The Diabetes Educator Diabetes Educator DOI: ... Data Sources The authors searched ... cost control, cost of illness, cost savings, cost-benefit analysis, costs and cost analysis,

http://tde.sagepub.com

The Diabetes Educator

DOI: 10.1177/0145721708326774 2009; 35; 72 The Diabetes Educator

Suzanne A. Boren, Karen A. Fitzner, Pallavi S. Panhalkar and James E. Specker Costs and Benefits Associated With Diabetes Education: A Review of the Literature

http://tde.sagepub.com/cgi/content/abstract/35/1/72 The online version of this article can be found at:

Published by:

http://www.sagepublications.com

On behalf of:

American Association of Diabetes Educators

can be found at:The Diabetes Educator Additional services and information for

http://tde.sagepub.com/cgi/alerts Email Alerts:

http://tde.sagepub.com/subscriptions Subscriptions:

http://www.sagepub.com/journalsReprints.navReprints:

http://www.sagepub.com/journalsPermissions.navPermissions:

at American Association of Diabetes Educators on June 8, 2009 http://tde.sagepub.comDownloaded from

http://www.diabeteseducator.org

http://tde.sagepub.com/cgi/alerts

http://tde.sagepub.com/subscriptions

http://www.sagepub.com/journalsReprints.nav

http://www.sagepub.com/journalsPermissions.nav


The Diabetes EDUCATOR

72

Volume 35, Number 1, January/February 2009

Costs and BenefitsAssociated WithDiabetes EducationA Review of the Literature

Purpose

The purpose of this article was to review the publishedliterature and evaluate the economic benefits and costsassociated with diabetes education.

Methods

The Medline database (1991-2006) and Google weresearched. Articles that addressed the economic and/orfinancial outcomes of a diabetes-related self-care or edu-cational intervention were included. The study aim, pop-ulation, design, intervention, financial and economicoutcomes, results, and conclusions were extracted fromeligible articles.

Results

Twenty-six papers were identified that addressed dia-betes self-management training and education. Studydesigns included meta-analysis (1); randomized con-trolled trials (8); prospective, quasi-experimental, andpre-post studies (8); and retrospective database analyses(9). The studies conducted cost analyses (6), cost-effec-tiveness analyses (13), cost-utilization analyses (7), andnumber needed to treat analyses (2). More than half (18)of the 26 papers identified by the literature reviewreported findings that associated diabetes education (anddisease management) with decreased cost, cost saving,cost-effectiveness, or positive return on investment. Fourstudies reported neutral results, 1 study found that costsincreased, and 3 studies did not fit into these categories.

Suzanne A. Boren, PhD

Karen A. Fitzner, PhD

Pallavi S. Panhalkar

James E. Specker

From Health Services Research and Development,Harry S. Truman Memorial Veterans’ Hospital,

Columbia, Missouri (Dr Boren); Department of HealthManagement and Informatics, University of Missouri,

Columbia, Missouri (Dr Boren, Ms Panhalkar); andAmerican Association of Diabetes Educators,

Chicago, Illinois (Dr Fitzner, Mr Specker).

Correspondence to Karen Fitzner, PhD, Chief Scienceand Practice Officer, American Association of

Diabetes Educators, 200 W. Madison St, Suite 800,Chicago, IL 60606 ([email protected]).

Acknowledgments: No funds were provided for thisstudy.

Disclaimer: The views expressed in this article arethose of the authors and do not necessarily represent

the views of the Department of Veterans Affairs.

DOI: 10.1177/0145721708326774

TDE326774.qxd 1/16/2009 6:38 PM Page 72



Costs and Benefits Associated With Diabetes Education

73

Boren et al

Conclusions

The findings indicate that the benefits associated witheducation on self-management and lifestyle modificationfor people with diabetes are positive and outweigh thecosts associated with the intervention. More research isneeded to validate that diabetes education provided bydiabetes educators is cost-effective.

In 2006, the United States spent 16% of its grossdomestic product (GDP) or $2 trillion on healthcare,1 and people with chronic conditionsaccounted for 85% of the expenditure.2 Diabetesaffects 7% of Americans and represents more than

$116 billion of these expenditures.3 The overall eco-nomic cost of diabetes in 2007 was $174 billion, withreduced national productivity accounting for $58 to $105billion.3,4 Moreover, the prevalence of the disease is ris-ing, and total health care is expected to reach 20% ofGDP by 2016.1 Interestingly, even with these consider-able expenditures, in 2005, the Centers for Medicare andMedicaid Services (CMS) reimbursed only $4.8 millionon diabetes self-management training codes G108 andG109.

Diabetes education, also known as diabetes self-man-agement training (DSMT) or diabetes self-managementeducation (DSME), is defined as a collaborative processthrough which people with or at risk for diabetes gain theknowledge and skills needed to modify behavior and suc-cessfully self-manage the disease and its related condi-tions. DSMT/DSME is an interactive, ongoing processinvolving the person with diabetes (or the caregiver orfamily) and a diabetes educator(s).5 Diabetes educatorsare health care professionals who focus on helping peo-ple with and at risk for diabetes and related conditionsachieve behavior change goals that, in turn, lead to betterclinical outcomes and improved health status.

Diabetes education is effective in helping people withdiabetes control their illness and maximize their health6-9

and is generally accepted as a cost-effective strategy.There is, however, a lack of available published informa-tion regarding economic evaluations of the benefits andcosts of diabetes education and the value that may beadded by a diabetes educator. Even among those provid-ing diabetes self-management education and training, thestudies that demonstrate this fact are not well-known.

In late 2007, the authors undertook an analysis of theliterature to better understand the economic benefits andcosts associated with diabetes education. This articlereports on the review of published literature and evalu-ates the economic benefits and costs associated with dia-betes education.

Methods

Data Sources

The authors searched MEDLINE (1991-2006) andGoogle in the fourth quarter of 2007 using combinationsand variations of the following search terms: (1) diabetescomplications, diabetes mellitus, type 1 diabetes melli-tus, or type 2 diabetes mellitus; (2) disease management,health promotion, patient education as topic, or self care;and (3) cost control, cost of illness, cost savings, cost-benefit analysis, costs and cost analysis, direct servicecosts, health care costs, health expenditures, health serv-ices, outcome assessment (health care), program evalua-tion, or quality-adjusted life years.

Inclusion and Exclusion Criteria

Diabetes self-management training and education pro-grams were defined broadly. By defining the topicbroadly, this study was able to identify a wider variety ofeconomic studies on diabetes education to support thisanalysis. Inclusion criteria were any article reporting theeconomic and/or financial outcomes of a diabetes-relatedself-care or educational intervention. This studyexcluded articles published prior to 1991, not publishedin English, or not reporting the results in a quantifiablemanner.

Study Selection and Data Extraction

Two of the investigators (KAF, JES) reviewed thetitles and abstracts of the identified citations and applieda screening algorithm based on the inclusion and exclu-sion criteria described above. The “potentially eligible”studies were then reviewed in full. Data abstraction wasperformed by one investigator independently (KAF)using a structured abstraction process, and the abstrac-tions were independently reviewed by another investiga-tor (PP). Any discrepancies between the 2 investigatorswere resolved through discussion and consensus. Theinformation extracted from the articles into the tables

TDE326774.qxd 1/16/2009 6:38 PM Page 73



included (1) study aim, (2) study population (eg, samplesize, age, type 1 or type 2 diabetes, gender, race/ethnicity,and recruitment location), (3) study design, (4) interven-tion, (5) financial and economic outcomes, (6) results,and (7) conclusions.

Results

Literature searches identified 609 articles. The titlesand abstracts were screened, and 26 articles were identi-fied that addressed the costs and benefits of diabetes edu-cation, using this study’s broad definition, and wereincluded in this review (Table 1).10-35 Most studies wereconducted in the United States, and 2 studies were con-ducted in the Netherlands.16,25 Data from 40 588 patientsare represented in the studies. Most of the studiesincluded adults, and 1 study focused on adolescents.13

Studies involved patients with impaired glucose tolerance(IGT),18,22,23,27 type 1 diabetes,13 type 2 diabetes,30,32,34 orboth type 1 and type 2 diabetes.10,12,14,24-26,28,29,31,35 Severalstudies did not specify the type of diabetes.11,15-17,19-21,33

Study designs included meta-analysis,26 randomizedcontrolled trials (RCTs),13,16,18,22-24,27,34 prospective quasi-experimental pre-post studies,10-12,14,15,20,25,29 and retro-spective database analyses.17,19,21,28,30,31-33,35 The studiesconducted cost analyses,13,19,22,28,29,32 cost-effectivenessanalyses,10-12,14-16,18,21,23,24,26,34,35 cost-utilization analy-ses,10,11,17,20,30,31,33 or number needed to treat (NNT) analy-ses.25,27 The types interventions that were studiedincluded comprehensive diabetes education or diseasemanagement programs,10-12,14-17,19,20,25,29,31,33 diabetes pre-vention programs,18,22,23,27 education for depression,24

transmission of glucose values,13 initiation of insulintherapy,30 diet education,34 and retrospective analysisbased on A1C level.21,28,32,35 The outcome measures gen-erally addressed cost savings and included the following:total health care costs,11,12,14-17,19-21,30,31,33,35 total diabetes-related costs,10,16,25,30,32 outpatient costs,13,24 inpatientcosts,28 medication costs,16 cost per quality-adjusted lifeyear,18,23,24 cost of primary prevention of diabetes,22,22,29

number needed to treat to reduce 1 case of diabetes,27

cost per depression-free day,24 and cost of restrictedactivity.34

Based on the results and conclusions presented inTable 1, each of the articles was assigned to 1 of 3 costimpact categories: (1) cost reduction/cost-effectivenessassociated with the intervention (18 studies),10,11,

13-15,17,19,20,25,26,28-35 (2) neutral impact associated with the

intervention (4 studies),16,18,23,24 or (3) increased costassociated with the intervention (1 study).22 Three stud-ies did not fit into these categories.12,21,27 More than half(18) of the 26 articles identified by the literature reviewreported findings that associated diabetes education (anddisease management) with decreased cost, cost saving,cost-effectiveness, or positive return on investment(ROI). One study demonstrated increased productivity atthe workplace.34 Three studies did not report on diabeteseducation per se but imply that a well-designed diabeteseducation program could be effective in reducing costs.These are Gilmer et al’s work on costs associated withrising A1C,21 Rubin et al’s findings that inpatient utiliza-tion declines with better management,31 and Rosenblumet al’s report of a 40% decrease in health care costs fol-lowing initiation of insulin.30 One study found theDiabetes Prevention Program (DPP) to be too costly forbroad implementation and called for more affordableapproaches for achieving weight loss outcomes that areassociated with better health for people with or at risk ofdiabetes.18 The DPP group suggests that self-manage-ment interventions are likely to be affordable in routineclinical practice when education is conducted in a groupand generic drugs are prescribed.27 The oldest of thestudies reported on a randomized control study thatfound no effect from education.16

Discussion

Health care policy makers and payers, faced with con-siderable resource constraints, are increasingly focusedon interventions that work well and do so for reasonablecost. Glycemic control among those with diabetes is acost-effective strategy,36 and health management pro-grams that empower people with chronic illnesses to self-manage their conditions are of interest in theworkplace.37,38 Behavior change is crucial to effectiveself-management. Diabetes educators are experts at fos-tering positive behavior change in people with diabetes,and the interventions they use are effective.10 The CMSand many other payers reimburse for diabetes self-man-agement education/training, implicitly recognizing theimportance and value of the intervention.39 Diabetes edu-cation aims to achieve optimal health status and betterquality of life, as well as reduce the need for costly healthcare. The primary purpose of this analysis is to increaseunderstanding of the economic value of diabetes educa-tion for people with diabetes.


74


TDE326774.qxd 1/16/2009 6:38 PM Page 74




75

Boren et al

Auth

or(Y

ear)

Bala

mur

ugan

et a

l

(200

6)10

Berg

and

Wad

hwa

(200

2)11

Stud

y Ai

m

Impl

emen

t a

diab

etes

sel

f-

man

agem

ent

educ

atio

n

(DSM

E) p

rogr

am

for M

edic

aid

reci

pien

ts u

sing

a co

ntin

uous

qual

ity

impr

ovem

ent

(CQI

) pro

cess

and

eval

uate

resu

lts o

f the

parti

cipa

nts'

clin

ical

outc

omes

and

heal

th c

are

cost

s

Asse

ss d

iffer

ence

s

in b

ehav

ior a

nd

med

ical

ser

vice

use

com

parin

g

base

line,

6-

mon

th,a

nd 1

year

resu

lts

Stud

y Po

pula

tion

212

Arka

nsas

Med

icai

d

reci

pien

ts w

ith

diab

etes

for a

t

leas

t 1 y

ear a

nd

enro

lled

in

Med

icai

d fo

r 11

cont

inuo

us

mon

ths.

Child

ren

(<19

yea

rs),

end-

stag

e re

nal

dise

ase

patie

nts,

and

preg

nant

wom

en w

ere

excl

uded

.

127

pers

ons

with

diab

etes

in a

heal

th

mai

nten

ance

orga

niza

tion

(HM

O) a

nd

pref

erre

d pr

ovid

e

orga

niza

tion

(PPO

).

Stud

y De

sign

Parti

cipa

nts

rece

ived

12

hour

s of

gro

up

educ

atio

n (o

ver

3 vi

sits

-initi

al

visi

t,6

mon

ths,

and

1 ye

ar) o

n

nutri

tion

and

self-

man

agem

ent

from

a

regi

ster

ed n

urse

and

a re

gist

ered

diet

icia

n.

Hist

oric

al c

ontro

l

com

paris

on o

f

diab

etes

dis

ease

man

agem

ent

parti

cipa

nts

in

com

mun

ity-

base

d se

tting

Inte

rven

tion

Diab

etes

sel

f-

man

agem

ent

educ

atio

n

prog

ram

Diab

etes

dis

ease

man

agem

ent

prog

ram

Fina

ncia

l/Ec

onom

ic O

utco

me

Expe

nditu

res;

over

all a

nd th

ose

rela

ted

to

diab

etes

Retu

rn o

n

inve

stm

ent (

ROI)

Resu

lts

Over

1 y

ear,

DSM

E

parti

cipa

nts

had

a

0.45

% d

eclin

e in

mea

n

A1C,

few

er h

ospi

tal

adm

issi

ons,

emer

genc

y

room

vis

its,a

nd

outp

atie

nt v

isits

.Ove

r 3

year

s,th

e es

timat

ed

savi

ngs

in d

iabe

tes-

rela

ted

cost

was

$41

5

per p

rogr

am c

ompl

eter

.

Over

10

year

s,

com

plet

ers

wer

e

estim

ated

to e

xper

ienc

e

a de

crea

se in

cor

onar

y

hear

t dis

ease

eve

nt a

nd

mic

rova

scul

ar d

isea

se

even

ts b

y 12

% a

nd

15%

,res

pect

ivel

y.

The

num

ber o

f par

ticip

ants

getti

ng a

n A1

C te

st

incr

ease

d by

44.

9%

(P<

.001

),an

d

hype

rgly

cem

ia

sym

ptom

s de

crea

sed

by

53.2

% (P

= .0

02).

Inpa

tient

adm

issi

ons

decr

ease

d by

391

per

Conc

lusi

ons

This

DSM

E pr

ogra

m

redu

ced

heal

th c

are

use

amon

g M

edic

aid

reci

pien

ts w

ith d

iabe

tes

with

in 1

yea

r and

is li

kely

to re

duce

cos

ts a

ssoc

iate

d

with

dec

reas

ed u

tiliz

atio

n

over

a lo

nger

per

iod

of

time.

The

impl

emen

tatio

n of

the

diab

etes

pro

gram

that

prov

ides

com

preh

ensi

ve

info

rmat

ion

and

coun

selin

g fo

r sel

f-

man

agem

ent o

f dia

bete

s

is a

ssoc

iate

d w

ith p

ositi

ve

beha

vior

al c

hang

e an

d

subs

tant

ial r

educ

tion

in

Tab

le 1

Diab

etes

Edu

catio

n

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 75




76


Auth

or(Y

ear)

Burto

n an

d

Conn

erty

(199

8)12

Chas

e et

al

(200

3)13

Stud

y Ai

m

Asse

ss a

wor

ksite

diab

etes

educ

atio

n

prog

ram

Com

paris

on o

f a

mod

em

trans

mis

sion

inte

rven

tion

to

usua

l clin

ic v

isit

Stud

y Po

pula

tion

53 e

mpl

oyed

indi

vidu

als

70 a

dole

scen

ts

with

type

1

diab

etes

for a

t

leas

t 1 y

ear,

ages

15-

20

Stud

y De

sign

Mea

n A1

C va

lues

at b

asel

ine

and

3 m

onth

s w

ere

calc

ulat

ed

Rand

omiz

ed

cont

rol t

rial

(RCT

)

Inte

rven

tion

3-m

onth

wor

ksite

diab

etes

educ

atio

n

prog

ram

Cont

rol g

roup

(qua

rterly

clin

ic

visi

ts) v

s m

odem

grou

p

(tran

smitt

ed

gluc

ose

read

ings

ever

y 2

wee

ks

for 6

mon

ths

inst

ead

of c

linic

visi

ts)

Fina

ncia

l/Ec

onom

ic O

utco

me

Dire

ct a

nd in

dire

ct

heal

th c

are

cost

,

prod

uctiv

ity

Savi

ngs/

patie

nt fo

r

the

mod

em g

roup

as c

ompa

red

with

the

cont

rol

grou

p

Resu

lts

1000

for e

ach

grou

p (P

<

.001

),w

hile

con

trolli

ng

for a

ge,l

engt

h of

mem

bers

hip,

and

the

num

ber o

f com

orbi

d

clai

ms

for c

onge

stiv

e

hear

t fai

lure

.

The

mea

n fa

stin

g bl

ood

gluc

ose

leve

ls fe

ll fro

m

197.

8 to

179

.6 m

g%

(P=

.12)

,mea

n

glyc

ohem

oglo

bin

decl

ined

from

11.

5% to

10.1

% (P

< .0

01),

and

mea

n A1

C de

clin

ed

from

9.0

% to

8.3

%

(P<

.001

).

The

aver

age

cost

for 6

mon

ths

was

$30

5 fo

r

the

visi

t gro

up a

nd $

163

for t

he m

odem

gro

up

(sav

ings

of $

142

per

patie

nt p

er 6

mon

ths)

.

Conc

lusi

ons

med

ical

ser

vice

util

izat

ion.

Cost

ana

lysi

s of

dis

ease

man

agem

ent p

rogr

am

cost

s fo

und

a $4

.34:

1 RO

I.

Alth

ough

the

valu

es in

this

stud

y w

ere

still

hig

her

than

the

idea

l,an

y

impr

ovem

ent i

n gl

ycem

ic

cont

rol h

as b

een

show

n to

redu

ce th

e ris

k fo

r

diab

etes

-rel

ated

com

plic

atio

ns a

nd

subs

eque

nt d

irect

and

indi

rect

hea

lth c

are

cost

s.

Whi

le th

e A1

C va

lues

did

not d

iffer

sig

nific

antly

betw

een

the

cont

rol a

nd

mod

em g

roup

s,th

e

aver

age

occu

rren

ce o

f

mild

to m

oder

ate

hypo

glyc

emic

epi

sode

s

was

sim

ilar b

etw

een

grou

ps w

ith n

o se

vere

hypo

glyc

emic

epi

sode

s fo

r

eith

er.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 76




77

Boren et al

Auth

or(Y

ear)

Chris

tens

en

et a

l

(200

4)14

Cran

or e

t al

(200

3)15

Stud

y Ai

m

Eval

uate

the

cost

savi

ngs

and

clin

ical

effe

ctiv

enes

s of

a di

abet

es

educ

atio

n

prog

ram

for

impr

ovin

g

nutri

tion

know

ledg

e,fo

od

porti

onin

g sk

ills,

hem

oglo

bin

A1C,

and

anth

ropo

met

ric

indi

ces

Asse

ss th

e

cont

inui

ty o

f

outc

omes

for 5

year

s,en

suin

g

afte

r the

initi

atio

n of

com

mun

ity-

base

d

phar

mac

eutic

al

care

ser

vice

s

Stud

y Po

pula

tion

155

parti

cipa

nts;

ages

54.

54

(11.

87) y

ears

;

fem

ales

,71.

4%;

type

1,5

.8%

;

type

2,6

7.7%

; no

diab

etes

,26.

5%;

63.2

%,≥

col

lege

grad

uate

136

patie

nts

with

diab

etes

cov

ered

by s

elf-

insu

red

empl

oyer

s’

heal

th p

lans

Stud

y De

sign

Quas

i-

expe

rimen

tal,

pre-

and

post

cour

se

anth

ropo

met

ric

mea

sure

men

ts;

a w

ritte

n fo

od

porti

on te

st; a

n

obse

rvat

iona

l

food

-por

tioni

ng

skill

test

; and

A1C

test

wer

e

adm

inis

tere

d

and

scor

ed fo

r

all p

artic

ipan

ts.

Quas

i-

expe

rimen

tal,

long

itudi

nal p

re-

post

coh

ort

stud

y

Inte

rven

tion

3-m

onth

dia

bete

s

educ

atio

n co

urse

focu

sing

on

food

-por

tioni

ng

skill

s

Educ

atio

n by

certi

fied

diab

etes

educ

ator

s

(CDE

s),l

ong-

term

com

mun

ity

phar

mac

ist

follo

w-u

p us

ing

sche

dule

d

cons

ulta

tions

,

Fina

ncia

l/Ec

onom

ic O

utco

me

Med

ical

cos

t

savi

ngs

(inpa

tient

)

Mea

n to

tal d

irect

med

ical

cos

t;

prod

uctiv

ity

estim

ates

in

dolla

rs a

nd d

ays

of s

ick

time

Resu

lts

Impr

oved

food

por

tion

know

ledg

e (4

9.67

% p

re

vs 5

9.56

% p

ost,

P=

.004

),im

prov

ed fo

od-

porti

onin

g sk

ills

out o

f 5

(2.4

3 pr

e vs

4.2

9 po

st,

P=

.023

),A1

C de

crea

sed

0.73

% (P

= .0

00),

body

mas

s in

dex

(BM

I)

decr

ease

d 0.

82 k

g/m

2

(P=

.000

),w

aist

circ

umfe

renc

e

decr

ease

d 1.

27 in

(P=

.000

),hi

p ci

rcum

fere

nce

decr

ease

d 0.

6 in

(P=

.000

),an

d w

aist

-to-

hip

ratio

dec

reas

ed 0

.01

(P=

.000

).

Mea

n A1

C de

crea

sed

at a

ll

follo

w-u

ps.T

he n

umbe

r

of p

atie

nts

with

opt

imal

A1C

valu

es (<

7%) a

lso

incr

ease

d at

eac

h

follo

w-u

p.M

ore

than

50%

of p

atie

nts

dem

onst

rate

d

impr

ovem

ent i

n A1

C

valu

es a

nd in

lipi

d le

vels

at e

very

mea

sure

men

t.

Conc

lusi

ons

Impr

oved

nut

ritio

n

know

ledg

e,

anth

ropo

met

ric m

easu

res,

and

gluc

ose

cont

rol a

re

estim

ated

to re

duce

med

ical

cos

ts

(hos

pita

lizat

ions

)

by $

94 0

10.

Patie

nts

mai

ntai

ned

impr

ovem

ent i

n A1

C ov

er

time,

and

empl

oyer

s

expe

rienc

ed a

dec

line

in

mea

n to

tal d

irect

med

ical

cost

s.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 77




78


Auth

or(Y

ear)

De W

eerd

t

et a

l

(199

1)16

Stud

y Ai

m

(PCS

) for

dia

betic

patie

nts

Eval

uate

if a

n

outp

atie

nt

educ

atio

n

prog

ram

for

insu

lin-t

reat

ed

diab

etic

pat

ient

s

impr

oved

the

leve

l of s

elf-

care

Stud

y Po

pula

tion

558

patie

nts

from

15 h

ospi

tals

Stud

y De

sign

Rand

omiz

ed

cont

rol s

tudy

; 2

expe

rimen

tal

grou

ps (g

uide

d

by a

hea

lth c

are

prof

essi

onal

or a

fello

w p

atie

nt)

and

a co

ntro

l

grou

p

Inte

rven

tion

clin

ical

asse

ssm

ent,

goal

set

ting,

mon

itorin

g,an

d

colla

bora

tive

drug

ther

apy

man

agem

ent

with

phy

sici

ans

Educ

atio

n pr

ogra

m

desi

gned

to

assi

st in

sulin

-

treat

ed d

iabe

tic

patie

nts

in s

elf-

care

Fina

ncia

l/Ec

onom

ic O

utco

me

Cost

of t

hera

py

Resu

lts

Patie

nts

with

hig

her

base

line

A1C

valu

es

wer

e m

ore

likel

y to

impr

ove;

thos

e w

ith

high

er b

asel

ine

cost

s

wer

e lik

ely

to h

ave

low

er

cost

s fo

llow

ing

educ

atio

n.To

tal m

ean

dire

ct m

edic

al c

osts

decr

ease

d by

$12

00 to

$187

2 pe

r pat

ient

per

year

com

pare

d w

ith

base

line.

Days

of s

ick

time

decr

ease

d ev

ery

year

(199

7-20

01) f

or

one

empl

oyer

gro

up,

with

est

imat

ed in

crea

ses

in p

rodu

ctiv

ity e

stim

ated

at $

18 0

00 a

nnua

lly.

The

effe

ct o

f the

pro

gram

on m

etab

olic

con

trol,

qual

ity o

f life

,and

cos

ts

of th

erap

y w

as

asse

ssed

,but

no

sign

ifica

nt c

hang

es w

ere

note

d.

Conc

lusi

ons

No s

igni

fican

t effe

ct o

f

educ

atio

n on

any

one

of

thes

e va

riabl

es c

ould

be

iden

tifie

d.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 78




79

Boren et al

Auth

or(Y

ear)

“Dia

bete

s

Cost

Savi

ngs

Legi

slat

ion

Wou

ld S

ave

Mill

ions

for

Ohio

Insu

ranc

e

Indu

stry

,

Busi

ness

,

and

Taxp

ayer

s in

Prod

uctiv

ity,

Emer

genc

y

Room

Vis

its,

and

Hosp

ital

Stay

s”

(200

5)17

Eddy

et a

l

(200

5)18

Stud

y Ai

m

Ratio

naliz

e th

e

impl

emen

tatio

n

of th

e Di

abet

es

Cost

Red

uctio

n

Act (

DCRA

) in

Ohio

by

prov

idin

g

evid

ence

of c

ost

savi

ngs

in s

tate

s

with

DCR

A an

d

high

light

ing

incr

ease

d co

sts

for O

hio

in

abse

nce

of th

e

act

Estim

ate

the

effe

cts

of th

e

lifes

tyle

mod

ifica

tion

prog

ram

use

d in

the

Diab

etes

Prev

entio

n

Prog

ram

(DPP

)

on h

ealth

and

econ

omic

outc

omes

Stud

y Po

pula

tion

Pers

ons

with

diab

etes

3234

adu

lts a

t

high

risk

for

diab

etes

(BM

I

>24

kg/

m2,

fast

ing

plas

ma

gluc

ose

leve

l of

5.27

25-6

.937

5

mm

ol/L

[95-

125

mg/

dL],

2-ho

ur

gluc

ose

tole

ranc

e te

st

Stud

y De

sign

Com

parin

g co

st in

med

ical

cla

ims

for p

atie

nts

who

took

the

diab

etes

educ

atio

n co

urse

to p

atie

nts

with

sim

ilar

sym

ptom

s an

d

prob

lem

s w

ho

did

not a

ttend

diab

etes

chr

onic

dise

ase

wor

ksho

ps

Cost

-effe

ctiv

enes

s

anal

ysis

usi

ng

the

Arch

imed

es

mod

el

Inte

rven

tion

Diab

etes

chr

onic

dise

ase

wor

ksho

ps

No p

reve

ntio

n,

DPP’

s lif

esty

le

mod

ifica

tion

prog

ram

,

lifes

tyle

mod

ifica

tion

initi

atin

g af

ter a

pers

on d

evel

ops

diab

etes

,and

met

form

in

Fina

ncia

l/Ec

onom

ic O

utco

me

Med

ical

cla

ims

cost

Cost

-effe

ctiv

enes

s

of D

PP li

fest

yle

prog

ram

in te

rms

of q

ualit

y-

adju

sted

life

year

s (Q

ALYs

)

gain

ed a

nd

cost

/per

son

Resu

lts

Patie

nts

who

com

plet

ed a

diab

etes

edu

catio

n

cour

se h

ad $

2324

less

in m

edic

al c

laim

s pe

r

year

than

pat

ient

s w

ith

sim

ilar s

ympt

oms

and

prob

lem

s w

ho d

id n

ot g

o

to a

dia

bete

s ed

ucat

ion

wor

ksho

p.

The

DPP

com

pare

d w

ith n

o

prev

entio

n w

ould

redu

ce

a hi

gh-r

isk

pers

on’s

30-

year

cha

nces

of g

ettin

g

diab

etes

by

abou

t 11%

,

the

chan

ces

of g

ettin

g a

serio

us c

ompl

icat

ion

by

8%,a

nd th

e ch

ance

s of

dyin

g of

a c

ompl

icat

ion

of d

iabe

tes

by 2

.3%

.

Com

pare

d w

ith th

e

Conc

lusi

ons

The

impl

emen

tatio

n of

the

DCRA

in O

hio

will

ena

ble

Ohio

ans

with

dia

bete

s to

obta

in a

bet

ter c

ontro

l of

thei

r blo

od g

luco

se,

ther

eby

min

imiz

ing

the

occu

rren

ce o

f cos

tly

diab

etes

-rel

ated

com

plic

atio

ns,p

rom

otin

g

cost

sav

ings

for t

he

insu

ranc

e in

dust

ry in

term

s of

dec

reas

ed

med

ical

cla

ims,

emer

genc

y ro

om v

isits

,

hosp

ital s

tays

,and

surg

erie

s.

Life

styl

e m

odifi

catio

n

shou

ld b

e re

com

men

ded

to a

ll hi

gh-r

isk

peop

le

beca

use

it is

like

ly to

hav

e

impo

rtant

effe

cts

on th

e

mor

bidi

ty a

nd m

orta

lity

of

diab

etes

.The

pro

gram

used

in th

e DP

P st

udy,

how

ever

,may

be

too

expe

nsiv

e fo

r hea

lth p

lans

or a

nat

iona

l pro

gram

to

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 79




80


Auth

or(Y

ear)

Stud

y Ai

mSt

udy

Popu

latio

n

resu

lt of

7.7

7-

11.0

445

mm

ol/L

[140

-199

mg/

dL])

Stud

y De

sign

Inte

rven

tion

Fina

ncia

l/Ec

onom

ic O

utco

me

Resu

lts

no-p

reve

ntio

n pr

ogra

m,

the

expe

cted

30-

year

cost

/QAL

Y of

the

DPP

lifes

tyle

inte

rven

tion

from

the

heal

th p

lan'

s

pers

pect

ive

wou

ld b

e

abou

t $14

3 00

0.Fr

om a

soci

etal

per

spec

tive,

the

cost

/QAL

Y of

the

lifes

tyle

inte

rven

tion

com

pare

d

with

doi

ng n

othi

ng w

ould

be a

bout

$62

600

.Eith

er

usin

g m

etfo

rmin

or

dela

ying

the

lifes

tyle

inte

rven

tion

until

afte

r a

pers

on d

evel

ops

diab

etes

wou

ld b

e m

ore

cost

-

effe

ctiv

e,co

stin

g ab

out

$35

400

or $

24 5

00 p

er

QALY

gai

ned,

resp

ectiv

ely,

com

pare

d w

ith n

o

prog

ram

.Com

pare

d w

ith

dela

ying

the

lifes

tyle

prog

ram

unt

il af

ter

diab

etes

is d

iagn

osed

,the

mar

gina

l cos

t-

effe

ctiv

enes

s of

beg

inni

ng

the

DPP

lifes

tyle

pro

gram

imm

edia

tely

wou

ld b

e

abou

t $20

1 80

0.

Conc

lusi

ons

impl

emen

t.Le

ss

expe

nsiv

e al

tern

ativ

es

are

need

ed.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 80




81

Boren et al

Auth

or(Y

ear)

Frie

s an

d

McS

hane

(199

8)19

Garr

ett a

nd

Blum

l

(200

5)20

Stud

y Ai

m

Com

pare

effe

ctiv

enes

s

and

cost

sav

ings

of h

ealth

educ

atio

n

prog

ram

s in

high

-ris

k

pers

ons

to th

ose

pers

ons

with

all

risk

leve

ls

Asse

ss c

linic

al

bene

fits,

satis

fact

ion,

and

econ

omic

mea

sure

s fro

m a

colla

bora

tive

heal

th

man

agem

ent

prog

ram

invo

lvin

g

com

mun

ity

Stud

y Po

pula

tion

2586

par

ticip

ants

of th

e hi

gh-r

isk

grou

p w

ere

mos

tly m

embe

rs

of e

mpl

oyee

grou

ps,w

ere

whi

te-c

olla

r

wor

kers

,had

priv

ate

heal

th

insu

ranc

e,an

d

had

a m

ean

age

of 4

9.7

year

s.

Empl

oyee

gro

up

had

a m

ean

age

of 4

1.2

year

s.

Seni

or g

roup

had

a m

ean

age

of

73.3

yea

rs.

256

diab

etic

patie

nts

unde

r

self-

insu

red

empl

oyer

s’

heal

th p

lans

; 80

com

mun

ity

phar

mac

y

prov

ider

s w

ith

train

ing

who

wer

e re

imbu

rsed

by e

mpl

oyer

s

Stud

y De

sign

Hist

oric

al c

ontro

l

com

paris

on o

f

man

agem

ent o

f

parti

cipa

nts

Quas

i-

expe

rimen

tal,

pre-

post

coh

ort

stud

y

Inte

rven

tion

Rand

omly

sel

ecte

d

parti

cipa

nts

rece

ived

hea

lth

asse

ssm

ent

ques

tionn

aire

,

lette

r,a

repo

rt,

and

heal

th

educ

atio

n

mat

eria

l bas

ed

on h

igh-

risk

prog

ram

are

as

(arth

ritis

,

diab

etes

,hig

h

bloo

d pr

essu

re,

smok

ing,

etc)

.

Com

mun

ity

phar

mac

ist

patie

nt c

are

serv

ices

usi

ng

sche

dule

d

cons

ulta

tions

,

clin

ical

goa

l

setti

ng,

mon

itorin

g,an

d

colla

bora

tive

drug

ther

apy

Fina

ncia

l/Ec

onom

ic O

utco

me

Dire

ct a

nd to

tal

cost

s; R

OI

Mea

n pr

ojec

ted

tota

l dire

ct

med

ical

cos

ts

Resu

lts

Prev

ious

yea

r cos

ts w

ere

$113

8 in

dire

ct c

osts

for

high

-ris

k gr

oups

(HR)

com

pare

d w

ith $

352

in

empl

oyee

(E) a

nd $

995

in s

enio

r gro

up (S

).At

6

mon

ths,

dire

ct c

osts

wer

e re

duce

d by

$30

4

(HR)

com

pare

d w

ith $

57

(E) a

nd $

70 (S

).To

tal

cost

s w

ere

redu

ced

by

$484

(HR)

vs

$87

(E) a

nd

$120

(S).

The

ROI w

as

6:1

in th

e hi

gh-r

isk

grou

p vs

4:1

in th

e

com

paris

on g

roup

s.

95.7

% re

porte

d be

ing

very

satis

fied/

satis

fied

with

care

from

pha

rmac

ist.

Influ

enza

vac

cina

tion

rate

s in

crea

sed

from

52%

to 7

7%,e

ye e

xam

rate

s in

crea

sed

from

46%

to 8

2%,f

oot e

xam

rate

s in

crea

sed

from

38%

to 8

0%,a

nd p

atie

nt

satis

fact

ion

with

ove

rall

Conc

lusi

ons

Inte

nsiv

e ed

ucat

iona

l

inte

rven

tions

may

be

just

ified

in h

igh-

risk

grou

ps w

hen

they

resu

lt in

larg

er c

hang

es in

hig

h-

risk

pers

ons

than

in

unsc

reen

ed p

erso

ns fo

r

use

and

cost

s.

Patie

nts

who

par

ticip

ated

in

the

prog

ram

had

incr

ease

d sa

tisfa

ctio

n w

ith

diab

etes

car

e,hi

gher

rate

s

of s

elf-

man

agem

ent g

oal

setti

ng a

nd a

chie

vem

ent,

and

sign

ifica

nt

impr

ovem

ent i

n cl

inic

al

indi

cato

rs o

f dia

bete

s

man

agem

ent.

Empl

oyer

s

expe

rienc

ed a

dec

line

in

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 81




82


Auth

or(Y

ear)

Gilm

er e

t al

(199

7)21

Stud

y Ai

m

phar

mac

ists

and

heal

th c

are

prov

ider

s ai

med

to a

ssis

t dia

betic

patie

nts

with

treat

men

t,

educ

atio

n,an

d

self-

man

agem

ent

stra

tegi

es

Asse

ss c

hang

es in

econ

omic

and

clin

ical

indi

cato

rs

Stud

y Po

pula

tion

3017

adu

lts w

ith

diab

etes

who

wer

e

cont

inuo

usly

enro

lled

in a

larg

e HM

O ov

er

a 4-

year

per

iod

Stud

y De

sign

Regr

essi

on

anal

ysis

use

d to

estim

ate

rela

tions

hip

betw

een

glyc

emic

con

trol

and

med

ical

care

cha

rges

Inte

rven

tion

man

agem

ent

with

phy

sici

ans

and

refe

rral

s to

diab

etes

educ

ator

s

Diag

nosi

s of

diab

etes

was

asce

rtain

ed fr

om

diag

nost

ic a

nd

phar

mac

eutic

al

data

base

s w

ith

sens

itivi

ty o

f

0.91

and

spec

ifici

ty o

f

0.99

.

Fina

ncia

l/Ec

onom

ic O

utco

me

Stan

dard

ized

cos

t

diffe

rent

ials

for

1% c

hang

es in

A1C

for p

atie

nts

with

dia

bete

s an

d

othe

r chr

onic

dise

ases

and

for

thos

e w

ith

diab

etes

onl

y

Resu

lts

diab

etes

car

e im

prov

ed

57%

to 8

7% in

hig

hest

rang

e.M

ean

A1C

decr

ease

d fro

m 7

.9%

to

7.1%

,mea

n lo

w-d

ensi

ty

lipop

rote

in c

hole

ster

ol

(LDL

-C) d

ecre

ased

from

113.

4 to

104

.5 m

g/dL

,

and

mea

n sy

stol

ic b

lood

pres

sure

dec

reas

ed fr

om

136.

2 to

131

.4 m

m H

g.

Tota

l mea

n co

sts/

patie

nt

wer

e $9

18 lo

wer

than

proj

ectio

n fro

m in

itial

year

of e

nrol

lmen

t.

Stan

dard

ized

3-y

ear

estim

ates

of c

harg

es

rang

ed fr

om $

10 4

39

(pat

ient

s w

ithou

t

com

orbi

ditie

s) to

$44

417

(pat

ient

s w

ith h

eart

dise

ase

and

hype

rtens

ion)

.Med

ical

care

cha

rges

incr

ease

d

sign

ifica

ntly

for e

very

Conc

lusi

ons

mea

n pr

ojec

ted

tota

l

dire

ct m

edic

al c

osts

.

A1C

prov

ides

use

ful

info

rmat

ion

to p

rovi

ders

and

patie

nts

rega

rdin

g

both

hea

lth s

tatu

s an

d

futu

re m

edic

al c

are

char

ges.

Econ

omic

dat

a

sugg

est t

hat c

linic

ians

shou

ld a

ssig

n hi

gh

impo

rtanc

e to

low

A1C

resu

lts a

nd a

ggre

ssiv

ely

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 82




83

Boren et al

Auth

or(Y

ear)

Herm

an e

t al

(200

3)22

Stud

y Ai

m

Repo

rt th

e co

sts

of

the

DPP

inte

rven

tions

Stud

y Po

pula

tion

3234

par

ticip

ants

with

impa

ired

gluc

ose

tole

ranc

e (IG

T)

enro

lled

in th

e

DPP

inte

rven

tions

Stud

y De

sign

Cost

ana

lysi

s

Inte

rven

tion

Life

styl

e

inte

rven

tion

or

met

form

in u

se

Fina

ncia

l/Ec

onom

ic O

utco

me

Dire

ct m

edic

al

cost

s,di

rect

nonm

edic

al

cost

s,an

d

indi

rect

cos

ts o

f

the

plac

ebo,

met

form

in,a

nd

Resu

lts

1% in

crea

se o

f A1C

abov

e 7%

.For

exa

mpl

e,

for a

per

son

with

an

A1C

valu

e of

6%

,suc

cess

ive

1% in

crea

ses

in A

1C

resu

lted

in c

umul

ativ

e

incr

ease

s in

cha

rges

of

appr

oxim

atel

y 4%

,10%

,

20%

,and

30%

.The

incr

ease

in c

harg

es

acce

lera

ted

as th

e A1

C

valu

e in

crea

sed.

The

rate

of in

crea

se in

cha

rges

with

A1C

was

con

sist

ent

for p

atie

nts

with

diab

etes

onl

y as

wel

l as

diab

etes

plu

s ot

her

chro

nic

cond

ition

s.

Over

3 y

ears

,the

dire

ct

med

ical

cos

ts o

f the

grou

ps a

ssig

ned

to th

e

inte

rven

tions

wer

e

$79/

parti

cipa

nt fo

r the

plac

ebo,

$254

2 fo

r

met

form

in,a

nd $

2780

Conc

lusi

ons

mai

ntai

n th

e A1

C st

atus

of

patie

nts

who

hav

e lo

w

A1C

valu

es.T

he m

edic

al

char

ge d

ata

sugg

est t

hat

inve

stm

ent i

n cl

inic

al

syst

ems

to im

prov

e

diab

etes

car

e m

ay b

enef

it

both

pay

ers

and

patie

nts.

Mod

est i

ncre

men

tal c

osts

are

asso

ciat

ed w

ith

met

form

in u

se a

nd

lifes

tyle

inte

rven

tions

whe

n co

mpa

rison

s ar

e

mad

e to

a p

lace

bo

inte

rven

tion.

Futu

re

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 83




84


Auth

or(Y

ear)

Herm

an e

t al

(200

3)23

Stud

y Ai

m

Asse

ss th

e co

st-

effe

ctiv

enes

s of

the

DPP

lifes

tyle

and

met

form

in

inte

rven

tions

rela

tive

to th

e

plac

ebo

inte

rven

tion

Stud

y Po

pula

tion

3234

par

ticip

ants

with

IGT

enro

lled

in th

e DP

P

inte

rven

tions

Stud

y De

sign

Cost

-effe

ctiv

enes

s

anal

ysis

of t

he

DPP

inte

rven

tions

from

bot

h he

alth

syst

em a

nd

soci

etal

pers

pect

ive

Inte

rven

tion

Inte

nsiv

e lif

esty

le

and

met

form

in

inte

rven

tions

Fina

ncia

l/Eco

nom

ic

Outc

ome

inte

nsiv

e lif

esty

le

inte

rven

tions

ove

r

the

3-ye

ar s

tudy

perio

d of

the

DPP

from

the

pers

pect

ive

of th

e

heal

th s

yste

m

and

soci

ety

Dire

ct m

edic

al

cost

s,di

rect

nonm

edic

al

cost

s,an

d

indi

rect

cos

ts;

QALY

from

a

soci

etal

and

heal

th s

yste

m

pers

pect

ive

Resu

lts

for l

ifest

yle.

Dire

ct

med

ical

cos

ts (d

irect

nonm

edic

al c

osts

) of

care

wer

e $2

72 ($

9) le

ss

per p

artic

ipan

t for

the

met

form

in g

roup

and

$432

less

($14

45

grea

ter)

for t

he li

fest

yle

grou

p as

com

pare

d w

ith

the

plac

ebo

grou

p.

Indi

rect

cos

ts b

y

inte

rven

tion

wer

e $2

30

mor

e/pa

rtici

pant

for

met

form

in a

nd $

174

less

for l

ifest

yle

as c

ompa

red

with

the

plac

ebo

grou

p.

Over

3 y

ears

,the

life

styl

e

and

met

form

in

inte

rven

tions

cos

t

appr

oxim

atel

y $2

250

mor

e pe

r par

ticip

ant

than

did

the

plac

ebo

in

the

DPP

stud

y.If

impl

emen

ted

in c

linic

al

prac

tice

(and

from

a

soci

etal

per

spec

tive)

,the

lifes

tyle

inte

rven

tion

cost

$13

200

and

met

form

in

Conc

lusi

ons

eval

uatio

n of

cos

ts re

lativ

e

to h

ealth

ben

efits

can

be

used

to e

stab

lish

the

valu

e of

thes

e

inte

rven

tions

to h

ealth

syst

ems.

Over

3 y

ears

,the

life

styl

e

and

met

form

in

inte

rven

tions

wer

e fo

und

to b

e bo

th e

ffect

ive

and

cost

-effe

ctiv

e fro

m a

heal

th s

yste

m a

nd s

ocie

tal

pers

pect

ive.

Mor

eove

r,

thes

e in

terv

entio

ns a

re

likel

y to

be

affo

rdab

le in

rout

ine

clin

ical

pra

ctic

e

whe

n ed

ucat

ion

is

cond

ucte

d in

a g

roup

and

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 84




85

Boren et al

Auth

or(Y

ear)

Kato

n et

al

(200

6)24

Stud

y Ai

m

Dete

rmin

e th

e

incr

emen

tal

cost

-

effe

ctiv

enes

s

and

net b

enef

it

of a

dep

ress

ion

colla

bora

tive

care

pro

gram

com

pare

d w

ith

usua

l car

e fo

r

patie

nts

with

diab

etes

and

depr

essi

on

Stud

y Po

pula

tion

A to

tal o

f 418

of

1801

pat

ient

s

rand

omiz

ed to

the

Impr

ovin

g

Moo

d-Pr

omot

ing

Acce

ss to

Colla

bora

tive

(IMPA

CT)

inte

rven

tion

(n =

204

) vs

usua

l car

e

(n =

214

) had

coex

istin

g

diab

etes

Stud

y De

sign

Prep

lann

ed

subg

roup

anal

ysis

of

patie

nts

with

diab

etes

from

the

IMPA

CT R

CT

Inte

rven

tion

IMPA

CT,t

hrou

gh a

depr

essi

on c

are

man

ager

(DCM

),

who

offe

red

educ

atio

n,

beha

vior

al

activ

atio

n,an

d a

choi

ce o

f

prob

lem

-sol

ving

treat

men

t or

supp

ort o

f

antid

epre

ssan

t

man

agem

ent

Fina

ncia

l/Ec

onom

ic O

utco

me

Incr

emen

tal c

ost-

effe

ctiv

enes

s an

d

net b

enef

it

Resu

lts

cost

$14

300

per

cas

e

of d

iabe

tes

dela

yed

or

prev

ente

d.Li

fest

yle

inte

rven

tions

cos

t $27

100/

QALY

; met

form

in

cost

$35

000

/QAL

Y

gain

ed.T

he li

fest

yle

inte

rven

tion

was

mor

e

cost

-effe

ctiv

e th

an th

e

met

form

in in

terv

entio

n

from

bot

h th

e he

alth

syst

em a

nd s

ocie

tal

pers

pect

ives

.

Rela

tive

to u

sual

car

e,

inte

rven

tion

patie

nts

expe

rienc

ed 1

15 m

ore

depr

essi

on-f

ree

days

ove

r

24 m

onth

s.To

tal

outp

atie

nt c

osts

wer

e $2

5

high

er d

urin

g th

is s

ame

perio

d.Th

e in

crem

enta

l

cost

per

dep

ress

ion-

free

day

was

25

cent

s,an

d

the

incr

emen

tal c

ost p

er

QALY

rang

ed fr

om $

198

to $

397.

An in

crem

enta

l

net b

enef

it of

$11

29

was

foun

d.

Conc

lusi

ons

gene

ric d

rugs

are

pres

crib

ed.H

ealth

pla

ns

are

likel

y to

acq

uire

impo

rtant

per

sona

l and

mem

ber b

enef

its a

t a

reas

onab

le c

ost a

nd in

a

shor

t ter

m b

y ad

optio

n of

the

diab

etes

pre

vent

ion

prog

ram

s.

The

IMPA

CT in

terv

entio

n is

asso

ciat

ed w

ith h

igh

clin

ical

ben

efits

at n

o

grea

ter c

ost t

han

usua

l

care

.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 85




86


Auth

or(Y

ear)

Keer

s et

al

(200

5)25

Klon

off a

nd

Schw

artz

(200

0)26

Stud

y Ai

m

Dete

rmin

e th

e co

st

and

bene

fits

of

an in

tens

ive

diab

etes

educ

atio

n

prog

ram

for

patie

nts

with

prol

onge

d se

lf-

man

agem

ent

prob

lem

s an

d to

dete

rmin

e th

e

incl

usio

n cr

iteria

for o

ptim

al

outc

omes

Stra

tify

inte

rven

tions

for

diab

etes

acco

rdin

g to

thei

r eco

nom

ic

impa

ct

Stud

y Po

pula

tion

61 p

artic

ipan

ts o

f

a di

abet

es

educ

atio

n

prog

ram

Artic

les

docu

men

ting

or

mod

elin

g th

e

achi

evem

ent o

f

a de

sire

d

outc

ome

or

bene

fit a

long

with

an

econ

omic

Stud

y De

sign

Pre-

and

post

inte

rven

tion

data

on

glyc

emic

cont

rol (

A1C)

,

diab

etes

-rel

ated

dist

ress

,and

cost

s w

ere

com

pare

d w

ith a

refe

renc

e gr

oup

of 2

30

nonr

efer

red

cons

ecut

ive

outp

atie

nts.

Met

a-an

alys

is/

liter

atur

e re

view

Inte

rven

tion

Mul

tidis

cipl

inar

y

inte

nsiv

e

diab

etes

educ

atio

n

prog

ram

(MID

EP)

Diab

etes

dis

ease

man

agem

ent

prog

ram

s

Fina

ncia

l/Ec

onom

ic O

utco

me

Diab

etes

-rel

ated

cost

s; im

med

iate

and

futu

re c

osts

of d

iabe

tes

com

plic

atio

ns;

num

ber n

eede

d

to tr

eat

Cost

sav

ing

and

cost

-

effe

ctiv

enes

s

Resu

lts

The

effe

ct o

f MID

EP o

n

A1C

and

diab

etes

-

rela

ted

dist

ress

was

satis

fact

ory,

with

1 in

less

than

3 p

atie

nts

havi

ng a

0.5

%

redu

ctio

n in

A1C

and

1

in s

light

ly m

ore

than

2

patie

nts

repo

rting

a

decr

ease

of >

1 SD

at

the

diab

etes

-rel

ated

dist

ress

.Sel

ectio

n of

patie

nts

with

A1C

8.0

%

and

diab

etes

-rel

ated

dist

ress

sco

res

≥ 4

0

furth

er in

crea

sed

MID

EP's

effi

cien

cy

with

out e

xclu

ding

man

y

patie

nts.

(1) C

lear

ly c

ost-

savi

ng

inte

rven

tions

incl

uded

eye

care

and

prec

once

ptio

n ca

re.

(2) C

lear

ly c

ost-

effe

ctiv

e

inte

rven

tions

incl

uded

neph

ropa

thy

prev

entio

n

in ty

pe 1

dia

bete

s an

d

impr

oved

gly

cem

ic

Conc

lusi

ons

The

inte

rven

tion

is e

ffect

ive

and

cost

-effe

ctiv

e in

impr

ovin

g gl

ycem

ic

cont

rol a

nd d

iabe

tes-

rela

ted

dist

ress

for

patie

nts

with

pro

long

ed

self-

man

agem

ent

diffi

culti

es.S

trict

er

incl

usio

n cr

iteria

rela

ted

to

A1C

and

diab

etes

-rel

ated

dist

ress

sco

res

may

enha

nce

the

prog

ram

’s

effic

ienc

y.

Wid

ely

prac

ticed

inte

rven

tions

for p

atie

nts

with

dia

bete

s ca

n be

cos

t

savi

ng a

nd c

ost-

effe

ctiv

e

from

bot

h a

med

ical

and

an e

cono

mic

per

spec

tive.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 86




87

Boren et al

Auth

or(Y

ear)

Know

ler e

t al

(200

2)27

Stud

y Ai

m

Asse

ss a

life

styl

e

inte

rven

tion

for

cont

rolli

ng a

nd

prev

entin

g

diab

etes

Stud

y Po

pula

tion

anal

ysis

for 1

7

wid

ely

prac

ticed

inte

rven

tions

for

diab

etes

3234

par

ticip

ants

with

IGT

enro

lled

in th

e DP

P

inte

rven

tions

Stud

y De

sign

RCT

Inte

rven

tion

Com

paris

on o

f a

plac

ebo

grou

p

with

gro

ups

assi

gned

to a

n

inte

nsiv

e lif

esty

le

chan

ge o

r

met

form

in u

se

Fina

ncia

l/Ec

onom

ic O

utco

me

Effic

acy

at

decr

easi

ng th

e

inci

denc

e of

diab

etes

Resu

lts

cont

rol.

(3) P

ossi

bly

cost

-

effe

ctiv

e in

terv

entio

ns

incl

uded

nep

hrop

athy

inte

rven

tions

in ty

pe

2 di

abet

es a

nd s

elf-

man

agem

ent t

rain

ing.

Uncl

ear e

cono

mic

impa

ct

inte

rven

tions

incl

ude

case

man

agem

ent,

MNT

,

self-

mon

itorin

g of

blo

od

gluc

ose,

foot

car

e,bl

ood

pres

sure

(BP)

con

trol,

bloo

d lip

id c

ontro

l,

smok

ing

cess

atio

n,

exer

cise

,wei

ght l

oss,

A1C

mea

sure

men

t,an

d

influ

enza

and

pneu

moc

occu

s

vacc

inat

ions

.

The

lifes

tyle

inte

rven

tion

was

mor

e ef

fect

ive

than

met

form

in.F

ifty

perc

ent

of th

e pa

rtici

pant

s in

lifes

tyle

inte

rven

tion

expe

rienc

ed >

7% lo

ss o

f

body

wei

ght.

The

inci

denc

e of

dia

bete

s

redu

ced

by 5

8% in

the

Conc

lusi

ons

Whi

le n

ot e

xplic

itly

stat

ed,

the

read

er c

ould

ass

ume

that

by

redu

cing

the

inci

denc

e of

dia

bete

s,

cost

s re

latin

g to

the

treat

men

t of t

he d

isea

se

and

com

orbi

d co

nditi

ons

are

redu

ced.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 87




88


Auth

or(Y

ear)

Men

zin

et a

l

(200

1)28

Ragu

cci e

t al

(200

5)29

Stud

y Ai

m

Exam

ine

impa

ct o

f

impr

oved

glyc

emic

con

trol

on s

hort-

term

com

plic

atio

ns o

f

diab

etes

and

asso

ciat

ed c

osts

Eval

uate

the

effe

ctiv

enes

s of

phar

mac

ist-

adm

inis

tere

d

diab

etes

mel

litus

educ

atio

n an

d

man

agem

ent

Stud

y Po

pula

tion

3294

adu

lts w

ith

diab

etes

in a

man

aged

car

e

setti

ng

191

patie

nts

with

diab

etes

at 3

univ

ersi

ty-b

ased

prim

ary

care

clin

ics

Stud

y De

sign

Retro

spec

tive

coho

rt de

sign

One-

year

obse

rvat

iona

l

stud

y

Inte

rven

tion

No in

terv

entio

n;

patie

nts

divi

ded

into

3 g

roup

s on

basi

s of

mea

n

A1C

leve

l:go

od

cont

rol

(≤8%

),fa

ir

cont

rol

(8%

-10%

),an

d

poor

con

trol

(>10

%)

Phar

mac

ist-

adm

inis

tere

d

diab

etes

educ

atio

n an

d

man

agem

ent

serv

ices

Fina

ncia

l/Ec

onom

ic O

utco

me

Savi

ngs

Savi

ngs

and

cost

avoi

danc

e fo

r

thos

e pa

tient

s

with

impr

oved

patie

nt c

are

outc

omes

-

redu

ctio

ns in

A1C

Resu

lts

lifes

tyle

inte

rven

tion

grou

p an

d by

31%

in th

e

met

form

in g

roup

as

com

pare

d w

ith th

e

plac

ebo

grou

p.

Abou

t 10%

of 2

394

patie

nts

with

dia

bete

s

had

at le

ast 1

inpa

tient

stay

for a

sho

rt-te

rm

com

plic

atio

n.Ov

er 3

year

s,th

e ad

just

ed ra

te

of in

patie

nt tr

eatm

ent f

or

3 gr

oups

rang

ed fr

om

13:1

6:31

per

100

patie

nts

for

good

:fair:

poor

A1C

cont

rol (

P=

.05)

.The

corr

espo

ndin

g m

ean

adju

sted

cha

rges

wer

e

$970

,$13

80,a

nd

$304

0,re

spec

tivel

y.

Aver

age

A1C

at 1

yea

r was

7.8%

(ran

ge,4

.5%

-

13.9

%) v

s 9.

5% (r

ange

,

5.4%

-19%

) at b

asel

ine

(cha

nge

-1.7

%,P

< .0

5).

Of th

e pa

tient

s,38

% h

ad

a 1%

or g

reat

er

Conc

lusi

ons

Patie

nts

with

goo

d gl

ycem

ic

cont

rol o

n av

erag

e sa

ved

$410

to $

2070

ove

r the

span

of 3

yea

rs w

hen

com

pare

d w

ith fa

ir an

d

poor

con

trol g

roup

cos

ts.

Clin

ical

pha

rmac

ist

prov

isio

n of

dia

bete

s

man

agem

ent s

ervi

ces

achi

eved

sig

nific

ant

impr

ovem

ents

in A

1C

valu

es,b

lood

pre

ssur

e,

and

aspi

rin u

se.C

ontin

ued

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 88




89

Boren et al

Auth

or(Y

ear)

Stud

y Ai

m

serv

ices

on

sele

cted

diab

etes

perfo

rman

ce

mea

sure

s

Stud

y Po

pula

tion

Stud

y De

sign

Inte

rven

tion

Fina

ncia

l/Ec

onom

ic O

utco

me

of a

t lea

st 1

%,

bloo

d pr

essu

re

cont

rol,

and

docu

men

ted

aspi

rin u

se

Resu

lts

redu

ctio

n in

A1C

.

Aver

age

bloo

d pr

essu

re

decr

ease

d ov

er th

e st

udy

perio

d fro

m 1

41/7

9 to

135/

75 m

m H

g (P

=

.007

),bu

t ave

rage

LDL

leve

ls d

id n

ot c

hang

e to

a st

atis

tical

ly s

igni

fican

t

exte

nt (1

14-1

12 m

g/dL

,

P>

.05)

.The

re w

as a

n

incr

ease

from

34%

at

base

line

to 7

3% a

t 1

year

(P<

.000

1) in

aspi

rin u

se.T

he p

rogr

am

achi

eved

the

A1C

and

LDL

valu

es th

at w

ould

qual

ify fo

r Nat

iona

l

Com

mitt

ee fo

r Qua

lity

Assu

ranc

e (N

CQA)

diab

etes

reco

gniti

on.

Cost

avo

idan

ce w

as

calc

ulat

ed a

s $5

9 04

0,

base

d on

an

estim

ated

savi

ngs

of $

820

for e

ach

1% d

ecre

ase

in A

1C.

Conc

lusi

ons

effo

rts in

dia

bete

s

educ

atio

n an

d

man

agem

ent a

re n

eede

d

to fu

rther

impr

ove

clin

ical

,

econ

omic

,and

hum

anis

tic

outc

omes

.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 89




90


Auth

or(Y

ear)

Rose

nblu

m

and

Kane

(200

3)30

Stud

y Ai

m

Anal

ysis

of t

he

cost

and

utili

zatio

n of

heal

th c

are

serv

ices

bef

ore

and

afte

r the

initi

atio

n of

insu

lin th

erap

y

in p

atie

nts

with

type

2 d

iabe

tes

Stud

y Po

pula

tion

1177

pat

ient

s w

ith

type

2 d

iabe

tes

betw

een

the

ages

of 1

8 an

d

65 y

ears

and

cont

inuo

usly

enro

lled

in a

man

aged

car

e

orga

niza

tion

for

9 m

onth

s be

fore

and

afte

r the

ir

insu

lin s

tart

date

Stud

y De

sign

Med

ical

,fac

ility

,

and

phar

mac

eutic

al

serv

ices

in th

e

prei

nsul

in a

nd

post

insu

lin ti

me

perio

d w

ere

exam

ined

alo

ng

with

a

suba

naly

sis

of

all t

ypes

of

med

ical

ser

vice

cost

cat

egor

ies

Inte

rven

tion

Initi

atio

n of

insu

lin

ther

apy

for

patie

nts

with

type

2 d

iabe

tes

to d

eter

min

e

decr

ease

in

dise

ase-

rela

ted

and

tota

l hea

lth

care

cos

ts

Fina

ncia

l/Ec

onom

ic O

utco

me

Tota

l cos

ts,

dise

ase-

rela

ted

cost

s,an

d co

sts

asso

ciat

ed w

ith

vario

us a

spec

ts

of d

irect

car

e

Resu

lts

Aver

age

tota

l and

dis

ease

-

rela

ted

cost

s in

crea

sed

afte

r ins

ulin

was

sta

rted,

with

a m

ean

diffe

renc

e

of $

2220

(P<

.001

) for

aver

age

tota

l cos

ts a

nd

$430

(P<

.001

) for

dise

ase-

rela

ted

cost

s.

Muc

h of

the

cost

incr

ease

afte

r the

sta

rt

of in

sulin

occ

urre

d in

the

initi

al 2

-mon

th

post

insu

lin p

erio

d,af

ter

whi

ch b

oth

tota

l cos

ts

and

dise

ase-

rela

ted

cost

s de

crea

sed

by 5

7%

(P<

.001

) and

49%

(P<

.001

),re

spec

tivel

y,

thro

ugho

ut th

e

rem

aind

er o

f the

post

insu

lin ti

me

perio

d.

Faci

lity

cost

s de

crea

sed

at a

ll po

stin

sulin

mea

sure

men

t int

erva

ls.

Phar

mac

y co

sts

wer

e

the

only

trea

tmen

t

com

pone

nt to

rem

ain

abov

e th

e pr

eins

ulin

perio

d.

Conc

lusi

ons

Initi

atio

n of

insu

lin th

erap

y

in th

e m

anag

emen

t of

type

2 d

iabe

tes

invo

lves

an a

ppro

xim

ate

10%

incr

ease

in to

tal h

ealth

care

exp

endi

ture

s.Th

is is

offs

et b

y a

40%

dec

reas

e

in s

ubse

quen

t tot

al h

ealth

care

exp

endi

ture

s 9

mon

ths

follo

win

g in

sulin

initi

atio

n.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 90




91

Boren et al

Auth

or(Y

ear)

Rubi

n et

al

(199

8)31

Shet

ty e

t al

(200

5)32

Stud

y Ai

m

Iden

tify

the

pote

ntia

l to

redu

ce d

iabe

tes

com

plic

atio

ns

and

cost

s

thro

ugh

inte

nsiv

e

man

agem

ent

Asse

ss d

iffer

ence

in c

osts

asso

ciat

ed w

ith

diffe

rent

A1C

leve

ls

Stud

y Po

pula

tion

7000

peo

ple

with

diab

etes

bei

ng

treat

ed th

roug

h

7 m

anag

ed c

are

plan

s

3121

pat

ient

s

(46%

) at t

arge

t

A1C

leve

l

(≤ 7

%) a

nd 3

659

patie

nts

(54%

)

abov

e ta

rget

A1C

leve

l

(≤ 7

%)

Stud

y De

sign

Retro

spec

tive

anal

ysis

of

shor

t-te

rm

base

line

and

follo

w-u

p

clin

ical

,

econ

omic

,

mem

ber,

and

prov

ider

satis

fact

ion

Retro

spec

tive

data

base

anal

ysis

usi

ng

elig

ibili

ty d

ata,

med

ical

and

phar

mac

y

adm

inis

trativ

e

clai

ms

data

,and

labo

rato

ry d

ata

from

a la

rge

US

man

aged

car

e

orga

niza

tion

Inte

rven

tion

Impl

emen

tatio

n of

a co

mpr

ehen

sive

heal

th c

are

man

agem

ent

prog

ram

for

peop

le w

ith

diab

etes

No in

terv

entio

n;

type

2 d

iabe

tes

patie

nts

<7%

vs

>7%

A1C

leve

ls

wer

e fo

llow

ed

for 1

yea

r to

dete

rmin

e

diffe

renc

e in

cost

s

Fina

ncia

l/Ec

onom

ic O

utco

me

Gros

s ec

onom

ic

savi

ngs

Diab

etes

-rel

ated

cost

s

Resu

lts

Gros

s-ad

just

ed s

avin

gs o

f

$50/

mem

ber w

ith

diab

etes

/mon

th (1

2.3%

)

was

ach

ieve

d,w

ith

gros

s un

adju

sted

savi

ngs

of $

44/d

iabe

tic

mem

ber/

mon

th (1

0.9%

).

Hosp

ital a

dmis

sion

s pe

r

1000

dia

betic

mem

ber

year

s de

crea

sed

by

18%

,and

bed

day

s fe

ll

by 2

1%.P

atie

nts

with

diab

etes

wer

e m

ore

likel

y to

get

A1C

test

s,

foot

exa

ms,

eye

exam

s,

and

chol

este

rol

scre

enin

gs w

hile

enro

lled

in th

e pr

ogra

m.

Afte

r adj

ustin

g fo

r

conf

ound

ers,

the

pred

icte

d to

tal d

iabe

tes-

rela

ted

cost

for t

he

abov

e-ta

rget

gro

up

durin

g th

e 1-

year

follo

w-

up p

erio

d w

as

$154

0/pa

tient

,32%

high

er th

an th

e to

tal

diab

etes

-rel

ated

cos

t

($11

71) f

or th

e at

-tar

get

grou

p (P

< .0

01).

Conc

lusi

ons

lmpl

emen

tatio

n of

a

com

preh

ensi

ve h

ealth

care

man

agem

ent

prog

ram

for p

eopl

e w

ith

diab

etes

can

not o

nly

lead

to s

ubst

antia

l

impr

ovem

ents

in c

osts

and

clin

ical

out

com

es in

the

shor

t ter

m b

ut a

lso

resu

lt in

con

tinui

ng

impr

ovem

ents

in h

ealth

stat

us a

nd a

redu

ctio

n in

the

num

ber o

f fut

ure

diab

etic

com

plic

atio

ns

over

tim

e.

Man

aged

car

e m

embe

rs

with

type

2 d

iabe

tes

who

stay

ed c

ontin

uous

ly a

t the

targ

et A

1C o

f 7%

or l

ess

over

a 1

-yea

r per

iod

incu

rred

low

er d

iabe

tes-

rela

ted

cost

s vs

thos

e w

ho

wer

e co

ntin

uous

ly o

ver t

he

targ

et o

f ≤7%

A1C

.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 91




92


Auth

or(Y

ear)

Sido

rov

et a

l

(200

2)33

Test

a an

d

Sim

onso

n

(199

8)34

Stud

y Ai

m

Asse

ss th

e im

pact

of d

iabe

tes

dise

ase

man

agem

ent

(DDM

) pro

gram

on m

edic

al c

osts

for p

atie

nts

with

diab

etes

Exam

ine

shor

t-

term

out

com

es

of g

lyce

mic

cont

rol i

n ty

pe

2 di

abet

es

Stud

y Po

pula

tion

6799

pat

ient

s

fulfi

lling

Hea

lth

Plan

Em

ploy

er

Data

and

Info

rmat

ion

Set

(HED

IS) c

riter

ia

for d

iabe

tes,

of

who

m 3

118

patie

nts

(45.

9%)

enro

lled

in D

DM

and

3681

patie

nts

(54.

1%)

not e

nrol

led

in D

DM

569

empl

oyed

indi

vidu

als

with

type

2 d

iabe

tes

Stud

y De

sign

Retro

spec

tive

exam

inat

ion

of

paid

hea

lth c

are

clai

ms

and

othe

r

mea

sure

s of

heal

th c

are

use

by th

e co

hort

over

2 y

ears

12-w

eek

rand

omiz

ed,

cont

rolle

d,

doub

le-b

lind

stud

y

Inte

rven

tion

DDM

pro

gram

Diet

and

titra

tion

with

eith

er 5

to

20 m

g of

glip

izid

e

gast

roin

test

inal

ther

apeu

tic

Fina

ncia

l/Ec

onom

ic O

utco

me

Aver

age

gros

s

savi

ngs;

ROI

Chan

ge in

glu

cose

and

A1C

leve

ls,

sym

ptom

dist

ress

,qua

lity

of li

fe (Q

OL),

and

heal

th e

cono

mic

Resu

lts

Low

er in

patie

nt u

se

amon

g DD

M p

atie

nts

(0.1

2 ad

mis

sion

s an

d

0.56

inpa

tient

days

/pat

ient

/yea

r vs

0.16

adm

issi

ons

and

0.98

inpa

tient

days

/pat

ient

/yea

r for

non-

DDM

).M

ean

num

ber

of e

mer

genc

y ro

om

visi

ts w

as 0

.49

(DDM

) vs

0.56

(non

-DDM

).DD

M

patie

nts

had

mor

e

prim

ary

care

offi

ce v

isits

8.4

vs 7

.8/p

atie

nt/y

ear

but l

ower

mea

n pa

id

clai

ms

amon

g

com

mer

cial

insu

ranc

e

($30

2.19

DDM

vs

$527

.96

non-

DDM

) and

Med

icar

e ($

424.

00 D

DM

vs $

500.

37 n

on-D

DM).

At 1

2 w

eeks

,mea

n A1

C

and

fast

ing

bloo

d

gluc

ose

leve

ls d

ecre

ased

with

act

ive

ther

apy

(glip

izid

e GI

TS) v

s

plac

ebo

(7.5

% ±

0.1%

vs

Conc

lusi

ons

Patie

nts

enro

lled

in th

e

DDM

ave

rage

d

$394

.62/

mem

ber/

mon

th

in p

aid

clai

ms

vs $

502.

48

for t

hose

not

in D

DM

(21%

sta

tistic

ally

sign

ifica

nt re

duct

ion

in

cost

s fo

r bot

h co

mm

erci

al

and

Med

icar

e ris

k

insu

ranc

e).A

vera

ge g

ross

savi

ngs:

$129

4.32

per

pers

on/y

ear.

Patie

nts

in

DDM

not

onl

y ex

perie

nced

low

er c

harg

es b

ut a

lso

had

sign

ifica

ntly

hig

her

mea

sure

s in

the

key

diab

etes

HED

IS m

easu

res.

Lost

ear

ning

s as

soci

ated

with

abs

ente

eism

wer

e

$24/

mal

e w

orke

r/m

onth

with

impr

oved

gly

cem

ic

cont

rol b

ut w

ere

$115

for

thos

e w

ithou

t unc

ontro

lled

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 92




93

Boren et al

Auth

or(Y

ear)

Stud

y Ai

mSt

udy

Popu

latio

nSt

udy

Desi

gnIn

terv

entio

n

syst

em (G

ITS)

or

plac

ebo

Fina

ncia

l/Ec

onom

ic O

utco

me

indi

cato

rs

(pro

duct

ivity

)

from

ques

tionn

aire

s

and

diar

ies

Resu

lts

9.3%

±0.

1% a

nd 7

.0 ±

0.1

mm

ol/L

[126

±2

mg/

dL] v

s 9.

3 ±

0.2

mm

ol/L

[168

±4

mg/

dL]

,res

pect

ivel

y;

P<

.001

).Qu

ality

-of-

life

treat

men

t diff

eren

ces

for

sym

ptom

dis

tress

gene

ral p

erce

ived

hea

lth

and

cogn

itive

func

tioni

ng

wer

e si

gnifi

cant

ly b

ette

r

for t

hose

in a

ctiv

e

ther

apy.

Econ

omic

outc

omes

for g

lipiz

ide

GITS

incl

uded

hig

her

reta

ined

em

ploy

men

t

(97%

vs

85%

; P<

.001

)

and

prod

uctiv

e ca

paci

ty

(99%

vs

87%

; P<

.001

),

less

abs

ente

eism

(loss

es =

$24

vs

$115

/wor

ker p

er m

onth

;

P<

.001

),fe

wer

bed

days

(los

ses

= $

1539

vs

$184

3 pe

r 100

0 pe

rson

days

; P=

.05)

,and

few

er

rest

ricte

d-ac

tivity

day

s

(loss

es =

$26

60 v

s

Conc

lusi

ons

bloo

d su

gar.

Lost

ear

ning

due

to re

stric

ted

activ

ity

wer

e $2

660/

1000

per

son

days

for m

ale

empl

oyee

s

with

goo

d gl

ycem

ic

cont

rol v

s $4

275

for t

hose

with

out.

Lost

wag

es fo

r

thos

e re

stric

ted

to b

ed

rest

wer

e $1

539/

1000

pers

on d

ays

com

pare

d

with

$18

43 fo

r poo

r

glyc

emic

con

trol.

Impr

oved

gly

cem

ic c

ontro

l

for p

atie

nts

with

type

2

diab

etes

is a

ssoc

iate

d

with

sub

stan

tial s

hort-

term

sym

ptom

atic

,QOL

,

and

heal

th e

cono

mic

bene

fits.

Empl

oyee

s w

ho

impr

oved

thei

r gly

cem

ic

cont

rol w

ere

mor

e

prod

uctiv

e on

the

job

(99%

vs

87%

) and

abl

e to

rem

ain

empl

oyed

long

er

(97%

vs

85%

) tha

n

empl

oyee

s w

ho d

id n

ot

cont

rol a

nd lo

wer

thei

r

bloo

d su

gar l

evel

s.

Tab

le 1

(c

on

tinu

ed

)

(con

tinue

d)

TDE326774.qxd 1/16/2009 6:38 PM Page 93




94


Auth

or(Y

ear)

Wag

ner e

t al

(200

1)35

Stud

y Ai

m

Dete

rmin

e im

pact

on c

ost o

f

patie

nts

with

impr

oved

A1C

Stud

y Po

pula

tion

4744

dia

bete

s

patie

nts

≥18

year

s,

cont

inuo

usly

enro

lled,

and

had

A1C

mea

sure

d at

leas

t onc

e a

year

Stud

y De

sign

Hist

oric

al c

ohor

t

stud

y be

twee

n

1992

and

199

7

in a

sta

ff-m

odel

HMO;

732

patie

nts

who

se

A1C

decr

ease

d

≥1%

bet

wee

n

1992

and

199

3

and

was

mai

ntai

ned

thro

ugh

1994

form

ed th

e

impr

oved

gro

up.

4012

pat

ient

s

who

se le

vels

decr

ease

d 0

.9%

com

pris

ed th

e

unim

prov

ed

grou

p.

Inte

rven

tion

Com

pare

pat

ient

s

with

dia

bete

s

who

se A

1C

impr

oved

to

thos

e w

hose

did

not

Fina

ncia

l/Ec

onom

ic O

utco

me

Mea

n to

tal c

osts

;

cost

sav

ings

Resu

lts

$427

5 pe

r 100

0 pe

rson

days

; P=

.01)

.

Patie

nts

with

dia

bete

s

who

se A

1C im

prov

ed

had

sim

ilar

dem

ogra

phic

s to

thos

e

who

se d

id n

ot b

ut h

ad

high

er b

asel

ine

mea

sure

men

ts (1

0.0%

vs 7

.7%

).Co

st s

avin

gs

in im

prov

ed c

ohor

t wer

e

stat

istic

ally

sig

nific

ant

only

am

ong

thos

e w

ith

the

high

est b

asel

ine

leve

ls (>

10%

) and

wer

e

unaf

fect

ed b

y

com

plic

atio

ns a

t

base

line.

Utili

zatio

n w

as

cons

iste

ntly

low

er in

the

impr

oved

coh

ort f

or

prim

ary

care

and

spec

ialty

vis

its.

Conc

lusi

ons

Abse

ntee

ism

rate

dro

pped

by 1

% c

ompa

red

with

an

8% in

crea

se in

em

ploy

ees

with

poo

r gly

cem

ic

cont

rol.

A su

stai

ned

redu

ctio

n in

A1C

leve

l am

ong

adul

t

patie

nts

with

dia

bete

s is

asso

ciat

ed w

ith s

igni

fican

t

cost

sav

ings

(mea

n to

tal

heal

th c

are

cost

s w

ere

$685

to $

950

less

eac

h

year

in th

e co

hort

with

impr

oved

A1C

mea

sure

men

ts) w

ithin

1

to 2

yea

rs o

f

impr

ovem

ent.

Tab

le 1

(c

on

tinu

ed

)

MNT

:med

ical

nut

ritio

n th

erap

y.

TDE326774.qxd 1/16/2009 6:38 PM Page 94




95

Boren et al

Most professional diabetes educators are members ofthe American Association of Diabetes Educators. Somediabetes educators are certified diabetes educators (CDEs)or Board Certified Advanced Diabetes Managers, havingmet certain eligibility and exam requirements. TheAmerican Association of Diabetes Educators advocatesdiabetes education that is provided by a diabetes educatorand focuses on 7 self-care behaviors (ie, healthy eating,being active, monitoring, taking medication, problem solv-ing, healthy coping, and reducing risks) that are essentialfor improved health status and greater quality of life. Noeconomic studies were available that met this morerestricted definition of diabetes education. Hence, thisstudy adopted a very broad definition of diabetes educationfor its literature review. The strength of this decision is thatmore than 25 studies were identified as being relevant. Theweakness is that the studies varied considerably in design,outcome metric, population studied, and their aims.

In summary, the review of the literature addresses eco-nomic and financial outcomes relating to diabetes educa-tion interventions that are supportive of diabeteseducation as a cost-effective intervention. One couldposit that diabetes education reduces cost because it isguided by the best available science-based evidence;incorporates the needs, goals, and life experiences of theperson with or at risk of diabetes; and supports the workof health care providers who treat these patients.

Most but not all published papers on the topic appearin Medline. Some of the studies are more robust than oth-ers. The inclusion criteria were broad, and hence it is notpossible to grade the rigor of the studies and the impor-tance of the findings of each. This study did, however,include findings from RCTs and a recent systematicreview. Finally, it is not possible to identify the impor-tance of the diabetes educator in the provision and out-comes of the programs in the study because of the broaddefinition of diabetes education that was used.

The findings indicate that the benefits associated witheducation on self-management and lifestyle modificationfor people with diabetes are positive and outweigh thecosts associated with the intervention. More research isneeded to validate that diabetes education provided bydiabetes educators is cost-effective.

Implications/Relevance

• Behavior change, lifestyle modification, and self-manage-ment are crucial elements to the cost-effective managementof chronic illnesses such as diabetes.

• For optimal comparisons, a standardized definition of diabeteseducation should be adopted for future economic studies.

• The benefits associated with diabetes education are positiveand, based on the literature, outweigh the costs associatedwith the intervention.

References

1. Schoen C, Guterman S, Shih A, et al. Bending the curve: optionsfor achieving savings and improving value in U.S. health spend-ing, The Commonwealth Fund, December 2007. http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=620087. Accessed January 29, 2008.

2. Anderson G. Chronic conditions: making the case for ongoingcare. Johns Hopkins University. November 2007. http://www.fightchronicdisease.com/news/pfcd/documents/ChronicCareChartbook_FINAL.pdf. Accessed January 29, 2008.

3. American Diabetes Association. Economic costs of diabetes inthe U.S. in 2007. Diabetes Care. 2008;31:1-20.

4. DeVol R, Bedroussian A, Charuworn A, et al. An unhealthyAmerica: the economic burden of chronic disease—charting anew course to save lives and increase productivity and economicgrowth. Milken Institute. October 2007. http://www.milkeninstitute.org/pdf/chronic_disease_report.pdf. Accessed January 29, 2008.

5. American Association of Diabetes Educators. About diabeteseducation. http://www.diabeteseducator.org/DiabetesEducation.Accessed February 5, 2008.

6. Norris SL, Nichols PL, Caspersen CJ, et al. The effectiveness ofdisease and case management for people with diabetes: a system-atic review. Am J Prev Med. 2002;22(suppl):15-38.

7. Norris SL, Lau J, Smith SJ, Schmidt CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care.2002;25:1159-1171.

8. Salber PR. How managed care organizations contribute toimproved diabetes outcomes. Am J Managed Care. 2008;14:9-12.

9. Gary TL, Genkinger JM, Guallar E, Peyrot M, Brancati FL. Meta-analysis of randomized educational and behavioral interventionsin type 2 diabetes. Diabetes Educ. 2003;29:488-501.

10. Balamurugan A, Ohsfeldt R, Hughes T, Phillips M. Diabetes self-management education program for Medicaid recipients: a con-tinuous quality improvement process. Diabetes Educ. 2006;32:893-900.

11. Berg GD, Wadhwa S. Diabetes disease management in a commu-nity-based setting. Manag Care. 2002;11:45-50.

12. Burton WN, Connerty CM. Evaluation of a worksite-basedpatient education intervention targeted at employees with diabetesmellitus. J Occup Environ Med. 1998;40:702-706.

13. Chase HP, Pearson JA, Wightman C, Roberts MD, Oderberg AD,Garg SK. Modem transmission of glucose values reduces the costsand need for clinic visits. Diabetes Care. 2003;26:1475-1479.

14. Christensen NK, Williams P, Pfister R. Cost savings and clinicaleffectiveness of an extension service diabetes program. DiabetesSpectrum. 2004;17:171-175.

15. Cranor CW, Bunting BA, Christensen DB. The Asheville project:long-term clinical and economic outcomes of a community phar-macy diabetes care program. J Am Pharm Assoc. 2003;43:173-184.

16. De Weerdt, Visser AP, Kok GJ, van der Veen EA. Randomizedcontrolled multicentre evaluation of an education programme for

TDE326774.qxd 1/16/2009 6:38 PM Page 95




96


insulin-treated diabetic patients: effects on metabolic control,quality of life and cost of therapy. Diabetes Med. 1991;8:338-345.

17. Diabetes cost savings legislation would save millions for Ohio insur-ance industry, business, and taxpayers in productivity, emergencyroom visits, and hospital stays. October 4, 2005 [cited January 7,2008]. http://www.diabetes.org/uedocuments/10.4.05DCRA.pdf.

18. Eddy DM, Schlessinger L, Kahn R. Clinical outcomes and cost-effectiveness of strategies for managing people at high risk fordiabetes. Ann Intern Med. 2005;143:251-264.

19. Fries JF, McShane D. Reducing need and demand for medicalservices in high-risk persons: a health education approach. West JMed. 1998;169:201-207.

20. Garrett DG, Bluml BM. Patient self-management program fordiabetes: first-year clinical, humanistic, and economic outcomes.J Am Pharm Assoc. 2005;45:130-137.

21. Gilmer TP, O’Connor PJ, Manning WG, Rush WA. The cost tohealth plans of poor glycemic control. Diabetes Care.1997;20:1847-1853.

22. Herman WH, Brandle M, Zhang P, et al. Diabetes PreventionProgram Research Group: costs associated with the primary pre-vention of type 2 diabetes mellitus in the diabetes prevention pro-gram. Diabetes Care. 2003;26:36-47.

23. Herman WH, Brandle M, Zhang P, et al. Diabetes PreventionProgram Research Group: within-trial cost-effectiveness oflifestyle intervention or metformin for the primary prevention oftype 2 diabetes. Diabetes Care. 2003;26:2518-2523.

24. Katon W, Unutzer J, Fan M, et al. Cost effectiveness and net ben-efit of enhanced treatment of depression for older adults with dia-betes and depression. Diabetes Care. 2006;29:265-270.

25. Keers JC, Groen H, Sluiter WJ, Bouma J, Links TP. Costs andbenefits of a multidisciplinary intensive diabetes education pro-gram. J Eval Clin Pract. 2005;11:293-303.

26. Klonoff DC, Schwartz DM. An economic analysis of interven-tions for diabetes. Diabetes Care. 2000;23:390-404.

27. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction inthe incidence of type 2 diabetes with lifestyle intervention or met-formin. N Engl J Med. 2002;346:393-403.

28. Menzin J, Langley-Hawthorne C, Friedman M, Boulanger L,Cavanaugh R. Potential short-term economic benefits ofimproved glycemic control. Diabetes Care. 2001;24:51-55.

29. Ragucci KR, Fermo JD, Wessell AM, Chumney ECG.Effectiveness of pharmacist-administered diabetes mellitus edu-cation and management services. Pharmacotherapy. 2005;25:1809-1816.

30. Rosenblum MS, Kane MP. Analysis of cost and utilization ofhealth care services before and after initiation of insulin therapyin patients with type 2 diabetes mellitus. J Manag Care Pharm.2003;9:309-316.

31. Rubin RJ, Dietrich KA, Hawk AD. Clinical and economicimpact of implementing a comprehensive diabetes managementprogram in managed care. J Clin Endocrinol Metab. 1998;83:2635-2642.

32. Shetty S, Secnik K, Oglesby AK. Relationship of glycemic con-trol to total diabetes-related costs for managed care health planmembers with type 2 diabetes. J Manag Care Pharm.2005;11:559-564.

33. Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, HarrisR. Does diabetes disease management save money and improveoutcomes? Diabetes Care. 2002;25:684-689.

34. Testa MA, Simonson DC. Health economic benefits and qualityof life during improved glycemic control in patients with type 2diabetes mellitus: a randomized, controlled, double-blind trial.JAMA. 1998;280:1490-1496.

35. Wagner EH, Sandhu N, Newton KM, McCulloch DK, RamseySD, Grothaus LC. Effect of improved glycemic control on healthcare costs and utilization. JAMA. 2001;285:182-189.

36. CDC Diabetes Cost-Effectiveness Group. Cost-effectiveness ofintensive glycemic control, intensified hypertension control andserum cholesterol level reduction for type 2 diabetes. JAMA.2002;287:2542-2551.

37. Ozminkowski RJ, Goetzel RZ, Smith MW, Cantor RI,Shaughnessy A, Harrison M. The impact of the Citibank, NA,health management program on changes in employee health risksover time. J Occup Environ Med. 2000;42:502-511.

38. Aldana SG. Financial impact of health promotion programs: acomprehensive review of the literature. Am J Health Promotion.2001;15:296-320.

39. Department of Health and Human Services, Health Care FinancingAdministration. Federal Register, Part II; 42 CFR Parts 410, 414,424, 480 and 498. Friday, December 29, 2000.

TDE326774.qxd 1/16/2009 6:38 PM Page 96



Documents

The Diabetes Educator Diabetes Educator DOI: ... Data Sources The authors searched ... cost control, cost of illness, cost savings, cost-benefit analysis, costs and cost analysis,