Monday, March 7, 2011

More Dollars Per Quality Adjusted Life Year (QALY) Versus Savings From Care Management: How Can The Studies Be Reconciled?

At a recent health care conference, the Disease Management Care made a brazen assertion: sure, traditional "cost effectiveness" studies like this, this and this show that diabetes control costs money, but diabetes disease management saves money.

How can the DMCB, much to the annonyance of health services researchers everywhere, make such an allegation?

Cost effectiveness studies typically rely on the "dollars per quality adjusted life years" statistic, or "$/QALY" for short. The DMCB has the handy explanation here and there is more info here. Without getting into the details, $/QALY is a handy way of comparing the price per year of life gained across a wide spectrum of health care treatments. All the studies that use "QALYs" to assess the impact of diabetes treatment have shown that every year of diabetes quality - from less diabetes related complications blindness, avoided amputations, less kidney disease - is gained at a price that runs into the tens of thousands of dollars.

In contrast, there are studies like this, this, this and this that demonstrate there are reductions in health care costs, i.e., it saves money. In these studies, persons entered into a disease management program, compared to persons not in a program, had lower health care costs that seem to exceed the cost of the intervention. Even worse, it often seems to happen within one fiscal year.

How can the disparate methodologies and findings of QALYs versus comparative studies be reconciled? It's easy, says the DMCB: while disease management programs may result in better short-term blood sugar control, the savings have less to do with the avoidance of discreet diabetes complications and the gain of quality adjusted life years gained. Instead, there are three "spill over" effects and one relatively recent advance in the science of care management:

1) the spill over of fewer emergency room visits and hospitalizations for acute cardiac and infectious causes. The DMCB tried to look this up and there is surprisingly little in the peer-reviewed literature about this. That being said, it recalls seeing the phenomenon when it examined claims in its own past programs. Maybe it's because the nurse coaching also addresses hypertension and chronically elevated blood glucoses make persons more prone to pneumonia.

2) the spill over of increased medication compliance, which not only has implications for diabetes control but other co-morbidities. For example, it's possible that taking ACE inhibitors, statins (or aspirin) lowers cardiac complications over the short term.

3) the spill over of better coping skills, making it less likely that patients will go to the emergency room for any reason, and

4) the advance of better targeting of disease management programs. The DMCB reviews the topic here, but the point is that patient surveys and predictive modeling makes it possible to identify which patients are most likely to benefit from disease management. Predictive modeling was one of the ingredients in this New England Journal published study.

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