Comparison of direct costs of type 2 diabetes care: Different care models with different outcomes
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 10β15% 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 60β70% 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)
- et al.
Diabetes Atlas. Global healthcare expenditure on diabetes for 2010 and 2030
Diabetes Res Clin Pract
(2010) The role of the care model in modifying prognosis in diabetes
Nutr Metab Cardiovasc Dis
(2013 Jan)- et al.
Socio-economic differences in prevalence of diabetes in Italy: the population-based Turin study
Nutr Metab Cardiovasc Dis
(2008) - et al.
ARNO working group. The direct economic cost of pharmacologically treated diabetes in Italy-2006. The ARNO observatory
Nutr Metab Cardiovasc Dis
(2011) - et al.
Direct costs in diabetic and non diabetic people: the population-based Turin study, Italy
Nutr Metab Cardiovasc Dis
(2012) - et al.
The economic costs of diabetes in developing countries: some concerns and recommendations
Diabetologia
(2010; Feb) - et al.
Scottish diabetes research network Epidemiology group. Inpatient costs for people with type 1 and type 2 diabetes in Scotland: a study from the Scottish diabetes research network Epidemiology group
Diabetologia
(2011; Aug) - et al.
Systems for routine surveillance in people with diabetes mellitus
Cochrane Database Syst Rev
(2009) - et al.
Determinants of quality in diabetes care process: the population-based Torino Study
Diabetes Care
(2009) - et al.
The impact of adherence to screening guidelines and of specialist referral on morbidity and mortality in diabetes. The population-based Torino Study
PLoS One
(2012)
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