Comparison of direct costs of type 2 diabetes care: Different care models with different outcomes

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Abstract

Backgrounds and aims

To compare direct costs of four different care models and health outcomes in adults with type 2 diabetes.

Methods and results

We used multiple independent data sources to identify 25,570 adults with type 2 diabetes residing in Turin, Italy, as of 1 July 2003. Data extracted from administrative data databases were used to create four care models ranging in organization from highly structured care (integrated primary and specialist care) to progressively less structured care (unstructured care). Regression analyses, adjusted for main confounders, were applied to examine the differences between the models in direct costs, mortality, and diabetes-related hospitalizations rates over a 4-year period. In patients managed according to the unstructured care model (i.e., usual care by a primary care provider and without strict guidelines adherence), excess of all-cause mortality was 84% and 4-year direct cost was 8% higher than in those managed according to the highly structured care model. Cost ratio analysis revealed that the major cost driver in the unstructured care model was hospital admissions, which were 31% higher than the rate calculated for the more structured care models. In contrast, spending on prescription medications and specialist consultations was higher in the highly structured care model.

Conclusion

A diabetes care model that integrates primary and specialty care, together with practices that adhere to guideline recommendations, was associated with a reduction in all-cause mortality and hospitalizations, as compared with less structured models, without increasing direct health costs.

Introduction

Aside from the toll diabetes takes on the body in terms of disability, morbidity and mortality, it has become one of the major cost drivers in national health service budgets [1], [2]. Currently, it absorbs 10–15% of total health care spending and its socioeconomic burden is estimated to increase in the coming decades [3]. Health care models that successfully implement patient recall and annual screening have proved to be effective in identifying and treating at-risk patients and in reducing complications, whereas less structured care has been associated with poorer outcomes [4], [5]. Although care models that reduce diabetes-related morbidity and hospital utilization can curb costs and promote the sustainability of diabetes care, little information exists on the real cost of such care models and the differences in actual consumption of resources.

In a previous analysis of multiple data sources for Turin, quality-of-care processes were evaluated with regard to adherence to guideline recommendations and as to whether guideline adherence was more consistent in patients receiving combined specialist and primary care than in those seen only by their primary care physician [6]. The main finding of the study was the effect of care processes and organizational factors (type and quality of care) had on diabetes endpoints [7]. As compared with patients who received high-quality care, in those who received usual care (i.e., no planned screening and no specialist referrals), excess all-cause mortality was 72%, and excess incidence of cardiovascular events was 32%. These trends were consistent for all outcomes: mortality for cardiovascular diseases and cancer was higher.

As seen in other chronic care models, however, the question arises as to whether current gaps in diabetes care need to be improved by reorganizing services and allocating resources so that investment in collaborative care would yield better health outcomes and cost savings. To address concerns about the sustainability of diabetes care, we thought it useful to compare the outcomes and costs of four different type 2 diabetes care models from the perspective of a universal public health service. Our aim was that this new understanding may be used to inform policies and develop strategies for diabetes care.

Section snippets

Methods

The study base of this cohort study included persons residing in Turin (population, 900,000) as of 1 July 2003, aged from 36 to 80 years, with a diagnosis of type 2 diabetes. All Italian citizens, irrespective of social class or income, are cared for by a primary care physician (GP) as part of the National Health Service (NHS). Up to 60–70% of the care for people with diabetes is shared with a public network of about 650 diabetes clinics which deliver diagnostic confirmation, therapy,

Results

We identified 25,570 persons with type 2 diabetes residing in Turin as of 1 July 2003. Baseline characteristics of the study population and the average 4-year gross/unadjusted costs of each care model are shown in Table 1. About 41% of patients had visited a diabetes clinic and undergone screening for complications (structured care), while 28% of patients sought specialist consultation, but did not undergo basic screening for complications (only specialist). A further 26% of patients were seen

Discussion

Type 2 diabetes is a leading cause of morbidity and mortality worldwide and places a huge burden on national health systems [1], [2]. Yet diabetes care is sometimes dismissed as a routine task for the primary care physician. By definition, specialist care is considered expensive and only warranted in advanced cases. Gaps in the quality of diabetes care reflect the difficulties and the differences in achieving improvement [10], [11]. Both treatment and prevention practices are influenced by

Acknowledgments

This study was supported in part by Chaira Medica Association (nonprofit organization for the study of endocrine and metabolic disorders), Chieri, Italy and by a P. Di Coste fellowship grant from AMD and SID (Italian Societies of Diabetologists).

References (20)

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