gains, the results provide a strong indication that increased involvement of practice nurses in clinical activities is associated with additional health benefits that are achieved at reasonable additional cost. Dissemination activities and incentives are required to encourage general practices to better integrate practice nurses in the active provision of clinical services.
authors.affiliation: Discipline of Public Health, School of Population Health, University of Adelaide, SA 5005, Australia. jonathan.karnon@adelaide.edu.au
authors.forename: J
authors.initials: J
authors.lastname: Karnon
authors.forename: H Haji
authors.initials: HH
authors.lastname: Ali Afzali
authors.forename: J
authors.initials: J
authors.lastname: Gray
authors.forename: C
authors.initials: C
authors.lastname: Holton
authors.forename: D
authors.initials: D
authors.lastname: Banham
authors.forename: J
authors.initials: J
authors.lastname: Beilby
mesh_terms: D015992:Body Mass Index; D001835:Body Weight; D003362:Cost-Benefit Analysis; D016208:Databases, Factual; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000706:statistics & numerical data*; D009765:Obesity / Q000191:economics* / Q000628:therapy*; D011320:Primary Health Care / Q000191:economics*; D019057:Quality-Adjusted Life Years