Identifying potentially cost effective chronic care programs for people with COPD.

OBJECTIVE: To review published evidence regarding the cost effectiveness of multi-component COPD programs and to illustrate how potentially cost effective programs can be identified. METHODS: Systematic search of Medline and Cochrane databases for evaluations of multi-component disease management or chronic care programs for adults with COPD, describing process, intermediate, and end results of care. Data were independently extracted by two reviewers and descriptively summarized. RESULTS: Twenty articles describing 17 unique COPD programs were included. There is little evidence for significant improvements in process and intermediate outcomes, except for increased provision of patient self-management education and improved disease-specific knowledge. Overall, the COPD programs generate end results equivalent to usual care, but programs containing >or=3 components show lower relative risks for hospitalization. There is limited scope for programs to break-even or save money. CONCLUSION: Identifying cost effective multi-component COPD programs remains a challenge due to scarce methodologically sound studies that demonstrate significant improvements on process, intermediate and end results of care. Estimations of potential cost effectiveness of specific programs illustrated in this paper can, in the absence of 'perfect data', support timely decision-making regarding these programs. Nevertheless, well-designed health economic studies are needed to decrease the current decision uncertainty.

A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

AIM: To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. METHODS: Single-group, pre-post design with 2-year follow-up in 473 patients. RESULTS: Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. CONCLUSION: Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management.

OBJECTIVE: Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management. STUDY DESIGN AND SETTING: An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated. RESULTS: Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions. CONCLUSION: With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.

Participation of general practitioners in disease management: experiences from The Netherlands.

OBJECTIVE: To investigate the extent to which GPs in The Netherlands participate in disease management and how personal opinions, impeding and promoting incentives as well as physician characteristics influence their attitude towards disease management. METHODS: The attitude-model of Fishbein and Ajzen was used to describe the attitude of GPs towards disease management and main influencing factors. After interviewing seventeen representatives of the GPs and testing a questionnaire, the final questionnaire was sent to all GPs in The Netherlands (7680 GPs) barring those involved in the testing of the questionnaire. RESULTS: At least 10.4% of all Dutch GPs are active in disease management. The main factors predicting a positive attitude towards disease management are the following: GPs' opinion that they are improving quality and efficiency of care when executing disease management, presence of a good quality network between actors involved prior to the start of disease management, working in a health centre, and performing sideline activities besides their daily activities as GPs. The main factors predicting a negative attitude are: GPs' opinion that the investment-time is too high, lack of reimbursement for disease management activities, working in a solo practice, and not performing any sideline activities beside their daily activities as GP. CONCLUSIONS: The factors predicting a negative attitude of Dutch GPs towards disease management dominate the factors predicting a positive attitude. The arguments in favour of disease management are matters of belief, for example concerning improvements in the quality of care, while arguments against are more concrete barriers e.g. high workload and financial reimbursement. Placed on the innovation timeline, the 10.4% participation might be taken to represent the start of a trend.