TABLE 1.

Examples of Studies Addressing the Quality of Glycemic Control among People with Type 2 Diabetes Mellitus or Quality of Care for Low Back Pain and Some Measure of Cost

Study	Description of Study
Studies of Associations between Measures of Quality and Measures of Cost in Patient Populations
Fritz et al. 2008	Methods: Determined whether or not patients with low back pain had received physical therapy services that adhered to guidelines (involved exercise or therapeutic activities).
	Key Findings: The 28.0% of patients receiving guideline-adherent care had $202 lower physical therapy charges. During the year following physical therapy care, receiving adherent care was associated with a lower likelihood of receiving prescription medication (46.2% vs. 57.2%), magnetic resonance imaging (8.3% vs. 15.9%), or epidural injections (5.3% vs. 12.1%); charges were not significantly different ($2,049 vs. $3,427) (inflated to 2009 dollars).
	Measures of Quality: Modified Oswestry Disability Questionnaire, pain rating scale, duration of physical therapy care, receipt of care during the year after physical therapy care.
	Measures of Cost: Number of physical therapy visits, physical therapy charges, charges associated with CPT codes for low back pain and collected for prescription medication, office or emergency room visits, inpatient/surgical services, and diagnostic procedures.
Menzin et al. 2001	Methods: Assigned adult members of the Fallon Clinic to three groups based on HbA1c: good (<8%), fair (8 to 10%), and poor control (>10%). Compared inpatient admissions for various complications and associated charges across the groups.
	Key Findings: Over three years, the adjusted rate of inpatient treatment per 100 patients was 13 for good, 16 for fair, and 31 for poor control. Corresponding mean adjusted charges were $1,507, $2,145, and $4,724, respectively. Among the 30% of subjects with long-term diabetic complications, the adjusted admissions per 100 patients (mean charges) were estimated to be 30 ($4,056) for good, 38 ($5,921) for fair, and 74 ($12,930) for poor control, respectively (inflated to 2009 dollars).
	Measures of Quality: HbA1c test result category (< 8%, 8 to 10%, >10%).
	Measures of Cost: Mean adjusted charges for inpatient care (hospital and skilled nursing facility) over three years.
Studies Estimating the Cost of Existing Quality Problems
Caro, Ward, and O'Brien 2002	Methods: Used a model based on existing epidemiologic studies to create a simulated cohort of 10,000 patients with diabetes, estimating complication rates for macrovascular disease, nephropathy, retinopathy, neuropathy, and hypoglycemia. Estimated the direct medical costs associated with the complications from all-payer databases, surveys, and literature.
	Major Findings: The average per-patient medical care costs for diabetes-related complications over thirty years were $68,037, largely due to macrovascular disease (inflated to 2009 dollars).
	Measures of Quality: Modeled risk of macrovascular disease, nephropathy, retinopathy, neuropathy, and hypoglycemia over thirty years.
	Measures of Cost: Modeled cumulative average cost of diabetes-related complications per patient over thirty years.
Minshall et al. 2005	Methods: Used the CORE diabetes model to estimate the long-term savings associated with averting the major complications that result from diabetes, modeling attaining HbA1c goals of <7% and <6.5% versus current population values.
	Key Findings: Reducing the average HbA1c to 7% nationwide would eliminate $39.8 billion (inflated to 2009 dollars) in direct medical expenditures for type 2 diabetes-related complications over ten years, plus an additional $17.2 billion in costs related to disability, lost productivity, and premature mortality.
	Measures of Quality: HbA1c test result over ten years, modeled risk of fifteen diabetes-related complications and nonspecific mortality over ten years.
	Measures of Cost: Modeled direct medical care expenses over ten years; modeled costs associated with lost productivity, premature mortality, and disability over ten years.
Studies of Efforts to Change Quality That Included Measures of Cost
Kotsos et al. 2009	Methods: Enrolled patients from a large insurer in a nurse-led disease management program that emphasized self-care for low back pain. Compared outcomes with controls from a period preceding the program.
	Key Findings: Costs per diseased member per month were lower during the intervention period for imaging, surgery, and medications.
	Measures of Quality: Existence of nurse-led self-care disease management program.
	Measures of Cost: Program costs per diseased member per month for low-back pain specific services, including physical therapy, imaging, manipulation, steroid injections, surgery, and medications.
Monte et al. 2009	Methods: Patients were referred to the MedSense program, a pharmacist-led, patient-centered pharmacotherapy management program. For one year from the enrollment date, followed HbA1c and other metabolic parameters as well as medical and prescription-related costs.
	Key Findings: HbA1c declined by 1.1% at twelve months. Other accompanying metabolic parameters improved by 40% to 64%. By twelve months, mean costs decreased by $222 relative to baseline (inflated to 2009 dollars).
	Measures of Quality: Existence of a pharmacist-led, patient-centered pharmacotherapy management program, HbA1c test result, fasting glucose test result, outcomes for diabetes unrelated to glycemic control, use of medication (aspirin, ACE/ARB, statin, insulin), use of nephropathy screening.
	Measures of Cost: Direct medical and prescription expenditures from the payer perspective.
Studies Determining the Cost-Effectiveness of Efforts to Change Quality
Kahn et al. 2008	Methods: Used NHANES data for 1998 to 2004 and the Archimedes model to estimate the cost-effectiveness of the maximum feasible attainment of HEDIS HbA1c goals for diabetes over thirty years.
	Key Findings: The maximum feasible attainment over thirty years would cost $56,666/quality-adjusted life year (inflated to 2009 dollars).
	Measures of Quality: HbA1c test result <7%, fasting plasma glucose test result <110 mg/dl, incidence of hypoglycemic attacks, body mass index <30 kg/m2, control of cardiovascular disease risk factors, quality-adjusted life years.
	Measures of Cost: Cost of prevention activities over thirty years, assuming maximum feasible performance (with subcategories for HbA1c, fasting plasma glucose, etc.), total cost of preventive plus other medical care over thirty years, total cost per quality-adjusted life year (did not consider cost of any quality improvement activities).
McRae et al. 2008	Methods: Assessed the cost effectiveness of an integrated approach to assisting general practitioners (GPs) with diabetes management in Australia using five years of data from the program and the UKPDS Outcomes Model.
	Key Findings: Most clinical measures improved or were unchanged over five years. The program led to projected improvements in expected life years and Quality Adjusted Life Expectancy (QALE), with incremental cost effectiveness ratios of $A8,106 per life year saved and $A9,730 per year of QALE gained.
	Measures of Quality: Existence of integrated approach to assisting general practitioners with diabetes management, HbA1c test result, control of cardiovascular disease risk factors, life years, quality-adjusted life expectancy.
	Measures of Cost: Costs of integrated approach program, costs of primary care services arising from adherence to the guidelines and drug costs, hospitalization costs, cost per quality-adjusted life expectancy.
Strong et al. 2006	Methods: Two randomized controlled trials in a large health maintenance organization enrolled adults who were not being considered for surgery in group educational programs on self-care, one led by laypersons and the other by psychologists.
	Key Findings: Patients assigned to the lay and psychologist groups had 14.3 and 26.2 additional low-impact back pain days, respectively, compared with usual care. Each additional low-impact back pain day cost $9.70 and $6.13 for the lay-led and psychologist-led interventions, respectively.
	Measures of Quality: Roland Disability Score, “low impact days.”
	Measures of Cost: Intervention costs (labor, mailing costs), total costs of back pain care in the one-year postrandomization (costs of back pain-related services, excluding inpatient care), net cost per “low impact day.”

Note: Costs were inflated to 2009 dollars using the Consumer Price Index (Bureau of Labor Statistics 2012).