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Improved diabetic control reduces healthcare costs

Study
Results
Comment
A major goal of diabetes care is better control of blood glucose. Reducing levels towards normal more of the time reduces tissue damage, organ damage, and all the horrid consequences of poorly controlled disease. That is a good enough reason for better glycaemic control, but another is that better control, by reducing the need for more intense medical care later, should reduce healthcare costs. That conclusion usually comes from economic modelling, but a new study from Seattle [1] shows in that real patients in a real setting better control equals reduced cost.

Study


The study was conducted in a health maintenance organisation of about half a million people around Puget Sound. Diabetics in the scheme from 1992 and with at least annual measurements of glycated haemoglobin (HbA1c) formed the study population. These 4744 patients were divided into those 732 with HbA1c levels that decreased by at least 1% between 1992 and 1993, and where the decrease was maintained to 1994. The other 4012 unimproved patients formed the control group. Demographic information and healthcare utilisation and costs were collected from administrative databases (and this particular HMO has a strong research background). Cost data was expressed in 1997 US$.

Results


The average age was 60 years with a heavy preponderance of type 2 diabetes. Patients saw a primary care physician 7-8 times a year on average, with four specality care visits a year. The improved cohort had higher baseline rates of foot ulcer, eye disease, heart attacks and strokes, but not ischaemic heart disease. Baseline HbA1c for improved patients was 10% and for those who did not improve it was 8%.

Total healthcare costs over the period 1992 to 1997 were lower by $685 to $950 a year for those patients whose HbA1c improved (Figure) than in those whose HbA1c did not improve, after an initial rise in 1993. This mirrored a reduction in hospital admissions, and fewer specialty care and primary care visits. Cost savings were most impressive in those whose initial HbA1c was above 10%, but savings occurred at all levels of HbA1c. Cost savings occurred in diabetics with cardiovascular disease, diabetics with other complications, and diabetics with no complications.

Figure: Average annual cost differences between improved and unimproved diabetics (US$ 1997)



Comment


This is a thorough examination of the cost-saving effects of better glycaemic control, mainly in type 2 diabetics. It demonstrates in a real population what has been previously theorised, that better glycaemic control will result in lower healthcare costs, and that this occurs within two years and is sustained.

There are two lessons. First is the obvious one that here is a lesson about investment in services. Invest now for better health at eventually lower costs. The second is about data sources. HMOs in the USA, if they have done one thing only, have provided excellent ways of collecting real-life cost and benefit information. It is curious that national services in Europe, and especially the UK, couldn't hope to provide anything like this quality of data.

References:

  1. EH Wagner et al. Effect of improved glycemic control on health care costs and utilization. JAMA 2001 285: 182-189.
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