Direct medical charges associated with myocardial infarction in patients with and without diabetes

How do type 2 diabetes mellitus (T2DM)-related complications and socioeconomic factors impact direct medical costs? A cross-sectional study in rural Southeast China

OBJECTIVE

To evaluate type 2 diabetes mellitus (T2DM)-related direct medical costs by complication type and complication number, and to assess the impacts of complications as well as socioeconomic factors on direct medical costs.

DESIGN

A cross-sectional study using data from the region's diabetes management system, social security system and death registry system, 2015.

SETTING

Tongxiang, China.

PARTICIPANTS

Individuals diagnosed with T2DM in the local diabetes management system, and who had 2015 insurance claims in the social security system. Patients younger than 35 years and patients whose insurance type changed in the year 2015 were excluded.

MAIN OUTCOME MEASURES

The mean of direct medical costs by complication type and number, and the percentage increase of direct medical costs relative to a reference group, considering complications and socioeconomic factors.

RESULTS

A total of 19 015 eligible individuals were identified. The total cost of patients with one complication was US$1399 at mean, compared with US$248 for patients without complications. The mean total cost for patients with 2 and 3+ complications was US$1705 and US$2994, respectively. After adjustment for socioeconomic confounders, patients with one complication had, respectively, 83.55% and 38.46% greater total costs for inpatient and outpatient services than did patients without complications. The presence of multiple complications was associated with a significant 44.55% adjusted increase in total outpatient costs, when compared with one complication. Acute complications, diabetic foot, stroke, ischaemic heart disease and diabetic nephropathy were the highest cost complications. Gender, age, education level, insurance type, T2DM duration and mortality were significantly associated with increased expenditures of T2DM.

CONCLUSIONS

Complications significantly aggravated expenditures on T2DM. Specific kinds of complications and the presence of multiple complications are correlated with much higher expenditures. Proper management and the prevention of related complications are urgently needed to reduce the growing economic burden of diabetes.

A Systematic Review of Cardiovascular Outcomes-Based Cost-Effectiveness Analyses of Lipid-Lowering Therapies

BACKGROUND

Previous reviews have evaluated economic analyses of lipid-lowering therapies using lipid levels as surrogate markers for cardiovascular disease. However, drug approval and health technology assessment agencies have stressed that surrogates should only be used in the absence of clinical endpoints.

OBJECTIVE

The aim of this systematic review was to identify and summarise the methodologies, weaknesses and strengths of economic models based on atherosclerotic cardiovascular disease event rates.

METHODS

Cost-effectiveness evaluations of lipid-lowering therapies using cardiovascular event rates in adults with hyperlipidaemia were sought in Medline, Embase, Medline In-Process, PubMed and NHS EED and conference proceedings. Search results were independently screened, extracted and quality checked by two reviewers.

RESULTS

Searches until February 2016 retrieved 3443 records, from which 26 studies (29 publications) were selected. Twenty-two studies evaluated secondary prevention (four also assessed primary prevention), two considered only primary prevention and two included mixed primary and secondary prevention populations. Most studies (18) based treatment-effect estimates on single trials, although more recent evaluations deployed meta-analyses (5/10 over the last 10 years). Markov models (14 studies) were most commonly used and only one study employed discrete event simulation. Models varied particularly in terms of health states and treatment-effect duration. No studies used a systematic review to obtain utilities. Most studies took a healthcare perspective (21/26) and sourced resource use from key trials instead of local data. Overall, reporting quality was suboptimal.

CONCLUSIONS

This review reveals methodological changes over time, but reporting weaknesses remain, particularly with respect to transparency of model reporting.

Cost-utility analysis of genotype-guided antiplatelet therapy in patients with moderate-to-high risk acute coronary syndrome and planned percutaneous coronary intervention

BACKGROUND

Prasugrel is recommended over clopidogrel in poor/intermediate CYP2C19 metabolizers with acute coronary syndrome (ACS) and planned percutaneous coronary intervention (PCI), reducing the risk of ischemic events. CYP2C19 genetic testing can guide antiplatelet therapy in ACS patients.

OBJECTIVE

The purpose of this study was to evaluate the cost-utility of genotype-guided treatment, compared with prasugrel or generic clopidogrel treatment without genotyping, from the US healthcare provider's perspective.

METHODS

A decision model was developed to project lifetime economic and humanistic burden associated with clinical outcomes (myocardial infarction [MI], stroke and major bleeding) for the three strategies in patients with ACS. Probabilities, costs and age-adjusted quality of life were identified through systematic literature review. Incremental cost-utility ratios (ICURs) were calculated for the treatment strategies, with quality-adjusted life years (QALYs) as the primary effectiveness outcome. Relative risk of developing myocardial infarction and stroke between patients with and without variant CYP2C19 when receiving clopidogrel were estimated to be 1.34 and 3.66, respectively. One-way and probabilistic sensitivity analyses were performed.

RESULTS

Clopidogrel cost USD19,147 and provided 10.03 QALYs versus prasugrel (USD21,425, 10.04 QALYs) and genotype-guided therapy (USD19,231, 10.05 QALYs). The ICUR of genotype-guided therapy compared with clopidogrel was USD4,200. Genotype-guided therapy provided more QALYs at lower costs compared with prasugrel. Results were sensitive to the cost of clopidogrel and relative risk of myocardial infarction and stroke between CYP2C19 variant vs. non-variant. Net monetary benefit curves showed that genotype-guided therapy had at least 70% likelihood of being the most cost-effective alternative at a willingness-to-pay of USD100,000/QALY. In comparison with clopidogrel, prasugrel therapy was more cost-effective with <21% certainty at willingness-to-pay of >USD170,000/QALY.

CONCLUSIONS

Our modeling analyses suggest that genotype-guided therapy is a cost-effective strategy in patients with acute coronary syndrome undergoing planned percutaneous coronary intervention.

Cost effectiveness and screening interval of lipid screening in Hodgkin's lymphoma survivors

PURPOSE

Survivors of Hodgkin's lymphoma (HL) who received mediastinal irradiation have an increased risk of coronary heart disease. We evaluated the cost effectiveness of lipid screening in survivors of HL and compared different screening intervals.

METHODS

We developed a decision-analytic model to evaluate lipid screening in a hypothetical cohort of 30-year-old survivors of HL who survived 5 years after mediastinal irradiation. We compared the following strategies: no screening, and screening at 1-, 3-, 5-, or 7-year intervals. Screen-positive patients were treated with statins. Markov models were used to calculate life expectancy, quality-adjusted life expectancy, and lifetime costs. Baseline probabilities, transition probabilities, and utilities were derived from published studies and US population data. Costs were estimated from Medicare fee schedules and the medical literature. Sensitivity analyses were performed.

RESULTS

Using an incremental cost-effectiveness ratio (ICER) threshold of $100,000 per quality-adjusted life-year (QALY) saved, lipid screening at every interval was cost effective relative to a strategy of no screening. When comparing screening intervals, a 3-year interval was cost effective relative to a 5-year interval, but annual screening, relative to screening every 3 years, had an ICER of more than $100,000/QALY saved. Factors with the most influence on the results included risk of cardiac events/death after HL, efficacy of statins in reducing cardiac events/death, and costs of statins.

CONCLUSION

Lipid screening in survivors of HL, with statin therapy for screen-positive patients, improves survival and is cost effective. A screening interval of 3 years seems reasonable in the long-term follow-up of survivors of HL.

[The cost of complications: implications for the measurement of the cost of type II diabetes mellitus]

BACKGROUND

A well-known methodology used to compute the macroeconomic cost of risk factors is the etiologic cost ratio, leading to estimates based on data on the prevalence of the risk factor in the general population, the relative risk of complications associated to it and the cost of the complications. A major problem of this method is that it is in some extent inconsistent with recent findings showing an increase in the per capita cost of some complications in presence of type II diabetes mellitus. The aim of the paper is to reconcile the approach with most recent economic studies and to overview the consequences of such an attempt in terms of methodological framework.

METHODS

We developed a methodological framework introducing heterogeneity in the cost of treating complications according to the presence of diabetes. We estimated the macroeconomic cost of type II diabetes mellitus based on selected complications (stroke, myocardial infarction, nephropathy and peripheral arterial obstructive disease) from French representative data in two situations: a situation in which the heterogeneity is not taken into account, another situation in which heterogeneity is introduced.

RESULTS

Our results point out that the assumption of homogeneity in the cost of complications is associated to an underestimation of the cost of diabetes by about 30%.

CONCLUSION

Our results present an attempt to reconcile the economic modeling of the cost of type II diabetes mellitus with the "real world". We conclude that the introduction of heterogeneity is necessary to capture the whole extent of the economic burden of the disease and that it places significant constraints on the data and the methodological framework to be used in such attempts.

Increased hospital expenditures in diabetic patients hospitalized for cardiovascular diseases

OBJECTIVES

To measure the impact of diabetes on hospital resource use and expenditures in patients hospitalized for cardiovascular diseases (CVD).

RESEARCH DESIGN AND METHODS

We conducted an observational study of 4865 hospitalizations for CVD over 2 years (January 1998 to December 1999). Information with respect of the presence of diabetes mellitus, length of stay, readmissions, mortality, and costs were obtained through retrospective chart review.

RESULTS

Diabetic patients accounted for 35.1% of hospital admissions (1706 admissions), 40.8% of hospital stays (23,309 days), and 39% of direct medical cost (5,735,884 euros). On average, diabetic patients had longer hospital stay (13.6+/-13.2 vs. 10.7+/-11.2 days; P<.001) and direct in-patient cost (3438+/-4308 vs. 2513+/-3384 euros; P<.001) and experienced more readmissions (relative risk: 1.67; 95% CI: 1.45-1.91) compared with nondiabetic patients. However, despite the hospital mortality rate being higher in nondiabetic patients (6.3% vs. 5.8%), these results were not statistically significant (relative risk: 1.09; 95% CI: 0.86-1.40).

CONCLUSIONS

Diabetic patients hospitalized for CVD have longer hospital stay, greater risk of short-term readmission, and are more costly than nondiabetic patients. However, in-hospital mortality risk in patients hospitalized by CVD is no greater in diabetic than in nondiabetics.

Estimates of direct medical costs for microvascular and macrovascular complications resulting from type 2 diabetes mellitus in the United States in 2000

BACKGROUND

Diabetes mellitus is a chronic condition that affects the health of Americans and the US health care system on many levels. According to the American Diabetes Association, approximately 16 million Americans have diabetes mellitus. The onset of type 2 diabetes mellitus, which accounts for the vast majority (90%-95%) of cases, precedes diagnosis by a mean 7 years, with the disease typically manifesting during adulthood. It is not uncommon for people to first realize they have diabetes mellitus due to the appearance of a related complication.

OBJECTIVE

The goal of this analysis was to estimate the direct medical costs of managing microvascular and macrovascular complications of type 2 diabetes mellitus in the United States in the year 2000.

METHODS

Complication costs were estimated by applying unit costs to typical resource-use profiles. A combination of direct data analysis and cost modeling was used. For each complication, the event costs referred to those associated with the acute episode and subsequent care in the first year. State costs were the annual costs of continued management. Data were obtained from many sources, including inpatient, ambulatory, and emergency department care databases from several states; national physician and laboratory fee schedules; government reports; and literature. All costs were expressed in 2000 US dollars.

RESULTS

Major events (eg, acute myocardial infarction--30,364 dollars event cost, 1678 dollars state cost) generated a greater financial burden than early-stage complica- tions (eg, microalbuminuria--63 dollars event cost, 15 dollars state cost). However, complications that were initially relatively low in cost (eg, microalbuminuria) can progress to more costly advanced stages (eg, end-stage renal disease--37,022 dollars state cost).

CONCLUSIONS

Given the scope of diabetes mellitus in the United States and its impact on health care and budgets, it is important for policy makers to have up-to-date information about treatment outcomes and costs. The costs presented here provide essential components for any analysis examining the economic burden of the complications of diabetes mellitus.

Geographic variation in health care utilization and outcomes in veterans with acute myocardial infarction

OBJECTIVES

To examine regional variation in health care utilization and outcomes during acute and chronic care of veterans following acute myocardial infarction (AMI), identifying potentially modifiable variables and processes of care that influence patient outcomes.

METHODS

Using national VA databases, we identified all veterans hospitalized at any VA Medical Center (VAMC) for AMI between October 1990 and September 1997. Demographic, inpatient, outpatient, mortality, and readmission data were extracted for 4 regions: Northeast, South, Midwest and West. Multivariable Cox proportional hazards regression models, controlled for comorbidity, were used to assess predictors of time to death and readmission.

RESULTS

We identified 67,889 patients with AMI. Patient demographic characteristics by region were similar. Patients in the Northeast had more comorbid conditions and longer lengths of stay during the index AMI hospitalization. Region of the country independently predicted time to death, with lower risk of death in the Northeast (hazard ratio [HR] = 0.875; 95% confidence interval [95% CI], 0.834 to 0.918; P < .0001) and West (HR = 0.856; 95%CI, 0.818 to 0.895; P = .0001) than in the South. Patients in the Northeast and West also had more cardiology or primary care follow-up within 60 days and at 1 year post-discharge than patients in the South and Midwest. Outpatient follow-up accounted for a significant portion of the variation in all-cause mortality.

CONCLUSION

Substantial geographic variation exists in subsequent clinical care and outcomes among veterans hospitalized in VAMCs for AMIs. Outpatient follow-up was highly variable and associated with decreased mortality. Further studies are needed to explore the causes of regional variation in processes of care and to determine the most effective strategies for improving outcomes after AMI.

Assessing the impact of complications on the costs of Type II diabetes

AIMS/HYPOTHESIS

'The Cost of Diabetes in Europe-Type II (CODE-2) study' provides the first coordinated attempt to assess the total costs of managing people with Type II (non-insulin-dependent) diabetes mellitus in Europe. Type II diabetes is associated with a number of serious long-term complications, which are a major cause of morbidity, hospitalisation and mortality in diabetic patients.

METHODS

Patients were divided into four broad categories defining their complication status in terms of no complications, one or more microvascular complications, one or more macrovascular complications or one or more of each microvascular and macrovascular complication. The prevalence of complications and associated costs were assessed retrospectively for 6 months.

RESULTS

In total, 72% of patients in the CODE-2 study had at least one complication, with 19% having microvascular only, 10% having macrovascular only and 24% of the total having both microvascular and macrovascular complications. Of patients with microvascular complications, 28% had neuropathy, 20% renal damage, 20% retinopathy and 6.5% required treatment for eye complications. Among the patients with macrovascular complications, 18% had peripheral vascular disease, 17% angina, 12% heart failure and 9% had myocardial infarction. Percutaneous transluminal coronary angioplasty, coronary artery bypass graft or stroke occurred in 3%, 4% and 5% of the patients, respectively. In patients with both microvascular and macrovascular complications, the total cost of management was increased by up to 250% compared to those without complications.

CONCLUSION/INTERPRETATION

Complications have a substantial impact on the costs of managing Type II diabetes. This study has confirmed that the prevention of diabetic complications will not only benefit patients, but potentially reduce overall healthcare expenditure.

The impact of cardiovascular disease on medical care costs in subjects with and without type 2 diabetes

OBJECTIVE

We examined whether cardiovascular disease (CVD) affects medical care costs differently in subjects with and without diabetes and explored the impact of CVD on costs across the dimensions of age and diabetes duration.

RESEARCH DESIGN AND METHODS

We compared the prevalence of CVD and medical care costs for subjects with and without CVD in all 16,180 full-year health maintenance organization members in 1999 who had been diagnosed with type 2 diabetes and in control members matched by year of birth and sex. We ascertained diagnoses from the Kaiser Permanente Northwest Region's electronic ambulatory medical record and from hospital discharge datafiles. Utilization from these and other data systems were multiplied by unit costs.

RESULTS

CVD was 76% more prevalent in subjects with diabetes, but the risk ratios of more severe forms of CVD were even greater. Risk ratios for CVD were greatest in younger subjects. Cost profiles for subjects with both CVD and diabetes differed markedly from those with diabetes but without CVD. In the latter group, costs grew steadily with age, whereas in the former group, costs peaked in the 55- to 64-year age group before declining with age.

CONCLUSIONS

The types of CVD present in diabetic patients are more likely to be more severe and therefore more costly than in similar subjects without diabetes. CVD also disproportionately affects younger diabetic subjects. Finally, when CVD is present in diabetes, more costs occur earlier in life as well as earlier in the course of diabetes.

Productivity and medical costs of diabetes in a large employer population

OBJECTIVE

The purpose of this study was to assess the economic burden of diabetes from an employer's perspective. We analyzed the costs of diabetes, using claims data for an employed population and the prevalence of selected comorbid conditions.

RESEARCH DESIGN AND METHODS

The data source is a claims database from a national Fortune 100 manufacturer. It includes medical, pharmacy, and disability claims for all beneficiaries (n >100,000). Both medical and work productivity costs of diabetes patients are compared by age with those of matched control subjects from the overall beneficiary population. Out-of-pocket and intangible costs are excluded.

RESULTS

In 1998, the employer's mean annual per capita costs were higher for all diabetes beneficiaries than for control subjects ($7,778 +/- 16,176 vs. $3,367 +/- 8,783; P < 0.0001), yielding an incremental cost of $4,410 +/- 18,407 associated with diabetes. The medical and productivity costs for employees with diabetes were significantly (P < 0.0008) higher than for control subjects. The incremental cost of diabetes among employees ranged from $4,671 (aged 18-35 years) to $4,369 (aged 56-64 years).

CONCLUSIONS

Diabetes imposes a significant economic burden on employers, particularly when including productivity costs. Employers should select health plans that provide enriched benefits to diabetes patients, including ready access to medical and pharmacy services as well as aggressive diabetes management programs.

How cost-effective is the treatment of dyslipidemia in patients with diabetes but without cardiovascular disease?

OBJECTIVE

Epidemiological studies have shown that the risk of myocardial infarction (MI) in diabetic patients without cardiovascular disease (CVD) is comparable to the risk of MI in patients with CVD. We used a validated Markov model to compare the long-term costs and benefits of treating dyslipidemia in diabetic patients without CVD versus treating CVD patients without diabetes in the U.S. The generalizability and robustness of these results were also compared across six other countries (Canada, France, Germany, Italy, Spain, and the U.K.).

RESEARCH DESIGN AND METHODS

With use of the Cardiovascular Disease Life Expectancy Model, cost effectiveness simulations of simvastatin treatment were performed for men and women who were 40-70 years of age and had dyslipidemia. We forecast the long-term risk reduction in CVD events after treatment. On the basis of the Scandinavian Simvastatin Survival Study results, we assumed a 35% reduction in LDL cholesterol and an 8% rise in HDL cholesterol.

RESULTS

In the U.S., treatment with simvastatin for CVD patients without diabetes was cost-effective, with estimates ranging from $8,799 to $21,628 per year of life saved (YOLS). Among diabetic individuals without CVD, lipid therapy also appeared to be cost-effective, with estimates ranging from $5,063 to $23,792 per YOLS. In the other countries studied, the cost effectiveness of treating diabetes in the absence of CVD was comparable to the cost effectiveness of treating CVD in the absence of diabetes.

CONCLUSIONS

Among diabetic men and women who do not have CVD, lipid therapy is likely to be as effective and cost-effective as treating nondiabetic individuals with CVD.