Clinical Economic Modeling in Lincolnshire

Martin McShaneSimon Swift

The Information Centre Analytical Fair9th September 2009

The Problem

• Lincolnshire is a large rural county. – 830,000 population– One PCT– 8 PBC clusters– One acute trust on 4 sites

• ~31,500 diabetes patients

• Inequity of access and outcomes• Traditional service model

• Desire for change• Little information and evidence on which to make decisions

The Solution: Clinical Economics Programme?

The Clinical Economics Programme is a toolset for modelling healthcare across a care community using a care pathway approach.

It delivers an evaluation and articulation of the impact of potential changes in service delivery on healthcare outcomes, the costs of service delivery and service capacity required.

This provides the commissioner with the evidence base to make an informed decision on the investments they should (or should not) make to achieve local goals in shifting healthcare.

To provide an overview of the current costs per patient for diabetes care as well as current state of workforce for diabetes care across Lincolnshire.

To create a solid evidence base, detailing the impact of interventions on agreed outcome domains, which will support the future care pathway assumptions.

To demonstrate, using economic modelling, the effects of various interventions on costs, outcomes and workforce requirements in thefuture care pathway and to use the results of this anaylsis as a toolkit for commissioning.

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Aims

Building the Current Pathway Model

The model design was created by Courtyard Group in close associationwith the core team and based on the pathway mapping from the widerstakeholder group workshop.The current pathway models were designed to represent, with a high Degree of accuracy, the possible journeys taken by a diabetes patient through the different levels of care in each cluster of Lincolnshire.

Clusters varied in terms of availability of care, here are a few examples:

SpotlightLincoln South:9.8% type 2s attending Spotlight

East Lindsey:0 % type 2s offered Spotlight

DieticianNorth West Lincs:48.8% type 2s seeing dietician/year

Mid Kesteven:1.2 % type 2s seeing dietician/year

PodiatristSkegness & Coast:51.1% type 1s seeing podiatrist/year

Welland:8.5 % type 1s seeing podiatrist/year

L o w H i g h

Datapoint Types for Current Pathway

Incidence of type 1 and type 2 diabetes

Outpatient appointments

Patient flows through community level care (eg.GP visits per year)

Prevalence of diabetic retinopathy and foot ulceration

Prevalence of type 1 and type 2 diabetes

Secondary care activity

Population mortality rate

Retinal screening rate Local

Local

Local

National

Local

Local

Local

Local

D a t a p o i n t: S o u r c e:

Costs of each healthcare intervention National

Screening and Primary Prevention

Screening for diabetes in people over the age of 45 or people with high risk due to family history of diabetes, ethnicity and other risk factors is key to improving quality of life for diabetics.

Early and effective screening ensures that every person with diabetes is diagnosed and is able to receive care for their condition as well as to prevent complications.

Following from a targeted population screening programme to identifyundiagnosed diabetes, a significant number of individuals will have been identified either with ‘pre-diabetes’ or as ‘at risk’. Preventing the development of type 2 diabetes in these groups would involve interventions such as the regulation of diet and weight and promotion of physical exercise.

A number of studies have assessed the impact of screening programmes and interventions on the development of type 2 diabetes. The figures in these studies range from 28.5% to 58% reduction in the incidence of type 2 diabetes due to screening and intervention (Ramachadran et al 2006, Tuomilehto et al 2001).

Education as Secondary Prevention

Education programmes for secondary prevention normally include guidanceon how to monitor and interpret blood glucose levels and how to monitor for acute and chronic complications.

Presently, only 11% of people with diabetes in England are on an education programme.

Lincolnshire education programmes:• ‘Spotlight on Diabetes’ offered by DSNs and dieticians in 7 out of 8 clusters in Lincolnshire for type 2 diabetes (DESMOND equivalent)• ‘Select’ education programme for type 1 diabetes patients offered in 5 out of 8 clusters. (DAFNE equivalent)

Participation in diabetes education programmes can reduce HbA1c levelsby 1.1-1.6% in type 1 diabetes patients and 0.8-1.25% in type 2diabetes patients (Loveman et al 2003).

Boston Current Pathway Model

Boston Type 2 Diabetes Pathway Branch

New Pathway

Pathway Elements

Tier Key Service ElementsLevel 1: Core Primary Care

Promoting healthy lifestyles- 1:1 support

Systematic and opportunistic screening for diabetes and IFG/IGT and complications of diabetesMaintaining risk registers

Raising awareness of the signs and symptoms of diabetes

Agreement of management plans with patients with type 2 diabetes who are controlled by diet or oral medicationReferral to structured education or relevant specialist(s), including smoking cessation and weight managementPsychological support (low level)

Appropriate review (Annual minimum)

Confirmation of initial diagnosis for those patients outside of normal parameters

Referral to ongoing support for self care

Referring on to level 4 for women with diabetes considering pregnancy

Level 2: Enhanced Primary Care

As level 1 plus:

Agreement of management plans with patients with Type 1 and type 2 diabetes managed with insulin or new therapies (such as Exanatide)Treatment and management planning for patients poorly controlled at levels 1

The Future Pathway model, assumptions and the ‘Supermodel’

Once the current pathways were built, future pathways were created for conservative, realistic and aggressive future state assumptions.

The future pathway model was not specific to a cluster and instead, covered the entire Lincolnshire population.

This was done in order to minimise variation between clusters and to promote a standard of equality and quality of care throughout the county in future.

Once both current and future pathways were completed, all 8 cluster-specific current models and the Lincolnshire-wide future model were linkedtogether creating supermodel.

This could then be run to provide a direct comparison of costs and outcomes between current models and future model.

The ‘Supermodel’

Why Change? – The EvidenceO u t c o m e

Current % of Diabetes Patients with HbA1c over 7.4%

Patients Avoiding Sequalae of Diabetic Retinopathy

Patients Avoiding Foot Ulceration

A&E Admissions forPatients withDiabetes Mellitus

Number of New OPDAppointments with Diabetes Mellitus

Costs per Patient from 2008 - 2017

F u t u r e

94,272

2066

716

75.6%

£890 - £1647

12,523

C u r r e n t

52.1%

654

1527

142,151

33,577

£940 - £1085

Total costs match by year 4 and by year ten are £2.7m less per year, sum total cost difference over ten years is -3.6%

Change requirements

3.06 times current workforce to achieverealistic future state.

W o r k f o r c e :

All workforce requirements are after 10 years.

8.52 times current workforce to achieverealistic future state.

12.29 times current workforce to achieverealistic future state.

12.78 times current workforce to achieverealistic future state.

7.04 times current workforce to achieverealistic future state.

Podiatry

I n t e r v e n t i o n :

DSN

Education - Spotlight

Education - Select

Dietician

Status

• NHS Lincolnshire PEC ratified the outcome of the project and agreed to commission an LHC wide service congruent with the designed future state

• Commissioning is in process

Potential outcomes and benefits• Data and information becomes available that shows the current state of

activity, providing evidence of gaps in service and duplication of provision

• A supporting research report provides evidence on policy, guidance and best practice to inform a re-designed care pathway

• The CEP works with clinical and other stakeholders to design and agree a new care pathway helping enable clinical stakeholder engagement

• A ‘what if’ stage during the programme also allows for comparison of alternative pathway designs

• Comparing changes between current and potential future care pathways demonstrates the impact on healthcare outcomes, the costs of service delivery and service capacity required

• Enables the PCT to behave as World Class Commissioners by making informed decisions through the use of the evidence base generated

• This means local priorities can be delivered and the desired balance between improvements in clinical outcomes and the efficiencies within service delivery can be achieved

• Provides key clinical and service measures that can be monitored to show progress towards desired local goals in shifting healthcare

Any Questions?

Thank you