The role of cost-effectiveness analysis in the development of indicators to support incentive-based behaviour in primary care in England

In England, general practitioners are incentivized through a national pay-for-performance scheme to adopt evidence-based quality improvement initiatives using a portfolio of Quality and Outcomes Framework (QOF) indicators. We describe the development of the methods used to assess the cost-effectiveness of these pay-for-performance indicators and how they have contributed to the development of new indicators. Prior to analysis of new potential indicators, an economic subgroup of the National Institute for Health and Care Excellence (NICE) Indicator Advisory Committee is formed to assess evidence on the cost-effectiveness of potential indicators in terms of the health benefits gained, compared to the cost of the intervention and the cost of the incentive. The expert subgroup is convened to reach consensus on the amounts that could potentially be paid to general practices for achieving new indicators. Indicators are also piloted in selected general practices and evidence gathered about their practical implementation. The methods used to assess economic viability of new pilot indicators represent a pragmatic and effective way of providing information to inform recommendations. Current policy to reduce QOF funding could shift the focus from national (QOF) to local schemes, with economic appraisal remaining central

A protocol for the development and piloting of quality measures to support the Healthier You : The NHS Diabetes Prevention Programme

Background The increasing prevalence of type 2 diabetes in the UK creates an additional, potentially preventable burden on health care and service providers. The Healthier You: NHS Diabetes Prevention Programme aims to reduce the incidence of type 2 diabetes through identification of people at risk and the provision of intensive lifestyle change support. The provision of this care can be monitored through quality measurement at both the general practice and specialist service level. Aim To develop quality measures through piloting to assess the validity, credibility, acceptability, reliability and feasibility of any proposed measures. Design and setting The non-experimental mixed design piloting study consists of consensus testing and exploratory research with general practitioners (GPs), commissioners and patients from Herefordshire, England. Methods A mixed-method approach will be used to develop and validate measures for diabetes prevention care and evaluate their performance over a six month pilot period consisting of i) consensus testing using a modified RAND approach with GPs and commissioners, ii) four focus groups with 10-12 participants discussing experiences of non-diabetic hyperglycaemia, perceived ability to access care and prevent diabetes, and views on potential quality measures, iii) piloting final measures with at least 5 general practices for baseline and 6 month data. Results The findings will inform the implementation of the diabetes prevention quality measures on a national scale whilst addressing any issue with validity, credibility, feasibility, and cost-effectiveness. Conclusion Health care professionals and patients have the opportunity to evaluate the reliability, acceptability and validity of measure

Are there long-term benefits of experiential, interprofessional education for non-specialists on clinical behaviours and outcomes in diabetes care? A cohort study.

OBJECTIVES: Our aim was to assess the impact of an educational initiative for non-specialist, healthcare professionals in the community on the process and quality measures of diabetes care delivered, and changes in their learning experiences and clinical management behaviour in the short and long term. SETTING: Single locality of 26 primary care practices associated with one secondary centre. PARTICIPANTS: General practitioners and practice nurses managing 4167 patients with diabetes. INTERVENTION: A rolling 10-week, experiential, interprofessional education programme delivered to 57 practitioners and observations in practice. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were changes in the proportion of patients receiving foot care, urine albumin:creatinine ratio assessments and achieving National Quality Outcome Framework targets for blood pressure (86 mmol/mol (10%) and 85 mmol/mol (10%) was significantly higher (44% vs 53% p=0.0001) and lower (12.5% vs 10%; p=0.002) respectively. There was an increase in the proportion (95% CI) of patients receiving foot care reviews (+26.0% (24.0% to 28.1%)), microalbuminuria screening (+29.8% (27.7% to 31.9%)) and who achieved targets for blood pressure (+9.6% (7.5% to 11.6%)) and total cholesterol (+14.4% (12.3% to 16.5%); p<0.001). 241 fewer patients were referred to secondary care. Increases in the healthcare professional's confidence and collaborative clinical behaviour were evident 3 years after completing the programme. CONCLUSIONS: An experiential, interprofessional intervention can result in significant improvements in quality outcomes in association with a sustained impact on behaviours and practices

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The cost of treating diabetic ketoacidosis in the UK: a national survey of hospital resource use

Aims: Diabetic ketoacidosis (DKA) is a commonly encountered metabolic emergency. In 2014 a national survey was conducted looking at the management of DKA in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, costs of treating DKA were not reported. Methods: We used a ‘bottom up’ approach to cost analysis to determine the total expense associated with treating DKA in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. Results: Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days, respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of DKA was £2064 per patient (95% CI: £1800, 2563). Conclusion: Despite relatively short stays in hospital, costs for managing episodes of DKA in adults were relatively high. Assumptions made in calculations did not take into account prolonged hospital stay due to co-morbidities nor costs incurred as a loss of productivity. Therefore the actual costs to the healthcare system and society in general are likely to be substantially higher

Demographics, insulin use and clinical targets in type 2 diabetes insulin users: comparison of a local integrated diabetes service vs a UK-wide cohort

Insulin-treated patients with type 2 diabetes require specialist multidisciplinary input to achieve treatment targets. We compared the demographics, achievement of combined NICE targets for HbA1c (≤7.5%), blood pressure (<140/80mmHg) and total cholesterol (<4mmol/L), and insulin use between patients from a local integrated diabetes service with those from a representative UK population. A cross-sectional evaluation of individual patient data from six randomly-selected primary care practices in Erewash (Integrated) Diabetes Service was compared with The Health Improvement Network (THIN) UK primary care database. Baseline age (61.5 years vs 65.8 years; p < 0.0001) and duration of insulin use (4.3 vs 6.3 years; p < 0.0001) use were lower in the THIN cohort. Mean HbA1c was similar between the two cohorts but weight, blood pressure, total and LDL cholesterol were significantly lower in the Erewash population compared with THIN. The combined achievement of HbA1c, total cholesterol and blood pressure was 17.5% in the Erewash cohort compared with 9.6% in the THIN cohort (p < 0.0001). There was a higher proportion of insulin users on basal-bolus than on premix in the Erewash cohort (89.3% vs 10.7%) compared with THIN (59.0% vs 41.1%). The proportion of patients who received concurrent oral glucose-lowering therapies in the Erewash integrated service was lower, except for SGLT2 inhibitors (2.5% in the Erewash cohort vs 0.5% in THIN; p < 0.0001). This model of an integrated diabetes service appears to confer better achievement for the NICE defined clinical targets compared with the THIN cohort. Further studies are required to investigate the impact of this service model on health economics, patient pathway and patient experience. Copyright © 2017 John Wiley & Sons

Can peer support be cost saving? An economic evaluation of RAPSID: a randomized controlled trial of peer support in diabetes compared to usual care alone in East of England communities

Background Diabetes peer support, where one person with diabetes helps others, may improve diabetes management. The objective of this study was to perform a cost analysis of peer support strategies used in RAndomized controlled trial of Peer Support in type 2 Diabetes. Methods We performed a 2×2 factorial randomized cluster controlled trial in England. People with type 2 diabetes were invited to participate as either ‘peer’ or ‘peer support facilitator’ (PSF) through postal invitation predominantly from general practice. Clusters, based on local communities, were each randomly assigned to one arm of group, 1:1, both group and 1:1 or control interventions. The intervention was delivered over 8–12 months by trained PSFs, supported by monthly meetings with a diabetes nurse. Out-of-pocket expenses/service utilization were self-reported at baseline, midpoint and on trial completion. Intervention costs were collated. Non-hospital costs used National Health Service (NHS) reference costs. Hospital payments were obtained from one local commissioning group and mean payments calculated. The analysis employed a societal perspective. Costs were evaluated at the conclusion of the trial. Results Participants (n=1299) were recruited across 130 clusters. The four arms were well balanced and matched (60% male, mean diabetes duration 9.5 years, mean glycated haemoglobin (HbA1c) 7.4+/-1.3%, 17% insulin treated). Implementation costs at 2013 rates were £13.84/participant/annum, participant out-of-pocket expenses for any intervention were £11.41/participant/annum and the NHS-incurred costs were reduced by £138.38/participant/annum. Savings for the 1:1, group and any intervention were £233.65, £90.52 and £113.13/participant/annum, respectively. Conclusions We conclude that both 1:1 and group diabetes peer support over 8–12 months are cost saving in this setting, although much of the benefit is largely derived by differences in self-reported healthcare utilization. Long-term benefits should be investigated