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Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
COSTS
OF DIABETES
Direct
Medical Costs
Oupatient
Care (Hospital, Physician, Emergency)
158
TITLE:
ACE Inhibition in Diabetic Patients: Economic Implications. Rodby, R.A.;
Lewis, E.J. PharmacoEconomics. 10(Supplement 4): 315-320. October
10, 1996.
OBJECTIVE:
To discuss angiotensin-converting enzyme (ACE) inhibitors, their role
in slowing the progression of diabetic nephropathy to end-stage renal
disease (ESRD), and their consequent influence on health care expenditures.
To project the economic impact of this class of antihypertensive agents
on diabetes mellitus.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Epidemiological cohort model.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
Use of captopril, an ACE inhibitor, in patients with diabetes mellitus
and overt nephropathy produces substantial cost savings and prolongs life.
RECOMMENDATION:
Continuing attention must be given to the cost-effectiveness of all therapies,
but a therapy need not save money to be justified.
ABSTRACT:
In patients with type 1 diabetes, histological changes from diabetic nephropathy
are present within 5 years of diagnosis; overt nephropathy usually occurs
after 15 to 25 years of diabetes. Treatment with ACE inhibitors is one
of the therapies that appear to influence development and progression
of nephropathy in patients with type 1 diabetes in a beneficial way. The
authors explore the issue of whether treatment with the ACE inhibitor
captopril to delay the onset of renal failure is cost effective. They
point out that unless ESRD therapy is avoided altogether for some patients,
captopril will not save money. Complete avoidance of ESRD could occur
if captopril halts the progression of diabetic nephropathy entirely in
some patients (which has not been shown in overt nephropathy) or if it
prevents ESRD long enough for a patient to succumb to another illness
first. The authors discuss their medical treatment model of the cost-benefit
and cost-effectiveness of captopril therapy in patients with type 1 diabetes
and diabetic nephropathy. In the model, patients receive either captopril
or placebo and are followed as they progress to ESRD, receive ESRD therapies,
and eventually die. Each year, the model predicts costs for the two study
groups. In each of the second through 16th years, placebo patients cost
more than those receiving captopril. In the 17th and succeeding years,
captopril patients cost more than their placebo counterparts. However,
the lower cost per captopril patient in the early years more than offsets
the higher cost for the captopril group in the later years, resulting
in overall cost savings. Captopril prolongs life and simultaneously saves
money because progression to ESRD is delayed long enough for some patients
taking captopril to die before ESRD develops. The authors' model predicts
per-patient savings from using captopril of $7,800 over 5 years, $30,110
over 12 years, and $32,550 over 31 years. 3 figures, 1 table, 11 references.
159
TITLE:
Closing the Gap: The Problem of Diabetes Mellitus in the United States.
Herman, W.H.; Teutsch, S.M.; Geiss, L.S. Diabetes Care. 8 (4):
391-406. July-August 1985.
OBJECTIVE:
To review the epidemiology and costs of diabetes and its complications;
to discuss methods of reducing the burden of diabetes on the health care
system.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Review of studies.
Perspective: Societal.
CONCLUSION:
Both type 2 diabetes mellitus and the complications of diabetes are often
preventable.
RECOMMENDATION:
Continuing to promote public health and Diabetes Research, assuring
that public health programs follow current standards for diabetes care,
and providing third party coverage of educational programs and preventive
screening for complications should all be used to reduce the morbidity
and mortality of diabetes.
ABSTRACT:
The authors review data on diabetes from population-based studies and
surveys of the National Center for Health Statistics. Among racial/ethnic
groups, the prevalence of type 1 diabetes mellitus is highest in whites,
and its peak onset is in children aged 10 to 14 years. The risk of type
2 diabetes increases with age, and the disease is relatively more common
among women and nonwhites. The risk of gestational diabetes increases
with maternal age. Genetic, familial, and environmental factors; obesity;
and inactivity are discussed as risk factors. The prevalence (number of
cases) of type 1 diabetes in 1980 was 435,000, and the prevalence of type
2 diabetes was about 5.1 million. Mortality in 1980 from diabetes was
estimated at 154 per 100,000 persons in the general population. About
86,000 women develop gestational diabetes annually. The major cause of
death in people with type 2 diabetes is cardiovascular disease; the major
causes of death for those with type 1 diabetes are renal and cardiovascular
diseases. People with diabetes are more than twice as likely to require
hospital services as those without diabetes, and in 1977, 15 percent of
people in nursing homes had diabetes. In 1980, the direct costs of diabetes
were $652 million for physician visits, $6,157 million for hospitalization,
$663 million for nursing home care, and $380 million for insulin and hypoglycemic
agents. Indirect costs were estimated at $10 billion per year. The authors
state that control of obesity, glycemia, and hypertension; patient education;
and smoking cessation could annually reduce the prevalence of diabetes
or its complications by the following amounts: type 2 diabetes, 293,000;
gestational diabetes, 28,000; ketoacidosis, 52,000; congenital malformations,
500; stroke, 19,000; coronary heart disease, 38,000; peripheral vascular
disease, 24,000; blindness, 3,500; end-stage renal disease, 2,000; and
amputations, 15,000. 23 tables, 105 references.
160
TITLE:
Direct Costs of Diabetes Care: A Survey in Ottawa, Ontario 1986. McKendry,
J.B. Canadian Journal of Public Health. 80 (2): 124-128. March/April
1989.
OBJECTIVE:
To determine the annual direct costs of care for patients with diabetes.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Of the costs of routine diabetic care, 23.4 percent were for at-home testing;
45.3 percent, treatment supplies; 20.9 percent, physician's services;
and 10.4 percent, miscellaneous items. Of direct nonroutine costs, 64.4
percent were for hospital services, 13.9 percent for treatment supplies,
9.6 percent for physician services, and 7.7 percent for testing supplies.
RECOMMENDATION:
Periodic cost-of-care surveys, with help from volunteers of the diabetes
association, offer an affordable means to monitor utilization trends and
costs of supplies and services in caring for patients with diabetes.
ABSTRACT:
A total of 205 Ottawa-area patients with diabetes completed questionnaires
designed to assess their annual use of equipment, supplies, and professional
and institutional services. Average age of respondents was 47.3 years;
their average duration of diabetes was 18.3 years. Indirect costs, such
as loss of time from work, were not addressed. Direct costs were divided
into routine (supplies and equipment for self-treatment and testing and
professional services during routine encounters) and nonroutine (nonroutine
emergency room and hospital services) categories. The costs of goods and
services were estimated using current fee schedules and local pharmacy
prices. Methods used for glucose monitoring at home included blood tests
only (64.9 percent), urine tests only (16.6 percent), urine and blood
tests (7.8 percent), and no testing (10.7 percent). Annual costs for treatment
regimens were as follows: diet only, no cost (4.4 percent); oral medication,
$236.40 (9.3 percent); insulin injections, $362.34 (79 percent); and insulin
by pump, $1,603.20 (7.3 percent). Assuming six or fewer visits to a family
physician or diabetologist, two or less to an ophthalmologist, and no
visits to a nephrologist or neurologist, annual costs for physician services
were estimated to be $201.47. Annual costs for routine care included 23.4
percent for test supplies, 45.3 percent for treatment supplies, 20.9 percent
for physicians' services, and 10.4 percent for miscellaneous items, for
a total of $962.01. Nonroutine costs averaged $45.84 for emergency room
visits and $1,936.40 for inpatient hospital care. When expressed in terms
of routine plus nonroutine cost, hospital care accounted for 64.4 percent;
treatment supplies, 13.9 percent; physician services, 9.6 percent; test
supplies, 7.7 percent; miscellaneous, 3.4 percent; and emergency care,
1 percent, for a total of $2,944.25. 7 tables, 2 figures.
161(Cross-Reference
102)
TITLE:
The Economics of Screening for Microalbuminuria in Patients with Insulin-Dependent
Diabetes Mellitus. Borch-Johnsen, K. PharmacoEconomics. 5(5): 357-360.
May 1994.
OBJECTIVE:
To discuss the cost benefit of screening for microalbuminuria followed
by antihypertensive treatment of early renal disease indicated by microalbuminuria
in patients with type 1 diabetes.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Patient screening.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
Screening and intervention for microalbuminuria in patients with type
1 diabetes appears to increase life expectancy significantly and improve
quality of life for patients while providing considerable savings for
health care providers.
RECOMMENDATION:
A screening program, including an annual measurement of the urinary albumin
excretion rate, should be instituted for all patients with type 1 diabetes.
ABSTRACT:
Patients with type 1 diabetes are at risk of developing diabetic nephropathy,
a condition in which the urinary albumin excretion rate exceeds 300 mg/day,
which can lead to end-stage renal failure, dialysis or kidney transplantation,
or death. Patients with microalbuminuria (i.e., a slightly elevated excretion
rate of 30 to 300 mg/day) have a much increased risk of developing diabetic
nephropathy. The Diabetes Control and Complication Trial Research Group
study (1993) showed that metabolic control could reduce the risk of developing
microalbuminuria by 39 percent. Intensive antihypertensive treatment may
be effective for microalbuminuria and is known to delay the onset of end-stage
renal failure if used in early clinical nephropathy. Semiannual screening
for microalbuminuria is sufficient for early detection using albumin assays
or less expensive reagent strips. Prevention by metabolic control is possible
but costly to maintain. Two studies evaluating screening for microalbuminuria
and intervention with antihypertensive drugs showed that the monetary
benefits of screening outweighed the costs, even with a limited treatment
effect. One study found that reducing the urinary albumin excretion rate
from 20 percent to 18 percent annually would result in a net savings because
the annual costs per patient for treating end-stage renal failure were
very high (dialysis: $35,000 to $55,000; transplantation: $14,000 to $35,000
initially and $7,000 subsequently), compared with screening ($9) and antihypertensive
treatment ($350). If, as indicated by recent trials, antihypertensive
treatment can reduce the progression of the urinary albumin excretion
rate by 33 percent or 67 percent, median life expectancy would increase
by 4 or 14 years, and the need for dialysis and transplantation would
decrease by 20 percent to 60 percent. 1 table, 25 references.
162
TITLE:
"Educating" the Person with Diabetes in an Ambulatory Setting.
Travis, L.B. Texas Medicine. 88(7): 69-71. July 1992.
OBJECTIVE:
To raise questions about the distribution of savings accruing from the
transition to the outpatient setting for educating and managing patients
with newly diagnosed diabetes; to discuss underwriting the cost of ambulatory
education programs.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Societal.
CONCLUSION:
Outpatient education and management of patients with diabetes results
in savings, but these savings are not necessarily returned to the health
care system. Health centers themselves under-write the diabetes program.
RECOMMENDATION:
None.
ABSTRACT:
The author comments on the benefits of outpatient management and education
of patients with type 1 diabetes. Increased public awareness of the symptoms
of diabetes, earlier detection by the medical profession, and efforts
to reduce health care costs have helped to move diabetes education to
the outpatient setting. At the Barbara Davis Center in Colorado, 60 percent
of patients received all their care as outpatients from 1980 through 1986.
In a Texas hospital, the percentage of those receiving only outpatient
services increased from 0 to 38 percent in just over 2 years. Outpatient
education reduces the disruption of the disease for patients and their
families. Although reports of cost savings are no doubt authentic, these
savings have not resulted in reduced health insurance premiums or lower
taxes. The author reports that outpatient education services at the Children's
Diabetes Management Center (University of Texas Medical Branch, Galveston)
require, per patient, 2 to 4 hours from the physician, 10 to 12 hours
from the nurse educator, and 2 to 4 hours from the dietitian. Using a
conservative estimate of 12 hours of professional time, total costs (salaries,
fringe benefits, clinic and laboratory fees, and supplies and education
materials) range from $500 to $800 per patient. Private insurance reimburses
less than 50 percent of costs, if any. In Texas, diabetes education is
not a reimbursable expense; the health care center pays for outpatient
education costs. Impediments to outpatient diabetes management and education
outside a medical center include the comfort level of practitioners in
managing new-onset diabetes, the availability of adequate instructional
services, and the cost to practitioners. 5 references.
163
TITLE:
Health Insurance and the Financial Impact of IDDM in Families with a Child
with IDDM. Songer, T.J.; LaPorte, R.E.; Lave, J.R.; Dorman, J.S.; Becker,
D.J. Diabetes Care 20 (4):577-584. April 1997.
OBJECTIVE:
To examine health insurance experience and out-of-pocket costs of families
with and without a child with type 1 diabetes.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Prospective.
Methodology: Statistical analysis.
Perspective: Societal.
CONCLUSION:
Having a child with diabetes exerts a substantial economic impact on the
family.
RECOMMENDATION:
The issue of whether limited access to insurance, limited coverage, or
high out-of-pocket costs have any long-term health effect on people with
diabetes remains to be investigated.
ABSTRACT:
The study included 197 families having a child with type 1 diabetes (identified
by the Allegheny County [Pennsylvania] IDDM Registry) and 142 control
families who did not have such a child. In addition to health insurance
issues, three measures of out-of-pocket costs were examined: (1) money
spent on health care services and supplies not reimbursed by insurance,
(2) reported out-of-pocket costs plus out-of-pocket insurance premiums,
and (3) out-of-pocket costs (including insurance premiums) as a share
of household income. Out-of-pocket costs were categorized in intervals
of $250 up to more than $2,750 (1990 dollars). Case families were older
than control families and more likely to be headed by a single parent.
About 90 percent of case and control families reported full-year insurance
coverage. Case families, however, were more likely to report being denied
coverage (8.4 percent versus 1.7 percent for controls, p = 0.03). In addition,
case families reported significantly higher out-of-pocket expenses (p
< 0.001), and the median amount of these expenses plus the out-of-pocket
costs for insurance premiums was also significantly higher in case families
($1,125 versus $625, p = 0.03). The case families spent 5.6 percent of
their income on health care, versus 3.1 percent for the control families
(p = 0.004). The authors note that there is some uncertainty about the
future availability of insurance and care for individuals and families
who use health services frequently. 2 figures, 6 tables, 38 references.
164
TITLE:
Hospital Costs, Use of Resources, and Dynamics of Death Associated with
Diabetes Mellitus. Muñoz, E.; Chalfin, D.; Birnbaum, E.; Goldstein,
J.; Cohen, J.; Wise, L. Southern Medical Journal. 82 (3): 300-304.
March 1989.
OBJECTIVE:
To analyze the use of hospital resources for patients with diabetes mellitus
admitted to a teaching hospital in a suburb of New York City.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
The diagnosis-related group hospital payment system is inequitable for
reimbursing the care of patients who die in the hospital from diabetes-related
causes.
RECOMMENDATION:
Physicians must be advocates for equitable reimbursement and for further
study of the economics of patient death in the hospital.
ABSTRACT:
The authors analyzed resource use and diagnosis-related group payment
for patients with diabetes at an 805-bed teaching hospital outside New
York City. Patients had type 1 or type 2 diabetes as a primary or secondary
diagnosis. Variables for which nonsurvivors had higher values than survivors
included mean age, mean diagnosis-related group weight index (by 5.9 percent),
length of stay (by 67.7 percent), number of diagnoses (89.5 percent),
procedures (28.2 percent), and severity of illness (56.2 percent); the
last value was calculated as the total number of diagnostic codes. Total
daily hospital cost was 129.7 percent greater for nonsurvivors; this group
generated a $9,910 loss per patient versus a $141 profit for survivors.
Nonsurvivors had much higher rates of emergency admission, admission to
ICU, and requirements for blood or plasma. The only profitable group of
nonsurvivors when these patients were defined by length of stay were those
who died within 7 days of admission. All age categories of nonsurvivors
except for those aged 25 to 34 years generated financial losses to the
hospital. Diabetes-related deaths after a nonemergency admission created
a much greater financial risk to the hospital than did such deaths after
an emergency admission. 5 tables, 2 figures, 12 references.
165
TITLE:
Medical and Financial Implications of Discontinuing a Statewide Free Insulin
Program Involving 3,720 People. Nicholas, W.; Watson, R. Southern Medical
Journal. 82(1): 13-17. January 1989.
OBJECTIVE:
To assess the effects of discontinuing a state program that provided free
insulin to people with diabetes for almost 20 years.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Cost analysis.
Perspective: Societal.
CONCLUSION:
Discontinuing the program did not affect recipients negatively, as measured
by physician or emergency room visits or hospitalizations.
RECOMMENDATION:
None.
ABSTRACT:
For almost 20 years, the Mississippi State Department of Health provided
free insulin to several thousand people with diabetes; the program was
discontinued in 1981. The authors hypothesized that discontinuation would
adversely affect the people involved. The periods studied were the 18
months before (period 1) and the 18 months after (period 2) discontinuation.
Most of the 351 sample patients interviewed were black; the majority were
female. Mean age at interview was 58.6 years. Fifty-seven percent had
Medicaid or Medicare coverage; 43 percent were uninsured. Mean daily insulin
dose, body weight, and blood glucose value did not differ significantly
between the study periods, although in period 2 there was a trend among
those aged 45 or over for a smaller percentage of patients to have fasting
serum glucose values higher than 300 mg/dL. About three-fifths of patients
indicated they were not doing without essentials to purchase insulin after
program discontinuation. Patients with Medicaid or Medicare coverage had
significantly fewer hospitalizations in period 2. For the overall sample,
17 patients were admitted for ketoacidosis in period 1; 7 during period
2. Visits to physicians averaged 8.4 for period 1; 8.9 for period 2. Emergency
room visits, which were infrequent, did not differ significantly by period.
Diabetes-related hospital admissions decreased from 45.2 to 34.9 per 100
persons, but again the difference was not significant. Using data from
the Medicaid Commission and the Mississippi Health Care Commission, the
authors extrapolated the decreased hospital admissions to a savings of
$85,618 for the sample group as a whole. The small (statistically insignificant)
increase in physician visits was projected to cost $2,250. The authors
concluded that discontinuing the free insulin program did not have a measurable
negative effect on the patients studied. The authors also found that the
3,720 patients who had comprised the complete group of patients receiving
free insulin had fewer hospitalizations in period 2, a projected cost
savings of $907,404 ($244 per person). A slight increase in physician
visits produced a cost increase of $23,846 ($6.40 per person). Overall
savings were $883,558 ($237.13 per person). The program had cost the state
$550,000 annually. 6 tables, 3 figures, 1 reference.
166
TITLE:
An Outpatient-Focused Program for Childhood Diabetes: Design, Implementation,
and Effectiveness. Lee, P.D. Texas Medicine. 88(7): 64-68. July
1992.
OBJECTIVE:
To determine the impact of an outpatient program for management and education
of patients with newly diagnosed diabetes.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Program evaluation.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Outpatient management and education of patients with new-onset diabetes
reduced costs, total days of stay, and length of hospitalizations for
diabetes-related problems.
RECOMMENDATION:
Third party payers of health care should adjust coverage to encourage
more cost-effective health care delivery through outpatient programs for
diabetes.
ABSTRACT:
The author analyzes the impact of implementing, in mid-1988 at Texas Children's
Hospital, outpatient management and education for children with newly
diagnosed diabetes mellitus. Patient records from 1985 to 1990 provided
comparative data. A pediatric endocrinologist, two nurse educators, a
dietitian, and a social worker provided outpatient care; initial sessions
usually lasted a total of 8 to 12 hours over 2 to 3 days. Hospitalization
for rehydration and initiation of insulin therapy was based on degree
of illness rather than specific laboratory criteria; patients entered
outpatient care when medically stable. Follow-up visits occurred 1 to
2 weeks and 1 month later. Thirty to 50 new cases of diabetes were seen
yearly. Yearly inpatient admissions (1985 to 1990) were 82, 114, 102,
88, 59, and 51; yearly outpatient visits (1986 to 1990) totaled 660, 837,
957, 816, and 964. The proportion of new-onset patients who were never
hospitalized increased from 0 to 38 percent between 1987 and 1990. Hospitalizations
for new-onset diabetes in 1987 and 1990 totaled 42 and 32, respectively,
with an average duration of 5.6 and 4.0 days, respectively (p < .05).
Readmissions for diabetes-related problems equaled 84 in 1986 and 20 in
1990; average length of stay for these admissions was 4.4 days in 1987
and 2.6 days in 1990 (p < .05). An analysis of readmissions from 1989
to 1990 found that none of the readmitted patients had received their
initial care as outpatients. Average hospitalization costs (excluding
physician, nursing, and dietitian fees) for the last 23 consecutive new-onset
patients at the hospital were approximately $1,000 per day. With the outpatient
program, average per-patient costs were reduced approximately $100,000
per year, and the average costs of all admissions declined. Outpatient
management of new-onset diabetes reduces initial costs and subsequent
need for hospitalization. 4 figures, 12 references.
167
TITLE:
Resource Utilization and Costs of Care in the Diabetes Control and Complications
Trial. The Diabetes Control and Complications Trial Research Group. Diabetes
Care. 18(11): 1468-1478. November 1995.
OBJECTIVE:
To detail the resources used and associated costs of care for patients
in the Diabetes Control and Complications Trial (DCCT).
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Intensive therapy to lower blood glucose concentrations as practiced in
the DCCT is associated with a substantial increment in cost.
RECOMMENDATION:
The costs of intensive therapy to treat type 1 diabetes should be balanced
against the cost savings related to reduction of long-term complications
of diabetes.
ABSTRACT:
The resources used and associated costs of care of patients in the DCCT
are detailed. Researchers calculated resources used for intensive and
conventional therapy, including health care professionals' time and services,
hospitalizations, outpatient care, and equipment and supplies, as well
as for managing the side effects of therapy. Most data were derived from
information routinely collected as part of the trial; a questionnaire
was used to gather data not available from existing sources. Costs were
calculated as the product of the resources used and the unit cost of those
resources. The annual cost of intensive therapy with multiple daily insulin
injections (approximately $4,000 per year) was $2,300, or 2.4 times, greater
than the cost of conventional therapy (approximately $1,700 per year).
Most of the difference in cost was attributable to differences in the
frequency of outpatient visits and self-monitoring of blood glucose. The
annual cost of intensive therapy with continuous subcutaneous insulin
infusion (approximately $5,800 per year) was $1,800, or 1.4 times, greater
than the cost of intensive therapy with multiple daily insulin injections.
The higher expense was due entirely to the cost of the pump and pump-related
supplies. The costs ($210 per year) associated with the major side effects
of intensive therapy, excessive weight gain and severe hypoglycemia, were
three times the cost of treating the side effects of conventional therapy
($70 per year), but as a percentage of the total there was little difference
between the groups (5 percent versus 4 percent). The authors point out
that costs associated with intensive therapy in the DCCT, which was carried
out in academic settings following a research protocol, would probably
be higher than the cost of such therapy in the general health care setting.
8 tables, 11 references.
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