Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
TYPES
OF INTERVENTION
Secondary
Intervention
Educational
Programs
52
TITLE:
Comparison of Five Glucose Meters for Self-Monitoring of Blood Glucose
by Diabetic Patients. Gifford-Jorgensen, R.A.; Borchert, J.; Hassanein,
R.; Tilzer, L.; Eaks, G.A.; Moore, W.V. Diabetes Care. 9(1): 70-76.
January-February 1986.
OBJECTIVE:
To compare the accuracy, ease of operation, and cost of five self-monitoring
blood glucose meters.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
For four of the five meters, adjusted blood glucose values were not significantly
different from laboratory values. Various advantages and disadvantages
were found relative to price, calibration, strip utilization, and ease
of operation.
RECOMMENDATION:
Patient education is absolutely necessary for accurate use of the blood
glucose meters.
ABSTRACT:
The authors assessed five kinds of currently marketed meters for home
use: Accu-Chek (Bio-Dynamics, Inc.); Glucochek II bG (Medistron/Larken),
with Chemstrip bG reagent strips; Glucochek II-Dextro (Medistron/Larken),
with Dextrostix reagent strips; two Glucometer (Ames Division, Miles Laboratories)
reflectance photometers, with calibration either by fluids or special
chips; and Glucoscan II (LifeScan, Inc.). Fasting blood samples were taken
from patients (n = 37) at the University of Kansas College of Health Sciences
and Hospital and tested immediately on the meters. Blood samples were
also taken to the laboratory for serum testing according to the glucose-oxidase
method. When unadjusted meter readings of whole blood glucose were plotted
against laboratory values, three of the meters had a 35-49 percent inaccuracy
rate; for the other two, inaccuracy rates were 65 and 70 percent. After
adjustment of the whole blood glucose values to match the serum values,
only the Glucochek II-Dextro with Dextrostix reagent strips had significantly
different values. (A technical revision by the manufacturers may have
changed this meter's performance.) For blood glucose ranges of both 60-180
mg/dL and 181-300 mg/dL, all meters except Glucoscan II were at least
95 percent accurate. For values of 301-400 mg/dL, both the Glucometer
(with "CHIP" calibration) and the Glucoscan II were less than
95 percent accurate. Prices approximated $150 for the Accu-Chek and the
Glucometers, $140 for the Glucochek models, and $178 for the Glucoscan
II; 404 to 704 for reagent strips. The Glucoscan II and the two Glucochek
models were factory calibrated; the other models required periodic recalibration.
7 figures, 3 tables, 32 references.
53
TITLE:
Conference Report: Approaches to the Treatment of Type II Diabetes and
Developments in Glucose Monitoring and Insulin Administration. Bloomgarden,
Z.T. Diabetes Care. 19(8): 906-909. August 1996.
OBJECTIVE:
To review presentations at conferences held in 1996 concerning treatment
of type 2 diabetes and developments in glucose monitoring systems and
insulin administration.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Conference summary.
Perspective: Health care system.
CONCLUSION:
None.
RECOMMENDATION:
None.
ABSTRACT:
The author reviews 1996 conference presentations concerning treatment
of type 2 diabetes, glucose monitoring, and insulin administration. In
1992, medical costs for diabetes were 12 percent of total health care
costs, but only 8 percent of patient visits were to diabetes specialists.
For each 1 percent fall in hemoglobin A1c (HbA1C), development
of proliferative retinopathy and nephropathy falls 50 percent. Diet and
exercise are effective in controlling blood glucose and in decreasing
the risk of developing type 2 diabetes. Elizabeth Barrett-Connor suggested
that achieving glycemic control is not a key to decreasing mortality.
A speaker on managed care stated that protocol-based care is needed, and
that outcomes and costs should be followed. Researchers in England are
looking at the effect that controlling blood glucose and hypertension
has on outcome for patients with type 2 diabetes. A new study of the effects
of obesity and exercise on development of type 2 diabetes is about to
start. According to one speaker, Julio Santiago, most self-glucose monitoring
is a waste of money. He indicated that an annual investment of $2,000
per patient would decrease mortality substantially in patients with diabetes
(supporting data are available). Santiago proposed that therapeutic programs
use algorithms based on the HbA1C, the fasting blood glucose
value, and the avoidance of hypoglycemia. Another speaker stated that
home blood glucose meters are inaccurate, especially at glucose concentrations
less than 75 mg/dL. An implantable insulin pump was found to decrease
blood glucose and HbA1C, but infections, mechanical failures,
and cost were problems. Inhalation, trans-dermal delivery, and sonophoresis
are being investigated, as is the use of computer programs for records
management and treatment advice. 4 references.
54
TITLE:
The Diabetes Education Study: A Controlled Trial of the Effects of Diabetes
Patient Education. Mazzuca, S.A.; Moorman, N.H.; Wheeler, M.L.; Norton,
J.A.; Fineberg, N.S.; Vinicor, F.; Cohen, S.J.; Clark, C.M. Diabetes
Care. 9(1): 1-10. January-February 1986.
OBJECTIVE:
To assess, in the context of a randomized clinical trial, the impact of
an education program for adult patients with diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Randomized clinical trial.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Patients in the intervention education group made lasting changes in skills
and self-care behavior and achieved modest improvement in glycemic control.
RECOMMENDATION:
More research in similar and different settings is needed to determine
whether the patients from this study are truly representative of patients
with type 2 diabetes.
ABSTRACT:
The authors report the results of the Diabetes Education Study (DIABEDS)
developed by the Indiana University School of Medicine. The DIABEDS is
a randomized, controlled trial of patient and physician education in managing
diabetes. The 532 patients recruited from a clinic population into the
study were primarily elderly, female, black, and obese; 95 percent had
type 2 diabetes. Patients could be assigned to intervention groups (patient
education, physician plus patient education) or control groups (control
group, physician education group). Staff were randomly assigned to care
groups. Patients in the intervention groups (n = 263) received interactive
instruction over an 8-week period on diabetes and its complications, use
of medications, the effects of diet and exercise, foot care, urine testing,
and behavior modification; they also received meal plans and menus as
well as a home visit. Patients in the control groups (n = 269) received
the standard institutional patient education. Patients were assessed at
entry into the study and at postintervention periods ranging from 6 to
14 months. Two hundred seventy-five patients took part in postintervention
assessment. On most knowledge items, there was little difference between
intervention and control groups; intervention patients did better in listing
causes of hyperglycemia, knowledge of urine test implications, and knowing
the diabetes exchange list system. Intervention patients were significantly
better on two of four urine testing skills as well as on food partitioning
and/or weighing. In addition, they made more improvement in fasting glucose
concentrations, glycosylated hemoglobin, body weight, diastolic and systolic
blood pressure, and serum creatinine concentrations. Intervention patients
also had statistically better diet compliance and safety habits. 8 tables,
13 references.
55
TITLE:
Effect of Diabetes Education on Self-Care Metabolic Control and Emotional
Well-Being. Flack, J.R. Diabetes Care. 13(10): 1094. October 1990.
OBJECTIVE:
To rebut the assertion by Rubin et al. (Diabetes Care. 12:673-679.
1989) that educational programs with a few sessions spread over a long
time period are probably less effective than a program of 5 consecutive
days.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Diabetes education programs that spread the education process over a period
of time (up to 6 weeks) may be more effective than five consecutive-day
programs.
RECOMMENDATION:
Future studies on diabetes programs need to focus on who should teach
what, when and how it should be taught, and how to assess outcome.
ABSTRACT:
The author questions the contention of Rubin et al. that educational interventions
for persons with diabetes that consist of a few sessions spread over a
long period will probably be less effective than the 5 consecutive-day
program of Rubin et al. A study presented by Beeney et al. (1988) at the
13th International Diabetes Federation meeting compared four diabetes
education programs over 3 years. At 12 months after entry, knowledge improvement
was independent of the program format. Psychological adjustment was better
in patients for whom the program was prolonged for up to 6 weeks. Beeney
et al. concluded that the demonstrated benefits of extended formats must
be rationalized with the size and requirements of the population served
to determine the most cost-effective program. They noted that shorter
programs have higher patient turnover. The author suggests that diabetes
education needs more study in terms of who is to teach what, when and
how it should be taught, and how to assess a suitable outcome. In a reply,
Rubin et al. agree that extended education programs can be effective.
They state that the content and time devoted to teaching are the most
important factors in a program, but they indicate that the point of diminishing
return for the amount of education has not been identified. They recommend
that future studies seek to identify the content and format that produce
the best results. 6 references.
56
TITLE:
Effect of Diabetes Education on Self-Care, Metabolic Control, and Emotional
Well-Being. Rubin, R.R.; Peyrot, M.; Saudek, C.D. Diabetes Care.
12(10): 673-679. November-December 1989.
OBJECTIVE:
To determine whether an intensive comprehensive educational program will
improve emotional well-being, self-care practices, and metabolic control
in patients with diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Prospective trial.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
An intensive comprehensive educational program improves emotional well-being,
self-care practices, and metabolic control, especially in patients whose
functional status in these areas is poor.
RECOMMENDATION:
Randomized, controlled studies are needed to assess more definitively
the effectiveness of diabetes education programs.
ABSTRACT:
Participants (n = 165) in this study at the Johns Hopkins Diabetes Center
were enrolled in a week-long outpatient diabetes education program designed
to improve self-care practices, emotional well-being, and metabolic control.
The study population was 70 percent white, mean age was 47.4 " 16.5 years,
and 59 percent had some college education; most participants were overweight.
Sixty-three percent were taking insulin, and 62 percent had type 2 diabetes.
Disease complications in the study group included neuropathies, retinopathy,
vascular complications, and infections. Baseline data were collected on
emotional status, self-care behaviors, diabetes knowledge levels, and
glycemic control as measured by hemoglobin A1c tests (HbA1C).
One hundred twenty-four (75 percent) of the participants completed a 6-month
follow-up questionnaire, and 71 (43 percent) had HbA1C tests
at 6-month follow-up. At both program end and 6-month follow-up, participants
had significantly improved from baseline on all measures of emotional
well-being as well as on knowledge. At 6 months (versus baseline), bingeing
was lower (p < 0.01), exercise was more frequent (p < 0.001), self-monitoring
of blood glucose was more frequent (p < 0.001), and HbA1C
was lower (p < 0.001). Program effects were unrelated to demographic
or disease characteristics but were strongly related to initial status.
On six different measures, participants who entered the program in the
worst condition improved the most; those who entered in the best condition
improved little, if at all. 1 figure, 3 tables, 28 references.
57
TITLE:
The Effectiveness of Diabetes Education for Non-Insulin-Dependent Diabetic
Persons. Scott, R.S.; Beaven, D.W.; Stafford, J.M. Diabetes Educator.
10(1): 36-39. Spring 1984.
OBJECTIVE:
To determine the effectiveness of a patient education program for patients
with type 2 diabetes in improving their understanding and management of
the disease and their use of hospital and specialist services.
CATEGORY:
Secondary intervention.
Type of
Study: Randomized clinical trial.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
The patient education program did not result in sustained improvement
in glycemic control or long-term behavior change.
RECOMMENDATION:
The effectiveness of any education program for people with type 2 diabetes
should be carefully assessed, as considerable investment of time by health
professionals may not result in substantial benefits.
ABSTRACT:
This two-part study was carried out at the Christchurch Diabetes Center
in New Zealand. In the first part, individuals with type 2 diabetes were
referred to a diabetes education program where they were randomly assigned
to a treatment (n = 32) or control (n = 28) group. The treatment group
entered an education program immediately, while the control group entered
it four weeks later. Researchers assessed participants' knowledge and
anxiety levels and glycemic control at the time of referral and 4 weeks
later, before the control group had begun the education program. At the
latter time, assessment indices (plasma glucose; urinary glucose; glycosylated
hemoglobin; and knowledge, anxiety, and depression levels) in the control
group showed no significant improvement except for a small increase in
the knowledge score (p < .05). In the treatment group, knowledge (p
< .001), plasma glucose (p < .01), glycosylated hemoglobin (p <
.1), and anxiety score (p < .1) had all improved, but the urinary glucose
score had increased (p < .05). Comparison of improvement in the control
and treatment groups found significant differences in favor of the treatment
group for knowledge, plasma glucose, glycosylated hemoglobin, and anxiety.
In the second part of the study, 30 patients received education at referral
and 26 patients received education after a 4-week delay. Glycemic control
was assessed at referral, at the end of the program, and 4 weeks after
the program's completion. In both groups, the mean values for blood glucose
and glycosylated hemoglobin were not significantly different 4 weeks after
program conclusion from the values at referral. 2 tables, 7 references.
58
TITLE:
Effects of Educational Interventions in Diabetes Care: A Meta-Analysis
of Findings. Brown, S.A. Nursing Research. 37(4): 223-230. July-August
1988.
OBJECTIVE:
To assess the effects of educating patients with diabetes on their knowledge,
self-care behavior, and metabolic control.
CATEGORY:
Secondary intervention.
Type of
Study: Formal meta-analysis of randomized controlled trials.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Patient education has positive outcomes in adults with diabetes.
RECOMMENDATION:
More research is needed to develop the statistical basis for meta-analysis,
and researchers must make data available in a form that permits comparisons
with other studies.
ABSTRACT:
The author used meta-analysis to explore several issues: What is the magnitude
of the effect of patient teaching in adults with diabetes? What outcomes
from teaching in this population have been documented in terms of patient
knowledge, self-care, and metabolic control? Is there a relationship between
outcome effects and various study characteristics (e.g., research design,
type of instruction)? Data were derived from published and unpublished
sources; studies had to have a control group (n = 27) or a preintervention
control phase (n = 20) for comparison of results. Studies had been published
between 1954 and 1986 (50 percent after 1982). The studies included 3,605
patients (range: 8 to 373), 236 effect sizes, and 52 pooled effect sizes.
(An effect size is the difference between the experimental and control
group in standard score form.) The author found that patient teaching
appears to enhance patient outcomes in diabetes management; she determined
that the weighted mean effect size across all studies was 0.33 (i.e.,
outcomes that are 0.33 standard deviation units higher than those for
the comparison group). The effect of teaching on patient knowledge was
moderate to large; on skill performance it was small to low-moderate.
There was a small effect of teaching on weight loss and a large effect
on dietary compliance. Teaching also had a positive effect on metabolic
control. The only study characteristic to be correlated with overall weighted
mean effect size was attrition. 3 tables, 59 references.
59
TITLE:
Evaluating the Costs and Benefits of Outpatient Diabetes Education and
Nutrition Counseling. Kaplan, R.M.; Davis, W.K. Diabetes Care.
9(1): 81-86. January-February 1986.
OBJECTIVE:
To analyze the studies that supported the resolution of the American Diabetes
Association recommending third party payment for outpatient education
and nutrition counseling of patients with diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Review of studies.
Perspective: Health care system.
CONCLUSION:
The reports cited by the American Diabetes Association in support of third
party reimbursement for outpatient education and nutrition counseling
of patients with diabetes do not meet criteria to measure benefits and
rarely include the full costs of such programs.
RECOMMENDATION:
The first criterion for evaluating education and nutrition counseling
should be evidence that they improve health status. Scientifically sound
experiments evaluating education of patients with diabetes should be undertaken.
ABSTRACT:
The authors analyzed the scientific validity of 13 studies cited by the
American Diabetes Association in support of its recommendation for third
party coverage of outpatient education and nutrition counseling of patients
with diabetes. Only two of the reports mentioned control or comparison
groups, and in neither case were the patients randomly assigned to such
groups. Only four studies provided health care cost accounting, and two
of these studies did not include the intervention costs. Some of the studies
seemed to show an increase in costs with intervention. None of the studies
included discount analyses and most failed to report net differences in
costs. Some studies did not report costs of related services or program
implementation costs. In some cases, apparent savings were in fact cost
shifting, which may not equate to cost reduction. None of the studies
estimated indirect patient costs, such as travel time, changes in diet,
and lost work. Only one study reported costs of medications and educational
materials. Costs of continuing intervention were not estimated. Attrition
was high in the five studies that reported it, and follow-up was nonexistent
or not reported in half of the studies. Researchers extrapolated limited
results nationwide, and the programs varied widely. None of the reports
meets accepted criteria to establish the cause and effect of education
intervention. Well-designed experiments are needed to assess the direct
and indirect program costs, the savings attributable to the program, and
the net program benefits. Costs must be based on all patients who receive
service, adequate patient follow-up, and discounted future benefits. 1
table, 23 references.
60
TITLE:
Evaluation of a Structured Treatment and Teaching Program for Non-Insulin-Treated
Type II Diabetic Outpatients in Germany after the Nationwide Introduction
of Reimbursement Policy for Physicians. Gruesser, M.; Bott, U.; Ellermann,
P.; Kronsbein, P.; Joergens, V. Diabetes Care. 16(9): 1268-1275.
September 1993.
OBJECTIVE:
To evaluate the practicability and efficacy of a structured treatment
and teaching program for patients with type 2 diabetes in a routine primary
care office setting.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
The structured treatment and teaching program improved the quality of
care, as evidenced by decreased patient weight, less use of oral antidiabetic
agents, and improved metabolic control.
RECOMMENDATION:
The participating physicians recommended a higher reimbursement rate for
providing a structured treatment and patient education program for their
type 2 diabetes patients.
ABSTRACT:
In 1991, nationwide insurance coverage of a standard treatment and teaching
program for outpatients with type 2 diabetes was introduced in Germany.
Physicians' fees and the costs of teaching materials were reimbursed.
Physicians and office staff were required to complete a training course
to obtain reimbursement. The authors interviewed 127 office-based physicians
in Hamburg who had completed the training course (42 percent were internists
and 58 percent were general practitioners) 12 months after the training,
and information was collected on 179 patients who participated in group
treatment and teaching programs, which were provided in 17 randomly selected
office practices. Of the 127 physicians, 122 (96 percent) rated the training
course content as good and useful, 2 reported they learned nothing new,
and 3 rated the content as useless or poor. Sixty-one percent of the physicians
had implemented at least one treatment and teaching course in their practice
at the time of the evaluation (median: 12 months after completing the
training course). Information on patients completing the program showed
substantial improvements in quality of treatment and self-care practices.
The number of patients who tested their urine for glucose at least twice
a week rose from 3 percent to 70 percent. Improved dietary habits led
to a reduction in body weight, which resulted in decreased use of oral
antidiabetic agents and improved metabolic control. The net cost for the
program was $35.80 (U.S. dollars) per patient in year 1, with an expected
savings of $13.20 per patient per year beginning in year 2. These savings
do not include anticipated reductions in the costs associated with treating
long-term complications of diabetes. Most of the physicians found reimbursement
for offering the program to be either "extremely inadequate"or
"inadequate." 1 figure, 4 tables, 40 references.
61
TITLE:
Obesity and the U.S. Navy [letter]. Yowell, S.K. Military Medicine.
156(12): A10. December 1991.
OBJECTIVE:
To show that the authors of an earlier article (Hoiberg, A.; McNally,
M.S. Military Medicine. 156(2): 76-82 [abstract 222]) did not provide
support for the Health and Physical Readiness Program of the U.S. Navy.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Review of study.
Perspective: Health care system.
CONCLUSION:
The referenced authors' support for the Navy's Health and Physical Readiness
Program was not justified by their study.
RECOMMENDATION:
A weight control program's efficacy, potential benefits, and adverse effects
should be examined, as should its cost of screening and monitoring.
ABSTRACT:
This letter to the editor offers several criticisms of Hoiberg and McNally's
article on overweight patients in the U.S. Navy. The author points out
that obesity was not defined in Hoiberg and McNally's article and that
data were obtained from sources that did not verify diagnoses. Furthermore,
the control group was not age-matched with the obese group. The author
also questions diagnoses of gout, hypertension, gallbladder disorders,
and diabetes on admissions of obese patients. He points out that admissions
for a diagnosis like diabetes are more likely to have obesity mentioned
in the workup than are admissions for diagnoses where weight is thought
to be irrelevant. Referring to the authors' finding of a high concordance
of alcoholism and obesity, the writer notes that during the study period
almost all obesity therapy was offered by alcohol rehabilitation staff;
a co-diagnosis of alcoholism was often needed to gain admission. Before
implementing weight control programs and examining their potential savings
in hospitalization, he suggests looking at their efficacy, potential benefit,
adverse effects, and the cost of screening and monitoring.
62
TITLE:
A Randomized Study of the Effects of a Home Diabetes Education Program.
Rettig, B.A.; Shrauger, D.G.; Recker, R.R.; Gallagher, T.F.; Wiltse, H.
Diabetes Care. 9(2): 173-178. March-April 1986.
OBJECTIVE:
To determine the effectiveness of a home-based individualized instruction
program in diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Randomized clinical trial.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Six months following enrollment, patients in the intervention group (home
teaching) had significantly greater knowledge and skill scores than the
control group (no teaching). Hospitalization rates, diabetes-related emergency
room visits, physician visits, and sick days did not differ significantly
by group at 12-month follow-up.
RECOMMENDATION:
Because diabetes is a chronic disease, new guidelines for diabetes patient
education should incorporate a long-term management plan in conjunction
with periodic reinforcement of self-care knowledge and skills.
ABSTRACT:
In this Nebraska-based study, home health nurses provided up to 12 educational
visits for 193 patients randomly assigned to the intervention group. The
180 patients in the control group, while not receiving home visits, were
free to participate in other types of health education. The two groups
did not vary in terms of demographic composition, diabetes duration, diabetes
type, or previous diabetes education. A survey instrument developed by
the Nebraska Diabetes Demonstration Project was used to measure self-care
knowledge and skills. At 6-month follow-up, total mean knowledge scores
were 60.2 for the intervention group, 51.6 for controls (p = 0.001); total
mean skill scores were 74.8 for the intervention group and 72.6 for controls,
a difference that was statistically significant (p = 0.04) but not considered
meaningful. At 12-month follow-up, hospitalization rates did not differ
by group on any of three types of admission: nondiabetes-related, nonpreventable
diabetes-related, and preventable diabetes-related. There was no difference
between the groups in mean foot appearance score at 6-month follow-up.
The authors warn of possible bias in the selection of study participants,
as those who chose to participate may have been more highly motivated
than those who did not (about 70 percent of patients who were asked to
participate actually did). Such a bias could have resulted in recruiting
patients for whom teaching would have added little to present knowledge
and skill levels. In addition, persons hospitalized with a diabetes-related
condition were more likely to have been identified as eligible to participate
than those hospitalized with a condition not overtly related to diabetes.
5 tables, 13 references.
63
TITLE:
Reduced Hospital Utilization and Cost Savings Associated with Diabetes
Patient Education. Sinnock, P. Journal of Insurance Medicine. 18(3):
24-30. Summer 1986.
OBJECTIVE:
To review data demonstrating the impact of patient education programs
on health care services used by patients with diabetes; to review the
system for assuring the quality of such programs and the current status
of reimbursement by third party payers for diabetes outpatient education.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Review of studies.
Perspective: Health care system.
CONCLUSION:
Diabetes patient education programs can dramatically reduce the physical
and economic costs of diabetes.
RECOMMENDATION:
The insurance industry and diabetes community should work together to
monitor and improve diabetes patient education programs.
ABSTRACT:
Numerous studies have demonstrated an association between diabetes patient
education and reduction in hospitalizations, resulting in cost savings.
A 2-year study of 6,000 persons with diabetes who participated in a patient
education program at Los Angeles County Hospital demonstrated a 73 percent
decrease in hospitalizations; cost savings over the study period were
estimated at $1.8 million. A program at Grady Memorial Hospital in Atlanta
showed a 65 percent decrease in admissions for diabetic ketoacidosis and
an estimated savings of $3.5 million over 8 years. In Maine, a Centers
for Disease Control state-based program demonstrated a 32 percent reduction
in hospitalizations among 1,000 participants, with net savings estimated
at $293 per participant per year. A 51 percent reduction in hospitalization
from diabetic acidosis and infection and a 63 percent reduction in emergency
room visits were seen in a Rhode Island program. Estimated cost savings
associated with this intervention were $355 per participant per year.
The quality of diabetes education programs in the United States has varied,
but it is hoped that the implementation of the National Standards for
Diabetes Patient Education Programs (National Diabetes Advisory Board
1983) will improve this situation. Blue Cross and/or Blue Shield and selected
private insurers reimburse for outpatient education in 14 states, Medicare
in 15 states, and Medicaid in 6 states. Several states are considering
legislation that would mandate coverage for self-management education
programs for diabetes outpatients. 1 figure, 2 tables, 30 references.
64
TITLE:
Third Party Reimbursement for Diabetes Mellitus: Outpatient Education:
A Year's Progress. Peddicord, M.; Lyons, A.; Tobin, C.; Vinicor, F. Diabetes
Spectrum. 3(1): 9-12. January-February 1990.
OBJECTIVE:
To determine the progress made in obtaining third party reimbursement
for outpatient education programs for patients with diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Survey.
Perspective: Health care system.
CONCLUSION:
Between 1986 and 1989, the number of states reporting reimbursement for
diabetes outpatient education increased. Medicare reimbursement increased
because of a national policy statement from the Health Care Financing
Administration (HCFA). An increase in private insurer reimbursement is
credited to consumer demand and Medicare policies. There was little change
in Medicaid programs.
RECOMMENDATION:
Continued consumer advocacy, emphasis on quality, providing additional
cost and cost-savings information, and ongoing exploration of strategies
and alternatives are recommended to continue the progress made in reimbursement
policies.
ABSTRACT:
Reimbursement for outpatient education programs for patients with diabetes
is increasing across the United States. Four states have enacted legislation
covering reimbursement of these programs. Medicare reimbursement has increased
for outpatient education programs because of a national policy statement
issued by the HCFA defining Medicare's criteria for reimbursement of prevention,
including diabetes education. Private insurers, including HMOs, have shown
the greatest increase in third party reimbursement for outpatient education
programs, primarily because of consumer demand and Medicare policies.
Medicaid programs, which are regulated by the states, have shown the least
change toward third party reimbursement. Among many insurers there is
an acceptance of education as a part of treatment, and not solely as a
preventive measure. Most reimbursed outpatient education programs are
either hospital-based or based in rural health clinics. Programs formally
recognized by an accrediting or recognition body at the state or national
level are more likely to be reimbursed. Concerns regarding reimbursement
for outpatient education for patients with diabetes include the fact that
only one or two education programs per state currently receive reimbursement,
that the prospective payment system is causing more programs to shift
from an inpatient to outpatient setting, and that little progress has
been made in reimbursement for free-standing education programs. 1 figure,
3 tables, 3 references.
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