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eComment. Nurse-led clinics and cost-effectiveness.

Reports from high-income countries, as seen from the article by Williams et al. [1], have documented that nurse-led clinics are safe and efficient alternatives to formal outpatient clinic review. The importance of consumer satisfaction with healthcare has been recognized and a greater emphasis is now placed on the consumer's view. Previously published studies of nurse-led clinics found them to improve health-related quality of life, patient satisfaction and cost-effectiveness [2]. 
 
In order to improve our management protocols of comprehensive assessment of the postoperative short-term treatment of patients after surgery for carotid occlusive disease (COD), we retrospectively examined records from our University Clinic Cardiovascular Department (UCCD), related to postoperative nurse-led cardiovascular clinic over a period from January to December 2010. Data included participants' attendances at nurse-led clinic, cardiovascular drugs, cardiovascular events and patient satisfaction. At the same time, we collected data by postal questionnaire on health-related quality of life (SF-36). We constructed Kaplan-Meier survival curves for postoperative mortality, life years, and quality adjusted life years (QALYs) [3]. Outpatient costs (of nurse-led clinic) were based on the number of attendances multiplied by the relevant hospital unit cost. We used sensitivity analysis to explore the increasing difference between nurse-led and classic postoperative outpatient clinic review, on the basis that the benefits may have been underestimated owing to use of intention-to-treat analysis. Compared with the wider range of health interventions, the cost effectiveness of nurse-led clinics remains favourable. The incremental cost per QALY of under £ 1000 that we found was due to the relatively small increase in cost per patient of £ 96, which was in turn mainly due to increases in the use of drugs and even costly statins. This pattern is consistent with other complex health service interventions, where incremental improvements in process outcomes are more likely to be achieved than wholesale changes [4]. Nonetheless, these relatively low increases in cost were linked to health gains that were considerable in terms of QALYs. 
 
This report by Williams et al. has documented high overall patient satisfaction with nurse-led services and supports the role of structured nurse-led management in outpatient COD postoperative care, but these results are not easily reproducible in middle-income countries, where support services and facilities are not readily available [1,5]. Our results, which are almost identical as those of Williams et al., indicated that well-trained nurses were able to look after the patient without any further medical input in note than 60% of patients. Because of this, it is important that a nurse-led clinic is scheduled during standard working hours, when surgeons are present to offer help if required. Data presented by Williams et al. could assist cardiovascular surgeons and nurses in the middle income countries, in the management of postoperative care of COD patients in a scope of cost effectiveness and improved patient satisfaction.