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Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
TYPES
OF INTERVENTION
Diabetes
in Pregnancy
Pregestational
Diabetes
134
TITLE:
Cost-Benefit Analysis of Preconception Care for Women with Established
Diabetes Mellitus. Elixhauser, A.; Wechsler, J.M.; Kitzmiller, J.L.; Marks,
J.S.; Bennert Jr., H.W.; Coustan, D.R.; Gabbe, S.G.; Herman, W.H.; Kaufmann,
R.C.; Ogata, E.S.; Sepe, S.J. Diabetes Care. 16(8):1146-1157. August
1993.
OBJECTIVE:
To determine whether the costs of pre-conception care in women with diabetes
are balanced by the savings that result from avoiding complications.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
Intensive preconception care for women with diabetes followed by prenatal
care is cost saving when compared with prenatal care only.
RECOMMENDATION:
None.
ABSTRACT:
Literature review, consensus development, and questionnaires were used
to compare the costs of preconception care plus prenatal care with the
costs of prenatal care only for hypothetical groups of 1,000 women each.
Preconception care was assumed to require 20 visits; the model specified
that only after glycemic control was achieved and maternal health status
evaluated would a couple be encouraged to conceive. For the prenatal-care-only
group, care was assumed to start at gestational age of 12 weeks. The economic
consequences of adverse outcomes of pregnancy included those for the mother
(e.g., a stay in the intensive care unit), initial hospitalization for
the newborn (costs of congenital anomalies, respiratory distress syndrome,
etc.), and subsequent care for the newborn. A cost-benefit analysis (all
costs in 1989 dollars) from the perspective of a third party payer was
performed in which total program costs were compared with the dollar value
of maternal and neonatal adverse outcomes. Net benefits and a benefit-cost
ratio were computed. Net benefits equaled the sum of the costs for prenatal
care only and the costs of associated adverse outcomes, minus the sum
of the costs of the preconception-plus-prenatal-care program and the associated
adverse outcomes. The benefit-cost ratio was calculated by dividing the
difference in adverse outcome costs between the programs by the difference
in program inputs. The model found that the preconception-care group incurred
costs of $11,294 per enrollee and $17,519 per delivery. In contrast, cost
per enrollee in the prenatal-care-only program was $12,889 and cost per
delivery was $13,843 (the cost was higher in the preconception-care group
because more women received medical services without going on to deliver).
Rates of adverse outcomes were generally lower for the preconception-care
patients. Total costs of adverse outcomes were $9,655,079 in the preconception
group and $13,372,792 in the group receiving prenatal care only. Net benefit
of the preconception care program was $1720 per enrollee; the benefit-cost
ratio was 1.86. 6 tables, 3 appendixes, 44 references.
135
TITLE:
Cost-Benefit Analysis of Preconception Care for Women with Established
Diabetes Mellitus. Final Report. Elixhauser, A.; Weschler, J.M. Battelle
Medical Technology and Policy Research Center, Washington, D.C., 1990.
OBJECTIVE:
To analyze and compare costs and benefits of preconception care plus prenatal
care versus prenatal care only in preventing adverse fetal and maternal
outcomes in women with pre-existing diabetes mellitus.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Epidemiological cohort model.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
The program of preconception care plus prenatal care resulted in net savings
of $1.7 million; the greatest savings were associated with reduction of
adverse outcomes in mothers and infants.
RECOMMENDATION:
Third party payers can expect to realize cost savings from reduced maternal
and fetal complications in women with pre-existing diabetes by reimbursing
for preconception care (including educational and support services provided
by allied health care providers) according to standards recommended by
the American Diabetes Association.
ABSTRACT:
The authors constructed a model, based on literature review, review by
an expert panel, and questionnaires, to compare among women with diabetes
the costs and benefits associated with preconception care plus prenatal
care with those for prenatal care only. The theoretical study population
included 1,000 women in the preconception care program, of whom 785 became
pregnant and entered prenatal care; and 1,000 women in the prenatal-care-only
program, of whom 900 became pregnant. The preconception component of the
program was 17 weeks long and included an initial preconception evaluation
and 20 visits for medical evaluation; laboratory tests; and education,
dietary, and counseling services. Women in the program were assumed to
enter prenatal care six weeks after their last menstrual period. The prenatal-care-only
program assumed that all women would have appropriate care and enter the
prenatal program at a later stage of pregnancy (10 to 12 weeks after the
last menstrual period), that 60 percent would enter the program in less
than optimal control and 25 percent would require hospitalization to improve
control, and that those in poor control would require more intensive medical
and dietary management. Cost-benefit analysis showed that the total costs
of care for women in the preconception plus prenatal care group were $11,294,100
(not including nonmedical costs); total costs for women in the prenatal-care-only
group were $9,296,900. Costs associated with adverse outcomes totaled
$9,655,079 for the first group and $13,372,676 for the second. Total costs
for women in the second group were $1,720,397 ($1,720 per woman) higher
than total costs for women receiving preconception care, resulting in
a cost-benefit ratio of 1.86. 14 tables, 3 figures, 4 appendices, 80 references.
136
TITLE:
Financial Implications of Implementing Standards of Care for Diabetes
and Pregnancy. Elixhauser, A.; Weschler, J.; Kitzmiller, J.; Bennert,
H.; Coustan, D.; Gabbe, S.; Herman, W.; Kauffmann, R.; Ogata, E.; Marks,
J.; et al. Diabetes Care. 15 (Supplement 1): S22-S28. March 1992.
OBJECTIVE:
To examine the financial implications of implementing standards of care
for pregnancy among women with diabetes.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient management.
Methodology: Review of studies.
Perspective: Health care system.
CONCLUSION:
Implementing standards of care for pregnancy among women with diabetes
will represent a greater use of health care resources for outpatient preconception
and prenatal care but can lead to avoided costs for maternal and fetal
complications of pregnancy.
RECOMMENDATION:
Reimbursement should be provided by third party payers for comprehensive
diabetes and pregnancy care to ensure that women with diabetes have access
to the care they require to prevent adverse outcomes for themselves and
their infants.
ABSTRACT:
The authors examine the financial implications of implementing standards
of care for pregnancy among women with diabetes. The standards of interest
were developed by the American Diabetes Association and address four main
areas of care: preconception care, blood glucose control, frequent visits,
and specialized laboratory and diagnostic tests. As these standards did
not specify the resources required for preconception and prenatal care,
the authors convened a panel of physicians to outline more precise guidelines.
The recommendations of the panel were examined for their economic implications.
Adherence to these standards may represent additional costs to patients
or third party payers for initial outpatient treatment. However, treatment-related
costs of adverse outcomes of pregnancy can be enormous, particularly those
due to poor maternal glucose control. Corrective surgery for infants with
congenital heart malformations secondary to poor glucose control may cost
up to $145,000 (1989 dollars) per survivor; lifetime care costs for infants
born with severe spina bifida are estimated at $330,000, including both
direct and indirect costs. In addition to avoiding costs related to poor
fetal outcomes, intensive preconception and prenatal care can help to
avoid expensive hospitalizations for maternal complications; hospitalization
for a single episode of ketoacidosis averages $4,500. Two recent cost-benefit
studies are cited that demonstrate that the savings resulting from avoided
adverse pregnancy outcomes in women with diabetes outweigh the added costs
of preconception care. Reimbursement of comprehensive diabetes and pregnancy
care by third party payers is crucial for ensuring the care necessary
to prevent adverse outcomes for these women and their infants. 1 figure,
49 references.
137
TITLE:
Prevention: The Cost-Effectiveness of the California Diabetes and Pregnancy
Program. Scheffler, R.M.; Feuchtbaum, L.B.; Phibbs, C.S. American Journal
of Public Health. 82(2): 168-175. February 1992.
OBJECTIVE:
To determine the cost-effectiveness of a California program aimed at improving
pregnancy outcomes through intensive diabetes management.
CATEGORY:
Tertiary intervention.
Type of
Study: Retrospective.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
The program significantly reduced hospital charges and length of stay;
it returned over $5 for every $1 spent.
RECOMMENDATION:
None.
ABSTRACT:
The California Diabetes and Pregnancy Program focuses on improving maternal
and infant perinatal outcomes in pregnancies complicated by diabetes.
Women in the program receive comprehensive preconception and prenatal
care, including nutrition, education, and support services. Data for 102
California Diabetes and Pregnancy Program cases were collected from July
1, 1986, to July 30, 1988, from three hospitals with well-established
programs, each with a level 3 neonatal intensive care unit. Data for 218
control cases were collected from five other hospitals, each with at least
a level 2 neonatal intensive care unit. The demographic characteristics
and health status indicators of mothers and babies at case and control
hospitals were similar. Program participants and control cases of the
same age, ethnicity, and diabetes classification were randomly matched,
yielding a data set of 90 program cases and 90 control cases. In this
data set, mean adjusted charges were $15,344 for cases, $21,699 for controls.
Mean length of stay (mother and baby combined) was 15.1 days for the program
cases, 18.0 days for controls. After adjustment for inflation and differences
in hospital charges, for every $1 of program costs, estimated savings
were $5.19. The authors' conservative assumptions suggest that actual
savings are even larger than their estimates. If 2,598 babies were born
to women with overt diabetes in 1990 (as estimated), yearly savings attributable
to the California Diabetes and Pregnancy Program would have been $14 million
to $19 million. In addition to short-term economic savings, mothers will
likely have better future health status, and there should be long-term
savings from fewer anomalies and other handicaps. With more normal pregnancies
and healthy babies, mothers can stay in the workforce longer and return
to work sooner. 6 tables, 27 references.
138
TITLE:
Women with Diabetes During Pregnancy: Sociodemographics, Outcomes, and
Costs of Care. York, R.; Brown, L.P. Public Health Nursing. 12(5):
290-293. October 1995.
OBJECTIVE:
To provide sociodemographic, outcome, and cost data for pregnancy through
the postpartum period for predominantly low-income women with diabetes
who were hospitalized during pregnancy for glucose control.
CATEGORY:
Diabetes in pregnancy.
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Women in the study were three times as likely as those in the general
Pennsylvania population to deliver low-birthweight infants; mean hospital
charges for these infants were $39,787.
RECOMMENDATION:
Monies must be targeted to provide a broad spectrum of health care services
that will meet the unique needs of low-income, childbearing women with
diabetes.
ABSTRACT:
The authors evaluated data for 55 women with diabetes who received care
at the University of Pennsylvania Medical Center in Philadelphia between
August 1988 and December 1992. Fourteen of the women had pregestational
diabetes; 41, gestational diabetes. Of the 55 women, 63 percent reported
annual family income of under $12,500. Data collection methods included
maternal interviews, review of maternal and infant hospital charts, and
postpartum telephone interviews. Mean hospital charges for antepartum
initial hospitalization for glucose control, evaluation, and education
were $4,665 (mean length of stay: 4.3 days). For women who required rehospitalization
for glucose control, mean hospital charges were $6,371 (mean length of
stay: 5.9 days). Mean charges for postpartum hospitalization were $7,793
(mean length of stay: 4.3 days). Of the 54 infants born to the study participants,
2 were stillborn and 11 were low birthweight. Mean hospital charges
per infant were $12,991; for the low-birthweight infants, $39,787. Compared
with Pennsylvania women as a whole, women in this study were twice as
likely not to have had first-trimester care (43 percent versus 20.4 percent)
and three times more likely to deliver a low-birthweight infant (20 percent
versus 7.2 percent). The results provide significant evidence of the complexity
of these women's health care needs and the need for monies targeted at
addressing these needs. 1 table, 13 references.
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