Specialist nurse-led clinics to improve control of hypertension and hyperlipidemia in diabetes - Economic analysis of the SPLINT trial

OBJECTIVE - To determine the cost-effectiveness of specialist nurse-led clinics provided to improve lipid and blood pressure control in diabetic patients receiving hospital-based care. RESEARCH DESIGN AND METHODS - A policy of targeting improved care through specialist nurse-led clinics is evaluated using a novel method, linking the cost-effectiveness of antihypertensive and lipid-lowering treatments with the cost and level of behavioral change achieved by the specialist nurse-led clinics. Treatment cost-effectiveness is modeled from the U.K. Prospective Diabetes Study and Heart Protection Study treatment trials, whereas specialist nurse-led clinics are evaluated using the Specialist Nurse-Led Clinics to Improve Control of Hypertension and Hyperlipidemia in Diabetes (SPLINT) trial. RESULTS - Good lipid and blood pressure control are cost-effective treatment goals for patients with diabetes. Modeling findings from treatment trials, blood pressure lowering is estimated to be cost saving and life prolonging (-$1,400/quality-adjusted life-year [QALY]), whereas lipid-lowering is estimated to be highly cost-effective ($8,230/QALY). Investing in nurse-led clinics to help achieve these benefits imposes an addition on treatment cost-effectiveness leading to higher estimates: $4,020/QALY and $19,950/QALY, respectively. For both clinics combined, the estimated cost-effectiveness is $9,070/QALY. Using an acceptability threshold of $50,000/QALY, the likelihood that blood pressure-lowering clinics are cost-effective is 77%, lipid clinics 99%, and combined clinics 83%. CONCLUSIONS - A method is described for evaluating the cost-effectiveness of policies to change patient uptake of health care. Such policies are less attractive than treatment cost-effectiveness (which implies cost-less self-implementation). However, specialist nurse-led clinics, as an adjunct to hospital-based diabetic care, combining both lipid and blood pressure control, appear effective and likely to provide excellent value for money. Diabetes Care 28:40-46, 2005.