Automated Telephone Self-Management Support Cost-Effective for Diabetes

"Because self-management support interventions are increasingly being implemented using population-based health communication strategies, such as those using telephone or computer-assisted outreach with or without nurse care management, it is important to measure the value of these programs from a public health perspective with respect to desired changes in health behaviors," write Margaret A. Handley, PhD, MPH, from the University of California–San Francisco (UCSF), and colleagues. "This study evaluated the cost-effectiveness of an [ATSM] support with nurse care management...intervention for patients with type 2 diabetes, which was tested among patients receiving primary care in publicly funded (safety net) clinics, focusing on non-English speakers."

At 4 San Francisco safety net clinics, the investigators performed cost analyses as part of a randomized trial comparing the effects of ATSM (n = 112) and usual care (n = 114) on diabetes-related outcomes among primary care patients. For a 9-month period, ATSM was implemented in 3 languages, using interactive telephone technology to provide surveillance, patient education, and one-on-one counseling.

Cost utility was determined from quality-adjusted life-years (QALYs) calculated from changes in scores on the 12-Item Short Form Health Survey. The investigators also looked at cost-effectiveness for costs needed to achieve a 10% increase in the proportion of patients meeting diabetes-specific public health goals for increasing exercise, which is recommended by Healthy People 2010 and the American Diabetes Association.

Compared with costs for usual care, the annual cost of the ATSM intervention per QALY gained was $65,167 for start-up and ongoing implementation costs combined and $32,333 for ongoing implementation costs alone. Costs per QALY ranged from $29,402 to $72,407, based on sensitivity analyses. When all costs were considered, the estimated per patient cost to achieve a 10% increase in the proportion of intervention patients meeting exercise guidelines recommended by the American Diabetes Association was $558. This decreased to $277 when only ongoing costs were considered.

"The ATSM intervention for diverse patients with diabetes had a cost utility for functional outcomes similar to that of many other accepted interventions targeted at diabetes prevention and treatment, and achieved public health physical activity objectives at modest costs," the study authors write. "Because a considerable proportion of costs were fixed, cost-utility and cost-effectiveness estimates would likely be substantially improved in a scaled-up ATSM program."

"We believe our cost findings are particularly relevant in the current environment in which health communication programs can harness diabetes registry data to implement population-level interventions for chronic care, and in light of increasing demand for information on the costs and benefits of new health care technologies in primary care settings," the study authors conclude. "The association of ATSM with meaningful QALY improvements related to functional status and the achievement of public health objectives at modest cost suggest there may be benefits associated with widespread implementation and dissemination of ATSM-based programs in reducing diabetes-related health disparities among vulnerable populations."
Ann Fam Med. 2008;6:512–518.