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The Economics of Diabetes Mellitus: An Annotated Bibliography

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COSTS OF DIABETES

Direct Medical Costs

Abstracts 158–167

Oupatient Care (Hospital, Physician, Emergency)

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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