title: Changes in costs and effects after the implementation of disease management programs in the Netherlands: variability and determinants.
abstract: OBJECTIVE
  The aim of the study was to investigate the changes in costs and outcomes after the implementation of various disease management programs (DMPs), to identify their potential determinants, and to compare the costs and outcomes of different DMPs.
  
  
  METHODS
  We investigated the 1-year changes in costs and effects of 1,322 patients in 16 DMPs for cardiovascular risk (CVR), chronic obstructive pulmonary disease (COPD), and diabetes mellitus (DMII) in the Netherlands. We also explored the within-DMP predictors of these changes. Finally, a cost-utility analysis was performed from the healthcare and societal perspective comparing the most and the least effective DMP within each disease category.
  
  
  RESULTS
  This study showed wide variation in development and implementation costs between DMPs (range:€16;€1,709) and highlighted the importance of economies of scale. Changes in health care utilization costs were not statistically significant. DMPs were associated with improvements in integration of CVR care (0.10 PACIC units), physical activity (+0.34 week-days) and smoking cessation (8% less smokers) in all diseases. Since an increase in physical activity and in self-efficacy were predictive of an improvement in quality-of-life, DMPs that aim to improve these are more likely to be effective. When comparing the most with the least effective DMP in a disease category, the vast majority of bootstrap replications (range:73%;97) pointed to cost savings, except for COPD (21%). QALY gains were small (range:0.003;+0.013) and surrounded by great uncertainty.
  
  
  CONCLUSIONS
  After one year we have found indications of improvements in level of integrated care for CVR patients and lifestyle indicators for all diseases, but in none of the diseases we have found indications of cost savings due to DMPs. However, it is likely that it takes more time before the improvements in care lead to reductions in complications and hospitalizations.
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR, The Netherlands ; Department of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR, The Netherlands.
authors.forename: Apostolos
authors.initials: A
authors.lastname: Tsiachristas
authors.affiliation: Department of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR, The Netherlands.
authors.forename: Jane Murray
authors.initials: JM
authors.lastname: Cramm
authors.affiliation: Department of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR, The Netherlands.
authors.forename: Anna P
authors.initials: AP
authors.lastname: Nieboer
authors.affiliation: Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR, The Netherlands ; Department of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR, The Netherlands.
authors.forename: Maureen Pmh
authors.initials: MP
authors.lastname: Rutten-van Mölken
keywords: COPD; Cardiovascular disease; Coordinated care; Costs; Diabetes; Effectiveness
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