Cost-effectiveness of centralised and partly centralised care compared to usual care for patients with type 2 diabetes

Background and aims: Due to an ever increasing number of type 2 diabetes patients, innovations to control the increasing health care use and costs are needed. Results of diabetes care programs on the costs or (cost-) effectiveness are heterogeneous. The aim of this study is to compare the cost-effectiveness of two diabetes care models with usual care for type 2 diabetes patients from the societal perspective. Materials and methods: An economic evaluation was performed alongside a clinical trial. In two distinct regions of the Netherlands, two diabetes care models were implemented with different levels of centralized organizational structures. One of them was centralized care (CC) with a central organization and coordination of the care between all care providers and the use of a central database. Patients receive an annual extended diabetes assessment at the Diabetes Care Centre, in addition to the care by patients' general practitioner (GP). GP's receive feedback about their performance. Partly centralized care (PC) focuses on adherence to type 2 diabetes guidelines. An online clinical database is used to monitor mean values of risk factors. All assessments were performed in patient's GP practice. Usual care (UC) has a decentralized organisation structure and patients' GP is responsible for the diabetes care. Clinical outcome measure was risk of a coronary heart disease (CHD) calculated with the UKDPS risk engine. Cost-effectiveness analysis was performed from the societal perspective comparing patients receiving CC (n=313), PC (n=293) and UC (n=485) during one year of follow-up. Missing costs and effects data were imputed using multiple imputation. Differences in costs, effects and cost-effectiveness between the diabetes care groups were analysed using bootstrapping techniques. Results: Differences in changes in CHD risk over 12 months of follow-up between the three groups were statistically insignificant and clinically irrelevant. Compared to UC, health care costs during the follow-up period were lower in CC (-1300 (95% CI: -2300 to -570)) and PC (-960 (95% CI: -1890 to -100)). Costs from the societal perspective showed the same trend, although not statistically significant. Conclusion: Clinical outcomes did not differ between the different care models. Lower health care costs were observed in (partly) centralized care compared to usual care, mainly due to substitution of secondary health care use by primary health care use. This suggests that centralizing the diabetes care results in equal outcomes at lower health care costs