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National Collaborating Centre for Chronic Conditions (UK). Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care. London: Royal College of Physicians (UK); 2003. (NICE Clinical Guidelines, No. 5.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Chronic Heart Failure: National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care.

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Appendix FHealth economics of other non-pharmacological therapies

Exercise training

Only one economic study was identified by the systematic review (Georgiou et al, 2001339). This is based on the results from the largest RCT of exercise training, and has a US setting.

The study shows exercise training to be cost effective. However, a major element of patient-borne costs (travel time and expenses) are excluded from the analysis.

Summary of Georgiou et al (2001): cost-effectiveness analysis of long-term moderate exercise training

The study uses efficacy results from Belardinelli et al.303 Ninety-nine patients were randomised to exercise program and control. All had stable CHF, NYHA II–IV, 90% were on ACEIs, age range 55–64. Only NYHA class II and III patients considered in the analysis.

Exercise training (ET) was performed in two phases over 14 months:

  • three times 1 hr/wk for eight weeks
  • two times 1 hr/wk for 12 months
  • a total of 128 hours per person.

Effectiveness was measured as the increment in life expectancy.

Modelling was used to estimate the cost and benefit scenarios beyond the 14-month trial follow-up period.

Efficacy results for the 14-month trial period were taken from the trial itself.

Age and sex specific estimates of survival for the next 10 years were taken from a national epidemiological study.304

These were adjusted upwards to reflect improvements in CHF survival with ACEIs.

Table F1Summary of results of Georgiou et al 2001

ET groupControl group
Mortality rates18%41%
Hospitalisation rates (all cause)10%29%

Costs of ET and monitoring

ET was carried out in hospital, by a trainer hired by hospital, who supervised patients in groups of four.

Costs included: salary of trainer, equipment, space rental, cardiopulmonary test. The main cost drivers were salary and space rental. Other costs considered were: wages lost due to attendance at ET (assumed all are full-time workers), hospitalisation (adapted from Delea et al).293

Travel costs of attendance at ET (a major patient burden) were excluded.

Table F2Cost effectiveness of ET

ET groupControl Group
Cost of ET per patient$2,054$0
Wage lost from ET per patient$2,509$0
Hospitalisation rate*10%29%
Averaged cost of hospitalisation per patient$719$2,055
Total cost per patient$5,282$2,055
Incremental cost of ET per patient$3,227N/A
Incremental life expectancy (yrs)1.82N/A
Cost effectiveness ratio ($/LYG)$1,773N/A
Sensitivity analysis of CER
 Upper limit$8,274
 Lower limit$1,012

Hospitalisation rates were assumed to be the same for both groups after the follow-up period. The common rate was taken from Delea et al.293

A discount rate of 3% is applied to costs and benefits. Sensitivity analysis varied survival probabilities (trial and post follow-up), rate of improvement provided by ACEIs, hospitalisation rates).


The methods and results are reported with sufficient detail. The sensitivity analysis is appropriate.

The results cannot be extrapolated to patients outside the 55–64 years age group, and the resource use and costs are US specific.

Improved survival is not adjusted by QoL as there are no suitable QoL data.

Qualitative data suggest that ET improves QoL, hence calculating QALYs would be likely to weight the CER more heavily in favour in ET.

The assumption of common hospitalisation rates after the 14 month follow-up period is very conservative.

This only quality economic study identified shows exercise training to be cost-effective. However, it is very specific to the location and specific exercise programme in question. In addition, its relevance to the UK context is questionable.

Multi-disciplinary teams

The searches identified very little economic evidence available. It is difficult to compare the costs and outcomes from different programs. Most evaluated interventions are based in the US.

McAlister et al (2001)220

Systematic review of nine RCTs comparing multidisciplinary teams providing specialised follow-up with usual care. Follow-up length varied from 3–12 months.

Table F3Summary of results of McAlister et al (2001)

OutcomeNo of RCTsResults
Mortality6None found a significant difference initially, but one found a significant benefit in favour of the intervention after 18 months follow-up.
Hospitalisation9All found fewer hospitalisations in intervention group. Only significant in two cases. Significant reduction in risk of hospitalisation overall. Suggests that for every eight patients with HF treated by a multidisciplinary team rather than usual care, there will be one fewer hospital admission over about six months.
Length of stay7Six found significantly reduced LoS or total no. of hospital days in intervention group.
Use of medications2Both showed significantly greater use in intervention patients.
QoL and/or functional status3Only one found significantly better outcomes in intervention arm.
Costs7All but one reported that the intervention was cost saving.

Capomolla et al (2002)305

RCT comparison between HF management program delivered by a day-hospital and usual care.

Setting is Italy. 234 patients, 112 randomised to intervention arm. Average follow-up is 12 months.

Table F4Summary of results of Capomolla et al (2002)

MortalitySignificantly fewer deaths in intervention group.
HospitalisationSignificantly fewer hospitalisations in intervention group.
Use of medicationsSignificantly higher doses of ACEIs, beta-blockers and nitrates in intervention group; lower doses of diuretics and digitalis.
QoL and/or functional statusSignificant improvement in NYHA class in intervention group; not significant in control group.
CostsAfter one year, annual drug costs per patient were significantly higher in the intervention group, but this was more than compensated for by savings in costs of hospitalisations.
Copyright © 2003, Royal College of Physicians of London.
Bookshelf ID: NBK65597


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