THE APPLICATION OF POLICY DISEASE MODELS TO HEALTH CARE DECISION-MAKING IN DIABETES: FINDINGS FROM AN EVALUATION OF FOUR STRATEGIES FOR THE MANAGEMENT OF TYPE 2 DIABETES USING THE ONTARIO DIABETES ECONOMIC MODEL (ODEM)

Background:  The Ontario Diabetes Economic Model (ODEM) is the first successful policy disease model created for policy decision-making in Ontario.  It provides a common evidence-based platform for evaluating technologies for the same disease.  After the announcement of the Ontario Diabetes Strategy (ODS), an analysis was undertaken by the Medical Advisory Secretariat (MAS) and the Program for Assessment of Technology in Health (PATH) Research Institute to evaluate several components of the ODS.  It was hypothesized that the ODEM could help provide decision makers with information to better inform healthcare decision-making and prioritization of these strategies.      

Purpose: To compare the lifetime costs, effects and cost effectiveness of four strategies for the successful management and treatment of type 2 diabetes using the ODEM. 

Methods: Systematic literature reviews were conducted on multidisciplinary programs, behavioural interventions, bariatric surgery (in morbidly obese diabetics), and continuous insulin infusion pumps for the management and treatment of type 2 diabetes.  The primary outcome across all studies was the reduction in haemoglobin A1c (HbA1c). Meta-analyses were performed for each of the identified strategies to determine the efficacy of the intervention on lowering HbA1c and pooled estimates of effect were used in the ODEM.     

Results: Based on an analysis from the ODEM, using data on clinical efficacy obtained from the systematic reviews, behavioural interventions, multidisciplinary programs, and bariatric surgery would be considered cost effective for the treatment and the management of adults with type 2 diabetes.  The costs per QALY of each of the interventions was $36,226, $19, 869, and $15,697 respectively.  Insulin pumps were not found to be cost effective for all patients ($1.9 M per QALY) or for the age 65+ subgroup.  The direction of prioritization (low to high) based on the evidence would be behavioural interventions, bariatric surgery and then community multidisciplinary programs. Priority of funding is based partly on value for money (i.e.  cost per QALY) and impact on reducing downstream complications from diabetes. 

Conclusions: The evidence available suggests that policy disease models can influence health care decision-making and prioritization of several strategies around a disease.  In the case of diabetes, all strategies were cost effective with the exception of insulin pumps.  The most cost-effective strategy was multidisciplinary programs.  The determination of relative cost-effectiveness would require head-to-head field evaluation information.