Jeroen N. Struijs

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.

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.

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

Utilization of health resources due to low back pain: survey and registered data compared.

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.

Future costs of stroke in the Netherlands : The impact of stroke services

BackgroundPay-for-performance (P4P) is increasingly implemented in the healthcare system to encourage improvements in healthcare quality. P4P is a payment model that rewards healthcare providers for meeting pre-established targets for delivery of healthcare services by financial incentives. Based on their performance, healthcare providers receive either additional or reduced payment. Currently, little is known about P4P schemes intending to improve delivery of chronic care through disease management. The objectives of this paper are therefore to provide an overview of P4P schemes used to stimulate delivery of chronic care through disease management and to provide insight into their effects on healthcare quality and costs.MethodsA systematic PubMed search was performed for English language papers published between 2000 and 2010 describing P4P schemes related to the implementation of disease management. Wagners chronic care model was used to make disease management operational.ResultsEight P4P schemes were identified, introduced in the USA (n = 6), Germany (n = 1), and Australia (n = 1). Five P4P schemes were part of a larger scheme of interventions to improve quality of care, whereas three P4P schemes were solely implemented. Most financial incentives were rewards, selective, and granted on the basis of absolute performance. More variation was found in incented entities and the basis for providing incentives. Information about motivation, certainty, size, frequency, and duration of the financial incentives was generally limited. Five studies were identified that evaluated the effects of P4P on healthcare quality. Most studies showed positive effects of P4P on healthcare quality. No studies were found that evaluated the effects of P4P on healthcare costs.ConclusionThe number of P4P schemes to encourage disease management is limited. Hardly any information is available about the effects of such schemes on healthcare quality and costs.

Transport, Accumulation and Transformation Processes

Study Design. Cross-sectional population-based survey and registration of general practice (GP). Objective. To describe the utilization of health care services among persons with low back pain on the basis of different databases, i.e., surveys and registrations. Special attention will be paid to utilization of GPs, specific medical specialists, and physiotherapists. Summary of Background Data. Both surveys and health care registrations can provide data on utilization of health care services due to low back pain. It is unclear as to how the utilization figures from different data sources can be compared. Methods. Survey data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort study, a postal health survey among Dutch inhabitants aged 25 years or older (n = 3664) in 1998, and registered data from the second Dutch National Survey of General Practice, which represents 2 years (2000–2001) of GP-registration data for 293,636 persons aged 25 years or older. Results. The size of the population that in 1 year had GP-contact due to low back pain was estimated as 13.0% (survey) and 8.9% (registration data). Less than one-third of those with low back pain consult their GP due to low back pain in the past year. Survey data show that 33.2% of those with low back pain have had contact with the physiotherapist. Of those contacts, 76% were explicitly due to low back pain. Based on the registration data, these percentages were slightly different: 25.9% and 83.8%, respectively. Large differences between survey and registration data were found for the contact with a medical specialist. Conclusion. Large health care resources are used for low back pain although the majority of low back pain sufferers do not have contact with health care. Survey data show slightly higher consultation figures than registration-based figures probably mainly due to response and recall bias, and registration thresholds.

Associations Among Health Literacy, Diabetes Knowledge, and Self-Management Behavior in Adults with Diabetes: Results of a Dutch Cross-Sectional Study

OBJECTIVES In the next decades, the number of stroke patients is expected to increase. Furthermore, organizational changes, such as stroke services, are expected to be implemented on a large scale. The purpose of this study is to estimate the future healthcare costs by taking into account the expected increase of stroke patients and a nationwide implementation of stroke services. METHODS By means of a dynamic multistate life table, the total number of stroke patients can be projected. The model calculates the annual number of patients by age and gender. The total healthcare costs are calculated by multiplying the average healthcare costs specified by age, gender, and healthcare sector with the total number of stroke patients specified by age and gender. RESULTS In the year 2000, the healthcare costs for stroke amounted to euro 1.62 billion. This amount is approximately 4.4 percent of the total national healthcare budget. Projections of the total costs of stroke based on current practice result in an increase of 28 percent (euro 2.08 billion) in the year 2020. A nationwide implementation of stroke services in 2020 would result in a substantial reduction of the costs of stroke (euro 1.81 billion: 13 percent cost reduction) compared with the regular care scenario. CONCLUSIONS A nationwide implementation of stroke services is a strong policy tool for cost containment of health care in an aging population like that in the Netherlands. Policy makers should optimize the organization of stroke care.