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Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
TYPES
OF INTERVENTION
Secondary
Intervention
Nutrition
Care
48
TITLE:
Cost-Effectiveness of Medical Nutrition Therapy Provided by Dietitians
for Persons with Non-Insulin-Dependent Diabetes Mellitus. Franz, M.J.;
Splett, P.L.; Monk, A.; Barry, B.; McClain, K.; Weaver, T.; Upham, P.;
Bergenstal, R.; Mazze, R.S. Journal of the American Dietetic Association.
95(9): 1018-1024. September 1995.
OBJECTIVE:
To report on the cost-effectiveness of nutrition care by practice guidelines
for patients with type 2 diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Randomized clinical trial.
Methodology: Cost-effectiveness analysis.
Perspective: Health care system.
CONCLUSION:
The implementation of nutrition guidelines in type 2 diabetes can be met
with a reasonable investment of resources and improvement in metabolic
control.
RECOMMENDATION:
Additional research should be conducted before more intensive nutrition
intervention can be recommended as the preferred approach for patients
with type 2 diabetes.
ABSTRACT:
The authors conducted a cost-effectiveness analysis of 179 adult patients
with type 2 diabetes randomized to basic nutrition care (n = 85) or nutrition
care following practice guidelines (n = 94). Basic care included just
one visit from the dietitian; practice guidelines, three or more. The
defined outcome for the cost-effectiveness analysis was the effect of
nutrition care on glycemic control at 6 months as measured by changes
from baseline in levels of fasting plasma glucose and glycated hemoglobin.
Costs were limited to those for direct health care as documented through
an accounting approach. The per-patient cost (1993 dollars) of providing
basic care was $41.95; the comparable cost for guidelines care was $112.07.
Each mg/dL of change in the fasting plasma glucose concentration after
6 months of intervention required an investment of $5.75 in the basic
group and $5.84 in the guidelines group. When net costs were considered
(per-patient costs minus cost savings due to changes in therapy), the
required investments were $5.32 and $4.20 for the basic and guidelines
groups, respectively. Changes in medical therapy resulted in a per-patient
cost savings over 12 months of $31.49 in the guidelines group and $3.13
in the basic group. Sensitivity analysis showed that the relative cost-effectiveness
of guidelines care versus basic care was unchanged by dietitian salary
or additional laboratory testing. Results show that nutrition therapy
can be provided in a cost-effective manner. Additional information is
needed, however, before more intensive nutrition intervention can be recommended
as the preferred approach for type 2 patients. 5 tables, 26 references.
49
TITLE:
Effects of Diet and Exercise Interventions on Control and Quality of Life
in Non-Insulin-Dependent Diabetes. Kaplan, R.M.; Hartwell, S.L.; Wilson,
D.K.; Wallace, J.P. Journal of General Internal Medicine. 2(4):
220-228. July-August 1987.
OBJECTIVE:
To assess the impact of diet and exercise on glycemic control and quality
of life in patients with type 2 diabetes.
CATEGORY:
Secondary intervention.
Type of
Study: Randomized clinical trial.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
Patients in the diet-plus-exercise group significantly improved their
quality of life and significantly decreased their glycosylated hemoglobin
(HbA1C) over 18 months.
RECOMMENDATION:
Additional studies of nonpharmacologic intervention for patients with
type 2 diabetes are needed using larger sample sizes.
ABSTRACT:
The authors report a study of 70 volunteers with type 2 diabetes who were
randomized to one of four types of nonpharmacologic management: diet,
exercise, diet and exercise, or education (control group). All participants
were given the same diet (the exchange diet recommended by the American
Diabetes Association) and asked to attend 10 consecutive weekly meetings;
exercise routines were prescribed individually based on graded exercise
tests. The intervention groups underwent behavioral modification sessions
that included goal-setting and diet and/or exercise plans. The control
group received lectures from a variety of health care specialists but
no specific behavior modification plans. After 3 and 6 months, the diet
group had significantly greater weight loss than the control group (2.52
kg loss versus a gain of 1.37 kg), but at 18 months, the diet group had
regained an average of 1.81 kg. Also at 18 months, the diet-plus-exercise
group had reduced its HbA1C levels from 9.18 to 7.70 percent,
versus an increase from 8.21 to 8.57 percent for the controls (p <
0.05). Changes in HbA1C in the diet-only and exercise-only
groups were not significant compared with controls. Over 18 months, quality
of life improved for participants in the combined intervention group,
improved less markedly for the diet group, remained relatively static
in the exercise group, and deteriorated for the control group. Estimated
direct cost of the diet-plus-exercise intervention was $1,000 per participant
per year; this program yielded 0.092 years of well-being over that obtained
by the control group, which was actually less than zero. Thus, the cost
of producing a well year was $10,870. 2 figures, 4 tables, 19 references.
50
TITLE:
Reliability and Cost of Diabetic Diets. Tunbridge, R.; Wetherill, J.H.
British Medical Journal. 2(701): 78-80. April 11, 1970.
OBJECTIVE:
To ascertain the adherence of patients with diabetes mellitus to the recommended
diet, and to calculate the cost of maintaining the recommended diet.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Thirty percent of patients adhered to within 10 percent of their recommended
diet. The cost of the recommended diet was higher than the cost of food
for the general population.
RECOMMENDATION:
None.
ABSTRACT:
The authors reported on adherence to prescribed diets for 63 patients
attending the diabetes clinic at the General Infirmary in Leeds, England,
for a single week in the spring of 1968. Dietary control was satisfactory
(90 to 100 percent within guidelines) for 30 percent of patients, tolerable
(80 to 89 percent within guidelines) for 38 percent, and "hopeless"
(less than 80 percent within guidelines) for 32 percent. Less than one-third
of women (n = 35) and men (n = 28) followed satisfactory diets. Adherence
was best among participants aged 40 years and under and worst among those
aged over 60 years. Dietary control was poorer among participants treated
by diet plus oral hypoglycemic agents than in those treated by dietary
control with or without insulin; it was poorer among those diagnosed within
10 years than among those diagnosed for more than 10 years. Dietary control
was best with diets of 1,201 to 1,999 calories and worst with 1,200 calories
or less. Diabetes control was satisfactory (blood glucose between 50 and
200 mg/ml, no ketonuria, weight steady) in 42 percent of patients with
satisfactory diets, 33 percent of those with tolerable diets, and 40 percent
of those with hopeless diets. The estimated cost per patient per week
to follow an ideal diet was 44 shillings and 1 penny, versus 38 shillings,
4 pennies for the general population. Low-income patients continue to
have difficulty purchasing the food to maintain a correct diet. 7 tables,
5 references.
51
TITLE:
Spin-Off Cost/Benefits of Expanded Nutritional Care. Davidson, J.; Delcher,
H.; Englund, A. Journal of the American Dietetic Association. 75(3):
250-257. September 1979.
OBJECTIVE:
To describe and evaluate an expanded nutrition care program developed
in a hospital diabetes unit; to compare projected costs of continuing
the preintervention program with actual costs incurred with the expanded
intervention.
CATEGORY:
Secondary intervention.
Type of
Study: Patient management.
Methodology: Cost-benefit analysis.
Perspective: Health care system.
CONCLUSION:
Over an 8-year period, the expanded nutrition care program saved the hospital
$379,988 from reduced use of insulin (1973 to 1978 only) and no use of
oral agents and over $3,700,000 from decreased incidence of lower extremity
amputations and severe diabetic ketoacidosis. Net savings for the year
1978 were $216,699.
RECOMMENDATION:
Registered dietitians should collaborate with physicians and nurses to
organize health care teams that will provide expanded nutrition care programs
for all Americans who have diabetes.
ABSTRACT:
The authors describe the outcome of an expanded nutrition care program
developed over an 8-year period (1971-1978) in the Grady Memorial Hospital
Diabetes Unit in Atlanta, Georgia; Grady is the primary teaching hospital
of the Emory University School of Medicine. Projected costs of continuing
the pre-1971 program, which consisted of basic nutrition care with high
use of insulin and oral agents, were compared with actual costs of the
expanded program. The latter program emphasized short-term fasts, hypocaloric
diets, patient education and follow-up, discontinued oral agents, and
limited use of insulin. Total costs of the pre-1971 program were estimated
at $125,863 per year, including $43,176 for oral agents, $23,723 for insulin,
$23,963 for the basic nutrition program, and $35,000 for personnel, facilities,
and supplies. Estimated total cost of the expanded nutrition care program
for the year 1978 was $615,164, including approximately $500,000 for personnel,
facilities, and equipment; $73,391 for expanded nutrition care; and $41,774
for insulin. Despite these increased costs, the hospital had an estimated
net savings of $216,699 for that year, as it saved more than $706,000
because of decreased prevalence of severe diabetic ketoacidosis and severe
lower extremity amputations. During the 8-year study period, decreased
hospitalization for severe diabetic ketoacidosis and lower extremity amputation
provided the hospital with gross savings of more than $3.7 million. 2
figures, 9 tables, 15 references.
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