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NHS stop smoking sevices are as cost-effective
- Tim Coleman, Christine Godfrey, Steve Parrot (both Department of Health Sciences, University of York) (14 April 2005)
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Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomized controlled trial
- Paddy Gillespie (10 May 2005)
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Tim Coleman, Senior Lecturer in General Practice University of Nottingham, Nottingham, England, NG7 2RD, Christine Godfrey, Steve Parrot (both Department of Health Sciences, University of York)
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Dear Editor, Raftery et al found that nurse-led clinics for the secondary prevention of coronary heart disease are highly cost-effective.[1] The incremental cost per life year saved of providing these clinics compared with the normal primary care approach to the modification of cardiovascular risk factors was £1236, and cost per quality adjusted life year saved was £1097. As the authors note, this compares very favourably with the National Institute for Clinical Excellence threshold for commissioning health care interventions (£30,000). The secondary prevention of coronary heart disease is already a standard component of primary care clinical practice, demonstrated by its inclusion in the Quality Outcomes Framework (QOF) of the recent UK general practitioner contract.[2] Through the QOF, general practitioners who undertake secondary prevention of coronary heart disease are paid for this clinical activity. We estimated that the English NHS stop smoking services have a cost- effectiveness of a similar magnitude to that reported by Raftery.[3] Our analysis was based upon data from routine practice, rather than from a clinical trial but, nevertheless, this included accurate cost data based on actual resource use and outcome data (smoking cessation rates) from 58 of the 92 cessation services operating in England. For smokers making use of stop smoking services, the mean cost per life year gained was £684 (95% CI £557-£811), falling to £438 when savings in future health-care costs were counted (those stopping smoking make less use of health services). If we had considered the gains in quality of life from stopping smoking, the cost per QALY of English smoking cessation services would have been well below Raftery’s figure for primary care coronary heart disease clinics. Via the QOF, general practitioners can earn payments for advising smokers with certain chronic diseases against smoking and for referring them to NHS stop smoking services but, unfortunately, relatively few smokers actually attend services.[4] We believe that action should be taken to maximise the numbers of smokers using services. The QOF will soon undergo its first revision and modifications are needed to ensure that greater numbers of smokers are referred to or encouraged to use NHS stop smoking services by general practitioners. Yours sincerely Tim Coleman, Christine Godfrey, Steve Parrott References 1. Raftery JP, Yao GL, Murchie P, Campbell NC, Ritchie LD. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomised controlled trial. BMJ 2005;330:707. 2. Department of Health. Investing in general practice: the new general medical services contract. 2004. London, Department of Health. 3. Godfrey C, Parrott S, Coleman T, Pound E. The cost-effectiveness of the English smoking treatment services: evidence from practice. Addiction 2005;100 (Suppl 2): 70-83. 4. Britton J,.Lewis S. Trends in the uptake and delivery of smoking cessation services to smokers in Great Britain. J Epidemiol Community Health 2004;58:569-70. Competing interests: Tim Coleman has no competing interests but would like it to be known that he has in the past been paid for speaking by Glaxo Smith Kline (once) and for consultancy work for Pharmacia. Both companies produce nicotine replacement therapy products. |
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Paddy Gillespie, PhD candidate Department of Economics, St Anthony's, NUI Galway
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Dear editor, We would like to congratulate James Raftery and colleagues on their well conducted and important study recently published in the BMJ (February 2005: 330: 707). Raftery et al. [1] found that nurse led clinics for the secondary prevention of coronary heart disease are highly cost-effective. The incremental cost per life year saved of providing these clinics compared with the existing primary care approach was £1236, and cost per quality adjusted life year saved was £1097. In our own research, we are comparing a similar nurse led secondary prevention intervention to existing primary care approaches in both health care systems in Ireland (Northern Ireland and the Republic). The study, entitled SPHERE (Secondary Prevention of Heart Disease in General Practice) is a randomised controlled trial with parallel qualitative, economic and policy analyses (ISRCTN24081411). In the preliminary stage of the SPHERE study, a qualitative analysis [2] involving health service provider and patient focus groups was conducted to identify the major barriers to secondary prevention provision in both health care systems in Ireland. Of particular concern to the patient was the cost imposed upon them and their families as a result of participating in the intervention. In effect, these costs may affect their uptake of secondary prevention services. Furthermore, health service providers recognised the adverse influences of poor social and economic situations on patients’ ability to comply with lifestyle advice, which is a central component of this kind of intervention. Additional costs imposed by participation in the intervention act to intensify this latter problem. The economic impact is also likely to be influenced by the nature of the healthcare system. In Northern Ireland, where primary care services are free to all, the relevant costs related to a potential loss of earnings when attending appointments for those who were employed. In the Republic of Ireland, where only one third of the population receive free primary care services, the direct costs of healthcare and individual views of its value influenced uptake of the service. As a result, in addition to the direct health service provider costs, we are attempting to calculate costs for the patients and their families. We will collect data on patient travel costs and waiting time for visits to general practice and the hospital. Estimates will be made of work and leisure time foregone as part of the treatment alternatives. We will also calculate patient-estimated additional expenditure or savings made in the process of lifestyle change as a result of the intervention such as changes to shopping bill with changed diet, paying for exercise facilities, giving up smoking. Essentially, the adoption of these patient and family costs should contribute to a broader view of the implications of the intervention. We hope to be able to calculate these costs as well as their impact upon compliance and ultimately clinical outcomes. This may or may not result in less impressive incremental cost per life saved and cost per quality adjusted life year than exhibited by Raftery et al.’s results. Paddy Gillespie Department of Economics, St Anthony’s, NUI Galway. Email:paddy.gillespie@nuigalway.ie References 1. James P Raftery, Guiqing L Yao, Peter Murchie, Neil C Campbell, Lewis D Ritchie. Cost effectiveness of nurse led secondary prevention clinics for coronary heart disease in primary care: follow up of a randomized controlled trial. BMJ 2005; 330: 707 2. Mairead Corrigan, Margaret E Cupples, Susan M Smith, Molly Byrne,Pauline Clerkin, Claire Leathem, Andrew W Murphy. Barriers to secondary prevention of coronary heart disease in primary care: a qualitative comparative study of two healthcare systems. Oral presentation, Association of University Departments of General Practice in Ireland, Dublin, 2005 Competing interests: None declared |
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