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  1. 1. Clinical Economic Modeling in Lincolnshire Martin McShane Simon Swift The Information Centre Analytical Fair 9th September 2009
  2. 2. 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
  3. 3. 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.
  4. 4. 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 the future care pathway and to use the results of this anaylsis as a toolkit for commissioning. 1 2 3 Aims
  5. 5. Building the Current Pathway Model The model design was created by Courtyard Group in close association with the core team and based on the pathway mapping from the wider stakeholder 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: Spotlight Lincoln South: 9.8% type 2s attending Spotlight East Lindsey: 0 % type 2s offered Spotlight Dietician North West Lincs: 48.8% type 2s seeing dietician/year Mid Kesteven: 1.2 % type 2s seeing dietician/year Podiatrist Skegness & Coast: 51.1% type 1s seeing podiatrist/year Welland: 8.5 % type 1s seeing podiatrist/year L o w H i g h
  6. 6. 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
  7. 7. 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 identify undiagnosed 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).
  8. 8. Education as Secondary Prevention Education programmes for secondary prevention normally include guidance on 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 levels by 1.1-1.6% in type 1 diabetes patients and 0.8-1.25% in type 2 diabetes patients (Loveman et al 2003).
  9. 9. Boston Current Pathway Model
  10. 10. Boston Type 2 Diabetes Pathway Branch
  11. 11. New Pathway
  12. 12. Pathway Elements Tier Key Service Elements Level 1: Core Primary Care Promoting healthy lifestyles- 1:1 support Systematic and opportunistic screening for diabetes and IFG/IGT and complications of diabetes Maintaining 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 medication Referral to structured education or relevant specialist(s), including smoking cessation and weight management Psychological 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
  13. 13. 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 linked together creating supermodel. This could then be run to provide a direct comparison of costs and outcomes between current models and future model.
  14. 14. The ‘Supermodel’
  15. 15. Why Change? – The Evidence O 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 for Patients with Diabetes Mellitus Number of New OPD Appointments 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%
  16. 16. Change requirements 3.06 times current workforce to achieve realistic future state. W o r k f o r c e : All workforce requirements are after 10 years. 8.52 times current workforce to achieve realistic future state. 12.29 times current workforce to achieve realistic future state. 12.78 times current workforce to achieve realistic future state. 7.04 times current workforce to achieve realistic future state. Podiatry I n t e r v e n t i o n : DSN Education - Spotlight Education - Select Dietician
  17. 17. 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
  18. 18. 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
  19. 19. Any Questions? Thank you