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Senior Citizen Health & Medicine
Better Diabetes Care May Lead to Reduced Blindness, Kidney
and Heart Disease
One of the first studies of quality improvement in
diabetes care
 May 18, 2007 - A relatively inexpensive national
effort to improve the process of diabetes care at selected clinics was
able to make enough difference in its first four years that, if
sustained, it could reduce patients' lifetime risk of blindness,
end-stage kidney disease and coronary artery disease - all common
complications of diabetes, a major chronic disease for senior citizens.
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In the June 2007 issue of Health Services Research,
a University of Chicago-based research team reports that spending money
to improve diabetes care at federally qualified community health centers
is a sound investment, according to one of the first studies to examine
the clinical and economic impact of quality improvement in diabetes
care.
At a cost of less than $500 per patient each year,
this modest quality improvement effort is projected to reduce the
incidence of major complications, such as end-stage renal disease, which
can cost $44,000 per patient each year.
"In this setting, we found that the economic value
of improving the delivery of existing diabetes care was roughly equal to
the benefits of developing a new treatment, such as a novel diagnostic
technology or a better drug," said study author Elbert Huang, MD,
assistant professor of medicine at the University of Chicago.
"A small
investment in upgrading the delivery of health care brought about a
substantial improvement in health that justified the costs of the
program."
"Unfortunately," he added, "the people who make
such financial investments are not the people who directly benefit from
them."
Federally qualified community health centers
(FQHCs) routinely lose money on health care improvement programs. The
added costs are borne by the health centers and by state and federal
government programs; the benefits accrue to society. "Cost-effective
medicine," Huang said, "depends entirely on an ongoing societal
commitment to providing chronic care for vulnerable patients."
The researchers studied how diabetes care changed
at 17 Midwestern FQHCs that participated in the Health Disparities
Collaborativesa national, federally funded quality-improvement
initiative launched in 1998.
The program was designed to make certain that
patients at these FQHCs, which provide primary care services in
underserved urban and rural communities, received the current standard
of care. This includes regular testing for glycosylated hemoglobin (a
measure of blood sugar control), assessment of fats and cholesterol in
the blood, eye exams and blood pressure checks, with appropriate
follow-up.
It also involves preventive treatments such as the use of ACE
inhibitors, which can treat high blood pressure and heart failure, and
aspirin, which can prevent heart attacks and strokes.
After reviewing four years of charts for 80
patients from each of the 17 centers, the researchers reported that
"multiple components of care improved from 1998 to 2002." Annual
glycosylated hemoglobin testing increased from 71 percent to 92 percent
of patients. Blood lipid testing rose from 15 percent to 44 percent. Eye
exams went from 25 percent to 44 percent. Prescriptions for ACE
inhibitors rose from 33 percent of patients to 55 percent, and aspirin
prescriptions rose from 22 percent to 45 percent.
These improvements added very little expense. The
diabetes quality-improvement program cost about $700 per patient the
first year, $600 the second year, $500 the third year and leveled off at
$378 per year beginning in year four.
The researchers then estimated how much the
patients' risk for the major complications from diabetes would be
decreased if these improvements were maintained. Better care, they
concluded, should reduce the lifetime incidence of blindness from 17
percent of patients down to 15 percent, of kidney failure from 18 down
to 15 percent and of coronary artery disease from 28 to 24 percent.
Next they tried to place a dollar value on the
benefits of the programa longer life with fewer complications. In
medical cost-effectiveness analysis, a commonly accepted standard is to
say that a new device, medication or program that generates one year of
extra life for a healthy person at less than $100,000 is a good value.
Another commonly used standard is $50,000 per one year of extra life in
perfect health.
The diabetes quality-improvement initiative passed
all these standards. Even at twice the price and with the benefits
deeply discounted, the value added by the program exceeded commonly
accepted standards.
"Since diabetes is so common and is increasing
rapidly, whatever enhances diabetes care is worth looking at," Huang
said.
A study released last month at the American
Association of Clinical Endocrinologists' annual meeting in Seattle
found that poorly managed type 2 diabetes costs the U.S. health system
an extra $22.9 billion a year in direct medical costs. Diabetic
complications cost almost $10,000 per patient each year, concluded the
author of that study, Willard Manning, PhD, a University of Chicago
health economist.
Multiple quality-improvement programs have been
found to produce improvements similar to those generated by the Health
Disparities Collaboratives' diabetes program, Huang said, but "the
economic value of these programs is generally unknown." The lessons
learned from this evaluation, he added, "can provide important insights
for policy makers."
Editors Notes:
The Agency for Healthcare Research and Quality, the
National Institutes of Health and the Chicago Center of Excellence in
Health Promotion Economics funded the study. Additional authors include
Marshal Chin, David Meltzer and Melina Drum of the University of
Chicago; Qi Zhang of Old Dominion University; and Sydney Brown of the
University of Pennsylvania School of Medicine.
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