Caroline A. Baan

Comorbidity in patients with diabetes mellitus: impact on medical health care utilization.

BackgroundComorbidity has been shown to intensify health care utilization and to increase medical care costs for patients with diabetes. However, most studies have been focused on one health care service, mainly hospital care, or limited their analyses to one additional comorbid disease, or the data were based on self-reported questionnaires instead of health care registration data. The purpose of this study is to estimate the effects a broad spectrum of of comorbidities on the type and volume of medical health care utilization of patients with diabetes.MethodsBy linking general practice and hospital based registrations in the Netherlands, data on comorbidity and health care utilization of patients with diabetes (n = 7,499) were obtained. Comorbidity was defined as diabetes-related comorbiiabetes-related comorbidity. Multilevel regression analyses were applied to estimate the effects of comorbidity on health care utilization.ResultsOur results show that both diabetes-related and non diabetes-related comorbidity increase the use of medical care substantially in patients with diabetes. Having both diabeterelated and non diabetes-related comorbidity incrases the demand for health care even more. Differences in health care utilization patterns were observed between the comorbidities.ConclusionNon diabetes-related comorbidity increases the health care demand as much as diabetes-related comorbidity. Current single-disease approach of integrated diabetes care should be extended with additional care modules, which must be generic and include multiple diseases in order to meet the complex health care demands of patients with diabetes in the future.

Integrating Care through Bundled Payments — Lessons from the Netherlands

In 2007, a bundled-payment approach to integrated chronic care was launched in the Netherlands, initially on an experimental basis with a focus on diabetes. The results provide lessons applicable to the U.S. concept of accountable care organizations.

Multimorbidity and comorbidity in the Dutch population - data from general practices.

BackgroundMultimorbidity is increasingly recognized as a major public health challenge of modern societies. However, knowledge about the size of the population suffering from multimorbidity and the type of multimorbidity is scarce. The objective of this study was to present an overview of the prevalence of multimorbidity and comorbidity of chronic diseases in the Dutch population and to explore disease clustering and common comorbidities.MethodsWe used 7 years data (2002–2008) of a large Dutch representative network of general practices (212,902 patients). Multimorbidity was defined as having two or more out of 29 chronic diseases. The prevalence of multimorbidity was calculated for the total population and by sex and age group. For 10 prevalent diseases among patients of 55 years and older (N = 52,014) logistic regressions analyses were used to study disease clustering and descriptive analyses to explore common comorbid diseases.ResultsMultimorbidity of chronic diseases was found among 13% of the Dutch population and in 37% of those older than 55 years. Among patients over 55 years with a specific chronic disease more than two-thirds also had one or more other chronic diseases. Most disease pairs occurred more frequently than would be expected if diseases had been independent. Comorbidity was not limited to specific combinations of diseases; about 70% of those with a disease had one or more extra chronic diseases recorded which were not included in the top five of most common diseases.ConclusionMultimorbidity is common at all ages though increasing with age, with over two-thirds of those with chronic diseases and aged 55 years and older being recorded with multimorbidity. Comorbidity encompassed many different combinations of chronic diseases. Given the ageing population, multimorbidity and its consequences should be taken into account in the organization of care in order to avoid fragmented care, in medical research and healthcare policy.

Lifestyle Interventions Are Cost-Effective in People With Different Levels of Diabetes Risk: Results from a modeling study.

OBJECTIVE—In the current study we explore the long-term health benefits and cost-effectiveness of both a community-based lifestyle program for the general population (community intervention) and an intensive lifestyle intervention for obese adults, implemented in a health care setting (health care intervention). RESEARCH DESIGN AND METHODS—Short-term intervention effects on BMI and physical activity were estimated from the international literature. The National Institute for Public Health and the Environment Chronic Diseases Model was used to project lifetime health effects and effects on health care costs for minimum and maximum estimates of short-term intervention effects. Cost-effectiveness was evaluated from a health care perspective and included intervention costs and related and unrelated medical costs. Effects and costs were discounted at 1.5 and 4.0% annually. RESULTS—One new case of diabetes per 20 years was prevented for every 7–30 participants in the health care intervention and for every 300–1,500 adults in the community intervention. Intervention costs needed to prevent one new case of diabetes (per 20 years) were lower for the community intervention (€2,000–9,000) than for the health care intervention (€5,000–21,000). The cost-effectiveness ratios were €3,100–3,900 per quality-adjusted life-year (QALY) for the community intervention and €3,900–5,500 per QALY for the health care intervention. CONCLUSIONS—Health care interventions for high-risk groups and community-based lifestyle interventions targeted to the general population (low risk) are both cost-effective ways of curbing the growing burden of diabetes.

Modeling the Future Burden of Stroke in the Netherlands Impact of Aging, Smoking, and Hypertension

Background and Purpose— In the near future, the number of stroke patients and their related healthcare costs are expected to rise. The purpose of this study was to estimate this expected increase in stroke patients in the Netherlands. We sought to determine what the future developments in the number of stroke patients due to demographic changes and trends in the prevalence of smoking and hypertension in terms of the prevalence, incidence, and potential years of life lost might be. Methods— A dynamic, multistate life table was used, which combined demographic projections and existing stroke morbidity and mortality data. It projected future changes in the number of stroke patients in several scenarios for the Dutch population for the period 2000 to 2020. The model calculated the annual number of new patients by age and sex by using incidence rates, defined by age, sex, and major risk factors. The change in the annual number of stroke patients is the result of incident cases minus mortality numbers. Results— Demographic changes in the population suggest an increase of 27% in number of stroke patients per 1000 in 2020 compared with 2000. Extrapolating past trends in the prevalence of smoking behavior, hypertension, and stroke incidence resulted in an increase of 4%. Conclusions— The number of stroke patients in the Netherlands will rise continuously until the year 2020. Our study demonstrates that a large part of this increase in the number of patients is an inevitable consequence of the aging of the population.

Comprehensive care programs for patients with multiple chronic conditions: A systematic literature review

OBJECTIVE To provide insight into the characteristics of comprehensive care programs for patients with multiple chronic conditions and their impact on patients, informal caregivers, and professional caregivers. METHODS Systematic literature search in multiple electronic databases for English language papers published between January 1995 and January 2011, supplemented by reference tracking and a manual search on the internet. Wagners chronic care model (CCM) was used to define comprehensive care. After inclusion, the methodological quality of each study was assessed. A best-evidence synthesis was applied to draw conclusions. RESULTS Forty-two publications were selected describing thirty-three studies evaluating twenty-eight comprehensive care programs for multimorbid patients. Programs varied in the target patient groups, implementation settings, number of included interventions, and number of CCM components to which these interventions related. Moderate evidence was found for a beneficial effect of comprehensive care on inpatient healthcare utilization and healthcare costs, health behavior of patients, perceived quality of care, and satisfaction of patients and caregivers. Insufficient evidence was found for a beneficial effect of comprehensive care on health-related quality of life in terms of mental functioning, medication use, and outpatient healthcare utilization and healthcare costs. No evidence was found for a beneficial effect of comprehensive care on cognitive functioning, depressive symptoms, functional status, mortality, quality of life in terms of physical functioning, and caregiver burden. CONCLUSION Because of the heterogeneity of comprehensive care programs, it is as yet too early to draw firm conclusions regarding their effectiveness. More rigorous evaluation studies are necessary to determine what constitutes best care for the increasing number of people with multiple chronic conditions.

Early Results From Adoption Of Bundled Payment For Diabetes Care In The Netherlands Show Improvement In Care Coordination

In 2010 a bundled payment system for diabetes care, chronic obstructive pulmonary disease care, and vascular risk management was introduced in the Netherlands. Health insurers now pay a single fee to a contracting entity, the care group, to cover all of the primary care needed by patients with these chronic conditions. The initial evaluation of the program indicated that it improved the organization and coordination of care and led to better collaboration among health care providers and better adherence to care protocols. Negative consequences included dominance of the care group by general practitioners, large price variations among care groups that were only partially explained by differences in the amount of care provided, and an administrative burden caused by outdated information and communication technology systems. It is too early to draw conclusions about the effects of the new payment system on the quality or the overall costs of care. However, the introduction of bundled payments might turn out to be a useful step in the direction of risk-adjusted integrated capitation payments for multidisciplinary provider groups offering primary and specialty care to a defined group of patients.

Impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or chronic obstructive pulmonary disease: A systematic review of the literature

OBJECTIVE Evaluating the impact of disease management programs on healthcare expenditures for patients with diabetes, depression, heart failure or COPD. METHODS Systematic Pubmed search for studies reporting the impact of disease management programs on healthcare expenditures. Included were studies that contained two or more components of Wagners chronic care model and were published between January 2007 and December 2009. RESULTS Thirty-one papers were selected, describing disease management programs for patients with diabetes (n=14), depression (n=4), heart failure (n=8), and COPD (n=5). Twenty-one studies reported incremental healthcare costs per patient per year, of which 13 showed cost-savings. Incremental costs ranged between -

Pay-for-performance in disease management: a systematic review of the literature

16,996 and

Meta‐analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes

3305 per patient per year. Substantial variation was found between studies in terms of study design, number and combination of components of disease management programs, interventions within components, and characteristics of economic evaluations. CONCLUSION Although it is widely believed that disease management programs reduce healthcare expenditures, the present study shows that evidence for this claim is still inconclusive. Nevertheless disease management programs are increasingly implemented in healthcare systems worldwide. To support well-considered decision-making in this field, well-designed economic evaluations should be stimulated.