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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
response from the authors to a letter on Cost-effectiveness paper by Handley, Shumway and Shillinger
The Differences Are Real to the Patients
Cost-effective...NOT!
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Margaret A Handley, San Francisco, CA Assistant Professor, UCSF Department of Epidemiology and Biostatistics, Martha Shumway, Dean Schillinger
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We thank Dr. Sattenspeil for advocating for a more extensive discussion concerning the trade-offs related to implementing interventions, such as the Automated Telephone Self-Management support intervention described in our paper (Handley, Shumway, Schillinger, 2008). We fully agree that it is critical to determine whether or not current care practices for diabetes and other chronic conditions are justifiable, or, if it might make sense to redistribute funding into new care management areas that show promise and cost-effectiveness. In California, as we note in the paper, a range of health systems, such as regional managed care plans, are asking for the type of information provided in this paper (ref 21), in order to determine how best to harness existing chronic disease registry data for patient outreach and care management activities. While it is often important to take the 10,000 foot high view on health policy decision-making, we are of the view that generating locally relevant population-based information for local health policy decisions comes first, and this is where we have put our research, dissemination and advocacy efforts to date. We welcome additional research that can add to both the local conversations about diabetes care management strategies, as well as to a broader dialogue about health care resource allocation. That said, we disagree with Dr. Sattenspeil ‘s sentiment that our paper simply advocates to spend more money on health care. First, because we currently may be spending considerable amounts of of money on interventions that may not be cost-effective, producing information on alternative strategies for consideration, such as ATSM with nurse care management, is not simply advocating for “spending more money on diabetes care”, as the author suggests. Tight control of blood sugar, for example, while possibly reducing complications over the long term, may not immediately impact quality of life (and may negatively impact it in the near term), so we agree that studies like this should provide a motivation to engage in real discussion regarding distribution of resources and incentives. Our study is one of the few that actually evaluates the cost effectiveness of a health communication intervention relative to standard medical/pharmaceutical type interventions. This type of information is sorely needed to inform health policy decisions. Second, allocating resources for a low-cost, effective self- management intervention could lead to better diabetes outcomes and reductions in healthcare costs over the long term. The promising results of this initial study suggest that it may be worthwhile evaluating its effects over the longer term. We hope that funders take note of the importance of sustaining intervention follow-up past traditionally short time frames, so that longer range outcomes can be more fully assessed. Competing interests: None declared |
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Sharon B Buchbinder, RN, PhD, Baltimore, MD, USA Professor & Chair, Department of Health Science, Towson University
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This elegant study, which utilized an automated telephone self- management support with nurse care management (ATSM) intervention and a multilingual approach, underscores the need to include everyone on the healthcare team in the ongoing treatment of type 2 diabetes: physicians, nurses--and patients! While previous analyses of the data did not find a change in metabolic outcomes or use of services, this study sought to investigate the relationship between the ATSM intervention and the quality -adjusted life years (QALY’s) gained through the intervention. The researchers found the ATSM increased the proportion of patients participating in exercise and achieving moderate or vigorous physical activity. The role of adherence and self-care in medical care are under greater scrutiny today due to the growing costs of care. (1) Chronic conditions such as CHF, wound care, obesity, and diabetes can benefit from lower cost providers’ follow-up on physician-directed care. One of the benefits of having nurses involved in this work is that patients will often ask questions or volunteer information to a nurse that they might be apprehensive to share with a physician. While changes in BMI were modest, and the P value did not reach statistical significance at .3, I would offer that in the real world, for those patients who did lose the 10-20 pounds needed to lower their BMI from 32.3 to 30.3 (on average) that the difference in their lives is very real. The only additional piece that I see that could be helpful in future interventions utilizing this model would be to add a nurse-led patient support group for those who might be interested, as in a UK nurse-led study of venous ulcers. Patients attending a “Leg Club” were more motivated, enthusiastic, had increased knowledge and support, and had a sense of ownership in their care. (2) By empowering patients to become their own advocates, behavioral adherence (always difficult to measure!) becomes a collaborative event. References: 1. Buchbinder, Dale & Buchbinder, Sharon B. Wound healing adjuvant therapy and treatment adherence. In Bergan, J. & Shortell, C. (Eds). Venous Ulcers. San Deigo, CA: Elsevier. 2007, pp. 91-103. 2. Lindsay E. Leg clubs: A new approach to patient-centered leg ulcer management. Nurs Health Sci. 2000;2:139-141. Competing interests: None declared |
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John E Sattenspiel, Eugene Oregon, USA Senior Medical Director, Medicaid/Medicare Health Plan
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In this article the authors conduct a typical cost effectiveness analysis and come to the conclusion that at a cost of $29,402 to $72,407 per QALY this intervention is worth considering. While, as a freestanding conclusion in a system with financial resources to spare, this statement may be valid, our current health care system is subject to severe financial constraints to the point where simply advocating for the value of an intervention is insufficient. No matter how you slice the conclusion, it advocates for spending more money on diabetes care. With only such advocacy, this article provides scant photons of illumination to the discussions that need to be held. At a positive cost per QALY, this intervention requires additional funding to the system or a redistribution of current funding. Where is the discussion of how to accomplish that. Without that discussion, this article is just another of the clammering voices asking for more, more, more. If, as physicians and researchers, we wish to be a productive part of health system redesign, then we must get off the conceit that information in and of itself is sufficient work product and start advocating more fully developed ideas about not just what to do but how to do it. Competing interests: None declared |
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