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Effects of a Population-Based Diabetes Management Program in Singapore
Woan Shin Tan, BSocSc, MSocSc; Yew Yoong Ding, MBBS, FRCP, MPH; Wu Christine Xia, BS(IT); and Bee Hoon Heng, MBBS, MSc
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Effects of a Population-Based Diabetes Management Program in Singapore

Woan Shin Tan, BSocSc, MSocSc; Yew Yoong Ding, MBBS, FRCP, MPH; Wu Christine Xia, BS(IT); and Bee Hoon Heng, MBBS, MSc
Patients utilizing Medisave for a diabetes management program in Singapore were more compliant with care processes, but reductions in hospitalization and costs were not sustained.
ABSTRACT
Objectives
We evaluated the impact of Singapore’s Medisave for Chronic Disease Management Program (CDMP) program for type 2 diabetes mellitus (T2DM) patients.

Study Design
A longitudinal study comparing differences in compliance with recommended diabetes care processes and management strategies, hospitalization, and costs among the Medisave for CDMP participants and propensity-matched nonparticipants.

Methods
Data on patients diagnosed with T2DM who participated in the Medisave for CDMP (n = 10,559) and eligible patients who did not participate (n = 22,089) were extracted from the National Healthcare Group (NHG) diabetes registry. Participants and nonparticipants were propensity-score matched. Processes of care, all-cause and diabetes-related hospitalization risk, and healthcare costs incurred in 2007, 2008, and 2009 were compared between groups. A difference-in-difference strategy and generalized estimating equation approach were used.

Results
Compliance with recommended processes of care improved significantly for program patients. Compared to nonparticipants, all-cause hospitalization risk for participants was significantly lower in 2007 (odds ratio [OR]: 0.76; 95% CI, 0.65-0.88) and 2008 (OR: 0.79; 95% CI, 0.68-0.92) but the difference was not statistically significant in 2009 (OR: 0.91; 95% CI, 0.79-1.05). Total healthcare cost was 14-15% lower for participants in 2007 and 2008 but not significantly different in 2009. Similar results were observed for diabetes-related hospitalization rates and inpatient costs. The policy did not have a significant impact on participants with wellcontrolled diabetes at baseline.

Conclusions
The extension of Medisave coverage to outpatient treatment increased the compliance with the processes of diabetes care. The policy reduced hospitalization risk and total healthcare cost in the short term but effects were not sustained by the third year.

Am J Manag Care. 2014;20(9):e388-e398
We evaluated the effects of the Medisave for Chronic Disease Management Program (CDMP), a population-based diabetes management program, on patients diagnosed with type 2 diabetes mellitus.
• The extension of Medisave for outpatient treatment was associated with an improvement in compliance with processes of diabetes care for participating patients.

•  Initial reductions in the odds of hospitalization and total healthcare cost associated with participation in the population-based diabetes management program were difficult to sustain.

• Nonetheless, cumulatively, there was a relative reduction in the overall healthcare cost for program patients over a 3-year period.
Diabetes is a challenging health problem worldwide. Internationally, the number of individuals with diabetes is estimated to increase from 366 million to 552 million by 2030.1 This emerging epidemic will have increasing implications for health policy worldwide, and for our country, Singapore. Global healthcare spending on diabetes is expected to grow by 30% over the next 20 years.2 Here, we face the same challenges of diabetes prevalence. Singapore’s growing affluence, lifestyle changes, and aging population have all contributed to the prevalence of diabetes growing from 2% in 1975 to 11.3% in 2010.3,4 Diabetes is a dynamically complex disease associated with an increased risk of microvascular and macrovascular complications. To improve health outcomes and contain costs, health systems have implemented disease management programs; they incorporate managing patients in accordance with accepted clinical guidelines, patient education, aggressive screening for complications, and early and appropriate specialty referral.5-7 Costs can be contained by slowing the development of diabetes-related complications. While individuals value interventions from which an immediate benefit can be derived, benefits from preventive interventions that accrue into the future are often underestimated.8 Therefore, disease management programs are often covered by thirdparty payers to reduce expenditures. Individual patients in fee-for-service systems such as Singapore’s, however, tend to find disease management programs less attractive financially.

Studies have shown that diabetes management programs are associated with substantial improvements in processes of care.6,9,10 However, greater compliance with processes has not been consistently linked to improvements in intermediate outcomes such as blood lipid levels.11 Several studies reported an improvement in clinical outcomes when patients were enrolled in diabetes management programs,6,12,13 whereas other studies found little impact.14,15 It is also widely believed that disease management programs lower healthcare expenditures by reducing hospital admissions and emergency department visits. However, systematic reviews have shown that the evidence substantiating this claim remains inconclusive.16,17

Despite mixed results from international studies and reviews, the Singapore Ministry of Health (MOH) launched the Medisave for Chronic Disease Management Program (CDMP) in October 2006. Type 2 diabetes mellitus (T2DM) was the first condition to be covered. Prior to this, Medisave could only be used for acute inpatient and day-surgery expenses. The restiction resulted in an underutilization of outpatient services because Medisave could not be drawn upon to offset the cost to patients.

The Medisave for CDMP aims to lower financial barriers to seeking outpatient treatment with the goal of improving compliance and preventing or delaying the development of complications that could lead to hospitalization and costly inpatient treatments.19 Although the Singapore MOH has published evaluations of the Medisave for CDMP policy,19-21 the pre-post analysis is prone to possible regression to the mean due to the absence of a control group. In this study, using a propensity score–matching approach, we examined the longitudinal effects of extending Medisave for a population-based diabetes management program. Specifically, the aim of our study was to assess whether the participants of the Medisave for CDMP compared with nonparticipants have 1) better compliance with the recommended processes of care, 2) lower risk of all-cause and diabetes-related hospitalization, and 3) lower total all-cause annual healthcare costs and diabetes-related inpatient costs. We also investigated the heterogeneity in results across patient subgroups differentiated by the presence of diabetes-related complications and level of glycemic control at baseline.

METHODS

Medisave for Chronic Disease Management Program (CDMP)


In Singapore, public healthcare is provided by 5 regional health systems: Alexandra Health (AH), Jurong Health Services (JHS), National Healthcare Group (NHG), National University Health System (NUHS), and Singapore Health Services (SHS). Together, these clusters provide 80% of all acute care service. The government primary care clinics under NHG and SHS provide approximately 20% of primary care services consumed. Each clinic provides general practitioner, nursing, allied health, and diagnostic services in a co-located facility.

Patients pay for outpatient care on a fee-for-service basis. Therefore, out-of-pocket payments associated with regular clinic visits and laboratory and screening tests can be high. Participants in the Medisave for CDMP, it was hypothesized, would face lower financial barriers and therefore be more compliant than nonparticipants with recommended strategies of diabetes management. The policy rationale was that this would in turn prevent or delay the onset of complications that would lead to hospitalization and costly inpatient treatments.

Therefore, in October 2006, individuals diagnosed with T2DM were allowed to use Medisave for outpatient care at public sector primary care clinics, public hospital specialist outpatient clinics, and private general practitioners. Previously, people were allowed to use their Medisave funds only for financing future medical needs related to, although the amount working Singaporeans contribute to these funds is substantial: 7% to 9.5% of their monthly wage, on average, for those who choose to enroll (participation in Medisave for CDMP is voluntary). Since T2DM set the precedent in October 2006, the plan has been extended to cover hypertension, hyperlipidemia, post–stroke care, asthma, chronic obstructive pulmonary disease (COPD), major depression, schizophrenia, bipolar disorder and dementia. Patients who visited the government primary care clinics for treatment of CDMP conditions incurred an annual bill of SGD 200 (USD 130) on average. SGD 300 (US $196 per account can be used per year (SGD 400 / US $261 from January 1, 2012). A SGD 30 (US $20) deductible per bill is applicable with another 15% copayment on the remaining balance (2006 exchange rate of US $1 = SGD 1.5336).

Evidence-based care components form the basis of the program. Participating clinics are all and have agreed to acceptpayments through. Although payments are not linked to performance, participating clinics must agree to submit the patient outcomes to the MOH.

Each year, a participating T2DM patient should receive all of the following: 2 glycated hemoglobin (A1C) tests; 2 blood pressure (BP) measurements; 2 body weight measurements; 1 serum cholesterol level (LDL-C) test; 1 retinal assessment; 1 foot assessment; 1 nephropathy screening assessment; and (for smokers) 1 smoking habit assessment. Clinics are also provided with guidelines on when to refer patients for specialist care, as well as educational tool-kits for use by the doctors help them explain to their patients more effectively. Patients also receive booklets for recording of vital clinical indicators to aid self-monitoring. The policy assumes that when the clinics have greater accountability, the compliance rates for participants will increase over time, eventually becoming higher in comparison with nonparticipants for whom results do not have to be submitted.

Data

The study cohort includes individuals diagnosed with T2DM who had at least 1 diabetes-related consultation visit at any of the 9 NHG primary care clinics in the preand immediate post policy years 2006 and 2007 respectively. We have excluded individuals who are non-Singapore residents and those aged 20 years and below. To exclude potential effect of expansion of the plan within our study time frame, patients with concurrent diagnoses of COPD, asthma, schizophrenia, and major depression were excluded. The final selected patient cohort was followed from January 1, 2006, to December 31, 2009, with baseline defined as the first primary care visit made by the patient in 2007.

We used data from a diabetes registry maintained by the National Healthcare Group (NHG). Patients diagnosed with T2DM were identified in the Chronic Disease Management Data-mart (CDMD) based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnostic codes (250.x0, 250. x2, 357.2, or 362.xx), which are available for patients who were discharged from the hospital or visited a primary care clinic. This is augmented by pharmacy medication records and laboratory records. More details on the algorithm used to identify patients with T2DM in the CDMD has been described elsewhere.22 The registry contains data on demographic characteristics, comorbid conditions, and clinical outcomes, as well as data about healthcare resource use.

The exposure of interest is participation in Medisave for CDMP. We have defined “participants” as patients who drew on Medisave to pay for NHG primary care clinics in all 3 years (2007, 2008, and 2009). Nonparticipants comprised patients who did not use Medisave at least once throughout the study time frame of 2006 to 2009. The main outcome variables were process indicators; risk of hospitalization; and total annual healthcare cost. For processes of care, we reported the percentage of participants and nonparticipants receiving guideline-prescribed measurements of A1C, BP, LDL-C, and body weight, as well as retinal, foot and nephropathy screenings.

Hospital admissions refer to inpatient episodes at acute care hospitals managed by 3 regional health clusters (JHS, NHG, and NUHS). Total annual healthcare costs refer to the cost of resources utilized at the primary care clinics, emergency departments, specialist outpatient clinics, and inpatient wards of these regional health clusters. To define diabetes-related hospitalizations and inpatient costs, we have adopted the diabetes-related hospitalization ICD-9-CM codes used in Jiang et al 200523 (eAppendix, available at www.ajmc.com). Hospitalizations with a principal diagnosis of diabetes, cardiovascular, renal disease, lower extremity disease, eye disease, and others (mycoses, fluid, and electrolyte disorders) were considered to be diabetesrelated for the study population comprising subjects diagnosed with T2DM.

Covariates include: age; gender; ethnicity (Chinese, Malay, Indian, or others); treatment regime (insulin or not); obesity; ICD-9-CM diagnosis of hypertension or hyperlipidemia; baseline glycemic control using A1C (<7%, 7-7.9%, ≥8%). We also constructed the 13-point Diabetes Complications Severity Index (DCSI) using ICD-9-CM codes of the primary and secondary diagnosis codes. It comprises 7 categories of complications and their severity levels: retinopathy, nephropathy, neuropathy, cerebrovascular, cardiovascular, peripheral vascular disease and metabolic.24 The DSCI score (0—indicating an absence of complications—1, 2, ≥3) has been shown to a good predictor of direct healthcare costs in Singapore.25

Statistical Analysis

 
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