Who pays and who saves may stymie implementation in the US

In this issue (p 211), Raftery et al report on a cost-effectiveness analysis of a now 10 year-old randomized controlled trial of nurse-led secondary prevention for coronary heart disease. This analysis is timely for the UK because up to 20% of physician income is now tied to performance measures.1 It is similarly relevant in the US, given our current interest in pay-for-performance, disease management, and the development of health care teams. It offers cost-effectiveness evidence for an enhanced nursing role in primary care, but the differing locations of the cost and the savings may make implementation difficult in the US.

The study by Raftery et al relates to an increased focus on team-based care that is patient-centered and breaks free from physician visits as the locus of care.

The investigators have previously reported on the successes of this intervention for improved secondary prevention and for health-related quality of life. The study, done in Scotland, randomized patients within general practice …