Compared to Usual Care, No Significant Cost Increase for Telephone-based BP Intervention for Veterans with Hypertension

BACKGROUND:
New models for treating hypertension have been proposed, and many integrate disease monitoring and telephone-based interventions delivered in patients' homes. This article evaluates the cost of implementing the four arms of the Hypertension Intervention Nurse Telemedicine Study (HINTS), results of which have previously been published and are briefly summarized here. The HINTS compared 3 methods of improving blood pressure (BP) control using home-based BP tele-monitoring vs. standard care among primary care patients in the VA healthcare system. Veterans (n=591) were randomized to either usual care (no home BP tele-monitoring or nurse contacts via telephone) or one of three telephone-based interventions when BP was inadequately controlled: 1) behavioral management (nurse administered, patient-tailored, scripted modules focused on self management), 2) medication management (nurse initiated discussion with the primary care physician about BP management and possible medication change), or 3) combined. HINTS led to clinically significant improvements in BP control at 12 months that were not sustained at 18 months. The objective of the present publication is to evaluate costs associated with each arm of the intervention and the healthcare costs incurred by the patients over the 18-month study period. Intervention costs were derived from information collected during the trial. Direct medical costs (inpatient, outpatient, and outpatient pharmacy, including hypertension-specific pharmacy) at 18 months by group were calculated using VA's Decision Support System data.

FINDINGS:

• In overall and sub-group samples, average intervention costs were similar in the three study arms, and at 18 months there were no significant differences in direct VA medical costs or total VA costs between treatment arms and usual care.
• Mean total VA costs per patient in the treatment arms were $14,441 for behavioral management; $14,453 for medication management; $13,009 for combined treatment; and $12,328 for usual care. The combined intervention resulted in observed net savings in outpatient care and overall medical care, as well as the lowest mean cost difference and total cost, but these differences were not statistically significant relative to the other intervention arms.
• Patients in all three intervention arms incurred $289 to $1,127 less in outpatient care compared to those treated under usual care, but these savings were not statistically significant.

LIMITATIONS:

• This study did not take into account post-intervention healthcare use provided outside VA.

IMPLICATIONS:

• These findings suggest that unless HINTS interventions improve BP control and reduce the actual number of clinic events, patient care costs will not change. Moreover, with overall improvements in 12-month clinical outcomes which were not sustained at 18 months, the long-term return-on-investment in clinical outcomes remains unclear. Longer follow-up will be needed to evaluate true health care costs.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (IIR 04-426 and MRP 05-311). Dr. Bosworth also was supported by an HSR&D Research Career Scientist Award. All authors, except Ms. McCant, are part of HSR&D's Center for Health Services Research in Primary Care, Durham, NC.

Wang V, Smith V, Bosworth H, Oddone E, Olsen M, McCant F, Powers B, and Van Houtven C. Economic Evaluation of Telephone Self-Management Interventions for Blood Pressure Control. American Heart Journal June 2012;163(6):980-86.