Evaluation of the Effects of a Diabetes Disease Management Program on Outpatient Health Care

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1 Evaluation of the Effects of a Diabetes Disease Management Program on Outpatient Health Care Prof. Dr. Herwig Ostermann 1 Dr. Margit Raich 1 Prof. Dr. Harald Stummer 2 Dr. Michael Müller 1,3 1 Division for Health Policy, Administration and Law 2 Division for Organisation and Health Promotions Department of Public Health and HTA University for Health Sciences, Medical Informatics and Technology Eduard Wallnöfer-Zentrum I, 6060 Hall in Tyrol, Austria 3 Unit for Health Management Social Insurance Institution for Business Wiedner Hauptstraße 84-86, 1050 Vienna, Austria 43

Michael Müller 1,3 1 Division for Health Policy, Administration and Law 2 Division for Organisation and Health Promotions Department of Public

2 Context I Diabetes Basics Complex, non-communicable chronic disease Number of people affected worldwide 2010 estimate: 285 million (prevalence 6.4%) 2030 estimate: 438 million (prevalence 7.8%) Regional variances United States: 8%+ European Union: 3-6% Austria: 4% Burden of diabetes Severe complications associated with (unmanaged) diabetes (high-income countries) Most common cause for adult blindness 1/3 of all dialysis patients suffer from diabetes 20 times more at risk of amputations 2-3 times more at risk of cardiovascular diseases (CVD) More frequent utilization of health care services Sources: World Diabetes Foundation, 2010; Lemmens et al., 2011; Pieber, 2008; 44

8%) Regional variances United States: 8%+ European Union: 3-6% Austria: 4% Burden of diabetes Severe complications associated with (unmanaged) diabetes (high-income

3 Context II Diabetes Basics (cont d) Treatment of diabetes Chronic disease, lifelong therapy Lifestyle modifications Diabetic diet (type 2) Oral mediations Anti-diabetic medications (type 2) Insulin therapy Usually injected subcutaneously (type 1, type 2) Combined therapy Anti-diabetic medications and insulin (type 2) Sources: Harris et al., 2010; Pieber,

medications (type 2) Insulin therapy Usually injected subcutaneously (type 1, type 2)

4 Context III The rationale of DMPs Main thrust of disease management Improvement of effectiveness and economic efficiency of health care delivery via Coordinated health care delivery Standardisation of treatment pathways Implementation of treatment guidelines Better outcomes at reasonable or even lower costs DMP target groups Chronic diseases (diabetes, CVD) High patient-involvement Chronic care delivery / long-term treatment Existence of treatment pathways and (evidence-based) guidelines Sources: Lemmens et al, 2001; Federation of Austrian Social Insurance Institutions,

or even lower costs DMP target groups Chronic diseases (diabetes, CVD) High patient-involvement Chronic care delivery / long-term treatment

5 Methods I Study population Patient records (outpatient care) of the Social Insurance Institution for Business Part of the Austrian mandatory social insurance system Covers self-employed persons and their relatives 705,607 insured persons (2009) 467,656 mandatorily insured persons / 225,633 relatives 21,299 diabetes patients treated with oral anti-diabetic medication and/or insulin Diabetes type 2 patients administered diabetic diet only not included, as patient records only include prescribed medication 514 patients enrolled in the DMP Data sources Central data warehouse (operated by the Federation of Austrian Social Insurance Institutions) Source: Social Insurance Institution for Business,

anti-diabetic medication and/or insulin Diabetes type 2 patients administered diabetic diet only not included, as patient records only include prescribed medication 514

6 Methods II Study population (cont d) Demographic characteristics of study population no substantial difference in terms of sex and age other data (income, education) not available overall collective of insurees homogenous in terms of sociodemographic characteristics due to coverage of self-employed persons only 48

(income, education) not available overall collective of insurees homogenous in

7 Methods III The Austrian diabetes DMP Therapie Aktiv Evidence-based treatment pathways International research Guidelines of the Austrian Society for Diabetes Basic characteristics Voluntary participation No financial incentive for participating patients Lump sum payment per patient enrolled for participating physicians Physician training Compulsory participation in certified courses Patient empowerment Quality management Compulsory checklists Standardized reporting Treatment pathways In order to support medical decision making of all physicians involved in treatment process Source: Federation of Austrian Social Insurance Institutions,

Physician training Compulsory participation in certified courses Patient empowerment Quality management Compulsory checklists Standardized reporting Treatment

8 Methods IV Assessed parameters Pattern of outpatient care service utilization Number of specific services received by each patient in 2009 Overall costs of specific services received by each patient in 2009 Hospitalization Patients hospitalized Days of hospitalization Average costs for outpatient care and medication Costs for hospital care not available in patient records due to central funding of the Austrian DRGs 50

Hospitalization Patients hospitalized Days of hospitalization Average costs for outpatient care and

9 Results I Outpatient service utilization Source of data: Data warehouse, own retrieval and analysis 51

10 Results II Outpatient service utilization (cont d) Source of data: Data warehouse, own retrieval and analysis 52

11 Results III Hospitalization Source of data: Date warehouse, own retrieval and analysis 53

12 Results IV Costs for outpatient care and medication Source of data: Data warehouse, own retrieval and analysis 54

13 Discussion I Overall effects Patients enrolled in the program benefit from More evolved pattern of outpatient services Higher amount of specialist services (33 vs. 23) and laboratory services (14 vs. 9) Less non-medical services such as wound care bandaging (14 vs. 42) or transport services (7 vs. 39) Less hospitalization Less share of patients hospitalized (33% vs. 37%) and less days hospitalized (10.7 vs. 17.3) Shift from inpatient to outpatient care DMP patients are expected to cause lower costs No significant difference in costs for outpatient care and medication ( 2,874 p.c. vs. 2,773 p.c.) Costs for hospital services are expected to be lower due to less hospitalization of enrolled patients Accounting for nearly half the days of regular patients (3.5 vs. 6.4) 55

39) Less hospitalization Less share of patients hospitalized (33% vs. 37%) and less days hospitalized (10.7 vs. 17.

14 Discussion II Limitations Limitations Empirical design No randomization, no baseline measurement Selection bias Personal factors (severity/length of disease, motivation, prognosis, comorbidity) not included Substantial differences in socio-demographic characteristics unlikely due to homogenous collective of insurees More evolved pattern of outpatient care and less hospitalization must not reflect better health outcomes Further research and/or Standardized reporting of health outcomes needed Time of survival not available due to start of DMP in 2007 Sources: Schäfer et al., 2010; Pieber, 2008; Miksch et al.,

collective of insurees More evolved pattern of outpatient care and less hospitalization must not reflect better health outcomes Further research and/or

15 Outlook Implications for health policy makers Results of the Austrian diabetes disease management program generally in line with international research as well as intended effects of DMPs better health care delivery at reasonable/lower costs BUT: Mechanisms causing these results still unclear due to limitations in design of current research Selection effects in enrolment may account for better results along with mechanisms of DMP Mechanisms of DMP may account for better results Approval procedure for implementation of alternative forms of management of health care delivery advisable In order to safeguard ethical standards as well as sufficient empirical evidence Sources: Schäfer et al., 2010; Miksch et al., 2010; Breyer,

enrolment may account for better results along with mechanisms of DMP Mechanisms of DMP may account for better results Approval procedure for implementation of alternative forms of

16 Comments? Questions? Remarks? 58

17 Acknowledgements Dr. Thomas Neumann Social Insurance Institution for Business Vienna, Austria Dr. Oskar Staudinger S2-engineering Steyr, Austria 59

The below tables outline the types of health care services as well as delivery settings:

The below tables outline the types of health care services as well as delivery settings: Assuring Quality Health Care Delivery in Asia Introduction Guk-Hee Suh, PhD, MD, 2014-2016 Chair, ISPOR Asia Consortium Health Service Providers (Clinicians) Committee, and Professor of Psychiatry, Hallym