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This information collection is a core HTA, i.e. an extensive analysis of one or more health technologies using all nine domains of the HTA Core Model. The core HTA is intended to be used as an information base for local (e.g. national or regional) HTAs.

Structured telephone support (STS) for adult patients with chronic heart failure

Structured telephone support (STS) for adult patients with chronic heart failure compared to Usual care defined as regular schedules of visits of the patient at the heart center/ GP/cardiologist or patient has to move (≠ at home) in the prevention of Chronic cardiac failure in adults and elderly with chronic heart failure (CHF) AND hospitalization due to heart failure at least once AND without implanted devices

(See detailed scope below)

HTA Core Model Application for Medical and Surgical Interventions (2.0)
Core HTA
Published
Tom Jefferson (Agenas - Italy), Marina Cerbo (Agenas - Italy), Nicola Vicari (Agenas - Italy)
Neill Booth (THL - Finland), Plamen Dimitrov (NCPHA - Bulgaria), Mirjana Huic (AAZ - Croatia), Valentina Rupel (IER - Slovenia), Alessandra Lo Scalzo (Agenas - Italy), Ingrid Wilbacher (HVB - Austria)
Agenas - Agenzia nazionale per i servizi sanitari regionali
AAZ (Croatia), Agenas (Italy), ASSR RER (Italy), Avalia-t (Spain), CEM (Luxembourg), GÖG (Austria), HVB (Austria), IER (Slovenia), ISC III (Spain), NCPHA (Bulgaria), NIPH (Slovenia), NSPH (Greece), NSPH MD (Romania), SBU (Sweden), SNHTA (Switzerland), THL (Finland), UTA (Estonia).
9.9.2014 11.18.00
4.12.2015 17.51.00
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 3 October 2022]. Available from: http://corehta.info/ViewCover.aspx?id=305

Structured telephone support (STS) for adult patients with chronic heart failure

<< Clinical EffectivenessEthical analysis >>

Costs and economic evaluation

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

Summary

In this summary, as set out in the guidance for undertaking this pilot assessment using the HTA Core Model 2.0, we only summarise the results of the ECO domain. The results themselves can be found from the Results Card –section of the ECO domain. Details on the aim of the ECO domain and its research questions can be found from the ECO Introduction. Details on the methods used can be found from the ECO Methodolgy sections, and discussion can be found from the ECO discussion -section and from the Collection summary.

It became apparent from the results of our systematic literature search (see the Methodology section below) and our review of the results from other domains that the meaning of the term Structured telephone support (STS) varies quite widely across the studies. Hence, there is no explicit definition STS and, instead, the term is refers to a diverse set of approaches to care management for adults with chronic heart failure using telephonic networks. Depending on the approach taken to STS, a range of different pieces of information can be collected by telephone from patients, and any such information can be handled and utilised by the management team or system in a large number of ways. Therefore, one main result of the ECO domain is that variation in the nature of the intervention poses major challenges to undertaking meaningful examination of intervention costs and to undertaking economic evaluations. If each type of STS intervention, has both different components and consequences, this has a significant effect on ability to make meaningful estimates of costs and to undertake robust economic evaluations. For this reason, we do not summarise the results of the studies per se but, instead, briefly describe those studies found.

Four published pieces of research from the systematic review were found to be useful in this domain ({1, 3, 4 & 5}, see also Appendix ECO-2: PRISMA 2009 Flow Diagram). One of these, a European economic evaluation by Klersy et al. (2011) {1}, was only used to describe costs and three of these were also used to produce the results pertaining to economic evaluation {3, 4 & 5}. The first of the included economic evaluations is a North American modelling study published in 2009 by Miller et al. (2009) {3}, it estimates the cost-effectiveness for a subset of the patients with chronic heart failure, namely for patients with systolic heart failure. The second was a cost-effectiveness study by Klersy et al. (2011) {1} and reported an analysis which combined evidence on both remote monitoring (RM) and on STS. However, as this article included information from cardiovascular implantable electronic devices, it was, as an example of an economic evaluation, classified as being outside the scope of this pilot assessment using the HTA Core Model 2.0. One additional study, Herbert et al. (2008) {2}, was found through the search of the references of the papers retrieved following the systematic search. Although this study reported a trial-based cost-effectiveness analysis, it was excluded due to its focus on a very specific, non-European ethnic population. The third and fourth economic evaluations were pieces of British research by Pandor et al. (2013) {4} and Thokala et al. (2013) {5}.  It both of these it was noted that clear descriptions of STS interventions and usual care were not provided in many of the studies they reviewed and that this has potentially major implications for the robustness of analyses of costs, outcomes, and economic efficiency.

Introduction

The ‘Costs and economic evaluation’ -domain (ECO) within the HTA Core Model 2.0 aims to provide information about the relative costs and ‘cost-effectiveness’ of the health-care technologies under assessment {6}. This pilot assessment presents information on costs and economic evaluation about structured telephone support (STS) and ‘usual care’ for adults with chronic heart failure (i.e., patients with New York Heart Association (NYHA) Functional Classification I to IV and without implantable cardiac defibrillators, cardiac resynchronisation therapy devices or pacemakers) who have been admitted to hospital at least once for chronic heart failure). As set out in the TEC -domain, STS refers to a specific set of approaches to remote heart-failure monitoring or self-care management. Often using simple telephone technology, STS contacts can be planned according to a schedule, or initiated by a computerised system or by a healthcare professional (e.g., nurse, physician, social worker or pharmacist). As part of a wide variety of approaches to STS, different types of patient data are collected and stored electronically. In the case of a STS human-to-machine interfaces (HM) this can be done by a computerised system or, in the case of a STS human-to-human interactions (HH), this can be done by a healthcare professional. Data can then be reviewed by healthcare professionals and, if necessary and possible, action can be undertaken. Extensive details concerning usual care are not, in general, well reported in the clinical effectiveness literature (see EFF discussion).

Within the constraints of this HTA Core Model 2.0 pilot assessment we surveyed the potential for the creation of a costing template or a model to assess budget impact (e.g., a cost template for Budget Impact Analysis (BIA)). However, after systematically searching the literature and reviewing the information from the CUR, TEC, SAF, EFF, SOC and ORG domains, it was clear that it would not be viable to attempt to produce a useful BIA costing template or a de novo economic model. This was mainly due to the diverse nature of the interventions covered by the label STS, and due to a lack of robust evidence on both costs and effectiveness. Therefore, in what follows we report a qualitative analysis of the available information, starting with the information on costs, we offer as full an answer as we can to the research questions which deal with costs, i.e., in ECO1, ECO2 and ECO3. In ECO4 we report findings from the literature and from other domains, such as SAF and EFF on the effectiveness of ‘STS’ versus ‘usual care’. In ECO 5 we describe some of the information from the economic evaluation literature relating to ‘STS’ versus ‘usual care’, and in ECO6, ECO7 and ECO8 we extend this qualitative assessment of the available information.

Methodology

Frame

The collection scope is used in this domain.

TechnologyStructured telephone support (STS) for adult patients with chronic heart failure
Description

Telemonitoring via structured telephone support with focus on patient reported signs (symptoms of congestion, peripheral edema, pulmonary congestion, dyspnea on exertion, abdominal fullness), medication adherence, physiological data (like heart rate, blood pressure, body weight – measured by the patient with home-device), activity level; done in regular schedules using risk stratification (with fixed algorithm by call center staff or experience-based by specialized staff); done by dedicated call centers, center-based staff, nurses, AND reduced visits to a GP or heart center

Intended use of the technologyPrevention

Remote transmission of information to alleviate symptoms, relieve suffering and allow timely treatment for chronic heart failure

Target condition
Chronic cardiac failure
Target condition description

Heart failure is a condition in which the heart has lost the ability to pump enough blood to the body's tissues. With too little blood being delivered, the organs and other tissues do not receive enough oxygen and nutrients to function properly.

Target population

Target population sex: Any. Target population age: adults and elderly. Target population group: Patients who have the target condition.

Target population description

Patients with chronic heart failure (CHF; defined as I50 http://www.icd10data.com/ICD10CM/Codes/I00-I99/I30-I52/I50-/I50 ) AND hospitalization due to heart failure at least once  AND without implanted devices

ComparisonUsual care defined as regular schedules of visits of the patient at the heart center/ GP/cardiologist or patient has to move (≠ at home)
Description

Usual care defined as regular schedules of visits of the patient at the heart center/ GP/cardiologist; patient has to move (≠ at home)

Outcomes

Mortality (disease specific and all cause) progressions, admissions, re-admissions, QoL or HRQoL, harms

Assessment elements

TopicIssue RelevantResearch questions or rationale for irrelevance
E0001Resource utilizationWhat types of resources are used when delivering the assessed technology and its comparators (resource-use identification)?yesWhat types of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, usual care' without STS (resource-use identification)?
E0002Resource utilizationWhat amounts of resources are used when delivering the assessed technology and its comparators (resource-use measurement)?yesWhat amounts of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS (resource-use measurement)?
E0009Resource utilizationWhat were the measured and/or estimated costs of the assessed technology and its comparator(s) (resource-use valuation)?yesWhat were the measured and/or estimated costs of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS (resource-use valuation)?
E0005Measurement and estimation of outcomesWhat is(are) the measured and/or estimated health-related outcome(s) of the assessed technology and its comparator(s)?yesWhat is (are) the measured and/or estimated health-related outcome(s) of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS?
E0006Examination of costs and outcomesWhat are the estimated differences in costs and outcomes between the technology and its comparator(s)?yesWhat 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?
E0010Characterising uncertaintyWhat are the uncertainties surrounding the costs and economic evaluation(s) of the technology and its comparator(s)?yesWhat are the uncertainties surrounding the costs and economic evaluation(s) of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS?
E0011Characterising heterogeneityTo what extent can differences in costs, outcomes, or ‘cost effectiveness’ be explained by variations between any subgroups using the technology and its comparator(s)?yesTo what extent can differences in costs, outcomes, or ‘cost effectiveness’ be explained by variations between any subgroups using Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS?
E0012Validity of the model(s)To what extent can the estimates of costs, outcomes, or economic evaluation(s) be considered as providing valid descriptions of the technology and its comparator(s)?yesTo what extent can the estimates of costs, outcomes, or economic evaluation(s) be considered as providing valid descriptions of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, 'usual care' without STS?

Methodology description

A systematic literature search was conducted in May 2015 by information specialist Jaana Isojärvi (THL, Finland) to find published studies on the costs and economic evaluation of structured telephone support for adult patients with chronic heart failure.

 

Information sources

The following databases were searched:

•           Centre for Reviews and Dissemination (HTA, NHS EED, DARE)

•           Cochrane Database of Systematic Reviews

•           Cochrane Central Register of Controlled Trials

•           MEDLINE (via Ovid)

•           NLM PubMed

•           SCOPUS

•           Journals@Ovid Full Text

•           CINAHL (via EBSCOhost)

•           PsycInfo (via EBSCOhost)

•           Web of Science

•           CEA Registry

A methodological search filter based on the filter developed in Healthcare Improvement Scotland was used. The systematic search strategy for this domain is presented in Appendix ECO-1.

In addition to database searches, we looked at the search results from Clinical Effectiveness, Safety and Social Aspects domains as well as the results from the searches undertaken according to the scope of the whole assessment using the HTA Core Model 2.0.

Articles that fit with the agreed PICO structure and presented estimations of outcomes and costs were searched using a two-stage process. All titles and abstracts were examined for inclusion by at least two reviewers and those chosen for potential inclusion were then examined as full-text articles by the same reviewers. Any disagreements were resolved through deliberation. In the end, four articles relevant for the questions in ECO domain were included from the 55 potentially relevant records identified through searching the databases and other sources. A flow-chart prepared according to the 2009 PRISMA statement is presented in Appendix ECO-2. Although the methodological quality of the included studies was not formally assessed, we undertook to describe the available information concerning costs and to describe relevant information from economic evaluations, using the method outlined in the section ‘Quality assessment tools or criteria’ below.

 

Quality assessment tools or criteria

We utilised the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement checklist ({7}) in the following way: each item in the checklist was examined by two authors for coherence between the reporting in the economic evaluations reviewed and the CHEERS checklist -items and any disagreements were resolved through discussions (see Appendix ECO-3). Although the CHEERS checklist is primarily intended for researchers reporting economic evaluations and the editors and peer reviewers assessing them for publication, when reviewing existing literature it has a potential role in identifying issues which may make the use of information from any economic evaluation less appropriate when undertaking assessment using the HTA Core Model 2.0.

 

Analysis and synthesis

The ECO -domain authors had the intention to produce a costing template for budget impact analysis (BIA) modelling, but due to a lack of robust evidence on costs (e.g., as noted by the ORG domain) and a lack of robust evidence on effectiveness (e.g., as noted by the SAF and EFF domains), the ECO -domain authors could not justify attempting to produce a de novo health-economic model or a costing template. Therefore, in what follows we report a qualitative analysis of the information which was available, starting with the information on costs. We offer as full an answer as we can to the research questions which deal with costs, i.e., in ECO1, ECO2 and ECO3. In ECO4 we report findings from the literature and from other domains, such as SAF and EFF on the effectiveness of ‘STS’ versus ‘usual care’. In ECO5 we describe some of the information from the economic evaluation literature relating to ‘STS’ versus ‘usual care’, and in ECO6, ECO7 and ECO8, go on to try to extend this qualitative assessment of the available information.

Result cards

Resource utilization

Result card for ECO1: "What types of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, usual care&#39; without STS (resource-use identification)?"

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ECO1: What types of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, usual care&#39; without STS (resource-use identification)?
Method
Result
Comment

Importance: Critical

Transferability: Completely

Result card for ECO2: "What amounts of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS (resource-use measurement)?"

View full card
ECO2: What amounts of resources are used when delivering Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS (resource-use measurement)?
Method
Result

Importance: Critical

Transferability: Partially

Result card for ECO3: "What were the measured and/or estimated costs of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS (resource-use valuation)?"

View full card
ECO3: What were the measured and/or estimated costs of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS (resource-use valuation)?
Method
Result
Comment

Importance: Critical

Transferability: Not

Measurement and estimation of outcomes

Result card for ECO4: "What is (are) the measured and/or estimated health-related outcome(s) of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?"

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ECO4: What is (are) the measured and/or estimated health-related outcome(s) of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?
Method
Result
Comment

Importance: Important

Transferability: Partially

Examination of costs and outcomes

Result card for 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, &#39;usual care&#39; without STS?"

View full 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, &#39;usual care&#39; without STS?
Result
Comment

Importance: Important

Transferability: Partially

Characterising uncertainty

Result card for ECO6: "What are the uncertainties surrounding the costs and economic evaluation(s) of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?"

View full card
ECO6: What are the uncertainties surrounding the costs and economic evaluation(s) of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?
Result

Importance: Critical

Transferability: Partially

Characterising heterogeneity

Result card for ECO7: "To what extent can differences in costs, outcomes, or ‘cost effectiveness’ be explained by variations between any subgroups using Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?"

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ECO7: To what extent can differences in costs, outcomes, or ‘cost effectiveness’ be explained by variations between any subgroups using Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?
Result
Comment

Importance: Important

Transferability: Completely

Validity of the model(s)

Result card for ECO8: "To what extent can the estimates of costs, outcomes, or economic evaluation(s) be considered as providing valid descriptions of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?"

View full card
ECO8: To what extent can the estimates of costs, outcomes, or economic evaluation(s) be considered as providing valid descriptions of Structured telephone support (STS) for adult patients with chronic heart failure and its comparator, &#39;usual care&#39; without STS?
Result

Importance: Important

Transferability: Completely

Discussion

Because of the results presented in ECO1, ECO2, ECO3, ECO4, ECO5 and ECO6 serious doubts are raised about the extent to which the estimates of costs, health-related outcomes, and economic evaluations can be considered as providing valid descriptions of structured telephone support (STS) for adult patients with chronic heart failure compared with its comparator, 'usual care' without STS

The other issue which has an effect on the interpretation of the findings in all the result cards of this domain is the varied definition of ‘STS’ and ‘usual care’ in the literature and its relationship to the way in which ‘STS’ and ‘usual care’ are defined in the scope of this pilot assessment using the HTA Core Model 2.0.

Perhaps the most serious doubts about the cost-effectiveness information are raised by the fact that individual patient-level data was not used and no adjustment was made for potential biases arising from study quality of the studies included in the NMA in the study by Pandor et al (2013) {4} and Thokala et al (2013) {5}. Further, the study by Miller et al. (2009) {3} mainly uses information from Galbreath et al. 2004 {8}, which is classed in EFF1 as having a high risk of bias, and the potential extent of the effect on results of structural uncertainty is not described. The quality of evidence in much of the available scientific literature is poor, therefore, more studies on all aspects of costs related to STS would be needed to reach an unbiased conclusion. Further, the lack of information concerning subgroups was noted, for example, by Pandor et al. (2013) {4}. They suggested that future studies should publish data in such a way as to identify which patient subgroups benefited most from the intervention.

Although analyses of subgroups of interventions can be undertaken, there is little peer-reviewed information available to support such analysis, such as robust estimates of the cost of software acquisition and maintenance when using different STS interventions. More importantly, perhaps, robust estimates of the impact of different types of STS on subsequent healthcare costs, as well as estimates of the impacts on costs outside the healthcare sector, are not available.

References

  1. Klersy C, De Silvestri A, Gabutti G, Raisaro A, Curti M, Regoli F, et al. Economic impact of remote patient monitoring: an integrated economic model derived from a meta-analysis of randomized controlled trials in heart failure. European Journal of Heart Failure. 2011;13(4):450-9.
  2. Hebert PL, Sisk JE, Wang JJ, Tuzzio L, Casabianca JM, Chassin MR, et al. Cost-Effectiveness of Nurse-Led Disease Management for Heart Failure in an Ethnically Diverse Urban Community. Annals of Internal Medicine. 2008;149(8):540-8.
  3. Miller G, Randolph S, Forkner E, Smith B, Galbreath AD. Long-term cost-effectiveness of disease management in systolic heart failure. Medical decision making : an international journal of the Society for Medical Decision Making. 2009 May-Jun;29(3):325-33.
  4. Pandor A, Thokala P, Gomersall T, Baalbaki H, Stevens JW, Wang J, et al. Home telemonitoring or structured telephone support programmes after recent discharge in patients with heart failure: systematic review and economic evaluation. Health technology assessment (Winchester, England). 2013;17(32):1-207, v-vi.
  5. Thokala P, Baalbaki H, Brennan A, Pandor A, Stevens JW, Gomersall T, et al. Telemonitoring after discharge from hospital with heart failure: Cost-effectiveness modelling of alternative service designs. BMJ Open. 2013;3(9).
  6. EUnetHTA Joint Action 2, Work Package 8. HTA Core Model ® version 2.0. A pdf-format file is available from http://www.corehta.info/BrowseModel.aspx; 2013.
  7. Husereau D, Drummond M, Petrou S, Carswell C, Moher D, Greenberg D, et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Statement. Int J Technol Assess Health Care. 2013 Apr;29(2):117-22.
  8. Galbreath AD, Krasuski RA, Smith B, Stajduhar KC, Kwan MD, Ellis R, et al. Long-Term Healthcare and Cost Outcomes of Disease Management in a Large, Randomized, Community-Based Population With Heart Failure. Circulation. 2004 December 7, 2004;110(23):3518-26.
  9. Cleland JGF, Louis AA, Rigby AS, Janssens U, Balk AHMM. Noninvasive Home Telemonitoring for Patients With Heart Failure at High Risk of Recurrent Admission and Death: The Trans-European Network-Home-Care Management System (TEN-HMS) study. J Am Coll Cardiol. 2005;45(10):1654-64.
  10. Bergmo TS. Can economic evaluation in telemedicine be trusted? A systematic review of the literature. Cost effectiveness and resource allocation. 2009;7:18.
  11. Riegel B, Carlson B, Kopp Z, LePetri B, Glaser D, Unger A. Effect of a standardized nurse case-management telephone intervention on resource use in patients with chronic heart failure. Archives of Internal Medicine. 2002;162(6):705-12.
  12. Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJL, et al. Transitional care interventions to prevent readmissions for persons with heart failure: A systematic review and meta-analysis. Annals of Internal Medicine. 2014;160(11):774-84.
  13. Krum H, Forbes A, Yallop J, Driscoll A, Croucher J, Chan B, et al. Telephone Support to Rural and Remote Patients with Heart Failure: The Chronic Heart Failure Assessment by Telephone (CHAT) study. Cardiovascular Therapeutics. 2013;31(4):230-7.
  14. Dar O, Riley J, Chapman C, Dubrey SW, Morris S, Rosen SD, et al. A randomized trial of home telemonitoring in a typical elderly heart failure population in North West London: results of the Home-HF study. European Journal of Heart Failure. 2009;11(3):319-25.
  15. Grustam AS, Severens JL, van Nijnatten J, Koymans R, Vrijhoef HJM. Cost-effectiveness of telehealth interventions for chronic heart failure patients: A literature review. International Journal of Technology Assessment in Health Care. 2014;30(01):59-68.

Appendices

 

ECO Appendix 1

 

Appendix ECO-1: ECO domain literature search strategies

 

ECO Appendix 2

Appendix ECO-2: PRISMA 2009 Flow Diagram

 

ECO Appendix 3

Appendix ECO-3: CHEERS coherence table

 

ECO Appendix 4

Appendix ECO-4: Potential cost drivers for ‘STS’ and ‘usual care’

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