Understanding the cost of care of type 2 diabetes mellitus - a value measurement perspective.

OBJECTIVES: We explore the cost of care of type 2 diabetes mellitus (T2DM) using time-driven activity-based costing (TDABC) and connect that cost to resulting patient health outcomes. DESIGN: We construct six care pathways varying from low-risk to high-risk patients over a 12-month cycle of care. We collect time, resource and cost data on activities in each care pathway and compute a time-driven estimate of cost. Use of patient outcome data highlights the health outcomes achieved. SETTING: Primary, secondary and tertiary care. PARTICIPANTS: Medical staff involved in the care of patients with T2DM. PRIMARY AND SECONDARY MEASURES: Primary: resources consumed to provide T2DM care. Secondary: health outcomes for representative patient within each patient category. RESULTS: By computing cost of T2DM care and associated complications of chronic kidney disease, active foot disease, moderate risk of active foot disease and myocardial infarction, we show that when patients develop acute complications, significant costs are incurred, as compared with the cost of maintaining a patient at low or moderate risk. Variance analysis further informs decision making by showing the need to have the right personnel doing the right tasks at the right time to control costs. CONCLUSIONS: A TDABC approach facilitates an understanding of the drivers of cost in chronic illness care. Our paper highlights the stages in the care pathway where different settings, decision making and a more optimal use of resources could assist with achievement of better patient outcomes.

Increasing Health Literacy May Reduce Health Inequalities: Evidence from a National Population Survey in Ireland.

Background. Health literacy has been separately associated with socio-economic status and worse health status and outcomes. However, the magnitude of the associations between health literacy and health status and outcomes may not be evenly distributed across society. This study aims to estimate and compare the associations between health status, health behaviours, and healthcare utilisation within different levels of social status in the Irish population. Materials and methods. Data from Ireland collected as part of the 2011 European Health Literacy Survey were analysed. General health literacy was measured on a 0-50 scale, low to high. There were four binary outcomes: long-standing health conditions, smoking, hospital visits in the last 12 months, and self-rated health status. Logistic regression analysis was conducted to estimate the likelihood of each health outcome. Health literacy was treated as the main independent variable. Marginal effects were calculated using the delta method to demonstrate the change in likelihood of each outcome associated with a 5-point increase in health literacy score. The sample was grouped into tertiles based on self-reported social status, and models were replicated and compared for each tertile. Models were adjusted for known correlates of health literacy and health: age, gender, and education. Analysis was conducted using Stata V14. Results. Higher health literacy scores were associated with a lower probability of having a limiting illness within the low social status group only. Higher health literacy scores were associated with a lower probability of three or more hospital visits in the past 12 months in the low and middle social status groups. For people in the low and middle social status groups, higher health literacy levels were associated with a lower probability of being a current smoker. The associations between health literacy and self-rated health status were similar in each social status group. Conclusions: Improvement in population health literacy may reduce the prevalence of long-term chronic health conditions, reduce smoking levels, and result in fewer hospital visits. Whilst improved health literacy should improve behaviours and outcomes in all groups, it should have a more marked impact in lower social status groups, and hence contribute to reducing the observed social disparities in these health outcomes.

Associations between health literacy and patient outcomes in adolescents and young adults with cystic fibrosis.

BACKGROUND: Interactive health literacy (HL) skills enable individuals to participate more fully in healthcare activities and play a role in improving their outcomes. We examine the associations between HL and cystic fibrosis (CF) outcomes and compare HL in a sample from both the Irish CF and general populations. METHODS: A total of251 CF Registry participants aged 13-30 years completed the HLS-EU-Q16 survey and a disease-specific instrument for measuring quality of life (QoL) in CF. Health outcome and healthcare resource utilization (HCRU) data were sourced from the registry. CF patient outcomes were examined using generalized linear models (GLMs) with interactive HL categorization included as a factor. General population interactive HL data are from the 2011 European HL Survey (HLS-EU). Interactive HL in 180 age-sex matched CF and general population individuals was examined using a GLM with study population, sex and educational level included as factors and age as a covariate. RESULTS: Sufficient interactive HL (total sum score ≥13) was self-reported by 81.7% of individuals with CF. Sufficient HL was associated with fewer outpatient visits [7.02(SD = 6.7: 7.4) vs. 8.74(SD = 7.9: 9.6), P < 0.001], days hospitalized [10.25(SD = 9.8: 10.7) vs. 12.8(SD = 11.8: 13.9), P < 0.001], days on intravenous antibiotics [15.3(SD = 14.7: 15.8) vs. 19.7(18.5: 21.1), P < 0.001], days on oral antibiotics [27.4(SD = 26.7: 28.1) vs. 48.48(38.7: 42.4), P < 0.001] and better QoL [77.1(SD = 75.4-78.9) vs. 64.6(60.8-68.3), P < 0.001]. Mean HL scores in CF and general populations were sufficient, although higher among individuals with CF (14.3 vs. 13.1, P < 0.01). CONCLUSION: CF adolescents and young adults with sufficient levels of HL to obtain, understand, appraise and apply health information have better health-related outcomes.

Age-friendly environments and psychosocial wellbeing: a study of older urban residents in Ireland.

OBJECTIVE: This article aims to estimate the association between age-friendly urban environments and psychosocial wellbeing in adults aged 55+ living in four Irish cities. METHOD: Data is from the Healthy and Positive Ageing Initiative 'Age-friendly Cities and Counties Survey' from four cities; Dublin, Cork, Limerick, and Galway (n = 2,094). The Age-friendly Urban Index (AFUI), a perception-based measure of safety, access to services, and walkability, is used to measure urban environment quality on a scale of 35 (least favourable) to 105 (most favourable). Wellbeing was estimated using the following composite measures: quality of life (comprising hedonic (pleasure) and eudaimonic (control, autonomy, self-realisation) wellbeing); affective (depressive mood); and social (loneliness). Multivariate regression analyses (negative binomial and Poisson regression) were used to investigate the association between the AFUI and each wellbeing indicator. Models were fully adjusted for known demographic (age, gender, household structure, marital status), socio-economic (material deprivation, employment/occupation, education), social (social engagement, community activities) and health (self-rated health, mobility limitations) correlates of psychosocial wellbeing. RESULTS: Older people living in cities with higher AFUI score were more likely to report higher quality of life overall, and higher hedonic and eudaimonic wellbeing. These adults also had lower depressive mood scores and reported lower loneliness levels. Results remain significant in the fully adjusted model. LIMITATIONS: Causal conclusions cannot be made because of cross-sectional data. CONCLUSION: This study provides evidence of the relationship between the age-friendliness (safety, services, and walkability) of urban environments and multiple aspects of psychosocial wellbeing for older adults in Ireland.

Age-Friendly Environments, Active Lives? Associations Between the Local Physical and Social Environment and Physical Activity Among Adults Aged 55 and Older in Ireland.

Despite the benefits, one in three older adults in Ireland has low activity levels. This study examined associations between the local social and built environment and physical activity of older adults to identify age-friendly factors that support physical activity among the aging population. Data were from the population-representative Healthy and Positive Ageing Initiative Age-Friendly City and Counties Survey (N = 10,540). Physical activity was measured using a short-form of the International Physical Activity Questionnaire. Mixed-effects negative binomial regression models were adjusted for known health and sociodemographic correlates of physical activity. Results are reported as unstandardized beta coefficients (ß) with standard errors. Loneliness, community participation, and difficulty in accessing green spaces partially explained the differences in the number of minutes that respondents were physically active. Combined with individual-level behavior change interventions, improvements to the local environment and promoting social connectedness may also be useful in promoting physical activity among older adults.

Measuring What Matters: Achieving Consensus on a Positive Aging Indicator Set For Ireland.

The objective of this study was to measure consensus among expert stakeholders on a set of positive aging outcome indicators in Ireland. Stakeholders from academic, public, and voluntary sectors and older people participated in a 3-round, online Delphi study to evaluate indicators for participation, security, healthy aging, attitudes to aging, and information access. Evaluation criteria included: acceptability, utility, accessibility, ranking, and balance and coherence. Consensus was achieved on 56 key indicators that are aligned with action areas in the National Positive Ageing Strategy. These indicators will be reported on a biannual basis to monitor progress in positive aging in Ireland.

Older Patients' Views of Health Care Interactions in Ireland.

BACKGROUND: Chronic and sensitive health conditions such as pain, urinary incontinence, and hearing loss are common but often untreated among older adults in Ireland, and many patients do not disclose these and other sensitive health issues to their health care provider. OBJECTIVE: This study investigates the link between provider communication and older patients' perceived encouragement to talk about physical, social, sensitive, and emotional problems with their usual source of care (USC), be it a doctor or nurse. METHODS: Data were from the Irish sample of the Survey of Health, Ageing and Retirement in Europe (SHARE; N = 720). Logistic regression models were used to estimate the association among (1) patient characteristics, (2) health care use, and (3) USC communication characteristics and the likelihood of feeling encouraged to talk about each health problem. Results are reported as odds ratios (OR) with confidence intervals at the 95% level. KEY RESULTS: More patients felt discouraged to talk about social (39%) and sensitive (42%) health problems with their USC compared with physical (18%) and emotional (29%) health problems. Many participants reported that their USC rarely or never explained the results of medical examinations (23.6%), explained different treatment options (26.2%), or listened to their opinions or preferences when making treatment decisions (29.1%). A USC "explaining test results" was associated with increased odds of feeling encouraged to discuss physical (OR = 2.82, 95% confidence interval [CI; 1.15, 6.91]) and social (OR = 2.02, 95% CI [1.01, 4.04]) problems. "Listening to patient preferences" was associated with increased odds of feeling encouraged to discuss physical (OR = 4.49; 95% CI [2.24-9.01]), emotional (OR = 2.31, 95% CI [1.27, 4.21]), and social (OR = 2.88, 95% CI [1.60, 5.18]) problems. Controlling for USC communication characteristics attenuated the association between lower educational attainment and perceived encouragement. CONCLUSIONS: An open and patient-centered communication style was associated with a greater sense of encouragement to discuss physical, emotional, and social health problems, particularly among older patients with lower levels of education. [HLRP: Health Literacy Research and Practice. 2018;2(4):e180-e191.]. PLAIN LANGUAGE SUMMARY: This is the first study in Ireland to investigate the link between the communication styles used by health care providers and to what extent older patients felt encouraged to talk about physical, emotional, social, or sensitive health problems. When providers took a more patient-centered approach, these patients felt more encouraged to disclose physical, social, and emotional health problems.

Patient level cost of diabetes self-management education programmes: an international evaluation.

OBJECTIVES: The objective of this study was to examine the value of time-driven activity-based costing (TDABC) in understanding the process and costs of delivering diabetes self-management education (DSME) programmes in a multicountry comparative study. SETTING: Outpatient settings in five European countries (Austria, Denmark, Germany, Ireland, UK) and two countries outside Europe, Taiwan and Israel. PARTICIPANTS: Providers of DSME programmes across participating countries (N=16) including healthcare professionals, administrators and patients taking part in DSME programmes. PRIMARY AND SECONDARY MEASURES: Primary measure: time spent by providers in the delivery of DSME and resources consumed in order to compute programme costs. Secondary measures: self-report measures of behavioural self-management and diabetes disease/health-related outcomes. RESULTS: We found significant variation in costs and the processes of how DSME programmes are provided across and within countries. Variations in costs were driven by a combination of price variances, mix of personnel skill and efficiency variances. Higher cost programmes were not found to have achieved better relative outcomes. The findings highlight the value of TDABC in calculating a patient level cost and potential of the methodology to identify process improvements in guiding the optimal allocation of scarce resources in diabetes care, in particular for DSME that is often underfunded. CONCLUSIONS: This study is the first to measure programme costs using estimates of the actual resources used to educate patients about managing their medical condition and is the first study to map such costs to self-reported behavioural and disease outcomes. The results of this study will inform clinicians, managers and policy makers seeking to enhance the delivery of DSME programmes. The findings highlight the benefits of adopting a TDABC approach to understanding the drivers of the cost of DSME programmes in a multicountry study to reveal opportunities to bend the cost curve for DSME.

Health Literacy, Health Care Utilization, and Direct Cost of Care Among Linguistically Diverse Patients with Type 2 Diabetes Mellitus.

BACKGROUND: Low functional health literacy (HL) has been associated with poor self-management of chronic conditions, including type 2 diabetes mellitus (T2DM), an inefficient use of health services, and higher health care costs. Low functional HL and limited English language proficiency both independently predict poor glycemic control among Latino and Chinese immigrants in the United States, and is more common among patients with diabetes with limited HL. OBJECTIVE: This study investigated the relationship between low functional HL, health care utilization, and costs of health care among a cohort of low-income patients with T2DM whose primary language was English, Spanish, or Cantonese (N = 277). METHODS: Patient data were collected from Medicaid administrative health care records as part of a low-income managed care program administered by the San Francisco Health Plan between April 2009 and March 2011. HL was measured with the Brief Questions Screening Tool for Health Literacy, administered via telephone survey. We used negative binomial regression with robust standard errors to estimate the effect of low functional HL on health care utilization, adjusting for demographic, socioeconomic, and health covariates. Results were reported as rate-ratios (RRs). We used two-part regression models to estimate the marginal difference in cost per patient associated with low functional HL. Utilization and cost models were also estimated, stratified by patient language. KEY RESULTS: We observed a nonsignificant association between low functional HL and lower health care utilization, and lower total health care costs (-$1,493.53, 95% confidence interval [CI]: $3,602 to $615). While we observed a nonsignificant trend for low functional HL and lower utilization and total cost among people who speak English and Cantonese, low functional HL was significantly associated with more outpatient visits among patients who spoke Spanish (RR 1.31, 95% CI 1 to 1.72). CONCLUSIONS: The relationship between low functional HL and health care utilization among this linguistically diverse cohort of patients with T2DM varied by patient language. Further research is needed to determine if lower utilization and costs in certain linguistic subgroups is indicative of barriers to access. [Health Literacy Research and Practice. 2017;1(3):e116-e126.]. PLAIN LANGUAGE SUMMARY: This study attempts to understand the relationship between health literacy, health care utilization, and costs of health care among an ethnically and linguistically diverse cohort of low-income patients with type 2 diabetes mellitus. We observed differences that could be due to actual differential effects of low HL by language status, or could be explained by unmeasured differences in health-seeking behaviors, access to care, degree of acculturation, or comorbidities.

Views of People With High and Low Levels of Health Literacy About a Digital Intervention to Promote Physical Activity for Diabetes: A Qualitative Study in Five Countries.

BACKGROUND: Low health literacy is associated with poor health-related knowledge, illness self-management, health service use, health, and survival, and thus addressing issues related to low health literacy has been highlighted as a pressing international priority. OBJECTIVE: To explore views of a digital health promotion intervention designed to be accessible to people with lower levels of health literacy, in particular examining reactions to the interactive and audiovisual elements of the intervention. METHODS: Qualitative think-aloud interviews were carried out with 65 adults with type 2 diabetes in the UK, Ireland, USA, Germany, and Austria, with purposive sampling to ensure representation of people with lower levels of health literacy. Inductive thematic analysis was used to identify common themes. We then systematically compared views in subgroups based on country, health literacy level, age, gender, and time since diagnosis. RESULTS: Most participants from the chosen countries expressed positive views of most elements and features of the intervention. Some interactive and audiovisual elements required modification to increase their usability and perceived credibility and relevance. There were some differences in views based on age and gender, but very few differences relating to health literacy level or time since diagnosis. CONCLUSIONS: In general, participants found the intervention content and format accessible, appropriate, engaging, and motivating. Digital interventions can and should be designed to be accessible and engaging for people with a wide range of health literacy levels.