Cost Variation in Diabetes Care across Dutch Care Groups?

Are social determinants of health associated with the development of early complications among young adults with type 2 diabetes? A population based study using linked databases

AIMS

To quantify the impact of social determinants of health (SDOH) on top of medical determinants on the development of diabetes-related complications in young adults with type 2 diabetes.

METHODS

In this observational population-based study, SDOH (income and origin) were linked to routine primary care data. Young adults (18-45 years) with incident type 2 diabetes between 2007 and 2013 were included. The main outcome, the development of the first micro- or macrovascular complication, was analyzed by multivariate Cox regression. Medical determinants included antidiabetic treatment, HbA1c in the year after diagnosis, body mass index, comorbidity and smoking.

RESULTS

Of 761 young adults (median age: 39 years (IQR 33-42), men: 49%, Western origin: 36%, low income: 48%), 154 developed at least one complication (median follow-up 99 months (IQR 73-123)). Young men of non-Western origin were more likely to develop a complication (HR 1.98 (1.19-3.30)), as were young adults with HbA1c > 7% (>53 mmol/mol) (HR: 1.72 95% CI: 1.15-2.57). No associations were found with income. Being women was protective.

CONCLUSION

In this multi-ethnic population, non-Western origin was associated with the development of complications, but only in men. Low income was not associated with developing complications. The importance of adequate HbA1c regulation was re-emphasized by this study.

Assessment of variation in long-term outcomes of integrated care initiatives in Dutch health care

Introduction

The care for many patients with diabetes mellitus type 2 in the Netherlands, is contracted by a local care group. The healthcare providers, who collectively shape a care group, provide protocolled diabetes care. Differences exist between care groups in terms of their organizational and financial arrangements. These differences may result in variation in outcomes. The aim of this study is to assess whether variation in healthcare costs, diabetes complications and related hospital admissions on the level of care groups exist.

Methods

A quantitative cohort study was conducted. Patients who used diabetes medication (more than 180 days of defined daily doses per year) for the first time between the years 2014 and 2019 were included. Data were extracted from health insurance claims between 2014 and 2019. Generalized linear mixed models were used to analyse patient variation in healthcare costs (two and six years follow-up), diabetes-related complications and hospital admission days. Intraclass correlation coefficients were calculated to estimate the amount of variation that was attributable to the care groups.

Results

A large variation in outcome variables was observed between patients and a small variation between care groups. The intraclass correlation coefficient for long-term costs was 0.4%; for short-term costs between 0.1% and 0.3%; for complications 1% and for hospital days 4%.

Discussion

A large variation between patients with diabetes mellitus type 2 exists in terms of their healthcare costs and complications. In our study, care groups accounted minimally for this variation. A generalized linear mixed model in combination with year cohorts is a tool to study variations in the long-term outcomes of integrated care initiatives.

How do integrated care programmes work for patients with cardiovascular disease, chronic obstructive pulmonary disease, depression, diabetes and multi-morbidity? A rapid realist review

Background

In previous years, many multi-faceted initiatives have been set up to improve outcomes for people with chronic diseases. Evaluation studies about the (cost-)effectiveness of these integrated care programs showed heterogeneity in outcomes. Hence, it has been suggested to use realist evaluation for the evaluation of integrated care programmes. Thus, our aim was to gain insight into whether and how existing integrated care programmes work for people with cardiovascular disease, chronic obstructive pulmonary disease, depression, diabetes and multi-morbidity, and under what conditions within the Dutch healthcare setting.

Methods

A rapid realist review was conducted to identify the context and mechanisms that are associated with the outcomes of integrated care programmes. From a selection of systematic reviews and meta-analyses and Dutch literature, data on the context, mechanisms and outcomes of integrated care programmes were extracted. The data were analysed by placing the extracted variables in context-mechanism-outcome configurations which showed their interrelatedness. A panel of executives from Dutch care groups assessed the face validity of the context-mechanism-outcome configurations.

Results

Based on the existing literature, context-mechanism-outcome configurations were compiled for all five diseases. Some configurations could be filled with more detail than others, with the configuration of integrated care for people with diabetes being the most complete. Context-mechanism-outcome configurations were completed and confirmed by executives from Dutch care groups.

Conclusion

The configurations together with the identified factors in them reveal the underlying preliminary program theories of integrated care programmes. These theories need to be tested in further research.