A Model-Based Economic Evaluation of Improved Primary Care Management of Patients with Type 2 Diabetes in Australia
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There are few studies investigating the economic value of the Australian practice nurse workforce on the management of chronic conditions. This is particularly important in Australia, where the government needs evidence to inform decisions on whether to maintain or redirect current financial incentives that encourage practices to recruit practice nurses.
The objective of this study was to estimate the lifetime costs and quality-adjusted life-years (QALYs) associated with two models of practice nurse involvement in clinical-based activities (high and low level) in the management of type 2 diabetes within the primary care setting.
A previously validated state transition model (the United Kingdom Prospective Diabetes Study Outcomes Model) was adapted, which uses baseline prognostic factors (e.g. gender, haemoglobin A1c [HbA1c]) to predict the risk of occurrence of diabetes-related complications (e.g. stroke). The model was populated by data from Australian and UK observational studies. Costs and utility values associated with complications were summed over patients’ lifetimes to estimate costs and QALY gains from the perspective of the health care system. All costs were expressed in 2011 Australian dollars (AU$). The base-case analysis assumed a 40-year time horizon with an annual discount rate of 5 %.
Relative to low-level involvement of practice nurses in the provision of clinical-based activities, the high-level model was associated with lower mean lifetime costs of management of complications (−AU$8,738; 95 % confidence interval [CI] −AU$12,522 to −AU$4,954), and a greater average gain in QALYs (0.3; 95 % CI 0.2–0.4). A range of sensitivity analyses were performed, in which the high-level model was dominant in all cases.
Our results suggest that the high-level model is a dominant management strategy over the low-level model in all modelled scenarios. These findings indicate the need for effective primary care-based incentives to encourage general practices not only to employ practice nurses, but to better integrate them into the provision of clinical services.
KeywordsPropensity Score Practice Nurse United Kingdom Prospective Diabetes Study Deterministic Sensitivity Analysis Utility Decrement
We would like to acknowledge the Australian Research Council (ARC) and our research partners (SA Health and the Central Northern Adelaide Health Service) for funding this research. We also acknowledge the significant part played by the Adelaide Northern Division of General Practice (ANDGP), in particular the CEO, Barbara Magin, and the eHealth Data Support Officer, Jodie Pycroft. Professor Phil Ryan and Thomas Sullivan provided statistical advice, and Wendy Sutton provided advice in her role as manager of the GP Plus Health Care Centre within the Northern Division. Finally, we would like to thank the general practices and patients who participated in the research, and acknowledge the support of Woolworths in supplying discounted gift cards offered to patients during recruitment. We received a research licence to use the UKPDS Outcomes Model, version 1.3, from the University of Oxford. The authors have no conflicts of interest that are relevant to the content of this article.
All authors contributed to the study design. Hossein Haji Ali Afzali and Jonathan Karnon performed the analysis and interpretation of data and drafted the manuscript. All authors made substantial contributions to the revisions of the manuscript and gave final approval of the version to be published.
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