title: Cost-effectiveness of home versus clinic-based management of chronic heart failure: Extended follow-up of a pragmatic, multicentre randomized trial cohort - The WHICH? study (Which Heart Failure Intervention Is Most Cost-Effective & Consumer Friendly in Reducing Hospital Care).
abstract: OBJECTIVE
  To assess the long-term cost-effectiveness of two multidisciplinary management programs for elderly patients hospitalized with chronic heart failure (CHF) and how it is influenced by patient characteristics.
  
  
  METHODS
  A trial-based analysis was conducted alongside a randomized controlled trial of 280 elderly patients with CHF discharged to home from three Australian tertiary hospitals. Two interventions were compared: home-based intervention (HBI) that involved home visiting with community-based care versus specialized clinic-based intervention (CBI). Bootstrapped incremental cost-utility ratios were computed based on quality-adjusted life-years (QALYs) and total healthcare costs. Cost-effectiveness acceptability curves were constructed based on incremental net monetary benefit (NMB). We performed multiple linear regression to explore which patient characteristics may impact patient-level NMB.
  
  
  RESULTS
  During median follow-up of 3.2 years, HBI was associated with slightly higher QALYs (+0.26 years per person; p=0.078) and lower total healthcare costs (AU$ -13,100 per person; p=0.025) mainly driven by significantly reduced duration of all-cause hospital stay (-10 days; p=0.006). At a willingness-to-pay threshold of AU$ 50,000 per additional QALY, the probability of HBI being better-valued was 96% and the incremental NMB of HBI was AU$ 24,342 (discounted, 5%). The variables associated with increased NMB were HBI (vs. CBI), lower Charlson Comorbidity Index, no hyponatremia, fewer months of HF, fewer prior HF admissions <1 year and a higher patient's self-care confidence. HBI's net benefit further increased in those with fewer comorbidities, a lower self-care confidence or no hyponatremia.
  
  
  CONCLUSIONS
  Compared with CBI, HBI is likely to be cost-effective in elderly CHF patients with significant comorbidity.
authors: Centre for Applied Health Economics, School of Medicine, Population & Social Health Research, Menzies Health Institute Queensland, Griffith University, Australia. Electronic address: shoko.maru@griffithuni.edu.au.
authors: Shoko
authors: S
authors: Maru
authors: Centre for Applied Health Economics, School of Medicine, Population & Social Health Research, Menzies Health Institute Queensland, Griffith University, Australia.
authors: Joshua
authors: J
authors: Byrnes
authors: Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
authors: Melinda J
authors: MJ
authors: Carrington
authors: Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
authors: Yih-Kai
authors: YK
authors: Chan
authors: Centre for Primary Care and Prevention, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
authors: David R
authors: DR
authors: Thompson
authors: Centre for Research Excellence to Reduce Inequality in Heart Disease, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia.
authors: Simon
authors: S
authors: Stewart
authors: Centre for Applied Health Economics, School of Medicine, Population & Social Health Research, Menzies Health Institute Queensland, Griffith University, Australia.
authors: Paul A
authors: PA
authors: Scuffham
mesh_terms: D000368:Aged; D001315:Australia; D006348:Cardiac Surgical Procedures / Q000191:economics; D002908:Chronic Disease; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D019468:Disease Management; D005260:Female; D005500:Follow-Up Studies; D017048:Health Care Costs; D006333:Heart Failure / Q000191:economics* / Q000503:physiopathology / Q000628:therapy*; D006699:Home Care Services / Q000191:economics*; D006760:Hospitalization / Q000191:economics*; D006801:Humans; D016014:Linear Models; D008297:Male; D019057:Quality-Adjusted Life Years; D012648:Self Care / Q000191:economics; D062606:Tertiary Care Centers / Q000191:economics
keywords: Cost effectiveness; Disease management; Economic evaluation; Heart failure; Net monetary benefit