|Cost implications to health care payers of improving glucose management among adults with type 2 diabetes
|Nuckols TK, McGlynn EA, Adams J, Lai J, Go MH, Keesey J, Aledort JE
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn.
The aim was to compare the costs to payers and the proportions of patients attaining treatment goals, between the usual care and improved care, for adults with type 2 diabetes. The authors concluded that the cost of improving glucose management was modest compared with total diabetes health care expenditure. There were some limitations to the study, in particular, some of the methods and results were not fully reported. The authors’ conclusions should be considered with caution.
Type of economic evaluation
The aim was to assess the cost implications to payers of improving glucose management in adults with type 2 diabetes.
Usual care as assessed by the Community Quality Index (CQI) study was compared with improved care, which assumed that patients received the complete provision of the recommended diabetes care, for various treatment goals. The recommended diabetes care, the time frames, and the treatment goals were mainly based on the 2010 guidelines of the American Diabetes Association and data from the National Committee on Quality Assurance’s Health Care Effectiveness Data and Information Set (HEDIS).
USA/community and institutional care.
A decision-tree model was developed to predict the costs and effects of glucose management with the two scenarios, over a year. The authors stated that a health care payer perspective was adopted.
For usual care, the care processes and glycated haemoglobin (HbA1c) outcomes were from medical records collected from 1996 to 2002 in the CQI study. This study provided nationally representative data on the quality of care processes for patients with diabetes. For improved care, the authors assumed full adherence to the recommended care processes, and improvements in HbA1c outcomes were based on published literature.
Monetary benefit and utility valuations:
Measure of benefit:
The measure of benefit was the percentage of patients achieving their HEDIS treatment goal. The three goals were a HbA1c of less than 7%, less than 8%, and 9% or less.
The direct costs were those of laboratory tests, medications, and physician visits. Hyperglycaemic and hypoglycaemic events were included in a supplementary analysis. The costs of glucose management for both scenarios were from Medicare and the medication costs, which excluded patient co-payments and rebates, were based on pharmaceutical claims data from four Massachusetts health plans (2004 to 2006). The care processes did not change depending on the HbA1c goal and so the costs were the same for all three goals. The price year was 2009 and all costs were reported in US dollars ($).
Analysis of uncertainty:
A second order, Monte Carlo sensitivity analysis was performed. The plausible ranges for the model parameters were from the literature. A uniform distribution was assumed for each parameter.
For a goal HbA1c of less than 7%, the annual per patient cost was $503.38 for usual care and $830.39 for improved care. This difference in costs was largely due to antihyperglycaemic medications. The percentage of patients achieving their goal was 37 for usual care and 51 for improved care.
The costs and effects were presented for the other two HbA1c goals.
The incremental annual cost of improved care, compared with usual care, to payers per patient who was previously above their goal and then achieved it, for any of the three HEDIS goals, was $1,128.
In the sensitivity analysis, with an HbA1c goal of less than 8%, the cost-effectiveness of improved care ranged from $1,277 to $11,847 per patient achieving the goal. In the supplemental analysis including the costs of severe hyperglycaemic and hypoglycaemic events, it ranged from $825 to $2,961.
The authors concluded that the cost of improving glucose management was modest compared with total diabetes health care expenditure, and that their results allowed payers to consider the short-term costs and outcomes that were important to them.
A justification was given for selecting the comparator, which assessed the gap between actual care for diabetes and the recommended care. These care scenarios might be generalisable to other settings.
The methods used to identify and select the effectiveness data from published clinical studies were not reported in the main article, but some details were given in an online appendix. These indicate that a systematic search was performed in PubMed and national guidelines as the search terms were reported, but it was unclear whether the best available evidence was used as other details were missing, such as the dates searched, and the study designs. For improved care, adherence to the care processes was assumed to be complete, and the sources for the improvements in HbA1c outcomes were not described. The benefit measure was appropriate, but did not assess quality of life, as mentioned by the authors when comparing their study with other published studies. The online appendix should be consulted to assess the validity of the clinical sources.
The cost analysis was carried out from the payers’ perspective and the authors appear to have included those costs relevant to this perspective. The sources for the unit costs were reported, they were US specific, and a breakdown of individual cost items was given. The resource quantities were generally presented separately from the costs, which enhances the transparency of the study. The price year was reported and this will allow the costs to be updated. Additional details of the data sources and cost calculations were reported in the online appendix.
Analysis and results:
The incremental approach was appropriate for comparing the relative costs and effectiveness of the two scenarios and a diagram of the model was provided in the online appendix. The authors stated that the one-year time horizon was relevant for the payer perspective. There were some limitations in the evidence used. For instance, the clinical parameters have changed since the CQI study began, with more patients on antihyperglycaemic drugs. These limitations could affect the HbA1c outcomes, but this was partly addressed by the sensitivity analysis, which investigated parameter uncertainty through Monte Carlo simulation. This analysis was not thoroughly reported and conducted, which makes it difficult to assess the impact of uncertainty in the parameter estimates on the findings. The authors discussed some limitations to their study.
There were some limitations to the study, in particular, some of the methods and results were not fully reported. The authors’ conclusions should be considered with caution.
Funded by the National Pharmaceutical Council, USA.
Nuckols TK, McGlynn EA, Adams J, Lai J, Go MH, Keesey J, Aledort JE. Cost implications to health care payers of improving glucose management among adults with type 2 diabetes. Health Services Research 2011; 46(4): 1158-1179
Subject indexing assigned by NLM
Blood Glucose; Costs and Cost Analysis; Diabetes Mellitus, Type 2 /economics /therapy; Drug Utilization; Health Expenditures /statistics & Hemoglobin A, Glycosylated /analysis; Humans; Hypoglycemic Agents /economics /therapeutic use; Insurance Claim Review /statistics & Models, Economic; Patient Compliance /statistics & Quality of Health Care /statistics & numerical data; numerical data; numerical data; numerical data
Date bibliographic record published
Date abstract record published