Edelman et al. (2010)69
USA | RCT | Cost of group clinics in terms of staff time | Staff time for clinic and for follow-up telephone calls | In 2009 USD, estimated cost of US$504 (range US$445–578) to conduct each group visit | Each group visit accommodates eight patients; per-patient cost is US$63 (range US$56–72). If patients attended all seven GMC sessions, annual per-patient cost would be US$441 (range US$389–506). Follow-up calls cost an additional US$19 (range US$4–48), which brings annual per-patient cost to US$460 (range US$393–554) | | | |
Clancy et al. (2008)62
USA | RCT | Impact of group clinics on patient costs to access other parts of the health system | | | | | Mann–Whitney test results show that group visit patients had 34.7% higher outpatient expenditures, 49.1% lower ED expenditures and 30.2% lower total expenditures than the control group (p < 0.05 for all). Based on these initial estimates, it seemed that group visit treatment increased outpatient costs by US$699.52 per patient per year. Although we found a statistically significant and marginally positive effect on group visits in the outpatient cost model that did not correct for endogeneity, the treatment effect model showed a statistically significant marginally negative effect of group visit treatment on outpatient charges of US$3065.47 | This cost study of group visits among inadequately insured patients with type 2 DM showed statistically significant reductions in outpatient charges after controlling for endogeneity of the group visit variable in the charge model via a treatment effect model. Because the group visit model of care is an intervention that depends on patient adherence, we hypothesised and found evidence of endogeneity of the group visit variable. Therefore, we believe that future studies on group visits should consider the potential for endogeneity in estimating the effect of group visit treatment on health-care utilisation and charges |
Clancy et al. (2003)58
USA | RCT | Outpatient, inpatient and emergency room costs and use (visits to outpatients and emergency room and admissions to inpatients) for patients who had participated in a group clinic intervention | Wilcoxon’s rank test | | | In the 6-month study period, overall costs were significantly higher (p = 0.0003) for group visit patients (US$2886 per patient) than control patients (US$1490 per patient)
Outpatient (US$1444 intervention and US$1099 control) and inpatient (US$1410 intervention and US$365 control) costs were statistically significant (p = 0.008 and p = 0.049) respectively but ED costs were not | | Higher costs for patients in group visits differs from previous studies. Findings should be interpreted with caution given small samples group visits may have served to ‘activate’ participants and possible time lag for decreased costs |
Wagner et al. (2001)86
USA | RCT | Primary care visits (mean/year). ER visits (mean/year). Specialty visits (mean/year) Hospital admissions (% admitted). Totals costs (median USD)
Examined intervention vs. control | Health-care uses and costs were also obtained from group health co-operative administrative data systems. The time required of the clinical study personnel is not included in the total health-care costs | | | Total health care costs did not differ between the groups | | Although chronic care clinics relied on existing clinic personnel to deliver services, study nurses played an important role that must be considered when estimating the full cost of the intervention |
Crane et al. (2012)136
USA | Intervention, including a DIGMA. Group size was 36 patients | | | Total annualised direct costs of programme, including value of donated physician time, was US$66,000 | | Total annualised cost of programme was US$66,000 ED use dropped from a rate of 0.58 per patient per month to 0.23 (p < 0.001), and hospital charges dropped from US$1167 per patient per month to US$230 (p < 0.001) | Total ED and inpatient mean charges per person per month fell from US$1167 for the 12 months before enrolment to US$230 since enrolment (p < 0 .001) | Low-income or uninsured may be more likely to use ED for non-emergent care because of reduced access to primary care or complex social, behavioural health, or physical health needs that are difficult to address in traditional primary care settings |
Levine et al. (2010)137
USA | Retrospective case-control design | Total direct health-care costs (all costs directly related to delivering health-care services) for individual in year after first group visit was primary outcome | Evaluate differences in direct costs and utilisation during the first year of the intervention
Because a few patients incurred higher total costs than others, the distribution of total cost was heavily skewed. Natural logarithm transformation of total costs was used in a linear regression model. Multivariate negative binomial regression was used for primary care and specialty care utilisation. Multivariate logistic regression was performed for urgent care and hospital utilisation | | | | Intervention patients had lower total costs in 12 months preceding intervention (mean total costs US$7968 vs. US$10,215; p = 0.007)
Total costs remained lower for group that participated in group visits than for controls but not statistically significant (US$8845 vs. US$10,288; p = 0.11)
No significant differences between intervention and controls on any form of utilisation: hospital admission, urgent care visits, primary care visits and visits to specialists. Group visits were not counted in the primary care visit counts | After adjustment for case mix, comorbidity, baseline costs and baseline utilisation, group visit intervention was not associated with an effect on total costs
Total costs were not statistically different for intervention patients and controls (US$8845 vs. US$10,288; p = 0.11) |
Scott et al. (2004)79
USA | RCT | Service utilisation and resulting costs were measured for 12 months before patient’s study enrolment and for 24 months after enrolment. Outpatient utilisation costs were measured for visits to each type of clinic department and provider
Pharmacy charges
A claims and referral database that tracks services and costs not directly provided by health plan provided hospital, ED, professional services, home health and skilled nursing facility charges
The total cost for all CHCC group meetings was estimated as the sum of the costs for each meeting based on the amount of time providers spent at the meeting and their mean hourly salaries. There were no adjustments for the number of patients attending a meeting because the cost of a meeting remained the same regardless of how many patients attended | | Average physician cost was US$375 (77.4% of total average cost) | | | CHCC members had significantly lower costs associated with ED visits than controls. No other significant differences in utilisation costs. Hospital, professional services and health-plan termination costs approached significance (p < 0.01), with lower costs in the CHCC group
Average per patient group cost over 24 months was US$484, which included salary and overheads for physician, nurse and any other provider attending the group
The average monthly cost advantage per CHCC member over the 24 months of the study was US$133 (US$463 for control patients US$330 for CHCC). The cost advantage for CHCC patients before the start of the study was US$92 per patient per month. CHCC group members’ monthly costs were US$42 per member less than those of control members when adjusted for costs 12 months before the start of the study (US$133 cost advantage during the study – US$92 cost advantage before the study), but this difference was not statistically significant | Service utilisation savings came from prevention of more costly ED visits, hospital admissions and professional services |
Bondonio et al. (2005)134
Italy | Cost-effectiveness analysis of two interventions from quasi-societal point of view | Differential direct costs to health service (staff and educational material costs) or to patients (transportation and opportunity costs) | Cost-effectiveness ratios for group care are calculated with sole reference to differential outcomes and costs (i.e. so where there is an overlap between costs of usual care and costs of group clinics, these are not accounted for) | T2DM:
Average estimated value of staff time led to a total cost of €126.43 per patient on group care and €66.37 per control patient | Costs to see one patient over study period: €111.50 for group care and €90.44 for individual consultations | In total, each patient on group care cost €831.57 and each control cost €731.82 with a difference of €99.75 per patient treated over the observation period
T1DM:
Direct costs for Indian NHS over 3 years totalled €271.24 for group care patients and €120.15 for control patients
The total cost differential between the group care and the control procedure was, therefore, €236.60 over 3 years | Transportation costs for patients were €48.45 for group care and €38.34 for controls
| Each incremental improvement in quality of life for patients on group care was obtained with an expenditure (i.e. cost-effectiveness ratio) of €2.28
T1DM:
‘. . . a cost-effectiveness ratio of €19.46 per each of 12.16 differential DQoL scores’. Not possible to calculate quality-adjusted life-years |
