Design of cost-effective packages of care for non-insulin-dependent diabetes mellitus. Defining the information needs

Cost-Effectiveness of Technology-Assisted Case Management in Low-Income, Rural Adults with Type 2 Diabetes

Objective: The objective of this study was to examine whether delivering technology-assisted case management (TACM) with medication titration by nurses under physician supervision is cost effective compared with usual care (standard office procedures) in low-income rural adults with type 2 diabetes.

Methods: One hundred and thirteen low-income, rural adults with type 2 diabetes and hemoglobin A1c (HbA1c) ≥8%, were randomized to a TACM intervention or usual care. Effectiveness was measured as differences in HbA1c between the TACM and usual care groups at 6 months. Total cost per patient included intervention or usual care cost, medical care cost, and income loss associated with lost workdays. The total cost per patient and HbA1c were used to estimate a joint distribution of incremental cost and incremental effect of TACM compared with usual care. Incremental cost-effectiveness ratios (ICERs) were estimated to summarize the cost-effectiveness of the TACM intervention relative to usual care to decrease HbA1c by 1%.

Results: Costs due to intervention, primary care, other health care, emergency room visits, and workdays missed showed statistically significant differences between the groups (usual care $1,360.49 vs. TACM $5,379.60, p=0.004), with an absolute cost difference of $4,019.11. Based on the intervention cost per patient and the change in HbA1c, the median bootstrapped ICERs was estimated to be $6,299.04 (standard error=731.71) per 1% decrease in HbA1c.

Conclusion: Based on these results, a 1% decrease in HbA1c can be obtained with the TACM intervention at an approximate cost of $6,300; therefore, it is a cost-effective option for treating vulnerable populations of adults with type 2 diabetes.

The economics of screening and treatment in type 2 diabetes mellitus

A systematic review of the literature was conducted to identify articles on the economics of type 2 diabetes mellitus. Articles were classified into two main categories: cost/burden-of-illness studies of type 2 diabetes and economic evaluations of type 2 diabetes interventions. This systematic review was supplemented by an overview of the findings relating to economic evaluations of associated diabetic complications. A number of conclusions emerge from this review, the most important of which is that intensive treatment of patients with type 2 diabetes appears to be relatively cost effective compared with more conservative strategies. This finding reflects the cost offsets that arise from the range and degree of complications attributable to diabetes. Primary prevention of type 2 diabetes also appears to be cost effective, particularly in high-risk groups. The evidence on screening for type 2 diabetes is less conclusive and further economic analysis is required.

A five-year evaluation of intervention in diabetes care in Trinidad and Tobago

AIMS

To evaluate an intervention to improve diabetes care in government-run heath centres in Trinidad and Tobago over 5 years.

METHODS

A cross-sectional survey of 690 subjects with clinical diabetes attending nine health centres was carried out in 1993. The intervention was: reports to the Ministry of Health, dissemination of management guidelines and annual training workshops for healthcare staff. Re-evaluation was through a survey of 1579 subjects with diabetes, attending 23 health centres in 1998.

RESULTS

Comparing 1993 with 1998, foot examinations in the previous year increased from 38 (6%) to 346 (22%) and fundoscopy from 6 (1%) to 139 (9%). For subjects attending for 1 year or less, 34/96 (35%) had dietary advice recorded in 1993 compared with 77/143 (54%) in 1998. Exercise advice was recorded for 3/96 (3%) in 1993 and 48/143 (34%) in 1998. In 1993, 329 (48%) were taking chlorpropamide but this fell to 57 (4%) in 1998. Glibenclamide use increased from 214 (31%) to 856 (54%) and gliclazide from four (1%) to 205 (13%). In 1993, 198/338 (56%) of hypertensive subjects were taking Brinerdin, this fell to 56/829 (7%) in 1998 while use of thiazide diuretics, methyldopa and angiotensin-converting enzyme (ACE) inhibitors increased. There were no changes in indicators of metabolic control, blood pressure control or body weight.

CONCLUSIONS

Use of audit data to inform health policy and practice, linked with educational interventions, may modify patterns of care in government-run primary care health centres in a middle-income country with a high prevalence of diabetes.

Relationship of health-related quality of life to symptom severity in diabetes mellitus: a study in Trinidad and Tobago

Our objective was to estimate the effect of greater symptom severity in diabetes mellitus on measures of health-related quality of life in a cross-sectional design in 35 government primary care health centres in Trinidad. Data were gathered on 2,117 subjects with clinical diabetes and analysed for 1,880 (89%). For each scale of the short form 36 (SF-36) questionnaire (a generic measure of health-related quality of life), scores were presented by quartile of symptom severity, measured using the Diabetes Symptom Checklist. Mean (SD) SF-36 scores were 44 (10) for the physical component score (PCS) and 45 (12) for the mental component score (MCS). Greater severity of diabetic symptoms was associated with lower scores on each of the subscales of the SF-36. Comparing lowest and highest quartiles of DSC score, the adjusted difference in PCS was -11 (95% confidence interval -12 to -9) and for MCS -16 (-18 to -14). Our results provide standardised data for health related quality of life in relation to severity of illness from diabetes, these might be used to aid the evaluation of relevant interventions.

Social inequalities in morbidity from diabetes mellitus in public primary care clinics in Trinidad and Tobago

Associations between socio-economic status and non-communicable diseases in middle income countries have received little study. We conducted an interview survey to evaluate the associations of morbidity with social conditions among people attending government primary care health centres with diabetes mellitus in Trinidad. Data collected included morbidity from hyperglycaemia, foot problems, visual problems and cardiovascular disease, as well as social and demographic variables. Of 622 subjects, 35% were aged > or = 65 years, 54% were Indo-Trinidadian, 13% had no schooling, only 11% were in full-time employment, and 33% had no piped drinking water supply in the home. Prevalent symptoms included itching, reported by 215 (35%), nocturia in 315 (51%), burning or numbness in the feet in 350 (56%), and difficulty with eyesight in 363 (58%). A morbidity summary score was used as dependent variable in regression analyses. Comparing those with no schooling with those with secondary education, the mean difference in morbidity score was 1.77 (95% CI 1.15-2.39), attenuated to 0.71 (0.06-1.37) after adjusting for age, gender, ethnic group and diabetes duration. The equivalent differences for those with no piped water supply in the house, compared with those with, were 0.53 (0.17-0.88) and 0.57 (0.24-0.89). For the unemployed, compared with those in full-time jobs, at ages 15-59 years the differences were 0.85 (0.14-1.56) and 0.58 (-0.11-1.27). We conclude that morbidity in persons with diabetes is associated with indicators of lower socio-economic status and that this association is partly explained by confounding with older age, female gender, longer duration of diabetes and Indo-Trinidadian ethnic group. A negative association between socio-economic status and morbidity from diabetes contributes to a justification for investment of public health resources in the control of diabetes and other non-communicable diseases.