Stratified Patient-Centered Care in Type 2 Diabetes
A cluster-randomized, controlled clinical trial of effectiveness and cost-effectiveness
- Annabelle S. Slingerland, MD, DSC, MPH, MScHSR1,2⇑,
- William H. Herman, MD, MPH3,
- William K. Redekop, PHD2,
- Rob F. Dijkstra, MD, PHD4,
- J. Wouter Jukema, MD, PHD1 and
- Louis W. Niessen, MD, PHD2,5
- 1Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- 2Institute of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus MC, Erasmus University Rotterdam, Rotterdam, the Netherlands
- 3University of Michigan Medical Center, Ann Arbor, Michigan
- 4Dutch College of General Practitioners, Utrecht, the Netherlands
- 5Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Corresponding author: Annabelle S. Slingerland, .
OBJECTIVE Diabetes treatment should be effective and cost-effective. HbA1c-associated complications are costly. Would patient-centered care be more (cost-) effective if it was targeted to patients within specific HbA1c ranges?
RESEARCH DESIGN AND METHODS This prospective, cluster-randomized, controlled trial involved 13 hospitals (clusters) in the Netherlands and 506 patients with type 2 diabetes randomized to patient-centered (n = 237) or usual care (controls) (n = 269). Primary outcomes were change in HbA1c and quality-adjusted life years (QALYs); costs and incremental costs (USD) after 1 year were secondary outcomes. We applied nonparametric bootstrapping and probabilistic modeling over a lifetime using a validated Dutch model. The baseline HbA1c strata were <7.0% (53 mmol/mol), 7.0–8.5%, and >8.5% (69 mmol/mol).
RESULTS Patient-centered care was most effective and cost-effective in those with baseline HbA1c >8.5% (69 mmol/mol). After 1 year, the HbA1c reduction was 0.83% (95% CI 0.81–0.84%) (6.7 mmol/mol [6.5–6.8]), and the incremental cost-effectiveness ratio (ICER) was 261 USD (235–288) per QALY. Over a lifetime, 0.54 QALYs (0.30–0.78) were gained at a cost of 3,482 USD (2,706–4,258); ICER 6,443 USD/QALY (3,199–9,686). For baseline HbA1c 7.0–8.5% (53–69 mmol/mol), 0.24 QALY (0.07–0.41) was gained at a cost of 4,731 USD (4,259–5,205); ICER 20,086 USD (5,979–34,193). Care was not cost-effective for patients at a baseline HbA1c <7.0% (53 mmol/mol).
CONCLUSIONS Patient-centered care is more valuable when targeted to patients with HbA1c >8.5% (69 mmol/mol), confirming clinical intuition. The findings support treatment in those with baseline HbA1c 7–8.5% (53–69 mmol/mol) and demonstrate little to no benefit among those with HbA1c <7% (53 mmol/mol). Further studies should assess different HbA1c strata and additional risk profiles to account for heterogeneity among patients.
- Received September 12, 2012.
- Accepted April 10, 2013.
- © 2013 by the American Diabetes Association.
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