From our publisher, Steve Freed, comes this thought-provoking discussion of how better diabetes control can impact cost, quality of life and mortality…
Epidemiological study cohorts have shown a gradual increase in the worldwide incidence of type 2 diabetes mellitus. Based on the National Diabetes Statistics Report, 2014, 29 million people in the U.S. have diabetes aged 20 years or older (12.3% of the adult population), and 1 in 4 do not know it. This number has increased from 26 million in 2010. In 2012 alone, 1.7 million people aged 20 years or older were newly diagnosed with diabetes. Eighty-six million people aged 20 years and older have pre-diabetes, and if no precautions or actions are taken, 15-30% of people with pre-diabetes will develop type 2 diabetes within 5 years. Diabetes and its related complications account for $245 billion in total medical costs to include lost work and wages. This number is up from the reported $174 billion in 2010. In addition, over $500 billion of an estimated $3 trillion spent on healthcare last year was spent on conditions related to three chronic diseases: diabetes, heart disease and obesity. In the United States, the number of Emergency Department visits with diabetes as any-listed diagnosis increased from 9,464,000 in 2006 to 11,492,000 in 2009. Based on studies the average lifetime cost of caring for a type 2 diabetic patient is approximately $85,200 and can range from $55,000 to $130,000. Studies have shown that better control of diabetes can reduce cost, increase quality of life, and decrease mortality rate. One study showed that just by reducing A1c by 1% to 1.5%, type 2 diabetic patients can cut costs to $1,717 per target patient over 1 year. Prevention efforts nationwide are very crucial right now to combat serious health risks and increased medical cost. If we can prevent just that 30% with pre-diabetes from developing diabetes we can save $74 billion dollars in medical cost and lost productivity.
Consistency in medical care can reduce overall emergency department visits, hospitalizations, and other inappropriate medication events, and medical costs. Earlier treatment in newly-diagnosed type 2 diabetes with sulfonylureas, insulin, or metformin is associated with decreased risks of all-cause mortality, diabetes-related death, and diabetes-related complications, such as microvascular disease, myocardial infarction, heart failure, stroke, renal failure, and blindness. Results have shown that there is a significantly elevated risk of developing outpatient complications among diabetic patients when there is decreased treatment and control of their diabetes, especially during the first year following type 2 diabetes diagnosis. This was also associated with an increase in the subsequent risks of diabetes-related complications and all-cause mortality. Another study suggests that medication counseling provided by trained medical assistant health coaches including a pharmacist is beneficial. It improves medication concordance and increases adherence which in turn will decrease the medical costs associated with other diabetes-related complications or events.
Complications of diabetes mellitus can be reduced with regular preventive care and guidance on self-management of the disease. A diabetes patient who received regular primary care was associated with an 89% increased likelihood of blood pressure control (95% confidence interval [CI], 59 –118%) and 177% increased likelihood of glycemic control (95% CI, 123–222%). Higher attendance at nutrition and exercise classes is also associated with significantly increased blood pressure control (P =0.001). Regular preventive care and exercise also had a similar comparison which showed a 49.3% increase for glycemic control. Other follow-up cohorts show A1c diabetes-specific Quality of Life (QoL) when looking between 1 and 5 years, the median QoL score decreased from -0.4 (-1 to -0.08) to -0.5 (-1.08 to -0.09), (P = 0.027). The proportion of participants reporting a negative impact of diabetes on their QoL increased from 76.5% to 81% (P < 0.001) and the mean score decreased from 45.6 (10.87) to 44.8 (11.25) (P=0.047), suggesting an adverse impact of diabetes on QoL. These results are in broad agreement with previous studies that have reported an inverse longitudinal association between A1c and diabetes-specific QoL.
We know from recent studies that the financial impact of better controlled diabetes can save an average of $1,328 per patient per month when looking at combined diabetes-related complications in both insured and medicare patients. However, other economic factors can play a role in outcomes as well. Findings using cross-sectional data measuring economic insecurity in diabetes show that 64.1% of patients reporting food insecurity had poor diabetes control compared with 41.6% of food-secure patients (P = 0.001). The food insecurity was associated with poor diabetes control (odds ratio [OR], 1.97 [95% CI, 1.58-2.47]; food-secure patients served as the reference group) and increased outpatient visits (incidence rate ratio [IRR], 1.19 [95% CI, 1.05-1.36]). An increasing number of insecurities was associated with increased odds of poor diabetes control, that is a 39% increase in the odds of poor diabetes control for each additional material need insecurity (OR, 1.39 [95% CI, 1.18-1.63]). These results were similar for the rates of outpatient visits which resulted in a 9% increase.
All of these factors discussed lead us back to the former topics covered that can help us slowly end this diabetes epidemic. If we are consistent with our patients and maintain continuity of care we can reduce many diabetes-related events and medical costs. This means: regular preventive care and guidance on self-management of the disease; coaching by health care providers to relay the importance of nutrition, exercise and consistent health regimens that should be followed; and diabetes education assistance to show the patient that there are healthier alternatives that can be budget friendly and improve quality of life. We cannot focus on one aspect being superior to the other when trying to control type 2 diabetes, but merely put everything together and treat this disease with a synergistic approach.
- Reducing medical cost of a diabetic patient depends not only the the individual patients but also the consistency and continuity of their healthcare providers that are there to guide them.
- Education on the adherence to the proper medication regimen, lifestyle modifications such as exercise and diet, by the healthcare providers is crucial to preventing unnecessary medical costs.
- One factor contributing to the diabetes epidemic is limited access to healthy food choices because of lack of guidance or knowledge for proper diabetes control.
- Pei-Ju Liao, PhD, Zu-Yu Lin, MHA, Jui-Chu Huang, MD. et al. “The Relationship Between Type 2 Diabetic Patients’ Early Medical Care–Seeking Consistency to the Same Clinician and Health Care System and Their Clinical Outcomes”. Medicine Volume 94, Number 7, February 2015.
- “New CDC Diabetes Report.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 10 June 2014. Web. 8 Mar. 2015.
- Kathryn Fitch, RN, MEd; Bruce S. Pyenson, FSA, MAAA, Kosuke Iwasaki, FIAJ, MAAA. “Medical Claim Cost Impact of Improved Diabetes Control for Medicare and Commercially Insured Patients with Type 2 Diabetes”. Journal of Managed Care Pharmacy. Vol.19, No.8, October 2013.
- David H. Thom, MD, MPH, PhD, Rachel Willard-Grace, MPH, Danielle Hessler, PhD. et al. “The Impact of Health Coaching on Medication Adherence in Patients With Poorly Controlled Diabetes, Hypertension, and/or Hyperlipidemia: A Randomized Controlled Trial”. JABFM January–February 2015 Vol. 28 No. 1.
- Julia J. Smith, MS, Matthew D. Berman, PhD, Vanessa Y. Hiratsuka, PhD, MPH. et al. “The Effect of Regular Primary Care Utilization on Long-Term Glycemic and Blood Pressure Control in Adults With Diabetes”. JABFM January–February 2015 Vol. 28 No. 1.
- L. Kuznetsov, G. H. Long, S. J. Griffin. et al. “Are changes in glycaemic control associated with diabetes-specific quality of life and health status in screen-detected type 2 diabetes patients? Four-year follow up of the ADDITION-Cambridge cohort”. Diabetes Metab Res Rev 2015; 31: 69–75.
- Seth A. Berkowitz, MD, MPH; James B. Meigs, MD, MPH; Darren DeWalt, MD, MPH. et al. “Material Need Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources.
- Results of the Measuring Economic Insecurity in Diabetes Study” JAMA Intern Med. 2015;175(2):257-265.
Steve Freed, Publisher, Diabetes In Control
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