Open Access Research article

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial

Amber AWA van der Heijden12*, Martine C de Bruijne13, Talitha L Feenstra24, Jacqueline M Dekker1, Caroline A Baan12, Judith E Bosmans5, Sandra DM Bot1, Gé A Donker6 and Giel Nijpels1

Author Affiliations

1 Department of General Practice, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands

2 National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands

3 Department of Public and Occupational Health, The EMGO Institute for Health and Care Research, VU University Medical Center, van der Boechorststraat 7, 1081BT Amsterdam, The Netherlands

4 Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands

5 Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, The Netherlands

6 NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands

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BMC Health Services Research 2014, 14:280  doi:10.1186/1472-6963-14-280

Published: 25 June 2014



The increasing prevalence of diabetes is associated with increased health care use and costs. Innovations to improve the quality of care, manage the increasing demand for health care and control the growth of health care costs are needed. The aim of this study is to evaluate the care process and costs of managed, protocolized and usual care for type 2 diabetes patients from a societal perspective.


In two distinct regions of the Netherlands, both managed and protocolized diabetes care were implemented. Managed care was characterized by centralized organization, coordination, responsibility and centralized annual assessment. Protocolized care had a partly centralized organizational structure. Usual care was characterized by a decentralized organizational structure. Using a quasi-experimental control group pretest-posttest design, the care process (guideline adherence) and costs were compared between managed (n = 253), protocolized (n = 197), and usual care (n = 333). We made a distinction between direct health care costs, direct non-health care costs and indirect costs. Multivariate regression models were used to estimate differences in costs adjusted for confounding factors. Because of the skewed distribution of the costs, bootstrapping methods (5000 replications) with a bias-corrected and accelerated approach were used to estimate 95% confidence intervals (CI) around the differences in costs.


Compared to usual and protocolized care, in managed care more patients were treated according to diabetes guidelines. Secondary health care use was higher in patients under usual care compared to managed and protocolized care. Compared to usual care, direct costs were significantly lower in managed care (€-1.181 (95% CI: -2.597 to -334)) while indirect costs were higher (€758 (95% CI: -353 to 2.701), although not significant. Direct, indirect and total costs were lower in protocolized care compared to usual care (though not significantly).


Compared to usual care, managed care was significantly associated with better process in terms of diabetes care, fewer secondary care consultations and lower health care costs. The same trends were seen for protocolized care, however they were not statistically significant.

Trial registration

Current Controlled trials: ISRCTN66124817.

Type 2 diabetes mellitus; Controlled clinical trial; Quality of health care; Health economy