This paper, titled “Understanding the cost of care of type 2 diabetes mellitus – a value measurement perspective,” published in BMJ Open in 2022, presents a pioneering exploration into the financial burden and associated health outcomes of Type 2 Diabetes Mellitus (T2DM) care. Authored by Gerardine Anne Doyle and colleagues from various institutions, including University College Dublin, the study addresses a critical gap in healthcare management research by focusing on the costs incurred to achieve medical outcomes, an area that has historically received less attention compared to outcome measurement itself.
The central objective of the study was to meticulously calculate the cost of T2DM care across primary, secondary, and tertiary healthcare settings using Time-Driven Activity-Based Costing (TDABC). This methodology was specifically chosen for its ability to compute detailed, patient-level costs and its uniform applicability across diverse healthcare settings, which is a key characteristic of T2DM management. TDABC also offers the advantage of providing a granular, bottom-up understanding of the care pathway, linking costs directly with health outcome data to provide a novel insight into the “true value” of healthcare delivery beyond purely economic terms.
To achieve its aim, the research constructed six distinct care pathways, representing patient profiles ranging from low-risk to high-risk over a 12-month care cycle. These profiles included patients with stable optimum glycaemic control, stable suboptimum glycaemic control, chronic kidney disease, active foot disease, moderate risk of active foot disease, and myocardial infarction. Data collection involved a multi-phase approach, including qualitative in-depth interviews with senior clinical staff to define patient profiles, vignette-based interviews to map decision-making and resource usage, and standard surveys to capture activity times and resources (TARs). Financial data, including personnel salaries, overheads, and equipment costs, were also gathered to calculate capacity cost rates and assign costs to each patient pathway. Health outcomes for matching patients were extracted and assessed based on lead clinician advice and American College of Cardiology/American Heart Association (ACC/AHA) guidelines for macrovascular and microvascular disease risks.
The results emphatically demonstrate that significant costs are incurred when patients develop acute complications of T2DM, contrasting sharply with the cost of maintaining patients at low or moderate risk. For instance, the annual cost for a patient with stable optimum glycaemic control was €798, while a patient experiencing myocardial infarction incurred an estimated cost of €21,926. This highlights that the cost of managing a low-risk patient is a mere 3% of that for a myocardial infarction patient and 16% of that for a patient with moderate risk of foot disease. Key drivers of cost variation identified include the duration of care pathways, the hours of practitioner time, the mix of personnel skill, medications, and consumables used. The study’s health outcome analysis, visually represented through radar charts, revealed a direct correlation: patients with better health outcomes consistently had lower annual care costs. These findings underscore the critical importance of investing in preventive care, enhanced patient self-management education, and specialist care at the community level to maintain stable glycaemic control, which not only improves patient outcomes but also significantly reduces the economic burden on national health services.
This study makes a significant contribution to the literature on value-based measurement and healthcare delivery, being the first to apply TDABC to a chronic illness like T2DM and to span both acute and community sectors. It provides ground-breaking data to inform the transformation of health service design around chronic conditions, advocating for a more integrated and value-based service delivery model. The analysis of process maps further suggests opportunities for enhanced decision-making regarding the optimal mix of personnel for greater clinical effectiveness and efficiency. Despite its innovative approach, the authors acknowledge limitations, including TDABC being a relatively new method for chronic conditions, the exploratory nature of the study with a small sample size, and the availability of only clinical outcome data (without patient-reported outcomes). Future research is encouraged to build on these findings by incorporating patient-reported outcomes and examining the costs of multiple complications and comorbidities.
Reference: Doyle, G. A., O’Donnell, S., Cullen, K., Quigley, E., Gibney, S., & The Diabetes Literacy Consortium. (2022). Understanding the cost of care of type 2 diabetes mellitus – a value measurement perspective. BMJ Open, 12(1), e053001. https://doi.org/10.1136/bmjopen-2021-053001.
