Cost-Effectiveness of the Diabetes Care Protocol, a Multifaceted Computerized Decision Support Diabetes Management Intervention That Reduces Cardiovascular Risk

Abstract

OBJECTIVEThe Diabetes Care Protocol (DCP), a multifaceted computerized decision support diabetes management intervention, reduces cardiovascular risk of type 2 diabetic patients. We performed a cost-effectiveness analysis of DCP from a Dutch health care perspective.RESEARCH DESIGN AND METHODSA cluster randomized trial provided data of DCP versus usual care. The 1-year follow-up patient data were extrapolated using a modified Dutch microsimulation diabetes model, computing individual lifetime health-related costs, and health effects. Incremental costs and effectiveness (quality-adjusted life-years [QALYs]) were estimated using multivariate generalized estimating equations to correct for practice-level clustering and confounding. Incremental cost-effectiveness ratios (ICERs) were calculated and cost-effectiveness acceptability curves were created. Stroke costs were calculated separately. Subgroup analyses examined patients with and without cardiovascular disease (CVD+ or CVD− patients, respectively).RESULTSExcluding stroke, DCP patients lived longer (0.14 life-years, P = NS), experienced more QALYs (0.037, P = NS), and incurred higher total costs (€1,415, P = NS), resulting in an ICER of €38,243 per QALY gained. The likelihood of cost-effectiveness given a willingness-to-pay threshold of €20,000 per QALY gained is 30%. DCP had a more favorable effect on CVD+ patients (ICER = €14,814) than for CVD− patients (ICER = €121,285). Coronary heart disease costs were reduced (€−587, P < 0.05).CONCLUSIONSDCP reduces cardiovascular risk, resulting in only a slight improvement in QALYs, lower CVD costs, but higher total costs, with a high cost-effectiveness ratio. Cost-effective care can be achieved by focusing on cardiovascular risk factors in type 2 diabetic patients with a history of CVD.

Computerized Decision Support Systems in Primary Care for Type 2 Diabetes Patients Only Improve Patients' Outcomes when Combined with Feedback on Performance and Case Management: A Systematic Review

“…25 The other 12 trials had a cluster randomized design, 6,11,[13][14][15][16][17]19,[27][28][29][30][31][32][33][34] and 10 trials adjusted for clustering in the analysis. 6,11,14,16,[30][31][32][33][34][35] Twelve trials reported a power calculation for a specified difference between groups and a specific outcome.…”

“…Three studies only showed improvements in the process of care. Improvements were found in yearly HbA1c testing, retinal exams, and the composite of three tests, as well as in laboratory monitoring, 18 low-density lipoprotein testing, and the composite of all Cleveringa et al, [15][16][17] Phillips et al 14 and Ziemer et al, 6 and MacLean et al 19 and Khan et al 18 represent the same respective study with different outcome parameters. a Value in randomized column is 1 if patients were randomized or when cluster randomization with the generalized estimating equation (GEE) was used.…”

“…13 The study from Phillips et al 14 and Ziemer et al 6 regarded the same study population, with different outcome measures. This also applies to the three studies of Cleveringa et al [15][16][17] and to the studies from Khan et al 18 and MacLean et al 19 Therefore eventually 20 RCTs were included. Ninety-five articles were excluded because of different reasons, for example, review article (n = 14), no RCT (n = 22), no CDSS used in the intervention (n = 26), glucose monitoring system (n = 10), or diabetes self-management program (n = 11) (Fig.…”

“…16 The process of care also significantly improved in one study. 33 For one intervention it was shown that it was not cost-effective 15 and that there was no negative influence on health status. 17 …”

Diabeteszorggroepen en de keten-DBC

“…Om de kosteneffectiviteit te vergroten zullen huisartsen zich moeten richten op patiënten met de hoogste cardiovasculair risico's en zich daarbij niet moeten concentreren op verdergaande verlaging van de HbA1c-waarde. 15 …”