Original Research

Impact of a Community Health Worker–Led Diabetes Education Program on Hospital and Emergency Department Utilization and Costs

Journal of Clinical Outcomes Management. 2015 May;22(5)

References

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In the first step, direct cost was modeled on DEP participants with an encounter to obtain parameter estimates for pre- and post- program enrollment, age, sex, and ethnicity. The model was based on the log-link function with the gamma distribution. In the second step, we ran a propensity score logistic regression model to estimate the probability of any encounter being identified in the DFWHC database, adjusted for age, sex, ethnicity, and DEP clinic. In the third step, we generated 10,000 bootstrap samples, with replacement, to estimate the DEP population’s median expected change in cost. In the bootstrap sample, the parameter estimates from step 1 were used to predict the cost pre- and post- program enrollment for each patient. The expected change in cost per participant was then calculated, while adjusting for the propensity to have an encounter, estimated in step 2. The formula for calculating change in cost was Expected change in cost = [pre probability*pre cost – post probability*post cost].

In the final step, we retained the median cost savings from each bootstrap sample. Inpatient and ED cost savings were combined to produce a total cost savings across the patient population. The ROI formula was Financial gain (utilization cost savings – DEP investment)/DEP investment.

Results

Participant Demographics

Of the 1140 study participants, 878 were DEP patients and 262 were controls ( Table 1 ). The majority of DEP patients were Hispanic females older than 40 years while the majority of the the control group was non-Hispanic males older than 40. Table 2 and Table 3 display the top 5 primary ICD-9 diagnoses by intervention group and pre/post enrollment status. Type 2 diabetes was the top diagnosis among DEP participants and controls with a pre-enrollment encounter.

Acute pancreatitis was the top diagnosis among DEP participants and controls with a post-enrollment encounter.

Inpatient Encounters

Fourteen percent of the DEP participants and 37% of control group patients matched to an inpatient record during the pre-enrollment time period. The number of mean inpatient encounters for DEP participants decreased from 0.18 to 0.08 ( P < 0.001) in the post period

(Table 4 ). Patients in the control group also experienced a reduction in mean inpatient encounters (0.66 to 0.52), but this reduction was not significant. Both DEP and control group patients had a significant reduction in mean LOS in the post period. LOS decreased from 0.67 days to 0.28 days ( P < 0.001) per encounter for DEP patients and from 2.32 days to 1.13 days ( P = 0.001) for controls. However, the mean percentage change in LOS was not significantly different between the 2 study groups ( P = 0.90). DEP patients and control patients also

had a significant reduction in mean inpatient cost per patient, decreasing from $902 to $406 ( P < 0.001) for DEP patients and from $3054 to $1688 for controls ( P = 0.006). Observed reductions in cost were not significantly different between the 2 groups ( P = 0.93).

Emergency Department Encounters

Eight percent of the DEP participants and 30% of controls matched to an ED record for the year prior to program enrollment. Neither DEP patients nor patients in the control group had a significant reduction in mean ED encounters ( P = 0.88 and 0.74, respectively) or costs ( P = 0.76 and 0.12, respectively) post enrollment.