The Effect And Economic Analysis Of "5+1" Staged Management Model For Diabetes In Community

BackgroundDiabetes is a chronic non-communicable disease associated with lifestyle.The development of social economy has raised people's standard of living,and it also makes the diabetes prevalence and diabetes patients showed a trend of rising.Then it indirectly cause health care costs related to diabetes rising.Many countries in the world are actively seek for the effective diabetes management model to prevent and control the diabetes and its complications.And all these diabetes management model are based on the concept of integrated management.The concept of comprehensive management of diabetes emphasizes that diabetes management is not only manage the blood glucose,but also need to manage the risk factors such as blood pressure and blood lipid,as well as prevent and control the diabetes related complications.The"5+1" diabetes staged management model(hereinafter referred to as "5+1" model)set up 5 management goal and 1 screening goal of diabetes complication.5 management goal including glycosylated hemoglobin(HbA1c),blood pressure(BP),low density lipoprotein cholesterol(LDL-C),quit smoking,and taking aspirin.The "5+1" model also divide patients into different stages to manage according to the patient's blood glucose.The "5+1" model defines the specific direction of diabetes management for community general practitioner.Objective1.To evaluate the effect of "5+1" model.2.To analyze the cost-ef'fectiveness and cost-utility of the "5+1" model.Methods1.Combined typical sampling with stratified cluster sampling,a total of 2 467 patients with type 2 diabetes from 12 commutities in 6 districts of 3 cities of Jiangsu,Shanxi and Ningxia Provinces during June to December of 2015 are included in the study.Jiangsu,Shanxi and Ningxia Provinces respectively represent the eastern,central and western of China,and whose economic development level is different.The 12 communities are set as 6 intervention groups and 6 control groups randomly.All patients are informed agreed,voluntary,and all patients in this research are conformed to the criteria of inclusion and exclusion.2.Combined community intervention with random controlled trial,the "5+1”model is used in intervention grotups and the basic public health services model is used in control groups.The study lasted 2 years.3,We collect demographic information(gender,age,occupation,the degree of education,the type of medical insurance,etc.)and health related information(smoking,drinking.personal history of diabetes and other diseases,etc.).The detection rate of glycosylated hemoglobin(HbA1c),blood pressure(BP),LDL-C and the screening rate of diabetic complications are collected as process indicators.The fasting blood glucose(FPG),Postprandial Blood Glucose(2hPG),HbA1c and BP.LDL-C and other related physiological or biochemical indexes are collected before and after the intervention.The questionnaire(SF-36)is used to investigate the quality of life(QOL)before and after the intervention.We also collect the labor costs,variable costs and fixed costs as the total cost of community during the study.4."SDTM" system is used to create the database.WPS 2016 is used to clean and verify the data.SPSS 22.0 and SAS 9.3 software are used to analyze the data.Mean and standard deviation are used to describe quantitative data,and ratio is used to describe qualitative data.T-test or Mann-Whitney Utest are used to compare in quantitative data,and ?2 test are used to compare ratios.The methods which called Difference in Difference is used to analyze the changes about FPG?2hPG?HbA1?BP and LDL-C.Standard for parameter estimation and hypothesis testing is set at 0.05.Economic evaluation use cost-effectiveness analysis(CEA)and cost effect-utility analysis(CUA).Results1.General conditionA total of 2 467 subjects are included in this study.of which 1 253 patients are in intervention group,accounting for 50.8%.1 214 patients are in control group,accounting for 49.2%.The proportion of male and female in intervention group is 46.9%and 53.1%,the control group is 43.5%and 56.5%.The average age of the patients in intervention group and control group are 64.1±8.8 years old and 65.7±9.2years old,and the mean course of the disease are 8.2±5.9 years and 8.6±7.3years.A total of 1 926 patients has completed a 2 year-long management,and the porportion of the loss patients is 21.9%.The porportion in intervention group and control group are 14.8%and 29.2%respectively.2.Effect of interventionBefore the intervention,the porportion of HbA1c,BP and LDL-C in intervention group is 15.6%,75.0%and 25.6%,and the porportion is raised to 63.1%,99.9%and 82.9%after the intervention.The changes are all statistically significant(P<0.05).In control group,the porportion of HbA1c,BP,LDL-C is 17.9%,99.4%,44.9%after intervention,and HbA1c and LDL-C are significantly lower than that of intervention group(P<0.05).Before the intervention,the porportion of fundus examination,diabetes foot examination,microalbuminuria test,glomerular filtration rate(GFR)test,electrocardiography(ECG)examination is 10.2%,1.2%,1.5%,32.4%,52.3%in intervention group,and the porportion is respectively increased to 45.4%,74.0%,36.0%,87.8%,87.1%after the intervention.The changes are statistically significant(P<0.05).In the control group,the porportion of fundus examination,diabetes foot examination,microalbuminuria test,GFR test,ECG examination is 38.5%,58.6%,0.7%,50.3%,42.7%after intervention,and all indicators above are significantly lower than that of intervention group(P<0.05).Before the intervention,the 2hPG of intervention group is(10.3±2.9)mmol/L,and it decreased to(9.4±2.0)mmol/L after the intervention,and the change is statistically significant(P<0.05).After the intervention,the 2hPG of control group is(10.3±2.6)mmol/L,and it is significantly higher than intervention group(P<0.05).Bef'ore the intervention,the HbA1c of the intervention group and the control group are(7.2±1.4)%and(6.6±1.6)%.After the intervention,the figures are change to(6.9±1.0)%and(6.9±1.4)%respectively,and the difference estimate is-0.64%between two groups,and which is statistically significant(P<0.05).Before the intervention,the systolic blood pressure(SBP)of the intervention group and the control group are(131.9±14.8)mmHg and(131.1±15.4)mmHg.After the intervention,the SBP of the two groups are(129.0±12.5)mmHg and(131.3±14.4)mmHg.The difference in the intervention group is statistically significant(P<0.05).Before the intervention,the diastolic blood pressure(DBP)of the intervention group and the control group are respectively(80.2±9.1)mmHg and(79.2±9.3)mmHg.After the intervention,the DBP are(78.1±7.7)mmHg and(78.6±8.7)mmHg.The difference estimate of DBP between two groups is-1.55mmHg,which is statistically significant(P<0.05).Before the intervention,the porportion of patients use aspirin is 27.6%in intervention group,and the porportion rised to 43.5%after intervention,the change is statistically significant(P<0.05).After intervention,the poprortion of patients use aspirin in control group is 35.7%,and it is significantly lower than intervention group(P<0.05).In the analysis of QOL,the scores of physical component summary(PCS)and mental component summary(MCS)in intervention group are 282.6±79.1 and 311.0±65.6 after intervention and they are significantly higher(P<0.05)than before the intervention(273.5±69.7 and 283.2±65.5).3.Cost-effectiveness analysis and cost-utility analysis During the study,the total cost of community was 235 186.8 yuan per year in the intervention group,and 202.7 yuan for one person per year.In the control group,96893.0 yuanwere spending per year,and 93.5 yuan for one person per year.The intervention group costs 109.2 yuan more than the control group.The increased cost in the intervention group.96.6%can be accounted by the labor cost increasing.Used HbA1c and health utility as the indicators to analyze cost-effectiveness and cost-utility,and the results are that 364.0 yuan would be paid for each 1%reduction of HbA1c,and 3640.0 yuan paid for a addition QALY.if "5+1" model were used to manage diabetes in community.conclusion1."5+1" model can effectively improve the HbAic of patients with type 2 diabetes.And it also increase the poiportion of patients to screening diabetic complications.All these changes make much sense to prevent and control the diabetic complications,and it also has important significance to improve the quality of life.2.The "5+1" model has health economic significance.However,China has a vast territory,and there is a great difference between the health service capacity,the allocation of health resources and the willingness of people to pay.For achieving maximum social benefits and economic benefits,suggest that adjusting management strategy according to the local health care environment,social and cultural backgrounds as well as relevant policies to adapt the local medical health conditions and patient needs.