gms | German Medical Science

Background: Practice guidelines can significantly contribute to the quality and impact of care. However, lack of resources may preclude successful implementation in primary care. Thus it is of interest to examine the costs of guideline implementation.

Aim: To estimate the costs of guideline implementation in primary care.

Method: Electronic search was conducted on 31.01.2017 within Medline and Embase, applying the search query referring to terms covering primary health care, practice guidelines, and implementation. The hits were restricted to studies published in the previous 7 years about non-communicable diseases of adult (≥18 years) population in English or German language, the interventions targeting the primary care provider (PCP). Further, for comparability, only studies from developed countries according to the categorisation of the United Nations Statistics Division were considered. Data extraction was performed by two independent reviewers with the help of a Microsoft Access-based form. Consensus was achieved by discussion.

Results: After removing duplicates, 1043 studies were assessed based on title or abstract, from which 200 qualified for full text reading. Among these, 31 studies fitted to the inclusion criteria, and ten reported costs: six randomised controlled trials, two controlled before-after studies, and two cohort studies.

Reporting of costs varied widely: four studies provided no in-depth information. One study using consensus processes and educational meetings reported that the effects were achieved without any additional cost by optimizing the use of existing resources. One study using educational meetings for improving hypertension medication reported that “intervention costs were the equivalent of twice the savings“. One study using educational meetings for improving the use of lipid lowering medication reported implementation costs of 2% of the medication costs. One study in diabetes care reported costs of 210 USD per patient for educational meetings and benchmarking, and 261 USD per patient for patient empowerment.

Three studies reported favourable cost-benefit ratios. A study on asthma management reported costs of 501 USD per patient for intervention development and 290 USD per patient for intervention maintenance; these implementation costs were contrasted with estimated savings of 321 USD due to decreased use of emergency services, and savings of 281 USD due to decreased sickness absence. One study using audit and feedback for improving the utilization of lipid lowering medication found intervention costs of 33 USD per practice and estimated savings of 813 USD per patient for medication in two years. A study on chronic kidney disease management using audit and financial intervention reported costs of 30,713 USD per practice; they estimated that a reduction of referrals into secondary care would result in 71,453 USD savings per year.

Three studies reported incremental cost-effectiveness ratios (ICER), two of them reported ICER favourable towards implementation, one simulation study reported unfavourable ICER.

Discussion: Only a minor proportion of studies reporting guideline implementation effectiveness included some type of economic evaluation, a fact repeatedly confirmed in the literature. Input cost metrics referred to the intervention development or maintenance; outcome metrics covered a wide range of indicators from estimated savings to ICER; preventing comparable evaluation of efficiency. In consensus with the literature findings, the general quality of economic evaluation was low.

Practical implications: More rigorous and standardized economic evaluation should complete the reporting of the effectiveness of guideline implementation interventions, supporting decision-making through comparability.