Cost-Effectiveness of Automated Telephone Self-Management Support With Nurse Care Management Among Patients With Diabetes

Abstract

PURPOSE This study evaluated the cost-effectiveness of an automated telephone self-management support with nurse care management (ATSM) intervention for patients with type 2 diabetes, which was tested among patients receiving primary care in publicly funded (safety net) clinics, focusing on non-English speakers. METHODSWe performed cost analyses in the context of a randomized trial among primary care patients comparing the effects of ATSM (n = 112) and usual care (n = 114) on diabetes-related outcomes in 4 San Francisco safety net clinics. ATSM uses interactive phone technology to provide surveillance, patient education, and one-on-one counseling, and was implemented in 3 languages for a 9-month period. Cost utility was examined using quality-adjusted life-years (QALYs) derived from changes in scores on the 12-Item Short Form Health Survey. We also examined cost-effectiveness for costs associated with a 10% increase in the proportion of patients meeting diabetes-specifi c public health goals for increasing exercise, as recommended by Healthy People 2010 and the American Diabetes Association. RESULTSThe annual cost of the ATSM intervention per QALY gained, relative to usual care, was $65,167 for start-up and ongoing implementation costs combined, and $32,333 for ongoing implementation costs alone. In sensitivity analyses, costs per QALY ranged from $29,402 to $72,407. The per-patient cost to achieve a 10% increase in the proportion of intervention patients meeting American Diabetes Association exercise guidelines was estimated to be $558 when all costs were considered and $277 when only ongoing costs were considered.CONCLUSIONS The ATSM intervention for diverse patients with diabetes had a cost utility for functional outcomes similar to that of many other accepted interventions targeted at diabetes prevention and treatment, and achieved public health physical activity objectives at modest costs. Because a considerable proportion of costs were fi xed, cost-utility and cost-effectiveness estimates would likely be substantially improved in a scaled-up ATSM program. INTRODUCTIONI n the United States, costs associated with chronic illness care account for nearly 75% of medical expenditures.1 Type 2 diabetes, which affects more than 20 million individuals in this country alone, is associated with substantial morbidity and cost. Although organ damage related to diabetes is well recognized, diabetes also causes functional decline, depression, pain, and lost productivity.2-5 The estimated direct and indirect societal and health system costs attributable to diabetes totaled approximately $132 billion in 2002, with costs expected to rise to $156 billion by 2010. [6][7][8] In recent reviews of the cost-effectiveness of interventions for prevent- COS T-EF F EC T IV ENES S O F AT S M F OR DIA BE T E Sing or treating diabetes in developed countries, the majority of studies focus either on screening for diabetes or on treatment to avert complications, emphasizing medication-sensitive outcomes with long-term benefi ts....

Hypertension Management Using Mobile Technology and Home Blood Pressure Monitoring: Results of a Randomized Trial in Two Low/Middle-Income Countries

“…Mobile health (m-health) services seek to increase access to between-visit support by augmenting clinician contact with automated services delivered via smart phones, 8 short message service (text messaging), [9][10][11][12] and automated calls. [13][14][15][16][17] Automated telephone management and behavior-change calls can improve selfcare and health outcomes among NCD patients and may be more cost-effective than in-person visits or calls with ''live'' clinicians. [14][15][16][17] However, rigorous studies of m-health services in LMICs are rare.…”

Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence

“…Handley et al used the cost to achieve a 10% increase in the proportion of participants achieving recommended moderate or vigorous physical activity levels in a study involving adults with type 2 diabetes. 22 The annual cost to increase activity by 10% for the automated telephone surveillance and nurse care management was estimated to be €551 per participant. In contrast, two studies by Elley et al 11,27 used a threshold of 5 x 30 minutes of activity per week and found the cost per person to be €957 when predominantly doctor delivered, 11 and €331 when nurse delivered.…”

“…With different infrastructures, funding models, and cost structures, it is also difficult to make comparisons between different countries. Furthermore, some studies included funder costs only, 17,[21][22][23][24][25][26] while others presented societal perspectives that also included costs to the participant. 11,[18][19][20]27 Consequently, there was a wide variation in costs per QALY gained between the studies.…”

Structured Caregiver Feedback Enhances Engagement and Impact of Mobile Health Support: A Randomized Trial in a Lower-Middle-Income Country

“…6 Mobile health (m-health) tools are part of a comprehensive plan to improve chronic illness care in LMICs. [7][8][9] Trials indicate that interactive voice response (IVR)-based interventions effectively address diabetes risk factors such as poor diet and sedentary behavior, [10][11][12] and IVR-supported nurse follow-up can improve glycemic control and self-care after diabetes is diagnosed. [12][13][14] In Honduras, weekly IVR self-management support calls were associated with improved diabetes self-management and A1c levels, 15 and in Honduras and Mexico, a similar IVR-based intervention resulted in better blood pressure control and improved self-care among hypertensive patients.…”