Discussion
This study assessed the effect of PA counselling intervention on the number of contacts and costs of physicians’ and nurses’ appointments related to T2D and MSD per person-year in PHC and SHC before and after PA intervention in the intervention and control groups. To our knowledge, there is no earlier research on the effects of the PA counselling of patients with T2D on the use of other health services and related costs. The primary finding of this study is that among the participants in the intervention, the number of physician and nurse appointments in the PHC related to T2D decreased (physicians—11%, nurses—25%), while it increased in the control group (physicians +16.6%, nurses +24%) after the intervention.
The number of physician appointments related to MSD in PHC decreased in the intervention group. In the intervention group, T2D-related costs of physician and nurse appointments per person-year in PHC decreased (−8%) and increased in the control group (+10%) after the intervention. Also, total costs of physician and nurse appointments related to either T2D or MSD per person-year in PHC and SHC in the intervention group decreased and increased in the control group after the intervention.
Clinical studies have found that enhancement of the treatment to achieve glycaemic control, and in this way reducing or preventing complications, may be one of the most cost-effective interventions for patients with T2D with inadequate glycaemic control.29 A study by Johansen et al30 observed that lifestyle interventions can maintain glycaemic control to at least the same extent as medication. Hence, in addition to medication, the measures supporting healthy lifestyles should always be key components of the treatment of patients with T2D.31 Our study found that, in addition to positive treatment effect on HbA1c levels that have been reported earlier,22 participating in PA counselling also decreased the number of physician and nurse appointments related to T2D in the PHC.
Among patients with unsatisfactory glycaemic control, an association between visit frequency and better diabetes control has been shown in several studies.32–34The patients with T2D with poor glycaemic control showed significant and clinically meaningful improvements in HbA1c when contacted weekly by members of the healthcare system.35 The international diabetes guidelines recommend regular and frequent visits, for example, every 3 months, and evaluation of the therapy until stable glycaemic control is achieved.36 37 Every effort to improve the glycaemic control and well-being of patients with T2D is important in order to reduce diabetic complications.38 Our study showed that a positive effect on achievement of treatment targets can also be achieved with PA counselling services,22 simultaneously reducing the need of other contacts to health services.
Given the rising incidence of T2D, and thus the burden on healthcare services, health economic (HE) evaluations of the management of T2D are becoming increasingly relevant worldwide.29According to Liebl et al,29 HE studies have shown that in T2D hospital inpatient care, mostly due to diabetes complications, the costs are considerably high. Instead, diabetes medication-related and supplies-related costs are much lower.29 In turn, Nuckols et al39 reported in their review that multifaceted QI interventions that lower HbA1c appear to be a reasonably good value relative to usual care.39
Prior studies indicate that improvements in HbA1c can be associated with declines in healthcare utilisation and expenditures in the short term and long term.40 41 Li et al40 reported that the multicomponent interventions are more effective in risk factor control and early prevention of complications and, thus, more cost saving compared with standard glycaemic control for persons with T2D. Sidorov et al41 reported that a specific disease management programme showed to be associated with a significant reduction in healthcare costs and other measures of healthcare use in patients with diabetes. Our study showed a cost reduction related to the decrease in other than intervention appointments. Our intervention itself led to, on average, a cost of €255 per person, which exceeds the 1-year cost reduction observed in costs of appointments related to T2D or MSD. However, the intervention cost is only realised during the intervention period, but the reduction in costs of other appointments can be cumulative during several years if improvements in lifestyles and treatment balance is achieved. So, it would be important to analyse the longer-term impact of the intervention. Also, in our study, only T2D-related and MSD-related visits were included in the analyses, as they are the most common causes of healthcare contacts among patients with T2D. Intervention might have also influenced the need of some other services, such as preventive, mental health, emergency and rehabilitation services.
Huckfeldt et al42 estimated the association of effective lifestyle interventions for weight loss with long-term healthcare use and Medicare spending. This ancillary study used data from the Look AHEAD randomised clinical trial, which randomised participants with T2D to an intensive lifestyle intervention (ILI) or control group. They found that reductions in healthcare use and spending associated with an ILI for T2D decreased as participants aged. We also found that the effects on healthcare visits seemed to be bigger among elderly women but also among men under 65 years of age. They also stated that their ILI clinical trial was not associated with reduced total Medicare spending in the years immediately following the intervention.42 However, from the same trial, Espeland et al43 reported that ILI led to reductions in annual hospitalisations, hospital days and number of medications, resulting in cost savings for hospitalisation and medication across an average of 10 years.43
As healthcare costs associated with chronic illnesses are constantly increasing, it is imperative to identify interventions to reduce long-term spending without harming patient care.42 Usually, the effect of interventions on healthcare costs are caused via improved treatment balance and thus reduce the need for appointments. In our study, we have been able to assess only the short-term effects of PA counselling provided in PHC settings on achieving treatment targets22 and on health service use and costs. There is a need for longer-term analyses, taking also into account the possible decline in the onset of complications among patients attending lifestyle counselling.
In our study, the physician appointments in the PHC decreased most among those with increased HbA1c levels, but the number of nurse appointments related to T2D in PHC decreased irrespective to the change in HbA1c or BMI. The visits to the PA counsellor might have also provided the patients with other types of support that may have normally been handled by nurses.42 However, aiming at better control is supported by the results by Wagner et al24 who compared healthcare utilisation and costs over a 5-year period between two cohorts of diabetic patients: a group whose glycaemic control improved and a group in whom it did not improve. Their study suggested that a sustained reduction in HbA1c levels among adult diabetic patients is associated with significant cost savings within 1–2 years of improvement.
The start of exercise training may see numerous acute and chronic health issues arise in individuals with T2D, especially if they have been very inactive. Of primary concern are exercise-related hypoglycaemia and hyperglycaemia.44 Increase in exercise might have also caused changes in other risk factors like blood pressure and thus caused a need for changes in medication and visits to the physician. In our study, we did not observe any remarkable increase in T2D-related SHC visits. Musculoskeletal injury is the most common exercise-related complication.45 46 Unaccustomed exercise demands, especially during the initial weeks of a physical conditioning regimen, often result in muscle soreness, musculoskeletal injury and attrition.47 48 In this study, a decrease was observed in MSD-related physician appointments in PHC and no change in SHC. It can be concluded that there was no increase in musculoskeletal injuries or other severe problems in the intervention group with the started exercise. Instead, the intervention participants benefited from the intervention in terms of their musculoskeletal health and had fewer physician appointments. A small increase in nurse appointments in SHC might be due to less severe acute symptoms related to the start of the exercise.
The study was conducted in a ‘real-world’ setting, and the results can be generalised to normal operation of healthcare. This can be considered as one of the strengths of this study. In the absence of a traditional study design, the study participation did not influence patient behaviour. All data needed for the study were collected from EHRs. The absence of the traditional study design and data extraction retrospectively from the existing EHRs resulted in the measurement data remaining partly incomplete. The measurement and laboratory data are based on the actual activities of the healthcare and thus the data are missing for patients who did not visit in healthcare or regular laboratory check-ups. The information on appointments in the health services was also achieved from the EHRs, giving reliable and objective information on contacts. However, the number of physiotherapist visits is most likely underestimated as they less often record ICD-10 or ICPC-2 codes for the appointments compared with physicians and nurses for whom it is mandatory. In addition, the registry does not, however, include information from private service providers and thus might somewhat underestimate the number of visits. However, it is unlikely that the share of use of public and private services would have changed during the follow-up period of this study.
