Evaluating chronic disease management in real-world settings in six European countries: Lessons from the collaborative DISMEVAL project

Objective

To describe the interventions, research methods and main findings of the international DISMEVAL project, in which the “real-world” impact of exemplary European disease management approaches was investigated in six countries using advanced analytic techniques.

Design

Across countries, the project captured a wide range of disease management strategies and settings; approaches to evaluation varied per country, but included, among others, difference-in-differences analysis and regression discontinuity analysis.

Setting

Austria, Denmark, France, Germany, The Netherlands, and Spain.

Participants

Health care providers and/or statutory insurance funds providing routine data from their disease management interventions, mostly retrospectively.

Intervention(s)

This study did not carry out an intervention but evaluated the impact of existing disease management interventions implemented in European care settings.

Main outcome measure(s)

Outcome measures were largely dependent on available routine data, but could concern health care structures, processes, and outcomes.

Results

Data covering 10 to 36 months were gathered concerning more than 154,000 patients with three conditions. The analyses demonstrated considerable positive effects of disease management on process quality (Austria, Germany), but no more than moderate improvements in intermediate health outcomes (Austria, France, Netherlands, Spain) or disease progression (Denmark) in intervention patients, where possible compared with a matched control group.

Conclusions

Assessing the “real-world” impact of chronic disease management remains a challenge. In settings where randomization is not possible and/or desirable, routine health care performance data can provide a valuable resource for practice-based evaluations using advanced analytic techniques.

Evaluating structured care for diabetes: can calibration on margins help to avoid overestimation of the benefits? An illustration from French diabetes provider networks using data from the ENTRED Survey

OBJECTIVE

While there is growing evidence on the effectiveness of structured care for diabetic patients in trial settings, standard population level evaluations may misestimate intervention benefits due to patient selection. In order to account for potential biases in measuring intervention benefits, we tested the impact of calibration on margins as a novel adjustment method in an evaluation context compared with simple poststratification.

RESEARCH DESIGN AND METHODS

We compared the results of a before-after evaluation on HbA1c levels after 1 year of enrollment in a French diabetes provider network (DPN) using an unadjusted sample and samples adjusted by simple poststratification to results obtained after adjustment via calibration on margins to the general diabetic population's characteristics using a national cross-sectional sample of diabetic patients.

RESULTS

Both with and without adjustment, patients in the DPN had significantly lower HbA1c levels after 1 year of enrollment. However, the reductions in HbA1c levels among the adjusted samples were 22-183% lower than those measured in the unadjusted sample, regardless of the poststratification method and characteristics used. Compared with simple poststratification, estimations using calibration on margins exhibited higher performance.

CONCLUSIONS

Evaluations of diabetes management interventions based on uncontrolled before-after experiments may overestimate the actual benefit for patients. This can be corrected by using poststratification approaches when data on the ultimate target population for the intervention are available. In order to more accurately estimate the effect an intervention would have if extended to the target population, calibration on margins seems to be preferable over simple poststratification in terms of performance and usability.

Evolution of direct costs in the first years of rheumatoid arthritis: impact of early versus late biologic initiation--an economic analysis based on the ESPOIR cohort

Objectives

To estimate annual direct costs of early RA by resource component in an inception cohort, with reference to four distinct treatment strategies: no disease modifying antirheumatic drugs (DMARDs), synthetic DMARDs only, biologic DMARDs in the first year (‘first-year biologic’, FYB), and biologic DMARDs from the second year after inclusion (‘later-year biologic’, LYB); to determine predictors of total and non-DMARD related costs.

Methods

The ESPOIR cohort is a French multicentric, prospective study of 813 patients with early arthritis. Data assessing RA-related resource utilisation and disease characteristics were collected at baseline, biannually during the first two years and annually thereafter. Costs predictors were determined by generalised linear mixed analyses.

Results

Over the 4-year follow-up, mean annual direct total costs per treatment strategy group were €3,612 for all patients and €998, €1,922, €14,791, €8,477 respectively for no DMARDs, synthetic DMARDs only, FYB and LYB users. The main predictors of higher costs were biologic use and higher Health Assessment Questionnaire (HAQ) scores at baseline. Being a biologic user led to a higher total cost (FYB Rate Ratio (RR) 7.22, [95% CI 5.59–9.31]; LYB RR 4.39, [95% CI 3.58–5.39]) compared to non-biologic users. Only LYB increased non-DMARD related costs compared to all other patients by 60%.

Conclusions

FYB users incurred the highest levels of total costs, while their non-DMARD related costs remained similar to non-biologic users, possibly reflecting better RA control.

Impact of chronic obstructive pulmonary disease on Valve Academic Research Consortium-defined outcomes after transcatheter aortic valve implantation (from the FRANCE 2 Registry)

The purposes of the present study were to determine the impact of chronic obstructive pulmonary disease (COPD) on Valve Academic Research Consortium-defined outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). A total of 3,933 consecutive patients underwent TAVI from January 2010 to December 2011 in 34 centers and were included in the French national TAVI registry "FRANCE 2"; 895 (22.7%) had concomitant COPD, 3,038 (77.3%) did not. There were no significant differences in procedural characteristics or 30-day Valve Academic Research Consortium-defined outcomes between those with and without COPD. Multivariate regression analysis showed COPD to be an independent predictor of 1-year mortality and combined efficacy end point after adjustment for concomitant co-morbidities (hazard ratio 1.19, 95% confidence interval 1.005 to 1.41, p = 0.03 and hazard ratio 1.52, 95% confidence interval 1.29 to 1.79, p <0.001, respectively). The higher mortality rate at 1 year in patients with COPD was related to cardiovascular deaths (COPD 10.0% vs non-COPD 6.2%, p = 0.008). Subgroup analysis found that the effect of COPD on 1-year mortality rate was constant across different subgroups, especially the type of approach and the type of anesthesia subgroups. In conclusion, concomitant COPD in patients referred for TAVI characterizes a high-risk population. The excess in mortality is largely determined by a higher rate of cardiovascular deaths and exists regardless of the type of procedure performed and its results.

The burden and treatment of diabetes in France

BACKGROUND

The objective of this review was to describe and situate the burden and treatment of diabetes within the broader context of the French health care system.

METHODS

Literature review on the burden, treatment and outcomes of diabetes in France, complemented by personal communication with with diabetes experts in the Paris public hospital system.

RESULTS

Prevalence of diabetes in the French population is estimated at 6%. Diabetes has the highest prevalence among all chronic conditions covered 100% by France's statutory health insurance (SHI), and the number of covered patients has doubled in the past 10 years. In 2010, the SHI cost for pharmacologically-treated diabetes patients amounted to €17.7 billion, including an estimated €2.5 billion directly related to diabetes treatment and prevention and €4.2 billion for treatment of diabetes-related complications. In 2007, the average annual SHI cost was €6 930 for patients with type 1 diabetes and €4 890 for patients with type 2 diabetes. Complications are associated with significantly increased costs. Diabetes is a leading cause of adult blindness, amputation and dialysis in France, which also has one of the highest rates of end-stage renal disease in Europe. Cardiovascular disease is the leading cause of death among people with diabetes. Historically, the French health care system has been more oriented to curative acute care rather than preventive medicine and management of long-term chronic diseases. More recently, the government has focused on primary prevention as part of its national nutrition and health program, with the goal of reducing overweight and obesity in adults and children. It has also recognized the critical role of the patient in managing chronic diseases such as diabetes and has put into place a free patient support program called "sophia". Additional initiatives focus on therapeutic patient education (TPE) and the development of personalized patient pathways.

CONCLUSIONS

While France has been successful in protecting patients from the financial consequences of diabetes through its SHI coverage, improvements are necessary in the areas of prevention, monitoring and reducing the incidence of complications. Systemic changes must be made to improve the coordination and delivery of chronic care.

Quality of life instruments used in mental health research: properties and utilization

Quality of life (QoL) assessment is increasingly used in mental health. Multiple instruments exist, but the conditions for choosing one instrument over another for purposes of a specific study are not clear. We performed a systematic review to identify the QoL instruments used in mental health. The instruments were systematically described regarding their intrinsic properties (e.g., generic v. disease-specific) and their characteristics of utilization in studies (e.g., study objectives). Using cluster analyses, we investigated the existence of similar instruments with respect to each of these sets of characteristics and studied potential links between instruments' intrinsic properties and their characteristics of utilization. We included 149 studies in which 56 distinct instruments were used. Similarities were found among instruments in terms of their intrinsic properties as well as their characteristics of utilization, leading to the construction of four clusters of instruments in each case. However, no relevant links were identified between instruments' intrinsic properties and their characteristics of utilization, suggesting that the choice of QoL instruments did not depend on their properties. A consensus about common QoL instruments must be reached to facilitate the choice of instruments, the comparison of results and thus to have an impact on clinical and policy decision-making.

ROAMER: roadmap for mental health research in Europe

Despite the high impact of mental disorders in society, European mental health research is at a critical situation with a relatively low level of funding, and few advances been achieved during the last decade. The development of coordinated research policies and integrated research networks in mental health is lagging behind other disciplines in Europe, resulting in lower degree of cooperation and scientific impact. To reduce more efficiently the burden of mental disorders in Europe, a concerted new research agenda is necessary. The ROAMER (Roadmap for Mental Health Research in Europe) project, funded under the European Commission's Seventh Framework Programme, aims to develop a comprehensive and integrated mental health research agenda within the perspective of the European Union (EU) Horizon 2020 programme, with a translational goal, covering basic, clinical and public health research. ROAMER covers six major domains: infrastructures and capacity building, biomedicine, psychological research and treatments, social and economic issues, public health and well-being. Within each of them, state-of-the-art and strength, weakness and gap analyses were conducted before building consensus on future research priorities. The process is inclusive and participatory, incorporating a wide diversity of European expert researchers as well as the views of service users, carers, professionals and policy and funding institutions.

Clinical results of transcatheter aortic valve implantation in octogenarians and nonagenarians: insights from the FRANCE-2 registry

BACKGROUND

Although transcatheter aortic valve implantation has been developing as an alternative treatment in elderly patients with high surgical risk, age-specific differences in clinical outcome have not been fully validated.

METHODS

Data were analyzed for 2,254 patients at least 80 years old who were enrolled between January 2010 and October 2011 in the French national transcatheter aortic valve implantation registry, FRANCE-2. Procedural and clinical outcomes defined according to the Valve Academic Research Consortium criteria were compared among subjects in three age groups: 80 to 84 years (n = 867), 85 to 89 years (n = 1,064), and at least 90 years (n = 349; range, 90 to 101 years).

RESULTS

The self-expandable prosthesis was implanted in 710 patients, and the balloon-expandable prosthesis was implanted in 1,544 patients. No differences were observed in rates of procedural success, Valve Academic Research Consortium-defined complications, and length of hospitalization among groups. Cumulative 30-day mortalities did not change among the three groups (80 to 84 years, 10.3% versus 85 to 89 years, 9.5% versus ≥ 90 years, 11.2%; p = 0.53). Cumulative 1-year mortalities also showed no statistical differences, although the mortality rate was higher in patients 85 to 89 years old and at least 90 years old compared with those 80 to 84 years old (19.8% versus 26.1% versus 27.7%; p = 0.16). After adjustment for differential baseline characteristics and potential confounders, patient age (85 to 89 years and ≥ 90 years compared with 80 to 84 years) was not associated with increasing risk of 30-day mortality (hazard ratio, 0.92, 1.26; 95% confidence interval, 0.66 to 1.27, 0.83 to 1.94; p = 0.38, 0.28, respectively) and 1-year mortality (hazard ratio, 1.16, 1.36; 95% confidence interval, 0.90 to 1.49, 0.97 to 1.89; p = 0.25, 0.073, respectively).

CONCLUSIONS

This study revealed acceptable clinical results of transcatheter aortic valve implantation even in very elderly populations.

The cost of mental disorders in France

AIMS

To provide burden estimates of mental disorders in France and compare the results with findings from other countries and EU in general.

METHOD

Stepwise top down approach, consisting of analyses of existing data sets, national surveys and ad hoc surveys. Mental disorder was defined by diagnoses in the chapter 'Mental and behavioural disorders' from the International Classification of Diseases, tenth revision (ICD-10), excluding, dementia and mental retardation. Disease burden was measured by total health care costs, social care costs, lost output and loss of well being, 2007 data was used consistently.

RESULTS

The total cost of mental health care was estimated at €13.4 billion, or 8% of total healthcare expenditures. Total cost of health and social services was estimated at €6.3 billion, including €1.3 billion for informal care. Total cost of lost production amounted to €24.4 billion, €20.0 billion for lost output and €4.4 billion for workers' compensation. Mental disorders resulted in a total loss of 2.2 million QALY and a total cost of lost well being of €65.08 billion. The total costs of mental disorders were estimated at €109 billion, 20% of which are actual money spent and 80% the social value of disease consequences.

CONCLUSION

In France with a population of 65 million, an estimated 12 million inhabitants currently suffer from one or more mental disorders. The true size and burden of mental disorders in France was significantly underestimated by policy makers in the past.

Financing long-term care for frail elderly in France: the ghost reform

Like many welfare states, France is faced with increasing demand for long term care (LTC) services. Public LTC coverage has evolved over the past 15 years, reaching a coverage depth of 70%. Nonetheless, it does not provide adequate and equitable financial protection for the growing number of frail elderly individuals, who are expected to constitute 3% of the population by the year 2060. Since 2005, various financing reform proposals have been debated, ranging from a newly covered risk under the social security system to targeted subsidies for private LTC insurance. However, to date no reform measure has been enacted. This article provides a brief history of publicly financed LTC in France in order to provide a context for the ongoing debate, including the positions and relative political power of the various stakeholders and the doubtful short-term prospect for reform.

Cost of stroke in France

BACKGROUND AND PURPOSE

A cost of illness study was undertaken on behalf of the French Ministry of Health to estimate the annual cost of stroke in France with the goal of better understanding the current economic burden so that improved strategies for care may be developed.

METHODS

Using primary data from exhaustive national databases and both top-down and bottom-up approaches, the stroke-related costs for healthcare, nursing care and lost productivity were estimated.

RESULTS

The total healthcare cost of stroke patients in France in 2007 was €5.3 billion, 92% of which was borne by statutory health insurance. The average cost of incident cases was €16 686 per patient in the first year, while the annual cost of prevalent cases was a little less than half that amount (€8099). Nursing care costs were estimated at €2.4 billion. Lost productivity reached €255.9 million and that income loss for stroke patients was partially compensated by €63.3 million in social benefit payments.

CONCLUSIONS

With healthcare costs representing 3% of total health expenditure in France, stroke constitutes an ongoing burden for the health system and overall economy. Nursing care added nearly half again the amount spent on healthcare, while productivity losses were more limited because nearly 80% of acute incident strokes were in patients over age 65. The high cost of illness underscores the need for improved prevention and interventions to limit the disabling effects of stroke.

Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches

Background

Self-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.

Methods

We conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice.

Results

Self-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.

Conclusions

Although collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.

Reported barriers to evaluation in chronic care: experiences in six European countries

INTRODUCTION

The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries.

METHODS

We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation.

RESULTS

We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors.

CONCLUSIONS

This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.

[Care for patients with chronic illness - concepts, assessment and foreign experiences]

The growing number of people with chronic diseases is a major challenge for health care systems in terms of morbidity, mortality, quality of care and financial impact. A range of organizational concepts for structured chronic disease care have been developed to address this challenge. The purpose of this literature review is to identify the key concepts, results and success factors of recent initiatives in this area. Four main concepts related to the broader notion of integrated care were identified: case management, disease management, the chronic care model and population management. The available evidence suggests that the expected results in terms of health gains and cost reductions have only been partially achieved, but that the quality of care has improved. The study identified several critical success factors for initiatives aimed at improving chronic care: the integration of patient education, the implementation of a patient identification system, provider feedback, primary care performance and financial incentives. Improved care for patients with chronic illness requires a range of interdependent measures. However, it is important to note that initiatives in this area are not usually associated with shortterm savings, but represent an investment for the future.