Cost and Utilization Associated
with
ith Group
G
Medical
M di l Clinics
Cli i for
f
Diabetes and Hypertension
yp
Recent Evidence
on Chronic Care
Treatment from
the VA
Santanu Datta, MBA, PhD
Cynthia Coffman, PhD
Amy Jeffreys, MStat
Morris Weinberger, PhD
David Edelman, MD
Funding: VA HSR&D 03-084
Diabetes & Hypertension
• Prevalent chronic conditions in the
veteran population
p p
• Substantial
S b t ti l morbidity
bidit and
d mortality
t lit
• Substantial health services utilization
and
d costs
t
Group Medical Clinics (GMCs)
• Combines facilitated peer support for
self-management with medical
managementt off chronic
h
i illness
ill
– Different from group self-management
clinics in that there is medical
management
• aka “Collaborative Care Clinics,”
“Shared
Shared Medical Appointments”
Appointments
– “Group Visits” can be either GMC or
self management groups
self-management
GMC effects on Cost/Utilization
• GMCs may be effective in improving
control of DM and HTN
• GMCs
GMC are a fairly
f i l intensive
i t
i chronic
h
i
illness intervention, using a lot of
person power
• Potential to offset costs by reducing
utilization
– In
I frail
f il elders,
ld
and
d in
i patients
ti t with
ith multiple
lti l
chronic illnesses, reduces ER visits
Study Objectives
• Assess the effectiveness of GMCs to
control blood glucose and blood
pressure in patients
p
p
with co-morbid
diabetes and hypertension
• Determine the cost of GMCs
• Assess impact on health services
utilization
Methods Clinical Trial
Methods–Clinical
• Two-site RCT
– Durham and Richmond VAMCs
• Usual care control
• Randomization:
– Stratified by
y A1c >= 9,, SBP >= 150
– 5:4 intervention to control ratio to
maximize power given clustering in
intervention arm but not in control arm
Methods– Patients
• Diabetes and hypertension both poorly
controlled; taking meds for both
– HbA1c
HbA1 ≥ 7.5%;
% SBP ≥ 140 mmHg
H or DBP ≥
90 mmHg
• Excluded if:
– Dual enrollment
– Cognitive impairment
– Life-limiting
Lif li iti
illness
ill
– New enrollment in endocrine clinic
Methods– Intervention and Personnel
• Care team for each GMC– A p
physician,
y
a
pharmacist, and a nurse or educator
• Each GMC always
y had the same care team and
patients (7 or 8 patients)
• Nurses, pharmacists, and physicians could be
on multiple care teams
• Patients allowed to choose care team that was
convenient for them
• GMCs met every 2 months, total of 7 visits in
year
• 9 GMCs in Durham, 10 in Richmond
GMC Session
1. Patient Intake & Data Collection
2a. Patient Education & Facilitated
Discussion
2b Internist
2b.
I t
i t and
d pharmacist
h
i t developed
d
l
d
tailored treatment plans
3. One-on-one breakout sessions
Methods- Intervention Cost
• Labor costs (salary and fringe benefits)
– Internist (1.5
(1 5 hrs.);
hrs ); pharmacist,
pharmacist nurse/educator (2
hours)
– Preparation and follow-up calls with patients
– Nurse/educator training costs (total of 2 hours)
• Equipment and material costs were minimal
 Not included in calculating intervention cost
• B
Base-case, minimum
i i
and
d maximum
i
costs
t
using appropriate ranges of personnel
salaries
l i and
d call
ll times
ti
• Costs presented in 2009 dollars
Methods- Utilization
• Source: VA administrative data
• All VA healthcare utilization measured
between 1-13 months after enrollment
(intervention usually began ~3 weeks
after enrollment))
• Primary care and emergency care visits
determined using VA-specific stop
codes (validated)
• Visit counts presented are exclusive of
group clinic sessions
Methods- Utilization Analysis
y
• Linear Mixed Model for ER and Primary Care
visits
i it
– Random effect to account for group visit clustering
in the intervention arm
• GEE for hospitalizations (each patient yes/no)
– Otherwise same model approach as LMM
• Covariates:
– treatment (covariate of interest)
– Stratification variables
•
•
•
•
site
SBP strata (High; ≥ 150; Low < 150)
A1c strata (High; ≥ 9%; Low < 9%)
Patient characteristics
Results Patients
Results–
Usual Care (N=
(N
106)
Intervention
(N=133)
Age (SD)
61 (10)
63 (9)
% Male
96%
96%
% White
28%
43%
% Afr.Am
65%
54%
A1c (%, mean, sd)
9.2% (1.5)
9.2% (1.3)
SBP(mmHg, mean,sd)
152 (13)
154 (15)
Race
Trial Clinical Results (brief)
• Intervention patients attended 78% of
their GMC sessions
• Intervention lowered SBP by 7.3
(p=0.01) and DBP by 3.8 (p=0.02) mmHg
compared to usual care
• Intervention lowered A1c by 0.3%
compared to usual care (p=0.16)
• Intervention lowered LDL by 9.2
9 2 mg/dl
compared to usual care (p=0.02)
Results– Intervention Cost
Results
Cost of a group visit session = $504 ($445-$578)
p
, per
p group
g
p cost = $504/8 = $63 ($56-$72)
(
)
Per-patient,
Annual per-patient cost = $63*7 = $441 ($389-$506)
Physicians and pharmacists placed 104 brief (< 5
minutes) calls and 71 longer (5-30 minute) follow-up
y Mean of $
$19
9p
per p
patientcalls over course of study.
year ($4-48)
• Total annual intervention cost per patient = $460
($393 - $554)
•
•
•
•
Results—Outpatient
Results
Outpatient Utilization
Service Use
(per patientyear)
GMC
(N=133)
UC
Diff
Difference
(N=106) (95% CI)
p-value
l
ER visits
0.9
1.3
- 0.4 (-0.7, -0.2)
<0.001
Pi
Primary
care visits
i it 5.3
53
61
6.1
- 0.9
0 9 ((-1.5,
1 5 -0.2)
0 2)
0 01
0.01
* Each GMC patient had an average of 5.5 GMC visits
Results Hospitalization
Results—Hospitalization
S
Service
i Use
U
GMC (N
(N=133)
133) UC (N
(N=106)
106)
Odds Ratio
Odd
R i
(95% CI)
Hospitalizations
(# of patients
experiencing)
23 (17%)
0.8 (0.4, 1.4)
23 (22%)
Limitations
• PCPs had to be unblinded to study arm
participation
• Cannot
C
t “t
“tease out”
t” which
hi h componentt
of the multi-faceted intervention was
effective
• Generalizability of results derived from
veteran population
Conclusions
• Supports evidence that diabetes GMCs
lower ER visits
• Small
S ll lowering
l
i off outpatient
t ti t visits;
i it nott
enough to offset GMC visits
• Potentially lower hospitalizations
• The $460 cost of this clinically effective
intervention is plausibly offset by
reduction in health care utilization
• Full cost analysis to follow