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

Cost-effectiveness of the adherence with recommendations for clinical monitoring of patients with diabetes

BACKGROUND AND AIMS

To validate a set of indicators for monitoring the quality of care of patients with diabetes in 'real-life' practice through its relationship with measurable clinical outcomes and healthcare costs.

METHODS AND RESULTS

A population-based cohort study was carried out by including the 20,635 patients, residents in the Lombardy Region (Italy), who in the year 2012 were newly taken-in-care for diabetes. Adherence with clinical recommendations (i.e., controls for glycated haemoglobin, lipid profile, urine albumin excretion and serum creatinine) was recorded during the first year after the patient was taken-in-care, and categorized according whether he/she complied with none or almost none (0 or 1), just some (2) or all or almost all (3 or 4) the recommendations, respectively denoted as poor, intermediate and high adherence. Short- and long-term complications of diabetes, and healthcare cost incurred by the National Health Service, were assessed during follow-up. Compared with patients with poor adherence, those with intermediate and high adherence respectively showed (i) a delay in outcome occurrence of 13 days (95% CI, -2 to 27) and 23 days (9-38), and (ii) a lower healthcare cost of 54 € and 77 €. In average, a gain of 18 Euros and 15 Euros for each day free from diabetic complication by increasing adherence respectively from poor to intermediate and from poor to high were observed.

CONCLUSION

Close control of patients with diabetes through regular clinical examinations must be considered the cornerstone of national guidance, national audits, and quality improvement incentive schemes.

Monitoring adherence to pharmacological therapy and follow-up examinations among patients with type 2 diabetes in community pharmacies. Results from an experience in Italy

Introduction

Type 2 diabetes is an important public health issue, yet adherence to drugs and regular clinical follow-up is still suboptimal. This study aims to evaluate a community pharmacy programme for monitoring and enhancing adherence to prescribed pharmacological therapies and recommended examinations among patients with confirmed diabetes.

Methods

The intervention was conducted in different Italian areas between April 2017 and January 2018. All adult patients who entered a pharmacy with a personal prescription for any antidiabetic drug and agreed to participate, were interviewed. Those found to be non-adherent received counselling from the pharmacists. All patients were invited for a follow-up interview after 3 months.

Results

Overall, 930 patients were enrolled and completed the baseline interview. We found low rates of non-adherence, ranging from 8% to 13% for prescribed pharmacological therapies, and 11–29% for the recommended clinical examinations. Non-adherence to oral therapies was higher among younger and recently diagnosed patients; that to clinical examinations was higher in men, those with an intermediate duration of diabetes and less educated patients. Large geographical differences persisted after the adjustment for individual factors. Only 306 patients (32.9%) returned for the follow-up interview, most of whom were already adherent at baseline.

Conclusions

Poor adherence to drugs or clinical examinations is not easy to identify in the usual operating setting of community pharmacies. Furthermore, the majority of patients did not return for follow-up, making it impossible to evaluate the efficacy of the pharmacists’ counselling. It might be more effective to plan interventions addressed to specific subgroups of patients or areas.

Exploring geographic variation of and influencing factors for utilization of four diabetes management measures in Swiss population using claims data

INTRODUCTION

Four strongly recommended diabetes management measures are biannual glycated hemoglobin (HbA1c) testing, annual eye examination, kidney function examination, and low-density lipoprotein (LDL) testing in patients below 75 years. We aimed to describe regional variation in the utilization of the four measures across small regions in Switzerland and to explore potential influencing factors.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional study of adult patients with drug-treated diabetes in 2014 using claims data. Four binary outcomes represented adherence to the recommendations. Possible influencing factors included sociodemographics, health insurance preferences, and clinical characteristics. We performed multilevel modeling with Medstat regions as the higher level. We calculated the median odds ratio (MOR) and checked spatial autocorrelation in region level residuals using Moran's I statistic. When significant, we further conducted spatial multilevel modeling.

RESULTS

Of 49 198 patients with diabetes (33 957 below 75 years), 69.6% had biannual HbA1c testing, 44.3% each had annual eye examination and kidney function examination, and 55.5% of the patients below 75 years had annual LDL testing. The effects of health insurance preferences were substantial and consistent. Having any supplementary insurance (ORs across measures were between 1.08 and 1.28), having supplementary hospital care insurance (1.08-1.30), having chosen a lower deductible level (eg, SFr2500 compared with SFr300: 0.57-0.69), and having chosen a managed care model (1.04-1.17) were positively associated with recommendations adherence. The MORs (1.27-1.33) showed only moderate unexplained variation, and we observed inconsistent spatial patterns of unexplained variation across the four measures.

CONCLUSION

Our findings indicate that the uptake of strongly recommended measures in diabetes management could possibly be optimized by providing further incentives to patients and care providers through insurance scheme design. The absence of marked regional variation implies limited potential for improvement by targeted regional intervention, while provider-specific promotion may be more impactful.

Does the hospitalization after a cancer diagnosis modify adherence to process indicators of diabetes care quality?

AIMS

This study was designed to answer the question whether surgery due to newly diagnosed cancer may modify quality of diabetes' management, as suggested by current guidelines.

METHODS

Adherence to guideline composite indicator (GCI), a process indicator including one annual assessment of HbA1c and at least two among eye examination, serum lipids measurement and microalbuminuria, was evaluated between years 2011-2012 and 2014-2015 in 158,069 diabetic patients living in Tuscany, Italy, on 1 January 2011 and surviving on 31 December 2015, of whom 661 were hospitalized in index year 2013 for a surgery procedure due to a newly incident cancer. Difference in GCI modification (DELTA_GCI) of these patients was compared with that of diabetic people without cancer, strictly matched for main confounders by means of a propensity score.

RESULTS

In diabetic patients with cancer, GCI adherence increased by about 8 % between years 2011-2012 and 2014-2015. When compared with controls, DELTA_GCI increased by 6 % in cancer group compared with controls (p < 0.05), but any significance was lost after matching the groups by propensity score (3 %; p = NS).

CONCLUSIONS

Our study suggests that a hospitalization for a surgical procedure due to a newly diagnosed cancer does not influence the compliance to a quality process indicator of diabetes care such as GCI.

The role of global and regional DNA methylation and histone modifications in glycemic traits and type 2 diabetes: A systematic review

BACKGROUND

New evidence suggests the potential involvement of epigenetic mechanisms in type 2 diabetes (T2D) as a crucial interface between the effects of genetic predisposition and environmental influences.

AIM

To systematically review studies investigating the association between epigenetic marks (DNA methylation and histone modifications) with T2D and glycemic traits (glucose and insulin levels, insulin resistance measured by HOMA-IR).

METHOD AND RESULTS

Six bibliographic databases (Embase.com, Medline (Ovid), Web-of-Science, PubMed, Cochrane Central and Google Scholar) were screened until 28th August 2015. We included randomized controlled trials, cohort, case-control and cross-sectional studies in humans that examined the association between epigenetic marks (global, candidate or genome-wide methylation of DNA and histone modifications) with T2D, glucose and insulin levels and insulin metabolism. Of the initially identified 3879 references, 53 articles, based on 47 unique studies met our inclusion criteria. Overall, data were available on 10,823 participants, with a total of 3358 T2D cases. There was no consistent evidence for an association between global DNA-methylation with T2D, glucose, insulin and insulin resistance. The studies reported epigenetic regulation of several candidate genes for diabetes susceptibility in blood cells, muscle, adipose tissue and placenta to be related with T2D without any general overlap between them. Histone modifications in relation to T2D were reported only in 3 observational studies.

CONCLUSIONS AND RELEVANCE

Current evidence supports an association between epigenetic marks and T2D. However, overall evidence is limited, highlighting the need for further larger-scale and prospective investigations to establish whether epigenetic marks may influence the risk of developing T2D.

Temporal HbA1c patterns amongst patients with type 2 diabetes referred for specialist care: Data from the S4S-DINGO-Diabetes Informatics Group

AIMS

To evaluate the achievement of HbA1c targets in patients with type 2 diabetes mellitus in specialist practice.

METHODS

This audit was undertaken by members of the S4S Diabetes Informatics Group (DINGO), a consortium of Australian endocrinologists in private practice who contribute de-identified data from their electronic medical record, Audit 4 (Software 4 Specialists, S4S, Australia & New Zealand) for audit purposes. Data from patients with type 2 diabetes was extracted. Inclusion criteria were: initial age<70years, baseline HbA1c>7% (53mmol/mol), with at least another HbA1c recorded in the next 2years, and a minimum of 2years follow-up. Data was analysed using a linear mixed effects model.

RESULTS

Of the 4796 patients in the dataset with type 2 diabetes mellitus, 1379 patients fulfilled inclusion criteria. The median age at initial consultation was 57 (49-64)years. The median baseline HbA1c was 8.7 (7.8-9.8)% (72mmol/mol). There was a 1.0% reduction in HbA1c to 7.7 (7.1-8.6)% (61mmol/mol) (p<0.0001) in the first 3-6months following referral, after which there were no further changes. The initial reduction was maintained with minimal loss of control at 4years. By 3-6months, 24% of patients achieved the target HbA1c.

CONCLUSIONS

Referral of patients with type 2 diabetes to an endocrinologist reduces HbA1c, and the effect is sustained over the medium term; however only a minority of patients reach targets.

A set of four simple performance measures reflecting adherence to guidelines predicts hospitalization: a claims-based cohort study of patients with diabetes

BACKGROUND

The link between guideline adherence and outcomes is a highly demanded issue in diabetes care. We aimed to assess the adherence to guidelines and its impact on hospitalization using a simple set of performance measures among patients with diabetes.

METHODS

We performed a retrospective cohort study, using health care claims data for adult patients with treated diabetes (2011-2013). Patients were categorized into three drug treatment groups (with oral antidiabetic agents [OAs] only, in combination with insulin, and insulin only). Performance measures were based on international established guidelines for diabetes care. Multivariate logistic regression models predicted the probability of hospitalization (2013) by adherence level (2011) among all treatment groups.

RESULTS

A total of 40,285 patients with diabetes were enrolled in 2011. Guideline adherence was quite low: about 70% of all patients received a biannual hemoglobin A1c measurement and 19.8% had undergone an annual low-density lipoprotein cholesterol test. Only 4.8% were exposed to full adherence including all performance measures (OAs: 3.7%; insulin: 7.7%; and in combination: 7.2%). Increased guideline adherence was associated with decreased probability of hospitalization. This effect was strongest in patients using OAs and insulin in combination.

CONCLUSION

Our study showed that measures to reflect physicians' guideline adherence in diabetes care can easily be calculated based on already available datasets. Furthermore, these measures are clearly linked with the probability of hospitalization suggesting that a better guideline adherence by physicians could help to prevent a large number of hospitalizations.

Effects of continuity of care on hospital admission in patients with type 2 diabetes: analysis of nationwide insurance data

BACKGROUND

A system for managing chronic disease including diabetes mellitus based on primary care clinics has been used in Korea since April 2012. This system can reduce copayments for patients that are managed by a single primary-care provider and lead to improve continuity of care. The aim of this study is to determine whether there is an association between continuity of care for outpatients and hospital admission and identify the continuity index that best explains hospital admissions for patients with type 2 diabetes.

METHODS

We performed a cross-sectional study using 2009 National Health Insurance Sample (NHIS) from the Health Insurance Review & Assessment Services (HIRA) of Korea. The dependent variable was hospital admission due to type 2 diabetes mellitus. Continuity of care was measured using the Usual Provider Care index (UPC), Continuity of Care index (COC), Sequential Continuity of Care index (SECON), and Integrated Continuity of Care index (ICOC).

RESULTS

Patients with low COC scores (<0.75) were more likely to be hospitalized [odds ratio, 2.44; 95% CI, 2.17-2.75] compared with the reference group (COC ≥0.75), after adjusting for all covariates. we calculated the area under the receiver operating characteristic (AUROC) curve for each index to find which index had the greatest explanatory ability for hospital admission. The AUROC of the COC was the greatest (0.598), but the AUROC curves for the UPC (0.597), SECON (0.593), and ICOC (0.597) were similar.

CONCLUSIONS

High continuity of care may reduce the likelihood for hospital admission. The COC had marginally more explanatory power.

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial

BACKGROUND

The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective.

METHODS

In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs.

RESULTS

Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€ 758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly).

CONCLUSIONS

Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant.

TRIAL REGISTRATION

Current Controlled trials: ISRCTN66124817.