Assessments of nursing practice: The role of medico‐economic analysis

Your journal published the following article in January 2022: Nurse-led interventions to manage hypertension in general practice: A systematic review and meta-analysis (Stephen et al., 2022), which evaluated the impact of current nursing practices on blood pressure control and risk factors of cardiovascular disease reduction for hypertensive patients. In this meta-analysis, the authors showed the GPN-led interventions to be heterogeneous and potentially favourable in risk prevention of targeted patients, but that research must be pursued to determine factors that positively influence this result and to assess its cost-effectiveness. We would like to discuss the latter point. The authors highlighted that patient satisfaction assessment and economic analyses were missing from the 11 studies retained for the meta-analysis and represented two multifactorial and nuanced variables that could impact the evaluation of nursing interventions. However, of these 11 selected articles, one (Bosworth et al., 2009) included economic elements which were not developed by the authors. This is the only paper that incorporated a cost-per-patient analysis of nursing interventions. The results of this randomized controlled trial indicate costs per patient over the 2 years of the study of $90 for home blood pressure monitoring, $345 for nursing intervention (i.e. ‘bi-monthly nurse administered behavioural self-management intervention’) and $416 for the combined intervention (nurse and home monitoring), not including the time spent by patients. No difference was recorded in the number of hospitalizations. Calculated costs in this study are direct medical costs (nursing time and medical equipment). It is to the authors' credit that financial issues were added to the clinical arguments, which of course take priority in care, but we regret that tools of economic disciplines are not more widely used in health programme assessment. In the Bosworth et al. (2009) article, it would have been advisable to explain these costs in relation to clinical outcomes so as not to discriminate between different interventions on clinical efficacy outcomes only but on a cost- effectiveness ratio, which represents a more complex but comprehensive indicator for optimal health choice decisions in a context of limited physical and human resources. Currently, insufficient use is made of medico-economic analyses in assessments of nursing practice, in particular, due to the complexity of tools, which are not sufficiently qualitative. It is difficult to decide clearly and precisely between several interventions. Marshall et al. (2015), in a literature review that assessed the quality of cost-effective economic studies of nursing practices, also made this statement and reported a recurrent lack of analysis and control of uncertainty in economic models. Of the 43 studies incorporated in their literature review, only three were classified as high-quality studies. In addition, economic analysis is still not routinely included in the university curriculum for nurses and a certain distrust remains palpable about the economic discipline because it is too often perceived as an obstacle and not as a decision-making tool (Caniard, 2015). According to the same authors, it is not easy to sell an economic assessment with an apparent gap between ‘tools for ambitious goals and sometimes disappointing results’. However, economic tools, when properly used, lead to useful results and provide helpful recommendations for decision-makers and funders. Examples of this include the work of Lacny et al. (2016) on a pre-study, which comes to the conclusion that a nursing intervention combined with medical intervention is superior to medical intervention alone in a Canadian health care home using an incremental cost-effectiveness ratio calculation. Similarly, an article by Mourgues et al. (2018) compared a follow-up programme for the comorbidities of arthritis patients to more conventional intervention. The purpose of this article was to determine at what level of intervention the use of nursing intervention is cost-effective. The cost of the intervention was assessed at €16,804.2. This intervention contributed to the performance of 747 additional preventive procedures, at a cost of €30,184.8. This intervention with these patients was financially balanced when at least 37 patients followed the recommendations for each preventive procedure. Ultimately, we wish to encourage nursing researchers to think about cost-effective medical tools as an aid in evaluating nursing interventions. None. No conflict of interest has been declared by the authors. Charline Mourgues: Conception and design. Charline Mourgues and Alexandra Usclade: Analysis and interpretation. Charline Mourgues: Writing. Charline Mourgues and Alexandra Usclade: Writing – review and editing.

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