title: Estimated Cost-Effectiveness, Cost Benefit, and Risk Reduction Associated with an Endocrinologist-Pharmacist Diabetes Intense Medical Management "Tune-Up" Clinic.
abstract: BACKGROUND
  In 2012 U.S. diabetes costs were estimated to be $245 billion, with $176 billion related to direct diabetes treatment and associated complications. Although a few studies have reported positive glycemic and economic benefits for diabetes patients treated under primary care physician (PCP)-pharmacist collaborative practice models, no studies have evaluated the cost-effectiveness of an endocrinologist-pharmacist collaborative practice model treating complex diabetes patients versus usual PCP care for similar patients.
  
  
  OBJECTIVE
  To estimate the cost-effectiveness and cost benefit of a collaborative endocrinologist-pharmacist Diabetes Intense Medical Management (DIMM) "Tune-Up" clinic for complex diabetes patients versus usual PCP care from 3 perspectives (clinic, health system, payer) and time frames.
  
  
  METHODS
  Data from a retrospective cohort study of adult patients with type 2 diabetes mellitus (T2DM) and glycosylated hemoglobin A1c (A1c) ≥ 8% who were referred to the DIMM clinic at the Veterans Affairs San Diego Health System were used for cost analyses against a comparator group of PCP patients meeting the same criteria. The DIMM clinic took more time with patients, compared with usual PCP visits. It provided personalized care in three 60-minute visits over 6 months, combining medication therapy management with patient-specific diabetes education, to achieve A1c treatment goals before discharge back to the PCP. Data for DIMM versus PCP patients were used to evaluate cost-effectiveness and cost benefit. Analyses included incremental cost-effectiveness ratios (ICERs) at 6 months, 3-year estimated total medical costs avoided and return on investment (ROI), absolute risk reduction of complications, resultant medical costs, and quality-adjusted life-years (QALYs) over 10 years.
  
  
  RESULTS
  Base case ICER results indicated that from the clinic perspective, the DIMM clinic costs $21 per additional percentage point of A1c improvement and $115-$164 per additional patient at target A1c goal level compared with the PCP group. From the health system perspective, medical cost avoidance due to improved A1c was $8,793 per DIMM patient versus $3,506 per PCP patient (P = 0.009), resulting in an ROI of $9.01 per dollar spent. From the payer perspective, DIMM patients had estimated lower total medical costs, a greater number of QALYs gained, and appreciable risk reductions for diabetes-related complications over 2-, 5- and 10-year time frames, indicating that the DIMM clinic was dominant. Sensitivity analyses indicated results were robust, and overall conclusions did not change appreciably when key parameters (including DIMM clinic effectiveness and cost) were varied within plausible ranges.
  
  
  CONCLUSIONS
  The DIMM clinic endocrinologist-pharmacist collaborative practice model, in which the pharmacist spent more time providing personalized care, improved glycemic control at a minimal cost per additional A1c benefit gained and produced greater cost avoidance, appreciable ROI, reduction in long-term complication risk, and lower cost for a greater gain in QALYs. Overall, the DIMM clinic represents an advanced pharmacy practice model with proven clinical and economic benefits from multiple perspectives for patients with T2DM and high medication and comorbidity complexity.
  
  
  BACKGROUND
  No outside funding supported this study. The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Preliminary versions of the study data were presented in abstract form at the American Pharmacists Association Annual Meeting & Exposition; March 27, 2015; San Diego, California, and the Academy of Managed Care Pharmacy Annual Meeting; April 21, 2016; San Francisco, California. Study concept and design were contributed by Hirsch, Bounthavong, and Edelman, along with Morello and Morreale. Arjmand, Ourth, Ha, Cadiz, and Zimmerman collected the data. Data interpretation was performed by Ha, Morreale, and Morello, along with Cadiz, Ourth, and Hirsch. The manuscript was written primarily by Hirsch and Zimmerman, along with Arjamand, Ourth, and Morello, and was revised by Hirsch and Cadiz, along with Bounthavong, Ha, Morreale, and Morello.
authors.affiliation: 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, and Veterans Affairs of San Diego Healthcare System, San Diego, California.
authors.forename: Jan D
authors.initials: JD
authors.lastname: Hirsch
authors.affiliation: 2 Veterans Affairs San Diego Healthcare System, San Diego, California.
authors.forename: Mark
authors.initials: M
authors.lastname: Bounthavong
authors.affiliation: 2 Veterans Affairs San Diego Healthcare System, San Diego, California.
authors.forename: Anisa
authors.initials: A
authors.lastname: Arjmand
authors.affiliation: 3 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla.
authors.forename: David R
authors.initials: DR
authors.lastname: Ha
authors.affiliation: 3 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla.
authors.forename: Christine L
authors.initials: CL
authors.lastname: Cadiz
authors.affiliation: 3 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla.
authors.forename: Andrew
authors.initials: A
authors.lastname: Zimmerman
authors.affiliation: 4 Pharmacy Benefit Management Services, Department of Veterans Affairs, Washington, DC.
authors.forename: Heather
authors.initials: H
authors.lastname: Ourth
authors.affiliation: 4 Pharmacy Benefit Management Services, Department of Veterans Affairs, Washington, DC.
authors.forename: Anthony P
authors.initials: AP
authors.lastname: Morreale
authors.affiliation: 5 Veterans Affairs of San Diego Healthcare System, San Diego, California; University of California, San Diego, La Jolla; and Taking Control of Your Diabetes, Del Mar, California.
authors.forename: Steven V
authors.initials: SV
authors.lastname: Edelman
authors.affiliation: 1 Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, and Veterans Affairs of San Diego Healthcare System, San Diego, California.
authors.forename: Candis M
authors.initials: CM
authors.lastname: Morello
mesh_terms: D003362:Cost-Benefit Analysis / Q000191:economics*; D048909:Diabetes Complications / Q000191:economics / Q000378:metabolism; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy* / Q000191:economics* / Q000378:metabolism; D000072097:Endocrinologists / Q000191:economics*; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000191:economics / Q000627:therapeutic use; D008297:Male; D008329:Managed Care Programs / Q000191:economics; D054539:Medication Therapy Management / Q000191:economics*; D008875:Middle Aged; D010593:Pharmaceutical Services / Q000191:economics*; D010595:Pharmacists / Q000191:economics*; D011320:Primary Health Care / Q000191:economics; D012189:Retrospective Studies; D040242:Risk Reduction Behavior
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents