Cost-Effectiveness of Supportive Counseling with Smoking Cessation Interventions

There are approximately 440,000 deaths due to coronary heart disease (CHD) each year in the United States, and smoking is the most preventable risk factor in the development of CHD. The association of smoking with acute myocardial infarction (AMI) is particularly strong, with an estimated risk of 36%, greater than that of obesity, hypertension, diabetes mellitus, or a sedentary lifestyle. The Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services have issued quality measures addressing care of hospitalized patients with AMI. One of the measures is smoking cessation counseling, a provision with increasing rates of adherence, from 41% in 1995 to 94% in 2008. Despite these efforts, however, as many as 60% to 70% of smokers with AMI continue to smoke following hospital discharge, putting themselves at increased risk of recurrent AMI, stroke, and death. Previous randomized controlled trials have shown the effectiveness of post-discharge interventions and supportive contact in the form of follow-up telephone calls for at least 1 month, but this rarely occurs in clinical practice. Because counseling and supportive contact for smokers following hospital discharge is inexpensive, researchers recently designed a study to determine the cost-effectiveness of such a program. They reported results in Archives of Internal Medicine [2011;171(1):39-45]. The researchers built a cost-effectiveness model to compare 2 options for managing smokers who were admitted to the hospital for AMI: (1) usual care, where smokers receive standard smoking cessation consultation, including advice to quit smoking and provision of printed materials with suggestions on how to quit, and (2) counseling and supportive follow-up, including usual care plus an evidence-based smoking cessation regimen including behavioral counseling prior to hospital discharge, a workbook and DVD furnished by the American Heart Association, and follow-up telephone calls 2 days, 1 week, 3 weeks, and 4 weeks following discharge. Using data from a meta-analysis of randomized trials of smoking cessation interventions as well as other published sources, the researchers developed a Monte Carlo model to project health and economic outcomes for a hypothetical US cohort of 327,600 smokers hospitalized with AMI. Primary outcomes were numbers of smokers, AMIs, and deaths averted; healthcare and productivity costs; cost per quitter; and cost per quality-adjusted life-year (QALY). The study model projected that implementation of evidence-based smoking cessation counseling for the 2010 cohort of smokers hospitalized with AMI would cost $27.3 million in wages and educational materials. It would generate 50,230 new quitters and prevent 1380 fatal AMIs and 7860 deaths from all causes. During a 10-year follow-up period, there would be an estimated gain of 38,250 life-years and 32,950 QALYs. The intervention would save $22.1 million in reduced hospitalizations for nonfatal AMI, but would increase total healthcare costs by $166.4 million (due to increased longevity and costs of ongoing care). Concurrently, there would be a reduction of $1.99 billion in productivity costs associated with premature death, and nonmedical expenditures would increase by $928 million, yielding a net positive economic value to society of $894 million. The program would cost $540 per quitter, considering only the costs of the intervention. Considering all healthcare costs, the cost-effectiveness would be $4350 per life-year and $505 per QALY. The researchers concluded that “smoking cessation counseling with supportive contact after discharge for smokers admitted with AMI has the potential to be cost-effective relative to the standard of care and may lead to significant reductions in the incidence of smoking and its associated adverse health events and social costs. Medicare and other health insurers should explore the inclusion of continued supportive contact with patients hospitalized for AMI who smoke as a quality measure.”