Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis
Patient-centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis
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DOI：
10.1111/j.1464-5491.2005.01751.x
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发表时间：
2006-02-01
影响因子：
3.5
通讯作者：
Grol, RTPM
中科院分区：
文献类型：
--
作者：
Dijkstra, RF;Niessen, LW;Grol, RTPM
目的：糖尿病干预措施的经济评估通常不包括对实施战略的效果和成本的分析。这导致了乐观的成本效益估计。这项研究报告了两种实施策略与常规医院门诊服务相比的成本效益的实证研究结果。它包括与患者相关的成本和与干预相关的成本。患者和方法：在整群随机对照试验设计中，13家荷兰综合医院被随机分配到对照组、专业指导或以患者为中心的实施计划。专业人士收到关于基线数据、教育和提醒的反馈。以患者为中心的患者接受了教育和糖尿病护照。结果：1年后糖化血红蛋白(HbA(1c))(用于预测糖尿病终生结局的指标)在专业更改组和以患者为中心的组分别下降了0.2%和0.3%，而对照组则上升了0.2%。两组的初步实施成本为每人5欧元，但改善护理和延长预期寿命的平均终身成本分别增加了9389欧元和9620欧元。预期寿命提高了0.34岁和0.63岁，质量调整寿命年(QALY)分别提高了0.29年和0.59岁。因此，与对照组相比，专业变革护理的每QALY增量成本为32218欧元，以患者为中心的护理的增量成本为16353欧元，而以患者为中心的护理相对于专业变革护理的增量成本为881欧元。可接受性曲线中存在不确定性：每年超过65欧元，以患者为导向的策略最有可能是最佳选择。结论：以荷兰的标准来看，二级护理中的两种指南实施策略与目前的护理相比都具有成本效益。使用患者护照的每位患者每年的额外成本很低。这项分析支持荷兰的患者参与糖尿病，可能在其他西欧环境中也是如此。
Aims: Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost.Patients and Methods: In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties.Results: Glycated haemoglobin (HbA(1c)) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice.Conclusion: Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings.