Patient centred and professional-directed implementation strategies for diabetes guidelines: a cluster-randomized trial-based cost-effectiveness analysis
Abstract
AIMS: Economic evaluations of diabetes interventions do not usually include analyses on effects and cost of implementation strategies. This leads to optimistic cost-effectiveness estimates. This study reports empirical findings on the cost-effectiveness of two implementation strategies compared with usual hospital outpatient care. It includes both patient-related and intervention-related cost. PATIENTS AND METHODS: In a clustered-randomized controlled trial design, 13 Dutch general hospitals were randomly assigned to a control group, a professional-directed or a patient-centred implementation programme. Professionals received feedback on baseline data, education and reminders. Patients in the patient-centred group received education and diabetes passports. A validated probabilistic Dutch diabetes model and the UKPDS risk engine are used to compute lifetime disease outcomes and cost in the three groups, including uncertainties. RESULTS: Glycated haemoglobin (HbA(1c)) at 1 year (the measure used to predict diabetes outcome changes over a lifetime) decreased by 0.2% in the professional-change group and by 0.3% in the patient-centred group, while it increased by 0.2% in the control group. Costs of primary implementation were < 5 Euro per head in both groups, but average lifetime costs of improved care and longer life expectancy rose by 9389 Euro and 9620 Euro, respectively. Life expectancy improved by 0.34 and 0.63 years, and quality-adjusted life years (QALY) by 0.29 and 0.59. Accordingly, the incremental cost per QALY was 32 218 Euro for professional-change care and 16 353 for patient-centred care compared with control, and 881 Euro for patient-centred vs. professional-change care. Uncertainties are presented in acceptability curves: above 65 Euro per annum the patient-directed strategy is most likely the optimum choice. CONCLUSION: Both guideline implementation strategies in secondary care are cost-effective compared with current care, by Dutch standards, for these patients. Additional annual costs per patient using patient passports are low. This analysis supports patient involvement in diabetes in the Netherlands, and probably also in other Western European settings.
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In the other 19 studies, it was either unlikely or unclear that an ITT approach had been used.
“In the other 19 studies, it was either unlikely or unclear that this approach had been used (Alder 2007; Clark 2000; Dijkstra 2006; Harmsen 2005; Haskard 2008; Heaven 2006; Krones 2008; Langewitz 1998; Levinson 1993; Lewis 1991; Loh 2007; Longo 2006; McLean 2004; Merckaert 2008; Pill 1998; Putnam 1988; Smith 1998; Stewart 2007; Wolf 2008).”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
In Dijkstra 2006, the intervention group had better blood pressure levels.
“Similarly, Dijkstra 2006 found better glycated haemoglobin and blood pressure levels in the intervention group, although they found no difference in systolic blood pressure, cholesterol or creatinine levels.”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
In Dijkstra 2006, the intervention group had better glycated haemoglobin levels.
“Similarly, Dijkstra 2006 found better glycated haemoglobin and blood pressure levels in the intervention group, although they found no difference in systolic blood pressure, cholesterol or creatinine levels.”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
In Dijkstra 2006, there was no difference in creatinine levels.
“Similarly, Dijkstra 2006 found better glycated haemoglobin and blood pressure levels in the intervention group, although they found no difference in systolic blood pressure, cholesterol or creatinine levels.”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
In Dijkstra 2006, there was no difference in cholesterol levels.
“Similarly, Dijkstra 2006 found better glycated haemoglobin and blood pressure levels in the intervention group, although they found no difference in systolic blood pressure, cholesterol or creatinine levels.”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
The intervention resulted in at least one positive outcome in three of the six studies (Brown 2001; Dijkstra 2006; Kinmonth 1998).
“the intervention resulted in at least one positive outcome in three of these studies (Brown 2001; Dijkstra 2006; Kinmonth 1998).”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
In Dijkstra 2006, there was no difference in systolic blood pressure.
“Similarly, Dijkstra 2006 found better glycated haemoglobin and blood pressure levels in the intervention group, although they found no difference in systolic blood pressure, cholesterol or creatinine levels.”
From Interventions for providers to promote a patient-centred approach in clinical consultations (2012) · cites this paper as Dijkstra 2006
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References 38 · Cited by 81
- Authors
- Dijkstra, R. F., Niessen, L. W., Braspenning, J. C. C., Adang, E., & Grol, R. T. P. M.
- Affiliations
- Radboud University Medical Center (NL)
- Erasmus MC (NL)
- Corresponding author
- Dijkstra, R. F.
- Venue
- Diabetic Medicine
- Publisher
- Wiley
- Published
- 2005-09-27
- Volume
- 23
- Issue
- 2
- Pages
- 164-170
- ISSN
- 0742-3071 (ISSN-L)
- 1464-5491
- OpenAlex
- W2060534090
- Cited by
- 81
- References
- 38
- Citations by year
- 2026: 2 · 2025: 1 · 2024: 7 · 2023: 1 · 2022: 4 · 2021: 1 · 2019: 2 · 2018: 3 · 2017: 3 · 2016: 3 · 2015: 9 · 2014: 5 · 2013: 6 · 2012: 7
- FWCI
- 11.41
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Diabetic Medicine (publishedVersion)
- PubMed (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (publishedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion)
- Radboud Repository (Radboud University) (submittedVersion)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Keywords
- diabetes guidelines, implementation strategies, patient-centered care, cost-effectiveness, patient education, HbA1c, quality-adjusted life years, life expectancy, secondary care, hospital outpatient services, UKPDS risk engine
- MeSH terms
- Aged, Cost-Benefit Analysis, Delivery of Health Care, Diabetes Mellitus, Diabetes Mellitus, Type 1, Diabetes Mellitus, Type 2, Female, Glycated Hemoglobin, Humans, Insulin, Life Expectancy, Long-Term Care, Male, Middle Aged, Quality of Life, Treatment Outcome, Health Care Costs, Practice Guidelines as Topic, Patient-Centered Care
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