The focus of this economic evaluation has been to predict long-term (20 years) costs and effects of private and public sector diabetes centers in the Iranian health care setting from a patient perspective. This is the first study to evaluate the cost-effectiveness of private-sector diabetes care, to the best of our knowledge. The results showed that the private sector diabetes care is associated with higher life expectancy when compared to the public sector (0.22 QALE gained) and higher direct medical costs ($7,292.56 cost increase). Calculated ICER ($33,148.02 per QALE gained), which is much higher than the country threshold, indicated that the private sector diabetes centers are not cost-effective strategies in the Iranian health care setting.
T2DM is one of the leading causes of morbidity and mortality in Iran and consumes about 8.7% of total health expenditure (16, 17). Hospital-inpatient care (mostly due to complications of diabetes) comprises the largest share of diabetes direct medical costs (18, 19). Our results showed that the average annual direct cost of diabetes treatment in the private sector is about two times higher than of the public sector ($15,385.33 versus $8,092.76). A study conducted with Iranian patients in 2011 found that the cost of inpatient services of T2DM in the private sector is 1.5 times higher than of the public sector (20). Other pieces of evidence confirm that this gap is expected to be exceedingly extensive (21).
Also, it is expectable that the public and private sectors were different in the quality of care provided. The quality of medical services and patient outcomes influenced by various(internal and external) factors such as resource availability, patient engagement, and provider collaboration. Public hospital diabetes clinics are often overcrowded, leading to prolonged waiting times and reduced face-to-face communication time between patient and physician (22). The limited-time available to each patient frequently translates into a simplistic laboratory test-prescription exchange and leaves other humanistic aspects of effective diabetes treatment unaddressed. (e.g., patient education, individualized treatment and self-management of diabetes) (23). The results of this study showed that the average life expectancy and QALE for 20 years in the private sector are higher than the public sector (0.22 life expectancy and QALE gained), but this difference is minimal. This slight difference in effectiveness could be explained by the fact that patients with acute severe and chronic morbidity are more likely to receive private-sector care (24, 25). Although no study to date has comparatively evaluated the quality of diabetes management by the private sector versus the public sector in Iran, evidence elsewhere indicates that, contrary to expectations, HrQoL and quality of care found to be similar across the two settings, especially as regards T2DM-related complications (8).
Our study has some limitations—first, the clinical evidence available limits the cost-effectiveness results (26). Second, our sample size due to the lack of access to all diabetes centers in Iran is relatively small, which reduces the generalizability of the results. Finally, the UKPDS model does not explicitly include several diabetes-related morbidities (e.g., peripheral neuropathy); as a result, the use of the UKPDS model may result in the slightly overestimated ICER (27).