DLM: Self-Management and Individualized Counseling (2001)

Citation:
 
Study Design:
Class:
- Click here for explanation of classification scheme.
Quality Rating:
Research Purpose:

The purpose was to measure the potential savings from medical nutrition therapy (MNT) and to estimate the net cost to Medicare of covering MNT services for Medicare enrollees. This includes developing an estimate of the cost of providing medical nutrition services to the Medicare population and estimating the savings in hospital and other spending resulting from the use of these services.

Inclusion Criteria:

Longitudinal data for persons aged 55 years and older who had Medicare coverage under Group Health Cooperative of Puget Sound and were diagnosed with diabetes, CVD or renal disease.

Exclusion Criteria:

Records of individuals who did not meet inclusion criteria.

Description of Study Protocol:

Design

Correlation study (analysis of longitudinal data).

Statistical Analysis

  • Data included longitudinal data for persons aged 55 years and older who had diabetes (N=12,308), cardiovascular disease (N=10,895) or renal disease (N=3,328) and who were covered under the Group Health Cooperative of Puget Sound, including Medicare beneficiaries enrolled in the plan's Medicare risk contract program
  • Extrapolation to the US Medicare population is based on data for persons served by the Group Health Cooperative of Puget Sound. Differences in health care utilization levels of persons with diabetes, cardiovascular disease and renal disease who do and do not receive MNT.
  • Differences in utilization were estimated for hospital discharges per calendar quarter, physician visits per quarter and other outpatient visits per quarter. Multivariate regression models of changes in utilization for persons after they receive MNT services.
Data Collection Summary:

Timing of Measurements

Collected data for members of Group Health Cooperative of Puget Sound for up to 24 quarters.

Dependent Variables

Differences in health care utilization by persons with diabetes, cardiovascular disease and renal disease who do not receive MNT were estimated for hospital discharges by quarter, physician visits per quarter and other outpatient visits per quarter.

Intervention

Use of medical nutrition therapy.

Description of Actual Data Sample:
  • Initial N: Diabetes (N=12,308), cardiovascular disease (N=10,895) or renal disease (N=3,328)
  • Location: Used data from Group Health Cooperative of Puget Sound, WA and extrapolated estimated cost and savings to Medicare under a bill to cover MNT services.
Summary of Results:
  • MNT was associated with a reduction in utilization of hospital services of 9.5% for patients with diabetes and 8.6% for patients with cardiovascular disease. Also, utilization of physician services declined by 23.5% for MNT users with diabetes and 16.9% for MNT users with cardiovascular disease.
  • There was a reduction in number of physician visits per calendar quarter after initial dietitian visit for diabetes patients. The average number of physician visits per quarter was 2.788 for diabetes patients. Utilization is reduced to a lower level based on the diet serve variable in the quarter in which the first MNT visit occurred and is subsequently reduced further in quarters following that visit based on the quarter since variable.
  • The estimated change in physician visits per quarter were 9.441 in the first quarter after the dietitian visit, 10.247 for the fourth quarter following the initial visit and 7.812 for the eighth quarter after the initial visit
  • The MNT variables in the renal disease equations were not statistically significant
  • The net cost of covering MNT under Medicare is estimated to be $369.7 million over the 1998 through 2004 period. The total cost of benefits is estimated to be $2.7 billion over this period.This would be partially offset by estimated savings of $2.3 billion, resulting in net costs of $369.7 million. The program would actually yield net savings after the third year of the program, which would continue through 2004 and beyond.

 

Summary of the Net Cost of Covering Medical Nutrition Therapy (MNT) under Medicare (in Millions)*

Variable

Cover MNT Visits for all Medicare Beneficiaries

 

1998

1999

2000

2001

2002

2003

2004

1998-2004

Cost of MNT benefits

$346.1

$359.9

$374.2

$389.2

$404.5

$420.6

$437.8

$2732.3

Savings

$85.0

$183.2

$295.2

$400.6

$430.0

$465.7

$502.9

$2362.9

Net costs

$261.1

$176.7

$79.0

($11.4)

($25.5)

($45.1)

($65.1)

($369.7)

Part A (Savings in Hospital spending)

($44.4)

($94.7)

($153.5)

($211.4)

($229.1)

($247.3)

($267.1)

($1247.5)

Part B (savings in physician spending)

$305.5

$271.4

$232.5

$200.0

$203.6

$202.2

$202.0

$1617.2

*Assumes no change in part B premium.

 

 

Author Conclusion:
  • After an initial period of implementation, coverage for MNT can result in a net reduction in health services utilization and costs for at least some populations
  • In the case of persons aged 55 years and older, the savings in utilization of hospital and other services will actually exceed the cost of providing the MNT benefit
  • These results suggest that Medicare coverage of MNT has the potential to pay for itself with savings in utilization for other services.

 

Funding Source:
Not-for-profit
The Lewin Group, Falls Church, VA
Other non-profit:
Reviewer Comments:
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? Yes
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) No
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? Yes
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) N/A
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? N/A
  4.1. Were follow-up methods described and the same for all groups? N/A
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) N/A
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? N/A
  4.4. Were reasons for withdrawals similar across groups? N/A
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) Yes
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? Yes
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? N/A
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? N/A
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? Yes
  6.6. Were extra or unplanned treatments described? Yes
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? N/A
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? N/A
  8.6. Was clinical significance as well as statistical significance reported? Yes
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes