Economic evaluation of a diabetes disease management programme with a central role for the diabetes nurse specialist

Background: In the region of Maastricht, The Netherlands, a disease management programme (DMP) for patients with diabetes mellitus was implemented. The programme aims to improve quality of care within existing budgets. To achieve this, diabetes nurse specialists (DNSs) were given a central role within a multidisciplinary team of care providers. This study describes the cost-effectiveness of this approach. - Aim: To measure the incremental cost-effectiveness of a diabetes DMP, with a central role for the diabetes nurse specialist, in comparison to usual diabetes care. - Methods: Within the DMP, patients with low, medium and high complexities of care are cared for by general practitioners, DNSs and endocrinologists, respectively. The DNSs independently treat patients assigned to them and pay special attention to extensive self-management education. A quasi-experimental trial with two-year follow-up (n = 473) was undertaken to measure the cost-effectiveness of the DMP compared with usual care. - Results: A total of 23% of patients were assigned to the GP, 66% to the DNS and 10% to the endocrinologist. Statistical significant improvements in glycaemic control, health-related quality of life, compliance and most aspects of self-care behaviour were found. No statistically significant changes were found concerning total costs of care. All improvements were greatest in patients assigned to DNS. - Conclusion: A DMP in which DNSs play a central role is associated with improved quality of care within existing budgets. Patients assigned to DNS benefit most, indicating that the central role of DNS in the diabetes DMP is one of its critical success factors

PRM97 – Evaluating the cost-effectiveness of multicomponent rehabilitation guidelines

Objectives: The Dutch guideline for cancer rehabilitation recommends patients to engage in multicomponent interventions, i.e. several single interventions combined into a rehabilitation programme. To perform a health economic evaluation of this guideline, data on the cost-effectiveness of these multicomponent interventions is required. However, to date, the interventions´ (cost-)effectiveness is almost exclusively assessed for the single interventions, rather than for the multicomponent intervention, which challenges the health economic analysis of the multicomponent interventions. The objective of this study was to identify or develop a method that allows to deduct the cost-effectiveness of multicomponent interventions from published data of the single interventions.Methods: We searched the literature for articles offering a method or ideas for the development of a method for assessing the cost-effectiveness of multicomponent interventions on the basis of data on the single interventions. The cost-effectiveness gap analysis method, which can be used for assessing the maximum cost of an intervention given a certain willingness-to-pay, was identified as suitable and was further developed to allow assessing if a multidimensional programmes is cost-effective, based on the (cost-)effectiveness data of the single interventions.Results: Cost-effectiveness gap analysis was identified in the literature as being a suitable method, with further refinement. We suggested to first calculate the costs of all interventions. Given the effectiveness of one intervention it is then possible to estimate how much additional effectiveness a second (or any subsequent) intervention would have to provide so that the multicomponent intervention remains cost-effective, given a range of ceiling ratios. Recommendations for methods for estimating the additional effect of subsequent interventions were deducted from the literature identified.Conclusions: We suggest estimating the cost-effectiveness of the combined interventions as recommended in clinical guidelines by performing a refined cost-effectiveness gap analysis metho

Applying the AHP in Health Economic Evaluations of New Technology.

Much research in health care is devoted to health economical modelling. Even though the Analytic Hierarchy Process (AHP) is increasingly being applied in health care, its value to health economical modelling is still unrecognized. We explored the value of using AHP-derived results in a health economic model. We applied the AHP to provide input for a health economic evaluation of a new technology to diagnose breast cancer. No clinical data were available about the sensitivity and specificity of this technology. By means of the AHP, an expert panel estimated the sensitivity and specificity to be used in this model. Moreover, additional criteria including patient comfort and risks could be added to the health economic model. On the basis of the methodology suggested, the AHP proved to be feasible to support a comprehensive health economical evaluation of new technology, where clinical evidence is not yet available, or incomplet

Integrating patient preferences in efficiency frontier analyses using the analytical hierarchy process

OBJECTIVES: In comparative effectiveness research and economic evaluations, benefits of technologies are measured using multiple outcomes measures. Information lacks however about the importance of these endpoints for patients. We propose a new methodology to integrate patient weighted outcomes in a cost-efficiency frontier. We illustrate this methodology by means of an efficiency frontier analysis of five alternative treatments of patients with equinovarus deformity poststroke. METHODS: The Analytic Hierarchy Process (AHP) is a technique for multi-criteria analysis. The AHP supported 140 patients to prioritize the outcome measures of treatments of equinovarus deformity poststroke, and 10 professionals to prioritize the treatments regarding the outcome measures. These outcome measures include functional outcomes, risk and side effects, comfort, daily effort, cosmetics, and impact of the treatment. Sensitivity analysis is based on bootstrapping of the participants’ priorities. Relative costs include the device related costs and the care related costs of the treatments. RESULTS: The overall effectiveness of soft-tissue surgery (.41) is ranked first, followed by orthopedic footwear (.18), ankle-footorthosis (.15), surface electrostimulation (.14), and finally implanted electrostimulation (.12). Implanted electrostimulation (.35) and soft-tissue surgery (.34) are considered to be most expensive, followed by surface electrostimulation (.26), orthopedic footwear (.03) and ankle-foot orthosis (.02). Based on these priorities of the treatments’ overall effectiveness and costs, an efficiency frontier was drawn that includes decision uncertainty. CONCLUSIONS: The results suggest that the cost-effectiveness of implanted electrostimulation and surface electrostimulation are unfavourable. This new methodology for efficiency frontier analysis allows decision makers to integrate the outcomes about the diverse values and costs of health care technology, and can be applied broadly. It is particularly suitable in the field of early technology assessment, since the AHP supports a systematic estimation of priors about the effectiveness of alternative treatments

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 technique

PCN77 – Cost-effectiveness of cognitive-behavioral therapy and physical exercise for alleviating treatment-induced menopausal symptoms in breast cancer patients

Objectives Many breast cancer patients suffer from (severe) menopausal symptoms after an early onset of menopause caused by cancer treatment. The standard treatment for these complaints is hormone replacement therapy, which, however, is contraindicated for this group, as it may have tumor-promoting effects. The aim of this study was to assess the cost-effectiveness of three interventions aimed at alleviating these symptoms: cognitive-behavioral therapy (CBT), physical exercise (PE), and the combination of both (CBT+PE). Methods A cost-effectiveness analysis was performed from a health care system perspective. The primary outcome was incremental health care costs (IHCC) per patient with a clinically relevant improvement after six months of treatments. The secondary outcome was incremental costs per quality-adjusted life years (QALYs) gained over a five-year time period. This was assessed using a Markov model, populated with data from a recent randomized controlled trial evaluating the effectiveness of CBT, PE, and CBT+PE in the clinical setting and additional cost data. The robustness of the results was analyzed through one-way and probabilistic sensitivity analyses. Results IHCCs for alleviating one patient of the perceived symptom burden by a clinically relevant difference after six months of treatment were EUR€605 for CBT, EUR€1,847 for CBT+PT, and EUR€1,250 for PE alone, compared to the waiting list control group. CBT generated 0.009 additional QALYs at an additional cost of EUR€162, compared to the control group, leading to an Incremental Cost Utility Ratio (ICUR) of EUR€18,655 per QALY gained and The ICUR of CBT+PE was EUR€42,375 per QALY in comparison to the control group. CBT had a high probability (circa 61%) of being cost-effective at prevailing ceiling ratios. Conclusions CBT is likely the most cost-effective of the three interventions investigated for alleviating treatment-induced menopausal symptoms in breast cancer patient

Caracterización de polvos de fundición de cobre y establecimiento de rutas de procesado

[spa] DOCTORAL: Se ha caracterizado tres muestras de fundiciones de cobre chilenas con diversas técnicas de caracterización, además se han analizado sus comportamientos ante la lixiviación con agua y con diferentes disoluciones lixiviantes ácidas y alcalinas. También se estudió la respuesta de estos polvos en operaciones de separación magnética y granulométrica y la inertización de las fracciones de material con mayor contenido de As. Se ha determinado que los polvos son materiales complejos muy solubles en agua y algo menos en ácido. Se propone dos rutas de procesado de estos materiales, las cuales contemplan etapas de lixiviación, cementación del cobre en las disoluciones y separación granulométrica para inertizar la fracción más fina; el material grueso recircula a la fundición y las disoluciones recirculan a la lixiviación de polvos frescos.[eng] "Characterization of powders of copper foundry and establishment of routes of having processed" TEXT: It has been characterized three samples of Chilean copper foundries with diverse caracterization techniques. It has been analyzed their behaviors before the leaching with water and with different acid and alkaline solutions. The answer of these powders was also studied in operations of magnetic separation and granulometric separation and the inertization of the material fractions with more content of As. It has been determined that the powders are material complex very soluble in water and something less in acid. It intends two routes of having processed of these materials. Which contemplate leaching stages, cementation of the copper in the solutions and granulometric separation for the inertization the finest fraction. The thick material recycles to the foundry and the solutions recycle to the leaching of fresh powders