8 Type 2 diabetics in primary care : Profiles of healthcare utilisation obtained from observational data

Background: The high burden of diabetes for healthcare costs and their impact on quality of life and management of the disease have triggered the design and introduction of disease management programmes (DMPs) in many countries. The extent to which diabetes patients vary with regard to their healthcare utilisation and costs is largely unknown and could impact on the design of DMPs. The objectives of this study are to develop profiles based on both the diabetes-related healthcare utilisation and total healthcare utilisation in primary care, to investigate which patient and disease characteristics determine ‘membership’ of each profile, and to investigate the association between these profiles. Methods: Data were used from electronic medical records of 6,721 known type 2 diabetes patients listed in 48 Dutch general practices. Latent Class Analyses were conducted to identify profiles of healthcare and regression analyses were used to analyse the characteristics of the profiles. Results: For both diabetes-related healthcare utilisation and total healthcare utilisation three profiles could be distinguished: for the diabetes-related healthcare utilisation these were characterised as “high utilisation and frequent home visits” (N=393), “low utilisation, GP only” (N=3,231) and “high utilisation, GP and nurse” (N=3,097). Profiles differed with respect to the patients’ age and type of medication; the oldest patients using insulin were dominant in the “high utilisation, GP and nurse” profile. High total healthcare utilisation was not associated with high diabetes-related healthcare utilisation. Conclusions: Healthcare utilisation of diabetes patients is heterogeneous. This challenges the development of distinguishable DMPs. LINH: Type 2 diabetes | 113 8 Background The number of people with type 2 diabetes mellitus is increasing [211]. Due to the high burden of diabetes in particular and chronic diseases in general for healthcare costs and their impact on quality of life, management of these diseases has become an important issue in health policy in many countries [212]. This has triggered the design and introduction of disease management programmes (DMPs) for type 2 diabetes mellitus in particular. According to the Disease Management Association of America (DMAA) disease management is defined as a system of coordinated healthcare interventions and communications for populations with conditions in which patients’ self-care efforts are significant. Disease management supports the physician or practitioner/ patient relationship and plan of care, emphasizes prevention of exacerbations and complications through the use of evidence-based practice guidelines and patient empowerment, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health [213]. DMPs are expected to be a solution for the inadequate coordination of care between health services, variation in quality of care and increasing costs for chronic illnesses [214]. However, literature on the design and effects on health and disease outcomes is inconclusive and research currently focuses mainly on refining these issues, such as defining the optimal patient group per programme [215, 216]. Remuneration of DMPs differs between European countries: a yearly price for total care for a chronic disease (e.g. Denmark, UK, the Netherlands), a financial bonus for general practitioners (GPs) per patient that is included in a DMP (e.g. France), dedication of one percent of the total health care budget and refunding additional services for DMP-patients (e.g. Germany) [217]. A position paper showed that providing financial incentives to relevant stakeholders is important for facilitating successful implementation of DMPs [214]. Stakeholders may be reluctant to invest in better chronic care if their investments are not accompanied by better payment, or at least equal compensation [218]. Setting the incentives correctly will encourage healthcare providers to efficiently provide healthcare services. In the case of DMPs, varying healthcare demands betweenand within patients over time might make it problematic to design a good financial compensation system for DMPs. If physicians are paid an equal amount per patient, they might be reluctant to include patients with a high healthcare demand and consequently risk of financial losses or risk of undertreatment [219]. On the other hand, a fee-for-service remuneration system