JAMIA: More data needed on CDS' long-term economic benefits

Researchers from the department of clinical epidemiology and biostatistics at McMaster University, while evaluating the long-term cost-effectiveness of a clinical decision support system (CDS) linked to evidence-based treatment recommendations for type 2 diabetes, found that a web-based prototype CDS system slightly improved short-term risk factors.

The findings were published in the May edition of the Journal of the American Medical Informatics Association.

Daria O’Reilly, PhD, from Hamilton, Ontario-based McMaster University, and colleagues estimated the cost-effectiveness through changes in factors (eg, HbA1c) from a randomized controlled trial using the Ontario Diabetes Economic Mode (ODEM). ODEM is a patient-level computerized simulation model that predicts the likely occurrence and cost of seven major diabetes-related complications (myocardial infarction, amputation, renal failure, stroke, blindness, ischemic heart disease, congestive heart failure) over a lifetime for patients with specified characteristics and time-varying risk factors.

The researchers assessed the cost of implementation, development and maintenance of the core dataset, as well as the projected diabetes-related complications.

A total of 511 patients 18 years of age and older, with a diagnosis of type 2 diabetes, were randomized into the study, 253 in the intervention group and 258 in the control group. The mean age of patients was 61 years in the intervention group and 60.5 years (SD=11.9) in the control group. The base case assumed a one-year treatment effect, 5 percent discount rate and 40-year time horizon. The perspective was the Ontario Ministry of Health and costs were in 2010 Canadian dollars.

The cost of implementing the intervention was CAD$483,699 (USD$489,029). “The one-year intervention reduced HbA1c by 0.2 and systolic blood pressure by 3.95mm Hg, but increased body mass index by 0.02kg/m², resulting in a relative risk reduction of 14 percent in the occurrence of amputation,” the authors found. “The model estimated that the intervention resulted in an additional 0.0117 quality-adjusted life year; the incremental cost-effectiveness ratio was CAD$160,845 (USD$162,617) per quality-adjusted life-year.”

The authors acknowledged the model has a few limitations, including its inability to assess uncertainty. "Uncertainty over the results of an analysis implies the possibility of incorrect decision making that would impose a cost in terms of benefits foregone," wrote the authors." A new model interface is being planned to address this limitation."

Additionally, the CDS system was implemented in a small group of practices and broader implementation would enable considerable economies of scale in initiating and maintaining the system. “In addition, the intervention period was short and over the longer term the intervention may be more economically attractive given that the upfront investment in infrastructure has been made (eg, roll-out costs),” the authors added.

The model predicted moderate improvements in long-term health outcomes, according to the report.

“The acceptance and diffusion of new information technologies used to manage chronic diseases is limited without evidence of both clinical and cost effectiveness,” the report concluded. “This study is one of the only true economic evaluations (ie, includes both costs and effects) of a CDS system for diabetes management. Although CDS systems for chronic disease management may improve the quality of care for patients with chronic disease, long-term studies are required to show the economic benefit and financial return on investment.”