Abstract
ObjectivesThe aim of the study was to investigate the changes in costs and outcomes after the implementation of various disease management programs (DMPs), to identify their potential determinants, and to compare the costs and outcomes of different DMPs.MethodsWe investigated the 1-year changes in costs and effects of 1,322 patients in 16 DMPs for cardiovascular risk (CVR), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DMII) in the Netherlands. We also explored the within-DMP predictors of these changes. Finally, a cost-utility analysis was performed from the healthcare and societal perspective comparing the most and the least effective DMP within each disease category.ResultsThis study showed wide variation in development and implementation costs between DMPs (range:€16;€1,709) and highlighted the importance of economies of scale. Changes in health care utilization costs were not statistically significant. DMPs were associated with improvements in integration of CVR care (0.10 PACIC units), physical activity (+0.34 week-days) and smoking cessation (8% less smokers) in all diseases. Since an increase in physical activity and in self-efficacy were predictive of an improvement in quality-of-life, DMPs that aim to improve these are more likely to be effective. When comparing the most with the least effective DMP in a disease category, the vast majority of bootstrap replications (range:73%;97) pointed to cost savings, except for COPD (21%). QALY gains were small (range:0.003;+0.013) and surrounded by great uncertainty.ConclusionsAfter one year we have found indications of improvements in level of integrated care for CVR patients and lifestyle indicators for all diseases, but in none of the diseases we have found indications of cost savings due to DMPs. However, it is likely that it takes more time before the improvements in care lead to reductions in complications and hospitalizations.
Highlights
Chronic diseases pose an increasing threat to population health, enlarge the burden of care giving, and constrain the financial viability of health care systems worldwide
We investigated the impact of Disease management program (DMP) on: a) the level of chronic care integration using the Patient Assessment Chronic Illness (PACIC) questionnaire [11], b) patient life-style measured by self-reported smoking status and physical activity, c) self-efficacy using the respective subscale of the Self-Management Ability Scale- Shorter (SMAS-S) [12], and d) the 3-level EQ-5D utility scores which were based on the Dutch value set and used to estimate quality adjusted life years (QALYs) [13]
This study of the short-term effects of DMPs found that the implementation of DMPs was associated with improvements in integration of care and lifestyle behaviour, such as physical activity and smoking, of patients with cardiovascular risk (CVR), diabetes and chronic obstructive pulmonary disorder (COPD)
Summary
Chronic diseases pose an increasing threat to population health, enlarge the burden of care giving, and constrain the financial viability of health care systems worldwide. The wide-scale implementation of DMII-DMPs was smooth and successful, the uptake of DMPs for COPD and cardiovascular risk (CVR) is still troublesome This is because health insurers, which contract DMPs from care groups, are yet to be convinced about the financial attractiveness of these programs [6]. Illustrative of this scepticism is that the largest Dutch health insurer does not contract CVRDMPs and provides only a yearly add-on payment per patient with an elevated CVR to cover costs of coordination, provider training and additional ICT support. The debate embeds the adequacy of the current single-disease DMPs for patients with multiple morbidities, which seems to be the norm rather than the exception [7]
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