6 Discussion
6.3 Significance of the findings in the Finnish health care system
6.3.7 Centralizing produces savings
The very expensive patients with total costs above 100 000 € during six study years were excluded from the comparison of health care costs. At least the majority of these six type 1 diabetic patients with nephropathy had not previously been in the follow-up of the local PHC. Four of these expensive patients lived in Nurmijärvi and two in Kouvola.
The outpatient specialist care in type 1 diabetes was 38.3 % cheaper per one patient and 14.3 % cheaper in type 2 diabetes in Nurmijärvi than in Kouvola. The costs of one type 1 diabetic patient in outpatient specialist care were more than four times higher than the costs of one type 2 diabetic patient. The specialist level inpatient periods of Kouvola were somewhat shorter in both diabetes types. The total yearly costs of the treatment of diabetes and its complications per one diabetic patient were 510 € lower in type 1 and 32 € lower in type 2 diabetes in Nurmijärvi with the centralized care system than in Kouvola with the decentralized care. The difference in type 2 diabetes is small when calculated per one patient but considering the higher prevalence of type 2 diabetes, the total sum becomes significant. Altogether, the centralized diabetes care model of
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Nurmijärvi seemed to produce yearly cost saving of 116 500 € when compared with the family doctor based follow-up system of Kouvola.
The savings produced by the centralized follow-up system of type 1 diabetes are nearly equivalent to the yearly costs of one general practitioner. If extrapolated to the whole country, the centralized follow-up of type 1 diabetic patients could produce savings of more than 10 million euro per year.
The saved money can, of course, be used in many ways: recruiting of a new doctor can produce extra savings in the long run, but that is uncertain. A marked proportion of the savings can be lost by unsuccessful decisions. The very expensive patients with total costs above 100 000 € during the six study years were decided to be excluded from the comparison of health care costs. At least the majority of these six type 1 diabetic patients with nephropathy had not been previously in the follow-up of the local PHC. Four of these expensive patients lived in Nurmijärvi and two in Kouvola.
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7 Summary and conclusions
HbA1c is not a good measure in comparing the quality of diabetes care of different care units, especially if the analyses have not been done by the same analysis method in the same laboratory. Moreover, HbA1c does not detect hypoglycaemias or glucose variability.
Almost half of all severe hypoglycaemias are suffered by type 2 diabetic patients. On average, type 1 diabetic patients suffer from severe hypoglycaemia once in 1.5 years and insulin-treated type 2 diabetic patients once in 4 years. Only the top of an iceberg is seen in the health care system, because most of all severe hypoglycaemias are treated at home or outside the hospitals by paramedics.
Depressive symptoms, physical activity and diagnosed diabetic nephropathy correlate with the risk of severe hypoglycaemias – but not the level of HbA1c, use of alcohol or the type of basal insulin (glargine vs. NPH). Eighty per cent of all insulin-treated diabetic patients do not have severe hypoglycaemias. Hypoglycaemias cluster to a small minority of all diabetic patients.
Patients with recurrent severe hypoglycaemias have valid driver´s licenses as frequently as the whole diabetic population on average. Many of them are outliers of the public diabetes care system having no visits to the health care system.
The centralized diabetes follow-up model in PHC produces significant savings in the care of type 1 diabetes and smaller savings in the care of type 2 diabetes. The difference is mostly due to more frequent consultations of specialist level outpatient health services in the decentralized care model.
Type 1 diabetic patients are more satisfied with the centralized follow-up system. The difference is especially notable in the satisfaction with the skills of doctors. The trust to the skills of diabetes specialist nurses is high in both models.
64 Conclusions
Modern patients need high-quality care also in the PHC. This is difficult to offer, if every doctor tries to be expert in all specialities. It seems to be also economically sensible to share the work of the doctors in the PHC according to their special interests.
The satisfaction inquiry confirms the old idea that the diabetes specialist nurses are a corner stone of diabetes care. Every type 1 diabetic patient should have an easy way to consult a diabetes specialist nurse.
An independent ´driving ability centre´ system should be established for problematic driving permission estimations.
Benchmarking of the quality of diabetes care needs new indicators, computerized data collection systems and national diabetes registers.
The connection between diabetes and depression is worth more research.
Avoidance of severe hypoglycaemias should be one of the main targets in diabetes care.
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8 Acknowledgements
This doctoral thesis was written in the doctoral school called the Network of Academic Health Centres (AcaHC) of the Department of General Practice and Primary Health Care, Faculty of Medicine, in University of Helsinki. The atmosphere of AcaHC has been friendly and supportive – the researchers have gradually become friends. Without these colleagues, this thesis would never have become ready. The multiprofessional idea of the group has been a great richness. Professors Mats Brommels and Johan Eriksson earn to be mentioned separately: it has been a great pleasure for me to notice that persons with the most wisdom can be so easily contacted.
I wish to express my deepest gratitude to my supervisors:
Docent Outi Elonheimo, the coordinator of AcaHC, for her great support throughout the whole decade with this work. Outi or “Tintti” has met a vast challenge when trying to make academic workers of health centres to researchers and doctors. The monthly seminars of AcaHC usually began with a cavalcade of reasons why so little progress had “just now” been achieved.
Professor h.c. Timo Sane with his overwhelming knowledge and experience with endocrinology and diabetes care has made it possible for me to complete this thesis. My career as a diabetologist began when I was working as an assistant doctor in Meilahti hospital department 111 during two consecutive summers about 25 years ago. I had the honour to work with professor Sane and the present archiatre Risto Pelkonen - both exceptional gentlemen with a lot of knowledge combined with an appreciating attitude to their patients. Those months taught me much about medicine and humanity.
I want to thank the official reviewers, docents Liisa Hiltunen and Jorma Lahtela, for their constructive evaluation of this thesis. Their comments helped me to make the manuscript to its final mode. Their concentration to the review and the amount of time given to the work made me a great influence.
This study would not have been possible without the work of the nurses in Kouvola and Nurmijärvi who helped me to reach the diabetic population of these municipalities. I want to extend my sincerest thanks to all of them. Especially I want to mention the already retired diabetes specialist nurse of Kouvola, Mrs Anja Borgman. During the work, I could notice how appreciated she was among the diabetic patients of Kouvola.
Naturally I am grateful to my employer for the possibility to make this thesis and for the possibility to develop my own work. I have been lucky with having co-workers, who are motivated to do their work well and to search for better outcomes.
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The past ten years have demanded a lot of my family; most of the work was done during the free time. I am grateful to my wife, Marita, for her understanding patience and support. I have had the privilege to have such a fine family and a home where it is always easy and relaxing to be.
The study behind this thesis was financially granted by the foundation of Kyllikki and Uolevi Lehikoinen, the Avohoidon tutkimussäätiö and the Diabetes Research Foundation. I want to thank these foundations for their support, which was especially important during the early phases of the study when the study population was gathered.
There are still many other people who have been important for this study project and I have no possibility to mention them all in this text. Many thanks for all of you.
I devote this thesis to the memory of my brother Jukka, who got cerebral cancer shortly after his academic dissertation and died after nine heavy months. His death caused the longest break in my academic work and it made me understand, how tiny the meaning of one person or one thesis can be in the history and in the universe.
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