Published Online:June 14, 2014
Trimming the costs of diabetes to the healthcare system will take multiple strategies, but there’s a lack of consensus on precisely how each will work. Are the new recommendations on statins worth the cost? How early should those at risk of prediabetes be screened? And how can health plans prevent hospital admissions by diabetics who still use the emergency department for primary care?
Presenters addressed these questions and others at “Health Care Economics and Health Delivery,” which took place Friday at the 74th Scientific Sessions of the American Diabetes Association (ADA), meeting at the Moscone Center in San Francisco, California.
Xiaohui Zhuo, PhD, a healthcare economist for the CDC, presented results that sought to identify the point at which statin use becomes cost-effective,1
based on the controversial recommendations unveiled in November 2013 at the meeting of the American Heart Association (AHA). Dr Zhuo’s results are noteworthy, as he and his co-authors have published extensively on the cost-effectiveness of early intervention in diabetes.2,3
As explained in January 2014 in Evidence-Based Diabetes Management
the cardiovascular risk calculator, an initiative of AHA and the American College of Cardiology, sparked criticism that it overestimated the number of people who should be taking statins. EBDM
explored how the use of different data sets by the calculator’s creators, and a pair of Harvard researchers who critiqued the tool in The New York Times
fueled the uproar.
Dr Zhuo’s group took a different approach, looking instead to decide at what point use of statins made sense a cost-effectiveness standpoint, and found that the statin recommendations in the AHA/ACC tool are simply not cost effective among patients with more moderate cardiovascular risk.1
Researchers used a simulation model based on published drug costs, and set the value of $50,000 per quality-of-life-year as a standard of cost-effectiveness. Data came from the 2005-2010 data from the National Health and Nutrition Examination Survey (NHANES). The researchers note that the recommended statin use in the CV risk calculator helps prevent atherosclerotic cardiovascular diseases (ASCVD) among diabetic adults, but increases the risk of type 2 diabetes mellitus (T2DM) in those who do not yet have the disease.
Recommendations call for using statins in diabetic adults ages 40-75 with low-density lipoprotein (LDL) of 70-189 mg/dL, or for nondiabetic adults of the same age and LDL level whose ASCVD risk exceeds 7.5%. Dr Zhou’s results concurred that intensive statin use was cost-effective in diabetic patients with the highest risk levels, or ASCVD risk above 10%. But moderate statin use was not cost-effective among diabetic adults for whom the ASCVD risk fell between 7.5% and 10%. Among adults without diabetes, moderate statin use was cost-effective for the ASCVD risk group above 10%, but not cost effective for other patients.
Screening for Prediabetes.
Timothy M. Dall, MS, of IHS Global Insight, and his co-authors examined the benefits of screening for prediabetes for at-risk persons who show no symptoms.5
ADA recommends such screening, but thus far the US Preventive Serves Task Force (USPSTF) does not. Mr Dall’s group created a simulation based on 2003-2010 NHANES population data, as well as prediction equations based on the Framingham Heart Study and the UK Prospective Diabetes Study, and compared how well the patients fared to 10-year outcomes from the lifestyle and control arms of the Diabetes Prevention Program. Per person benefits over year years were calculated to be $6,040 in medical savings, as well as $17,230 in total economic benefits. In addition, the study projected a 22% lower mortality risk from screening based on ADA recommendations.
Look AHEAD (Action for Health in Diabetes) is a multicenter, randomized controlled trial examining the effects of intensive lifestyle interventions for persons with diabetes, compared to traditional support and education. Ping Zhang, PhD, a senior health economist at CDC, presented the long-term effects of the intervention on health utility, comparing measurements with 3 different, multi-attribute indexes: the Health Utilities Index Mark 3 (HUI-3), the SF-6D, derived from Short Form 36, and the Feeling Thermometer (FT). The first 2 measures were taken at baseline, and at points that became less frequent over the 10 years of the study. Average HUI scores over the decade did not differ much between the 2 intervention groups, but the intensive intervention did produce statistically significiant improvements for those overweight and obese patients with T2DM. Dr Zhang’s group concluded that intensive interventions might be cost-effective, depending on the cost of intervention.6
Another abstract, presented by Tannaz Moin, MD, MBA,7
of the University of California, Los Angeles, and the VA Greater Los Angeles Healthcare System, examined employer-level data of patients with diabetes and prediabetes to see how enrollment in a Diabetes Health Plan (DHP), purchased by the employer, had affected hospitalization rates. Hospitalization rates for similar for 2 groups prior to the start of the DHP. At the 2-year mark, those enrolled in DHP had a 46% decrease compared with what projected at baseline. Dr Moin and his co-authors say that health plans that invest in such designs, including lower out-of-pocket costs for prescriptions and preventive care, will help reduce ED visits.
Emergency Department Interventions.
Hospital emergency departments (ED), which are too often the place where diabetes assessment occurs. Marie M. McDonnell, MD, presented results from the Diabetes ED Rapid Follow Up program (EDRP) at Boston Medical Center,8
created in 2011. Patients who appear at the ED are immediately booked in open slots sometime in the next 24 hours at a diabetes clinic, where patients receive education and start insulin. The intervention produced between health outcomes for those who kept their appointments and saved $2,819,000 in hospitalization costs. Patients who showed up at their EDRP appointments were more likely to have follow-up care within 6 months than those who did not (35% vs 22%). Those who showed up at their visit also reported better overall glycated hemoglobin (A1C) reduction (2.6% vs 2%), and return trips to the ED in the next 30 days were also reduced (5% vs 15%). The hospitalization rate was lower (4% vs 15%) among those who showed up at the appointment the next day.
Zhuo X, Zhang P, Bardenheier B, Mohammed A, Williams DE, Gregg EW. Implications of new American Heart Association (AHA) / American College of Cardiology (ACC) cholesterol guidelines on diabetes care and prevention: balancing the benefits and costs. Diabetes. 2014;63(suppl 1): Abstract 17-OR.
Zhou X, Zhang P, Khan HS, Gregg EW. Cost-effectiveness of alternative thresholds of the fasting plasma glucose test to identify the target population for type 2 diabetes prevention in adults aged ≥45 years. Diabetes Care. 2013;36(12):3992-3998.
Zhuo X, Zhang P, Hoerger TJ. Lifetime direct medical costs of treating type 2 diabetes and diabetic complications. Am J Prev Med. 2013;45(3):253-261.
Smith A. Understanding the role of Big Data in the CV risk calculator controversy. Am J Manag Care. 2014;20(SP1):SP1,SP22-SP23.
Dall T, Storm MV, Gillespie KB, et al. Health and economic benefits of preventing diabetes and sequelae among a prediabetes population. Diabetes. 2014;63(suppl 1): Abstract 20-OR.
Zhang P, Hire D, Espeland M, et al. Impact of intensive lifestyle intervention on health utility in type 2 diabetes: results from the Look AHEAD trial. Diabetes. 2014;63(suppl 1): Abstract 19-OR.
Moin T, Steers WN, Ettner SL, et al. Impact of a diabetes-specific helath plan on ED and inpatient hospital use. Diabetes. 2014;63(suppl 1): Abstract 24-OR.
McDonnell ME, Palermo N, Modzelewski K, et al. Direct access to acute diabetes clinic reduces hospitalizations and cost at 1 year. Diabetes. 2014;63(suppl 1): Abstract 23-OR.