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Specialist Nurse–Led Clinics to Improve Control of Hypertension and Hyperlipidemia in Diabetes

Economic analysis of the SPLINT trial

¹ School for Health, University of Durham, Stockton-on-Tees, U.K
² Department of Primary Care and General Practice, University of Birmingham, Birmingham, U.K
³ Department of Diabetes, Hope Hospital, Salford, U.K

Address correspondence and reprint requests to Professor James Mason, School for Health, University of Durham, Queen’s Campus, Wolfson Research Unit, University Boulevard, Stockton-on-Tees, TS17 6BH, U.K. E-mail: j.m.mason{at}durham.ac.uk

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.

Abbreviations: HPS, Heart Protection Study • MI, myocardial infarction • QALY, quality-adjusted life-year • SPLINT, Specialist Nurse–Led Clinics to Improve Control of Hypertension and Hyperlipidemia in Diabetes • UKPDS, U.K. Prospective Diabetes Study

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