TYPES OF INTERVENTION 

Primary Intervention 

Screening for Impaired Glucose Tolerance (IGT) 

TITLE: Effectiveness of Screening for Diabetes. Gerken, K.L.; Van Lente, F. Archives of 

Pathology and Laboratory Medicine. 114(2): 201-203. February 1990. 

OBJECTIVE: To evaluate the diagnostic yield from screening patients for diabetes by 

measuring their fasting serum glucose and hemoglobin A1c levels during routine health 

surveillance. To compare the oral glucose tolerance test and repeat fasting glucose 

determination as a follow-up to screening. 

CATEGORY: Primary intervention. 

Type of Study: Retrospective. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Oral glucose tolerance testing was as cost effective and more efficient for 

diagnosing diabetes after an abnormal fasting serum glucose test than were repeat fasting 

serum glucose determinations. Hemoglobin A1c did not reliably predict impaired or diabetic 

glucose tolerance. 

RECOMMENDATION: If mass screening for diabetes is instituted, obligatory oral glucose 

tolerance testing must be made part of the follow-up protocols for positive findings on a 

fasting serum glucose test. 

ABSTRACT: The authors analyzed the effectiveness of screening for diabetes mellitus in an 

executive health surveillance program by examining laboratory records for 6,445 patient visits 

from 1985 to 1988. They retrospectively identified 336 persons with borderline high (6.6 to 

7.6 mmol/L) or high (7.7 mmol/L or higher) fasting serum glucose levels; 29 of these persons 

had no further records, and 110 were known to have diabetes. Of the remainder, 61 had a 

follow-up fasting serum glucose test and 33 had an oral glucose tolerance test. Ninety-three 

persons had hemoglobin A1c (HbA1C) tested. Among borderline high individuals, on repeat 

fasting serum glucose, 38 percent had levels of 6.1 mmol/L or less; 55 percent had 6.2 to 7.6 

mmol/L; and 7 percent had 7.7 mmol/L or greater. Comparable results for persons with high 

initial fasting serum glucose were 14, 25, and 61 percent, respectively. Follow-up oral glucose 

1 
tolerance tests resulted in normal, impaired, and diabetic glucose levels in 32, 40, and 28 

percent of the borderline high persons and 25, 0, and 75 percent of the persons with high 

values, respectively. Significantly different levels of HbA1C (p < .01) were found between the 

two groups of persons (borderline high and high), but only 3 percent of those with borderline 

high fasting serum glucose and only 64 percent of those with high fasting serum glucose had 

increased HbA1C. From screening, 30 new cases of diabetes and 10 new cases of impaired 

glucose tolerance were identified, a total of 40 (0.6 percent) of 6,445 patients screened. The 

overall rate of identification of abnormal serum glucose was 0.6 percent. The cost per case 

found (based on Medicare reimbursement rates) was $488.04 with repeat fasting serum 

glucose and an oral glucose tolerance test and $484.54 with a follow-up oral glucose 

tolerance test alone. The oral glucose tolerance test is as cost effective as repeat fasting serum 

glucose with oral glucose tolerance testing as needed and more diagnostically efficient than 

repeating that test Addition of HbA1C increased cost to $522 and cannot be recommended. 

The oral glucose tolerance test should be made obligatory to follow-up abnormal initial serum 

glucose tests. 3 tables, 12 references. 

TITLE: Technical and Clinical Evaluation of Fructosamine Determination in Serum. 

Desjarlais, F.; Comtois, R.; Beauregard, H.; Nguyen, M.; Letellier, G. Clinical Biochemistry. 

22(4): 329-335. August 1989. 

OBJECTIVE: To evaluate the effectiveness of a serum fructosamine (glycated serum 

proteins) assay for diagnosis and follow-up of patients with diabetes; to compare its 

effectiveness with a serum glycosylated hemoglobin measurement. 

CATEGORY: Primary intervention. 

Type of Study: Nonrandomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The serum fructosamine assay is simple, rapid, and cost efficient. 

RECOMMENDATION: The serum fructosamine assay should be a valuable addition to 

monitoring glucose control in patients with diabetes. 

ABSTRACT: Researchers evaluated a serum fructosamine assay and compared the results 

with those of glycosylated hemoglobin for diagnosing and managing diabetes. Blood samples 

were drawn from 375 participants with or without diabetes (total: 514 samples). The serum 

fructosamine assay was not significantly affected by hemolysates, but high lipemia and 

addition of bilirubin decreased and increased the values, respectively. In 48 normal 

participants, the correlation between serum fructosamine and serum protein or serum albumin 

was statistically significant, with a linear correlation of 0.809 and 0.746, respectively. Overall, 

the linear correlation between serum fructosamine and glycosylated hemoglobin was 0.794; 

2 
when fructosamine was corrected for protein, the value was 0.838. Among 16 patients with 

diabetes hospitalized to improve blood glucose control, the linear correlation of the percent 

decrease for glycosylated hemoglobin and blood glucose was 0.28 (p > 0.05); for 

fructosamine and blood glucose, it was 0.64 (p < 0.01). Using a fructosamine concentration 

cutoff of 2.70 mmol/L (the normal mean plus two standard deviations), this test had a 96 

percent specificity and a 90 percent sensitivity for patients with overt diabetes but only an 11 

percent sensitivity for patients with diabetes by glucose tolerance test but normal fasting 

glucose levels. When applied to gestational diabetes, fructosamine had a specificity of 95 

percent but a sensitivity of just 21 percent. Because the assay for fructosamine can be 

automated, it is easy and fast to use and the average per-patient cost is $0.93, including 

protein measurements. The glycosylated hemoglobin test is performed manually, is difficult to 

interpret, and the per-patient cost is $6.15. The serum fructosamine assay is simple, reliable, 

and economic for measuring ambient glucose concentration in stable and unstable diabetes 

mellitus. It may be useful in diagnosing diabetes when the fasting blood glucose exceeds 7.8 

mmol/L (overt diabetes). In such cases, a concomitant fructosamine evaluation might preclude 

the need for a second fasting glucose. 5 figures, 2 tables, 30 references. 

Secondary Intervention Screening and Diagnosis for Type 2 Diabetes 

Secondary Intervention 

Screening and Diagnosis for Type 2 Diabetes 

TITLE: Comparison of glycosylated Hemoglobin and Fasting Plasma Glucose with TwoHour Post-Load Plasma Glucose in the Detection of Diabetes Mellitus. Simon, D.; Coignet, 

M.C.; Thibult, N.; Senan, C.; Eschwege, E. American Journal of Epidemiology. 122(4): 589-

593. October 1985. 

OBJECTIVE: To compare the use of a glycosylated hemoglobin (HbA1C) test alone with a 

combination of that test and a plasma glucose measurement in a diabetes screening program. 

CATEGORY: Secondary intervention. 

Type of Study: Patient screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Using the combination of an HbA1C measurement and a fasting plasma 

glucose measurement increases the specificity and predictive value of a positive diagnosis of 

diabetes over that obtained by glycosylated hemoglobin alone. 

RECOMMENDATION: Longitudinal surveys should be performed to assess the validity of 

3 
HbA1C as a measurement tool for diabetes screening. 

ABSTRACT: From September 15, 1981, to April 1, 1984, 333 outpatients were recruited 

from the screening diabetes center of the Hôtel-Dieu Hospital in Paris. Patients filled out a 

questionnaire; underwent a physical exam; had blood drawn for fasting plasma glucose, 

HbA1C, cholesterol, and triglyceride measurements; and took an oral glucose tolerance test 

with a 75-g glucose load. With 2-hour plasma glucose values as a reference, sensitivities of 

the fasting plasma glucose measurement, HbA1C, and a combination of fasting plasma glucose 

and glycosylated hemoglobin were, respectively, 52 percent, 60 percent, and 40 percent; the 

specificities were 98.7 percent, 90.9 percent, and 99.4 percent; and the predictive values for a 

positive diagnosis were 76.5 percent, 34.9 percent, and 83.3 percent. Taking into account the 

economic and psychosociologic implications of a diagnosis of diabetes, it is better for a 

screening test for asymptomatic diabetes to have a high degree of specificity and a high 

predictive value for a positive diagnosis than to have good sensitivity but poor specificity. As 

an oral glucose tolerance test is time-consuming for patients and nurses, measurements of 

HbA1C by chromatography and of fasting plasma glucose appear to be less expensive (about 5 

versus 10 U.S. dollars). Longitudinal surveys are needed to assess the validity of HbA1C as a 

tool for diabetes screening. 1 table, 32 references. 

TITLE: Comparison of Screening Tests for Non-Insulin-Dependent Diabetes Mellitus. 

Hanson, R.L.; Nelson, R.G.; McCance, D.R.; Beart, J.A.; Charles, M.A.; Pettitt, D.J.; 

Knowler, W.C. Archives of Internal Medicine. 153(18): 2133-2140. September 27, 1993. 

OBJECTIVE: To compare four screening tests for type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Population screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Fasting plasma glucose was the best test for screening, but glycated 

hemoglobin and quantitative urine glucose also provided high specificity with sensitivities 

approximately 80 percent or higher. 

RECOMMENDATION: The choice of a particular screening test should depend on assay 

cost, convenience, and availability. 

ABSTRACT: The authors compared the sensitivity of measuring quantitative urine glucose, 

dipstick urine glucose, fasting plasma glucose, and glycated hemoglobin to screen for diabetes 

in Pima Indians, a tribe at high risk for type 2 diabetes. Fasting plasma glucose concentrations 

and glycated hemoglobin (HbA1 or HbA1C) were compared in 2,092 fasting participants; 

4 
glycated hemoglobin, quantitative glycosuria, and dipstick glycosuria were compared in 237 

nonfasting participants. Among nonfasting participants, at specificities of 98 or 99 percent, 

sensitivities for detecting diabetes were 80.6 percent for quantitative glycosuria, 64.3 percent 

for dipstick glycosuria, and 92.9 percent for HbA1. For detecting diabetes with severe 

hyperglycemia, sensitivities for the 3 tests ranged from 85.0 percent (HbA1) to 96.0 percent 

(quantitative glycosuria), with similar specificities. Among fasting participants, at a specificity 

of 98.3 percent the sensitivity of fasting plasma glucose was 88.0 percent; at similar 

specificities, HbA1 had a sensitivity of 78.8 percent and HbA1C, 80.3 percent. For detecting 

diabetes with severe hyperglycemia, all 3 tests had a sensitivity of 94.6 percent or greater with 

specificity of 98 percent. The slightly higher sensitivity of fasting plasma glucose (versus 

glycated hemoglobin) is probably of minimal significance because fasting plasma glucose is a 

less convenient test. glycosuria assays have limited ability to detect diabetes with moderate 

hyperglycemia, but they reliably detect severe hyperglycemia. 4 figures, 4 tables, 41 

references. 

TITLE: Effectiveness of glycosylated Hemoglobin, Fasting Plasma Glucose, and a Single 

Post Load Plasma Glucose Level in Population Screening for Glucose Intolerance. Modan, 

M.; Halkin, H.; Karasik, A.; Lusky, A. American Journal of Epidemiology. 119(3): 431-444. 

March 1984. 

OBJECTIVE: To determine which of the following methods is the most effective screening 

test for glucose intolerance (impaired glucose tolerance and type 2 diabetes): glycosylated 

hemoglobin, fasting plasma glucose, combination of fasting plasma glucose and glycosylated 

hemoglobin, plasma glucose 1-hour post oral glucose load, and plasma glucose 2-hour post 

oral glucose load. 

CATEGORY: Secondary intervention. 

Type of Study: Population screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: The most effective screening methods were the 1- and 2-hour post oral 

glucose loads. The 1-hour post oral glucose load worked better for detecting glucose 

intolerance, and the 2-hour post oral glucose load was better for detecting diabetes. 

RECOMMENDATION: For clinical diagnosis, a two-stage screening using a fasting or 

random blood glucose test and an oral glucose load may be adequate, but for epidemiologic 

studies a full oral glucose tolerance test that includes a fasting test and two post-load levels is 

preferred. 

ABSTRACT: The study population included a sample group of 2,040 people, aged 40-70 

years, who were participating in the Israel Study of Glucose Intolerance, Obesity and 

5 
Hypertension. Members of the sample group who were not known to have diabetes 

underwent a glucose tolerance test based on a fasting test and 1-hour and 2-hour post oral 

glucose loads. In 1,058 participants, glycosylated hemoglobin was also measured. Results 

showed that glycosylated hemoglobin alone is inefficient and inferior to a fasting plasma 

glucose test to determine glucose intolerance. Although glycosylated hemoglobin increased 

with glucose intolerance, there was considerable overlap in the distributions between newly 

identified patients with diabetes and patients with normal tolerance. The combination of the 

glycosylated hemoglobin test with the fasting plasma glucose test did not perform any better 

than the fasting test alone. However, testing fasting plasma glucose is not a satisfactory 

screening method because of its low specificities at adequate sensitivity levels compared with 

the 1- and 2-hour post glucose load tests. Of these tests, the 2-hour post glucose load level is 

more reliable when screening for diabetes alone, and the 1-hour post glucose load is more 

effective in screening for impaired glucose tolerance. Adding a fasting test to the 1- and 2-

hour post glucose load tests raised the cost less than 5 percent, and the risk analysis showed 

that the venipunctures needed for the tests were not associated with any problems in patients. 

If a distinction is desired between impaired glucose tolerance and diabetes, a two-stage 

screening is indicated. In this method, everyone gets a 1-hour post load and the positive 

subgroup is retested by a full oral glucose tolerance test. For purposes of epidemiologic 

screening, a full oral glucose tolerance test is preferred over any "shortcut" method. 1 figure, 

6 tables, 28 references. 

TITLE: The glycosylated Hemoglobin as a Diagnostic and Monitoring Tool for Diabetes: 

Evidence from Claims Data (abstract). Altan, A.E.; Carlson, A.M.; Nettles, A. AHSR FHSR 

Annual Meeting Abstract Book. 1996; 13:11. 

OBJECTIVE: To investigate how often the glycosylated hemoglobin (HbAlc) test is used to 

diagnose type 2 diabetes and the extent to which it is used to monitor diabetes control. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Claims review. 

Perspective: Health care system. 

CONCLUSION: The HbAlc test may be misused as a diagnostic tool for type 2 diabetes and 

underused as a tool to monitor diabetes control. 

RECOMMENDATION: None. 

ABSTRACT: The investigators examined claims records of 81,039 persons enrolled in three 

1993 managed care plans located in large metropolitan areas in the western, midwestern, or 

eastern United States. The researchers identified individuals with diagnosed diabetes (both 

insulin-treated and noninsulin-treated); those who had received the oral glucose tolerance test, 

the recognized diagnostic test for diabetes; and those who had received the HbAlc test. 

6 
Among enrollees identified as not having diabetes (n = 70,068), 1,141 received an HbAlc test; 

of these persons, 4 percent (44 enrollees) also were given an oral glucose tolerance test. Of 

the 10,970 persons identified as having diabetes, 40 percent had had at least one HbAlc test 

during the year. 

7 

TITLE: Immunization to Prevent Insulin-Dependent Diabetes Mellitus? The Economics of 

Genetic Screening and Vaccination for Diabetes. England, W.L.; Roberts, S.D. Annals of 

Internal Medicine. 94(3): 395-400. March 1981. 

OBJECTIVE: To determine the relative value of several strategies for preventing diabetes 

through the use of vaccine. 

CATEGORY: Secondary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Vaccinating all children at age 3 was preferable, both economically and for 

disease prevention, to strategies that involved histocompatibility leukocyte antigen (HLA) 

screening prior to vaccination or to no vaccination at all. 

RECOMMENDATION: Health programs and technologies need to be analyzed (e.g., for 

cost and risk) before they become available. 

ABSTRACT: Numerous studies have shown an association between type 1 diabetes and viral 

infections, which suggests that vaccination for diabetes may be possible. The principal 

assumption behind the present paper is that viruses are involved in precipitating diabetes and 

that a vaccine for them can be developed. The author calculated an incidence rate for new 

cases of diabetes and program costs for 12 approaches to vaccination, 10 involving screening 

— the other 2 were vaccinating everyone and vaccinating no one. A decision tree analysis 

framework was used: the cost analysis considered the direct cost of diabetes, vaccine 

production and immunization, screening for predisposition to diabetes (measures evaluated 

included eight types of HLA tests, the Lewis negative erythrocyte phenotype, and the 

presence of diabetes in a parent or sibling), and side effects. The investigators used data based 

on published sources if possible; when data were inadequate or not available, a sensitivity 

analysis was performed. Only direct costs were tabulated. The analysis presupposed that any 

vaccinations would take place at age 3 (the most cost-effective age for all policies); incidence 

rates are the projected results after 27 years of vaccinating. Vaccinating everyone would 

reduce incidence by 29 percent and decrease the nondiscounted annual cost of diabetes by 18 

percent; this policy was preferred to the other 11 on the basis of both incidence and cost. 

These results were, however, heavily influenced by the cost and efficacy of the vaccine, cost 

and probability of a vaccine reaction, cost and probability of diabetes, and the discount rate. A 

decision to vaccinate everyone was preferred to other alternatives for a wide range of vaccine 
characteristics. 7 tables, 51 references. 

8 

TITLE: Multiple Biochemical Blood Testing as a Case-Finding Tool in Ambulatory Medical 

Patients. Ruttimann, S.; Dreifuss, M.; Clemencon, D.; di Gallo, A.; Dubach, U.C. The 

American Journal of Medicine. 94(2): 141-148. February 1993. 

OBJECTIVE: To prospectively assess the yield, disadvantages, and charges associated with 

routine biomedical testing in a medical outpatient clinic. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost-analysis. 

Perspective: Health care system. 

CONCLUSION: Routine biochemical testing in the university teaching setting was useful in 

identifying new diagnoses, but the number of newly discovered disorders that required new 

medical management was small. 

RECOMMENDATION: Reducing the number of routine biomedical tests to three — 

cholesterol, glucose, and alanine aminotransferase measurements — to detect disorders that 

need treatment may be preferable to ordering large biochemical profiles. 

ABSTRACT: The authors assessed the utility of routine biochemical tests in finding new 

disorders that changed medical management. Patients (n = 493) attending the medical 

outpatient clinic of the University Hospital in Basel, Switzerland, for the first time during 

1989 underwent a 23-test biochemical screen. To differentiate clinically indicated from routine 

tests, resident physicians were instructed to order only tests required to monitor known or 

suspected medical conditions, even though the complete profile was performed. Patient 

charges were $40 for the biochemical profile and $17.60 for each additional visit caused 

exclusively by abnormal routine tests; charges were counted until diagnosis or patient 

discharge. Ninety percent of the tests were considered routine; 11.4 percent of these routine 

tests were abnormal. Four hundred thirty of the 493 patients had new abnormalities diagnosed 

on the routine tests; further tests were ordered for 10.9 percent of these patients, additional 

visits were required for 1.4 percent, and new diagnoses were reached for 11.1 percent. A 

change in management occurred in 5.8 percent (n = 25) of these patients; in all but 4 of these 

cases the newly detected disorder was hypercholesterolemia, alcoholic liver disease, or 

diabetes mellitus. These 21 cases could have been detected with cholesterol, glucose, and 

alanine aminotransferase tests alone. Total charges for all tests were $20,938; total charges for 

tests considered clinically indicated were $8,256. Additional charges per patient for the 

detection of the new diagnoses averaged $25.72. Using only the tests relevant to the new 

diagnoses, per-patient charges would have been reduced 30 percent. Biochemical screening in 

this setting is feasible and results in acceptable amounts of further testing and additional 

patient laboratory costs. Prospective studies should be developed to test the utility of reducing 
screening to cholesterol, glucose, and alanine aminotransferase tests only. 4 tables, 41 

references. 

9 

TITLE: Screening for Diabetes Mellitus in General Practice Using a Reflectance Meter 

System: The Islington Diabetes Survey. Forrest, R.D.; Jackson, C.A.; Yudkin, J.S. Diabetes 

Research. 6(3): 119-122. November 1987. 

OBJECTIVE: To assess the accuracy of a reflectance meter system in screening for diabetes 

mellitus in a community-based screening program; to compare the results obtained with the 

laboratory assessment of blood glucose; and to estimate the costs of screening for diabetes 

mellitus with this system. 

CATEGORY: Secondary intervention. 

Type of Study: Population screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The reflectance meter system accurately estimated the prevalence of 

diabetes mellitus in the study population. Blood glucose concentrations obtained with the 

reflectance meter were higher than those of the laboratory assay, and confirmatory glucose 

tolerance tests were needed in a large number of misclassified patients. However, total costs 

of screening, even with the additional confirmatory glucose tolerance tests, were still 

significantly lower for the reflectance meter assay. 

RECOMMENDATION: The glucose reflectance meter system, along with confirmatory 

glucose tolerance tests, can provide an acceptable, lower-cost alternative to the autoanalyzer 

glucose-oxidase method of blood glucose assay for community-based screening for diabetes 

mellitus. 

ABSTRACT: The authors assessed the accuracy and costs of a reflectance meter system for 

screening for diabetes mellitus and compared the results obtained with laboratory assessment 

of blood glucose. As a component of the Islington Diabetes Survey, 1,084 randomly selected 

persons over age 40 were screened with an oral glucose tolerance test after an overnight fast. 

Two-hour blood glucose was measured using an automated glucose-oxidase method. For 530 

persons, blood glucose was also measured using the reflectance meter system. The reflectance 

meter system gave an acceptable estimate of the prevalence of diabetes mellitus, identifying 14 

of the 15 cases found by the glucose-oxidase system, but it did not provide an accurate 

estimate of the prevalence of impaired glucose tolerance. (Reflectance meter values were 

higher than glucose-oxidase values in 82 percent of cases.) Costs associated with screening 

the 530 individuals were calculated at £1,166.00 for the glucose-oxidase method and £358.75 

for the reflectance meter. Confirmatory glucose tolerance tests were required in 29 persons on 

the basis of glucose-oxidase values and in 47 on the basis of reflectance meter values. Total 

costs for these confirmatory tests were estimated at £1,460.90 for patients initially screened 
via glucose-oxidase and £857.95 for those screened by the reflectance meter. Estimated total 

costs per case of diabetes mellitus identified were £97.39 for the glucose-oxidase method and 

£ 61.28 for the reflectance meter. The authors conclude that the reflectance meter is an 

acceptable screening tool for diabetes; it is less costly, it is simpler and easier to use, and it 

provides results faster than the glucose-oxidase method. 2 figures, 1 table, 16 references. 

10 

TITLE: Screening for Retinopathy: A Relative Cost-Effectiveness Analysis of Alternative 

Modalities and Strategies. Sculpher, M.J.; Buxton, M.J.; Ferguson, B.A.; Spiegelhalter, D.J.; 

Kirby, A.J. Health Economics. 1(1): 39-51. April 1992. 

OBJECTIVE: To assess the relative cost-effectiveness of various screening strategies for 

retinopathy associated with diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Systematic screening carried out in the general practitioner's office at the 

same time as routine diabetes care checks can save considerable costs over screening that 

requires additional visits to a hospital or an optician. 

RECOMMENDATION: None. 

ABSTRACT: The authors used data from a 1985-1988 English study of the costeffectiveness of screening for retinopathy to compare various screening options, including 

single modalities (either ophthalmoscopy or fundus photography), combined approaches, and 

selective screening. The base study was conducted at three community-based health centers in 

England; 3,423 patients with diabetes were screened. The authors defined cost-effectiveness 

as cost per true-positive case detected. Total cost per patient for ophthalmoscopy at the 

general practitioner's office was £ 20.66; at an optician's office, £ 19.31; for fundus 

photography, this cost was £ 25.46 at the hospital and £ 14.87 at the general practitioner's 

office (costs at the general practitioner's office were less if screening was part of a general 

checkup). The sensitivity of these approaches (in the order just listed) was 0.53, 0.48, 0.40, 

and 0.58; specificity was 0.91, 0.94, 0.96, and 0.97. Combined approaches (e.g., both 

ophthalmoscopy and fundus photography at the general practitioner's office) had higher 

sensitivity but lower specificity. Expected cost per true-positive case detected was £ 784 for 

ophthalmoscopy (same for general practitioner and optician), £ 1,178 for hospital-based 

fundus photography, £ 497 for photography at the general practitioner's office, £ 734 for both 

ophthalmoscopy and photography at the general practitioner's office, and £ 968 for 

ophthalmoscopy by an optician combined with photography at a general practice. If screening 

at the general practitioner's office was combined with regular follow-up, these costs dropped 

to £ 273 for ophthalmoscopy, £ 434 for fundus photography, £ 419 for ophthalmoscopy plus 
photography, and £ 914 for photography at the office combined with ophthalmoscopy on the 

optician's premises. Among the selective screening options, directly referring high-risk patients 

and not screening those who were low-risk had the lowest cost per true-positive case ( £ 168) 

but only 0.25 sensitivity. Directly referring high-risk patents and providing both 

ophthalmoscopy and photography at the general practitioner's office had a sensitivity of 0.85 

and a cost per true positive of £ 679 ( £ 407 if part of a general check-up). 1 figure, 5 tables, 

42 references. 

11 

TITLE: Targeted Screening for Diabetes in Community Chiropody Clinics. Gill, G.V.; 

Lishman, L.; Kaczmarczyk, E.; Tesfaye, S. Quarterly Journal of Medicine. 89:229-232. 1996. 

OBJECTIVE: To assess the cost-effectiveness of screening for diabetes in adults attending 

community podiatry clinics. 

CATEGORY: Secondary intervention. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Screening was simple and very cost effective, but the diagnostic yield was 

moderate. 

RECOMMENDATION: Screening of a podiatry clinic's population for diabetes cannot be 

recommended without knowing what percentage of that population is already known to have 

diabetes. 

ABSTRACT: Patients who have known foot problems may have an increased likelihood of 

having diabetes. In this study, which was based in Liverpool, England, all patients aged 40 to 

75 years attending community chiropody (podiatry) clinics who were not previously known to 

have diabetes were offered postprandial screening for glycosuria. Patients who reported 

positive results on the self-test were brought to the hospital for a glucose tolerance test. Of 

1,058 patients who accepted screening, 11 (1.0 percent) reported positive results; of this 

group, 4 had diabetes, 2 had impaired glucose tolerance, and 5 had normal glucose tolerance. 

The cost for each person screened was 11 pence; for each person with a positive urine test, £ 

2.06; and for each newly diagnosed patient with diabetes, £ 34.46. No cost was included for 

staff time in the coordinating hospital chiropody department to respond to the participants. 

The authors indicate that their slightly disappointing result (0.4 percent new diabetes patients) 

is probably due to the very high proportion (17.3 percent) of Liverpool chiropody clinic 

patients already known to have type 2 diabetes. According to the authors, screening of a 

podiatry clinic's population cannot be recommended without knowing its proportion of 

already identified diabetes patients. They also observe that a major difficulty with screening 

for type 2 diabetes is the lack of a sufficiently sensitive and specific test. The authors also 

point out that handing out rather than mailing the test strips was cost-saving, as was having 
the patients telephone in their results. 1 figure, 2 tables, 15 references. 

12 

TITLE: Value of Serum Glucose Assay as Part of the Biochemical Profile in Screening for 

Diabetes. Northam, B.E.; Smith, J.H.; Fitzgerald, M.G.; Nattrass, M.; Wright, A.D. Annals of 

Clinical Biochemistry. 19(6): 412-415. November 1982. 

OBJECTIVE: To evaluate a system of identifying patients with previously undetected 

diabetes that begins with a screening assay for serum glucose. 

CATEGORY: Secondary intervention. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Addition of serum glucose testing for inpatients undergoing other 

laboratory evaluations is a useful and cost-effective method of screening for diabetes. 

RECOMMENDATION: None. 

ABSTRACT: The authors report the effectiveness and cost of diabetes screening for adult 

inpatients at General Hospital in Birmingham, England, during 3 months in 1980. A serum 

glucose test was added to the routine biochemical profiles of 2,050 patients; 453 had values of 

10 mmol/L or higher. After elimination of those known to have diabetes or receiving 

intravenous glucose, 152 patients underwent capillary blood glucose tests; 71 had elevated 

values. Ten of these patients were referred to the diabetes clinic, 42 underwent oral glucose 

tolerance testing, and 19 were lost because of illness, death, or discharge. Fifteen patients 

were found to have normal glucose tolerance, 11 had impaired glucose tolerance, and for 16, 

the glucose tolerance test was in the diabetes range (3 of these 16 patients were referred to 

the diabetes clinic). Retesting as outpatients 3 months later resulted in referral of two of the 

patients with impaired glucose tolerance and one with apparent diabetes to the diabetes clinic. 

In all, 16 patients with previously undetected diabetes were identified. Additional costs on an 

annual basis for direct screening were £ 500 for serum glucose testing (reagent only), £ 320 

for 2 blood glucose tests (including labor for sample collection and analysis), and £ 440 for 

oral glucose tolerance testing, for a total of £ 1,260, or £ 20 per case of diabetes identified (64 

cases in a year). If time for staff (other than the clinical staff) to eliminate patients with 

diabetes and on intravenous glucose was added, the total per case would be doubled. The 

prevalence of diabetes (0.8 percent of inpatients) may have been underestimated because of 

losses to follow-up (30 patients), size of dose of glucose for the glucose tolerance testing (50 

g rather than 75 g), arbitrary selection of serum glucose concentration required for follow-up, 

and elimination of patients receiving intravenous glucose. The true prevalence of diabetes was 

probably 0.8 percent to 3.5 percent. This screening method is cost effective, based on the 

additional screening cost of only £ 20 per case of diabetes identified. 1 figure, 2 tables, 8 

references.Disease Management 
Disease Management 

13 

TITLE: Adherence to Treatment and Social Support in Patients with Non-Insulin Dependant 

Diabetes. Garay-Sevilla, M.E.; Nava, L.E.; Malacara, J.M.; Huerta, R.; Díaz de León, J.; 

Mena, A.; Fajardo, M.E. Journal of Diabetes and Its Complications. 9(2): 81-86. April-June 

1995. 

OBJECTIVE: To evaluate factors associated with adherence to diet and medication in 

patients with type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Adherence to diet was associated with years since diagnosis and greater 

social support; adherence to medication was associated with greater social support and older 

age of spouse. 

RECOMMENDATION: Further research should be conducted to identify psychological and 

social factors that influence adherence to diet and medication in patients with type 2 diabetes. 

ABSTRACT: The authors studied 200 adults with type 2 diabetes recruited from diabetes 

support groups at two hospitals in Leon, Mexico. Only about 20 percent of patients invited 

actually participated in the study. These patients completed validated questionnaires detailing 

adherence to treatment, social support, lifestyle, family structure, family function, and 

knowledge of diabetes. Adherence to diet was associated with years since diagnosis (p = 

0.003) and greater social support (p = 0.007); adherence to medication was associated with 

greater social support (p = 0.002) and older age of spouse (p = 0.016). Patients with rigid 

control in their families had lower adherence to medication than patients where families had 

laissez-faire or flexible control. Evaluation of the psychological and social factors that 

influence adherence to diet and medication is essential because of their important role in the 

management of patients with type 2 diabetes. 1 figure, 3 tables, 18 references. 

14 

TITLE: Analysis of Direct Cost of Standard Compared with Intensive Insulin Treatment of 

Insulin-Dependent Diabetes Mellitus and Cost of Complications. Stern, Z.; Levy, R. Acta 

Diabetologica. 33(1): 48-52. March 1996. 
OBJECTIVE: To compare the direct costs of standard and intensive insulin treatment for 

type 1 diabetes; to compare these approaches when their impact on complications is 

considered. 

CATEGORY: Secondary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: According to the authors' model, standard insulin therapy was less 

expensive over a 35-year period than was intensive insulin therapy, whether or not the cost of 

complications was considered. 

RECOMMENDATION: Because of the high direct costs of intensive treatment, guidelines 

should be developed to better identify, select, and treat those patients for whom such therapy 

is warranted. Intensive treatment should be aimed particularly at patients with nephropathy. 

ABSTRACT: The authors modeled annual treatment costs over a 35-year period for a 

hypothetical patient who had contracted type 1 diabetes at a young age. Results in the 

literature, including findings of the Diabetes Control and Complications Trial, were used in the 

model, as was standard practice in Israel, which follows the recommendations of the American 

Diabetes Association. Annual direct costs (in 1995 dollars) for standard and intensive insulin 

treatment were calculated to be $1,184 and $3,329 per patient, respectively. Over a 35-year 

period, total direct costs per patient were $41,000 and $116,000 for the standard and 

intensive treatments, respectively, a difference of $75,000. The authors found that intensified 

treatment lowered complication costs by $53,520 (versus standard treatment). Thus, total 

direct costs of standard therapy were $329,400, versus $350,980 for the intensified treatment. 

Assuming a discount rate of 6 percent, it was estimated that the intensive treatment entailed 

lower complication costs (by $20,900) than the standard treatment, but the total cost of the 

standard treatment was $132,900, compared with $151,900 for the intensive treatment. 3 

tables, 16 references. 

15 

TITLE: Assessment of the Effect of a Comprehensive Diabetes Management Program on 

Hospital Admission Rates of Children with Diabetes Mellitus. Drozda, D.J.; Dawson, V.A.; 

Long, D.J.; Freson, L.S.; Sperling, M.A. Diabetes Educator. 16(5): 389-393. SeptemberOctober 1990. 

OBJECTIVE: To determine the impact of a comprehensive diabetes management program 

on hospitalization parameters in children with diabetes seen at a major pediatric referral 

center. 
CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Care provided through the diabetes management program is expected to 

save $342,000 annually in direct health service costs. 

RECOMMENDATION: Comparison of data from pediatric hospitals not offering 

comprehensive diabetes programs would help to assess the impact of such programs. 

ABSTRACT: The authors evaluated the impact of a comprehensive diabetes management 

program initiated in July 1978 on admission of children with diabetes mellitus to Children's 

Hospital Medical Center in Cincinnati, Ohio. Those in the study had a primary diagnosis of 

type 1 diabetes; the main reason for admission was diabetic ketoacidosis, hyperglycemia, or 

hypoglycemia. Admission records from January 1973 through December 1987 were reviewed; 

comparisons were made of admission parameters for January 1973 to June 1978 (period A) 

and July 1978 to December 1987 (period B). The program included medical and support 

services and individualized educational interventions; two telephone hot lines were provided 

as well. Admissions for type 1 diabetes not associated with diabetic ketoacidosis or other 

diagnoses rose from 27 percent of all admissions in period A to 37 percent in period B (p = 

0.01). The proportion of admissions for diabetes that were for diabetic ketoacidosis not 

associated with other diagnoses decreased from 63 percent in period A to 29 percent in period 

B (p = 0.0001). This positive outcome may have reflected the effect of the education program 

on patient self-management. Mean length of stay for admissions for diabetic ketoacidosis only 

decreased from 5.8 days (period A) to 4.6 days (period B) (p = 0.01), but the introduction of 

managed care may have encouraged early discharge. 2 figures, 2 tables, 13 references. 

16 

TITLE: Audit in General Practice by a Receptionist: A Feasibility Study. Essex, B.; Bate, J. 

British Medical Journal. 302(6776): 573-576. March 9, 1991. 

OBJECTIVE: To assess whether a medical practice audit, including care of patients with 

diabetes, can be performed cost effectively by a practice's receptionist. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The practice audit was performed by the receptionist in a cost-effective 
manner. 

RECOMMENDATION: Audit by a practice's receptionist should be considered a costeffective alternative to audit by the physicians themselves. 

ABSTRACT: The authors assessed the feasibility and cost-effectiveness of having a medical 

practice audit performed by a practice receptionist. The practice was composed of 6 

physicians in London, England, treating 11,500 patients. A system developed to allow the 

receptionist to audit medical records was evaluated over a 2-year period. Patients with 

diabetes were identified from disease registers; most data were derived from patient records. 

A total of 136 patients with diabetes were identified by the receptionist and their records 

reviewed. The receptionist provided the practice with a breakdown of the level of care 

(general practitioner only, hospital only, shared, or unknown). The receptionist notified 

practice physicians of any patients with diabetes under the care of a general practitioner who 

had not had an annual review. The receptionist spent about 4 hours weekly performing the 

audit as part of her general duties at a cost of £ 5.20 per hour ( £ 960 per year). Regular 

supervision of the receptionist the first year lasted about 30 minutes weekly; in the second 

year, about 30 minutes every 2 weeks. After deduction of reimbursements and tax, the cost 

came to £ 30 per practice physician per year. This system was extremely cost-effective 

compared with the costs that would be incurred were physicians to perform the audit 

themselves. 4 figures, 10 references. 

17 

TITLE: Bedside Blood Sugar Determinations in the Critically Ill. Newman, R.H. Heart and 

Lung. 17(6 Part 1): 667669. November 1988. 

OBJECTIVE: To compare various glucose monitoring systems with standard laboratory 

testing in terms of accuracy and cost-effectiveness. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Results for a bedside system called the Glucoscan 2000 were highly 

correlated with hospital laboratory results, but the bedside system took less time (mean: 2.4 

minutes versus 2.6 hours) and was significantly less expensive (for 110 determinations, $55 in 

costs versus $990 in charges). 

RECOMMENDATION: Glucose monitoring systems cannot and should not replace 

laboratory glucose determinations, but they can greatly reduce their frequency and supplement 

expensive laboratory data. A quality control regimen must be implemented for the selected 

glucose monitoring device to ensure its accuracy. 
ABSTRACT: Intensive care unit patients may have large fluctuations in blood glucose 

concentration; accurate and timely glucose values must be obtained so that these fluctuations 

may be stabilized. The author compared three blood glucose monitoring systems (AccuCheck, 

Glucometer, Glucoscan 2000) with the hospital laboratory; there were no significant 

differences in results between the systems. In a subsequent 3month study, the Glucoscan 2000 

and hospital laboratory performed 110 blood glucose determinations in 41 patients; for the 

first 50 blood glucose tests, mean completion time was 2.4 minutes for the Glucoscan 2000 

and 2.6 hours for the hospital (routine) or 0.5 hours ("stat"). Laboratory charges for 110 

laboratory determinations totaled $990, versus Glucoscan costs of $55. The author concludes 

that blood glucose monitoring systems can be effective for close monitoring of blood glucose 

in the intensive care unit or elsewhere. The purchase price of the Glucoscan 2000 was $127. 1 

figure, 2 tables, 16 references. 

18 

TITLE: Cardiovascular Morbidity and Mortality in Type 2 Diabetic Patients: A 22 Year 

Historical Cohort Study in Dutch General Practice. de Grauw, W.J.C.; van de Lisdonk, E.H.; 

van den Hoogen, H.J.M.; van Weel, C. Diabetic Medicine. 12(2): 117122. February 1995. 

OBJECTIVE: To assess the impact of cardiovascular morbidity and mortality on patients in 

general practice with type 2 diabetes over a 22year period. 

CATEGORY: Secondary intervention. 

Type of Study: Historical cohort. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Patients in general practice with type 2 diabetes were at higher risk of 

cardiovascular morbidity, mortality from any cause, and cardiovascular mortality than were 

those without diabetes. 

RECOMMENDATION: None. 

ABSTRACT: An historical cohort study was performed to measure cardiovascular morbidity 

and mortality in patients with type 2 diabetes; data were collected from 1967 to 1989 in four 

Dutch general practices involved in the Continuous Morbidity Registration Nijmegen. A total 

of 265 patients with type 2 diabetes (112 men, 153 women) who met World Health 

Organization (WHO) criteria were included in the cohort. The remaining 162 patients who 

were registered during the study period as diagnosed with diabetes were not included because 

they did not meet WHO criteria or because of other reasons. At diagnosis, 60 percent of the 

study cohort were aged 65 or under; mean follow-up was 6.8 years. Compared with a 

matched control group of persons without diabetes, those with type 2 diabetes had higher 

cardiovascular morbidity (risk ratio, 1.76; 95 percent confidence interval, 1.34 to 2.30). The 

risk of mortality was also higher in patients with diabetes than in controls (relative risk, 1.54; 
95 percent confidence interval, 1.07 to 2.23). Relative risk of cardiovascular mortality was 

2.05 in patients with diabetes (95 percent confidence interval, 1.24 to 3.37). Mortality after 10 

years for patients with type 2 diabetes was 36 percent, versus 20 percent for the control group 

(p < 0.01). Cumulative survival rates in the group aged 65 to 74 years were significantly lower 

(p < 0.01) in patients with type 2 diabetes than in controls. 2 figures, 3 tables, 32 references. 

19 

TITLE: Care of the Diabetic Child in the Community. Farquhar, J.W.; Campbell, M.L. 

British Medical Journal. 281(6254): 1534-1537. December 6, 1980. 

OBJECTIVE: To describe community care for children with newly diagnosed type 1 

diabetes, and to describe in-hospital care for such children. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Descriptive analysis. 

Perspective: Health care system. 

CONCLUSION: Admitting children with newly diagnosed diabetes to the hospital, then 

providing them with a home care team, offers numerous advantages for the children and their 

parents. 

RECOMMENDATION: None. 

ABSTRACT: The authors describe experience with children newly diagnosed with diabetes 

who have been admitted to the Royal Hospital for Sick Children in Edinburgh, Scotland. 

Admitting to the hospital a child newly diagnosed with diabetes along with one or both 

parents allows parents to develop trust in the staff, to learn more effectively about their child, 

and to meet the home care sisters. Staff can obtain an indication of parental ability and 

stability, and an insulin reaction can be induced safely so that the parent can watch the child's 

reaction to hypoglycemia. The child is normally discharged within 1 week. Having a home 

care team enabled the hospital to have an average length of stay of about 4.5 days in 1976, 

versus the national average of 8 days. The home care team permits reduced readmissions, 

relieves maternal and school teacher anxiety, and decreases school absences. The home care 

team continually assesses the home — its organization, finances, presence of alcoholism, 

stability of the parents and marriage, relationships of parents and children and relationships 

between children, how procedures are conducted, and the extent to which parents seek further 

education toward controlling diabetes. The home care team visits the school and briefs staff 

and the school nurse on symptoms and treatment of hypoglycemia and the needs of the child. 

The team provides continuing care through phone consultations, visits the home when the 

children are in school, and obtains spot urine specimens or blood checks if there is a question 

of diabetic control. To avoid disharmony between the hospital clinic and the primary care and 

community health services, each important contact with the home care team or the unit staff 

should be recorded. 4 references. 
20 

TITLE: A Comparison of Accuracy and Estimated Cost of Methods for Home Blood 

Glucose Monitoring. Shapiro, B.; Savage, P.J.; Lomatch, D.; Gniadek, T.; Forbes, R.; 

Mitchell, R.; Hein, K.; Starr, R.; Nutter, M.; Scherdt, B. Diabetes Care. 4(3): 396-403. MayJune 1981. 

OBJECTIVE: To compare the accuracy, convenience, and cost of various methods of home 

blood glucose monitoring. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: All the capillary blood glucose methods correlated well with laboratory 

blood glucose measurements and all were more accurate than urine glucose measurements. 

The Chemstrip bG was the least expensive and easiest method to measure blood glucose 

concentrations at home. 

RECOMMENDATION: None. 

ABSTRACT: The authors compared accuracy, convenience, and cost of four products for 

home blood glucose monitoring. Sixteen patients used Eyetone, Dextrometer, StatTek (all of 

which used a reflectance meter and a reagent strip), and Chemstrip bG (reagent strip only) 

twice daily within 1 minute of collection of venous blood for laboratory blood glucose 

measurement. Urine glucose was measured from collections made before and after blood 

collection. For laboratory blood glucose concentrations of 48 to 464 mg/dL and 48 to 250 

mg/dL, correlation coefficients for Eyetone, Dextrometer, and StatTek reflectance meter 

readings (by a physician or nurse) and for Chemstrip bG readings by the patient, a nurse, and a 

physician ranged from 0.90 to 0.95 and from 0.85 to 0.92, respectively (p < 0.0001). All home 

blood glucose monitoring methods except StatTek underestimated blood glucose 

concentrations between 48 and 250 mg/dL. The correlation coefficient for urine glucose 

concentrations was 0.74. When Chemstrip bG was reread at intervals over 14 days, glucose 

readings decreased by 6.8 to 10.1 percent (not clinically significant) in the first 2 days; no 

further decrease was noted. The coefficient of variation (CV) for repeated readings of the 

three reflectance meters was 8.9 to 12.0 percent for nurses and 6.7 to 9.0 percent for 

physicians; the CV for Chemstrip bG was 17.8 and 11.6 percent, respectively. The costs 

(1980 dollars) per glucose determination (excluding cost of reflectance meter) for 

Dextrometer, Eyetone, StatTek, and Chemstrip were $0.71 to $1.32, $0.51 to $0.71, $0.72 to 

$1.01, and $0.53, respectively, and reflectance meters for the first three cost between $339.95 

and $395.00. The Chemstrip bG method is easy to use and less expensive than the other 

systems, and readings can be verified by a physician up to 2 weeks later. 3 figures, 5 tables, 26 

references. 
21 

TITLE: Comparison of Different Models of Diabetes Care on Compliance with SelfMonitoring of Blood Glucose by Memory Glucometer. Hoskins, P.L.; Alford, J.B.; 

Handelsman, D.J.; Yue, D.K.; Turtle, J.R. Diabetes Care. 11(9): 719-724. October 1988. 

OBJECTIVE: To evaluate the accuracy of patient-generated records of blood glucose 

concentrations, and to determine whether the model of diabetes care influences the validity of 

these patient records. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: There was no difference in validity of reported blood glucose results based 

on instruction technique, but private health insurance status was associated with greater 

validity of patient records. 

RECOMMENDATION: Health professionals should not assume that patients will follow 

treatment instructions because they have been fully counseled. 

ABSTRACT: The authors evaluated 34 patients with diabetes on their self-monitoring of 

blood glucose. Participants had been referred to the diabetes center of Royal Prince Alfred 

Hospital in Camperdown, Australia; 17 had gestational diabetes; 13 had type 2 diabetes; and 4 

had type 1 diabetes. Participants were randomized to one of three models of instruction: 

mutual decision making (emphasized team approach; patient could adjust treatment based on 

results), didactic (nurse educator would make decisions based on results), and authoritarian 

(physician would make decisions based on results). Participants performed blood glucose 

estimations four times daily over 2 weeks using a blood glucose monitor with memory but 

were not informed of the memory capacity. Blood glucose results recorded in patient 

logbooks were compared with monitor records. No difference was found in the validity of 

patients' records by instruction group. The overall proportion of correctly recorded 

estimations was 86 percent; 70 percent of examinations were actually performed as requested 

and correctly recorded, and another 16 percent were correctly recorded as not done. 

Conversely, 30 percent of scheduled examinations were not performed properly or were 

recorded incorrectly. Compared with patients with type 2 diabetes, patients with gestational 

diabetes recorded a lower percentage of blood glucose estimations accurately. Private health 

insurance was one of two predictors of greater validity of blood glucose records (the other 

was perceived high intelligence). Although there were no direct financial disincentives for 

compliance with testing, as patients were not required to copay, health insurance status may 

represent a surrogate socioeconomic indicator. Some patients may have experienced financial 

or social pressures that act as a barrier to successful completion of diabetes self-care activities. 

6 tables, 8 references. 
22 

TITLE: Continuous Quality Improvement Can Improve Glycemic Control for HMO Patients 

with Diabetes. O'Connor, P.J.; Rush, W.A.; Peterson, J.; Morben, P.; Cherney, L.; Keogh, C.; 

Lasch, S. Archives of Family Medicine. 5(9): 502-506. October 1996. 

OBJECTIVE: To evaluate the impact of a continuous quality improvement (CQI) 

intervention on glycemic control of patients with diabetes mellitus attending a primary care 

clinic. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Use of a CQI intervention can improve glycemic control without increasing 

utilization or charges. 

RECOMMENDATION: Health care providers should consider implementing CQI to 

improve adult diabetes care; several of the strategies developed by the CQI team may be 

useful for other primary care settings. 

ABSTRACT: The authors analyzed the effect of implementing a CQI plan on glycemic 

control in patients with diabetes. Patients were followed for 18 months at two clinics of a 

Midwest staff model health maintenance organization. The intervention clinic had 4,100 

patients; the comparison clinic, 4,700 patients. The staff at the intervention clinic developed a 

computerized patient audit system and held monthly 1-hour CQI meetings. The patient audit 

and review of the process of care led to a modified system using computerized printouts, 

targeting certain patients for special attention, and authorizing more aggressive outreach by 

resource nurses. Patients were selected for readiness to undertake behavioral change and 

given appropriate levels of support. Success of management was based on change in 

glycosylated hemoglobin (HbA1C) levels. After intervention, in the CQI and comparison 

clinics, respectively, (HbA1C levels were acceptable, # 8 percent) in 51 versus 40 percent of 

patients, fair (8 to 10 percent) in 37 versus 33 percent, and poor ($ 10 percent) in 12 percent 

versus 27 percent (p = .008). Intervention clinic patients had significant improvement in 

HbA1C levels relative to patients at the comparison clinic (p = .01). Mean outpatient visits at 

the intervention and the comparison clinics were 7.86 and 7.40 prior to and 9.08 and 8.96 

after initiation of CQI, respectively. Mean charges for outpatient services were $991 and $958 

prior to and $1,218 and $1,281 after initiation of CQI, respectively. 1 table, 25 references. 

23 
TITLE: A Cost-Benefit Analysis of Subcutaneous Insulin Pump Infusion Therapy for InsulinDependent Diabetes Mellitus. Turkelson, C.M.; Coates, V. Abstract 195. Annual Meeting of 

the International Society for Technology Assessment in Health Care. 11. 1995. 

OBJECTIVE: To compare the costs of subcutaneous insulin pump infusion therapy and 

conventional therapy for type 1 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Insulin pump therapy may be more cost-beneficial than conventional 

therapy, but it may take 9 years of treatment for this to be true. How many patients will 

remain on pump therapy for this long is not known. 

RECOMMENDATION: The conclusions of this study and other cost analyses of insulin 

pump therapy must be treated cautiously. 

ABSTRACT: The authors used Markov analysis to compare the costs of insulin pump and 

conventional therapy. Separate models were used to determine treatment-specific costs 

associated with diabetic nephropathy, retinopathy, and amputations. When just retinopathy 

and amputations were considered, insulin pump therapy did not provide as great a cost-benefit 

as conventional therapy. However, the savings associated with the third complication (diabetic 

nephropathy) were large enough for a greater cost-benefit to be realized for insulin pump 

therapy after 9 years of treatment when all three complications were considered 

simultaneously. The authors note that the proportion of patients who should be given this type 

of therapy (or any form of intensive therapy) is unknown, as is the effectiveness of this therapy 

under regular clinical practice conditions. 

24 

TITLE: Cost-Effectiveness Analyses of the Conversion of Patients with Non-InsulinDependent Diabetes Mellitus from Glipizide to Glyburide and of the Accompanying Pharmacy 

Follow-up Clinic. Law, A.V.; Pathak, D.S.; Segraves, A.M.; Weinstein, C.R.; Arneson, W.H. 

Clinical Therapeutics. 17(5): 977987. September/October 1995. 

OBJECTIVE: To retrospectively evaluate the cost effectiveness of converting from glipizide 

therapy to glyburide therapy and of using a pharmacy follow-up clinic. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 
Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The conversion from glipizide to glyburide was cost effective, as was the 

follow-up clinic. For every 1 percent of patients in the follow-up group who achieved good 

glycemic control, the Department of Veterans Affairs would spend only $1.01 more per 

patient on costs related to the follow-up clinic. 

RECOMMENDATION: Due to its cost-effectiveness, the conversion from glipizide to 

glyburide is recommended in practice settings similar to that of the Department of Veterans 

Affairs. Follow-up clinics are justifiable because they are cost effective and possibly increase 

patient compliance with the medication regimen or with nondrug factors (e.g., diet, exercise). 

ABSTRACT: During a 6month period in 1993, the Department of Veterans Affairs 

Outpatient Clinic in Columbus, Ohio, converted patients with type 2 diabetes from glipizide to 

glyburide therapy as a way to reduce costs. For this retrospective study, patients were divided 

into groups: I included all 730 patients while they were being treated with glipizide; II, 408 

patients who converted to glyburide and returned to the follow-up clinic; III, 244 patients who 

converted to glyburide but did not return to the follow-up clinic (records were missing for the 

other 78 patients). Cost data were gathered by examining the direct costs (in 1994 dollars) of 

the conversion and the follow-up clinic. Costs common to all three groups were not included 

in the analysis. The effectiveness measure was defined as the percentage of patients whose 

glycemic control was rated as good (i.e., fasting blood glucose 200 mg/dL or less). The 

authors found that the average mean daily dose for glipizide was 1.82 to 1.85 times that for 

the glyburide dose. Based on a daily dose of two 10mg tablets of glipizide (Group I) and two 

5mg tablets of glyburide (Groups II and III), the cost savings to the Department of Veterans 

Affairs for the first year after conversion were $104,974.12 for Group II and $132,132.12 for 

Group III. Although Group III achieved higher cost savings, Group II had a higher percentage 

of patients who achieved good glycemic control. 5 tables, 14 references. 

25 

TITLE: Cost-Effectiveness Study of a Lipid-Lowering Therapy in Hyperlipoproteinaemia 

Type IIb and Type IV (Frederickson). Bergemann, R.; Brandt, A.; Siegrist, W. 

PharmacoEconomics. 3(Supplement 2): 131-139. February 1993. 

OBJECTIVE: To conduct a cost-effectiveness analysis of four drugs (acipimox, bezafibrate, 

fenofibrate, and gemfibrozil) for treating patients with hyperlipoproteinemia types IIb and type 

IV (according to Frederickson), with and without type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 
CONCLUSION: When hospitalization costs for treating gallstones are taken into account, 

acipimox is a more cost-effective therapy than the other three drugs. 

RECOMMENDATION: None. 

ABSTRACT: In this Swiss study, a computer model was developed of hyperlipoproteinemia 

types IIb and IV and their treatment. The study was based on up to 7 years of therapy; in 10.5 

percent to 11.8 percent of patients, according to the model, the therapy was interrupted 

because of adverse events or inadequate therapeutic effect. Only direct costs were included 

(for drugs, physician visits, and hospitalizations for coronary vascular disease, coronary artery 

bypass graft surgery, peripheral arterial occlusive disease, and gallstone operations). 

Calculations were based on computer-aided medical decision analysis and the Monte Carlo 

method; the discount rate was 5 percent per year. Results from various epidemiologic and 

clinical trials were used to compare long-term outcomes. Efficacy studies with long-term 

endpoints are available for the three fibrate drugs; the authors used various studies to derive 

estimates for the effects of acipimox. Yearly costs of medication for the four drugs ranged 

from 434 to 446 Swiss francs. Annual treatment costs with the three fibrate drugs were about 

100 Swiss francs more than with acipimox for both kinds of hyperlipoproteinemia, with or 

without type 2 diabetes. The risk of gallstones with the fibrate drugs was more than three 

times that for acipimox; this difference, according to the authors, explained the marked 

differences in the cost of therapy. The authors state that estimated savings with acipimox were 

conservative because only the cost of the hospital stay was included; additional expenses for 

diagnosing and treating gallstones as well as for lost productivity were not included. They 

note that the dosages (mg/day) in the study were specific to Switzerland: 500 for acipimox; 

400, bezafibrate; 300, fenofibrate; and 900, gemfibrozil. 1 figure, 7 tables, 1 appendix, 38 

references. 

26 

TITLE: The Costs and Effects of Two Different Lipid Intervention Programmes in Primary 

Health Care. Tomson, Y.; Johannesson, M.; Åberg, H. Journal of Internal Medicine. 237(1): 

1317. January 1995. 

OBJECTIVE: To compare the costs and effects of two different intervention strategies for 

the nonpharmacological treatment of hypercholesterolemia. 

CATEGORY: Secondary intervention. 

Type of Study: Other prospective trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: There was no difference in the effectiveness of the two intervention 

strategies. 
RECOMMENDATION: Of the two strategies, the low-intensity program is preferable from 

a Cost-effectiveness viewpoint. 

ABSTRACT: All persons aged 25 to 54 years who resided in the catchment area of a health 

center south of Stockholm were invited to a health check; 2,338 were screened for 

hypercholesterolemia. From a group of 372 persons found to have this disorder, the authors 

selected men and women with a serum cholesterol in the range of 7.07.8 mmol L-1. Those 

with hypertension, diabetes mellitus, and ischemic heart disease were excluded. The 92 

persons who met all criteria were randomized to low-intensity (n = 45) or moderate-intensity 

(n = 47) intervention programs. The low-intensity program focused on diet modification; 

participants were given brochures. The moderate-intensity program, which followed Swedish 

national guidelines, also focused on diet modification but included more active involvement 

with the participant's general practitioner and with a dietitian. Both groups were followed for 

a year and compared with respect to serum cholesterol concentration and treatment costs in 

Swedish crowns (SEK), using 1993 prices. (Apart from the health care costs, the treatment 

costs for the patient included the time cost for the visits and travel costs to the health care 

center.) Both intervention strategies resulted in small decreases (3.3 percent for low intensity, 

3.7 percent for moderate intensity) in total cholesterol, with no significant difference between 

the groups. The total cost per patient in the low-intensity group was SEK 753; in the mediumintensity group, SEK 3,614. The authors estimate that if only 30 percent of the population 

aged 25 to 54 years in Stockholm county with hypercholesterolemia were discovered by the 

primary health care system and followed the dietary advice, the net savings with the lowintensity model (versus the moderate-intensity model) would be SEK 93 million. 5 tables, 10 

references. 

27 

TITLE: The Development of Community Orientated Recommendations for Diabetes Care in 

South Auckland. Wilson, P.; Simmons, D. New Zealand Medical Journal. 107(989): 456-459. 

November 9, 1994. 

OBJECTIVE: To describe the development of recommendations for preventing and 

controlling diabetes and its effects in South Auckland, New Zealand, a community in which 

diabetes is a major public health priority. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Historical review. 

Perspective: Societal. 
CONCLUSION: The provision of scientifically derived data, followed by discussion of the 

data with community representatives and its subsequent dissemination throughout the 

community, has provided an opportunity to begin controlling diabetes in the South Auckland 

area. 

RECOMMENDATION: Numerous recommendations are set forth in the body of the report. 

ABSTRACT: South Auckland, New Zealand, a community with considerable socioeconomic 

deprivation, has many residents of Maori and Pacific Islander descent, two groups with a 

disproportionate risk for diabetes. In 1990-1991 the South Auckland Diabetes Survey 

canvassed all general practitioners and practice nurses in that district on diabetes management 

and barriers to care. Community experience was obtained from existing diabetes focus groups. 

Patients and selected general practitioners were interviewed about barriers to care. Additional 

interviews were conducted with physicians, dietitians, and others involved in diabetes care, 

and a 54-page preliminary information document was prepared. A 12-member planning group 

found the document to be too long and technical; a 4-page summary was prepared and 

distributed to a variety of groups. The next draft followed 12 meetings and extensive 

community consultation. Sixty-eight recommendations were eventually made on diabetes care, 

including altering the environment, coordination and standardization, access, cost reduction, 

diabetes support groups, foot and eye care, diabetes in pregnancy and impaired glucose 

tolerance, and screening. A cost-outcome evaluation of the plan suggested significant savings 

in direct health expenditure, and full funding was subsequently recommended. 1 table, 1 

figure, 22 references. 

28 

TITLE: Diabetes in Urban African Americans: III. Management of Type II Diabetes in a 

Municipal Hospital Setting. Ziemer, D.C.; Goldschmid, M.G.; Musey, V.C.; Domin, W.S.; 

Thule, P.M.; Gallina, D.L.; Phillips, L.S. American Journal of Medicine. 101(1): 25-33. July 

1996. 

OBJECTIVE: To prospectively study the effectiveness of multidisciplinary, nonphysician, 

nonpharmacologic management in an urban outpatient setting of a largely African American 

group of patients with type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Nonpharmacologic, nonphysician management of type 2 diabetes is 

effective in a socioeconomically disadvantaged population. 
RECOMMENDATION: Further study is needed to identify risk factors for patient loss to 

follow-up. 

ABSTRACT: The authors prospectively evaluated care provided to patients with type 2 

diabetes in a municipal hospital clinic in Atlanta, Georgia; most study patients were African 

Americans and socioeconomically disadvantaged. At an initial visit, the diagnosis was 

confirmed, family history obtained, patient education initiated, and a nurse practitioner or 

registered nurse assigned for follow-up; obese patients were instructed in a hypocaloric diet. 

Drug therapy was initiated, adjusted, or eliminated based on fasting plasma glucose levels at 

each visit. Data were analyzed for 325 patients who returned for follow-up visits at 2, 4, 6, 

and 12 months. Patients were more likely to return if diagnosed less than 1 year previously, 

over age 55 years, or female; 80 percent missed at least 1 visit. Compared with initial levels, 

both fasting plasma glucose and glycosylated hemoglobin improved significantly in the first 2 

months (p < .001); levels were somewhat higher at 12 months. Initially, 36 percent of obese 

patients were managed by diet only, 24 percent by sulfonylureas, and 40 percent by insulin. 

After 2 months, 70 percent were managed by diet alone; at 6 months, 61 percent; and at 12 

months, 55 percent. Lean patients had little change in management over the 12 months. 

Neither weight gain nor loss correlated with metabolic control at 12 months. Keeping 

appointments correlated with better metabolic control. Average cost per patient visit for 

physician and staff salaries, rent, utilities, and administrative overhead was $59 (1994 costs). 

The program was effective for a socioeconomically disadvantaged population, but further 

study is needed to identify risk factors for patient loss to follow-up. 7 figures, 1 table, 37 

references. 

29 

TITLE: Effect of Value-Added Utilities on Prescription Refill Compliance and Medicaid 

Health Care Expenditures: A Study of Patients with Non-Insulin Dependant Diabetes 

Mellitus. Skaer, T.L.; Sclar, D.A.; Markowski, D.J.; Won, J.K. Journal of Clinical Pharmacy 

and Therapeutics. 18(4): 295-299. August 1993. 

OBJECTIVE: To determine the effect of mailed prescription-refill reminders, specialized 

packaging, or a combination of both interventions on prescription refill compliance and health 

service utilization among patients with type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized trial. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Mailed prescription refill reminders, specialized packaging, or a 

combination of both significantly increased patient refill compliance. Patients receiving both 

interventions also had decreased expenses for physician, laboratory, and hospital services. 
RECOMMENDATION: Pharmacy-based value-added utilities should be used more under 

both public and private health insurance programs. 

ABSTRACT: From 10 to 30 percent of patients with type 2 diabetes withdraw from 

prescribed treatment within 1 year of diagnosis; of the remainder, about 20 percent do not 

take enough prescribed medication to maintain their blood glucose at satisfactory 

concentrations. A randomized trial was undertaken to determine the effects of valued-added 

pharmacy services on the compliance of type 2 patients with prescription refills and their use 

of health services. The 1-year study included 258 Medicaid beneficiaries with previously 

untreated type 2 diabetes. Patients lived in South Carolina, were less than 65 years old, had 

prescriptions to administer 5 mg glyburide twice daily, and were not to have received an 

alternative sulfonylurea or used insulin after receipt of the initial glyburide prescription. The 

patients were assigned to one of four groups: a control group (standard pharmacy care), 

standard pharmacy care plus mailing of a reminder 10 days before the refill date, standard 

pharmacy care plus unit-of-use packaging, and standard pharmacy care plus both mailed refill 

reminders and unit-of-use packaging. The medication possession ratio (MPR) was used to 

compare groups; the MPR is the days' supply of medication obtained by the patient relative to 

the days in the study period (optimal = 1.00). Dispensing of drugs was authorized in 30-day 

supplies. Analysis of data after 1 year revealed that patients receiving mailed prescription refill 

reminders, unit-of-use packaging, or a combination of both achieved a significant (p < 0.05) 

increase in the MPR for sulfonylurea therapy relative to the controls. The MPR for those 

receiving both interventions was significantly higher than for the groups receiving one 

intervention. Multivariate regression analysis revealed that patients receiving both 

interventions had significant (p < 0.05) reductions in expenditures for physician, laboratory, 

and hospital services relative to the control group. 2 tables, 22 references. 

30 

TITLE: Efficacy of Insulin and Sulfonylurea Combination Therapy in Type II Diabetes. A 

Meta-Analysis of the Randomized Placebo-Controlled Trials. Johnson, J.L.; Wolf, S.L.; 

Kabadi, U.M. Archives of Internal Medicine. 156(3): 259-264. February 12, 1996. 

OBJECTIVE: To evaluate the efficacy of combination therapy with insulin and sulfonylurea 

in type 2 diabetes by performing a meta-analysis of studies that met strict criteria. 

CATEGORY: Secondary intervention. 

Type of Study: Formal meta-analysis of randomized clinical trials. 

Methodology: Data analysis. 

Perspective: Health care system 

CONCLUSION: Combination therapy improves glycemic control while lowering daily 

insulin dosages and without adversely affecting body weight. In developing countries, 

combination therapy is far less expensive than insulin monotherapy. 
RECOMMENDATION: None. 

ABSTRACT: Forty-three citations were obtained from a search of the MEDLINE database 

from January 1980 through March 1982; 16 studies with a total population of 351 participants 

were analyzed — these studies met strict criteria for study design and outcome measures. The 

meta-analysis showed that the combination of insulin and sulfonylurea improves metabolic 

control for periods of at least 16 weeks. This improved metabolic control is achieved despite a 

decrease in daily insulin dose and does not result in a significant change in body weight. 

Combination therapy appears to be more expensive than mono-therapy with insulin, as the 

total monthly cost for combination therapy is about $60 to $85, versus $20 for two daily 

injections of a total dose of 100 U of intermediate-acting insulin. However, for patients using 

insulin monotherapy, the costs of insulin administration are higher, more frequent glucose 

monitoring may increase expense, and more frequent office and emergency department visits 

may be needed. In addition, money could be saved by substituting a first-generation 

sulfonylurea such as tolazamide for a second-generation drug. However, second-generation 

sulfonylureas are dropping in price. In developing countries, the cost of sulfonylureas is 

minuscule compared with insulin. 7 tables, 61 references. 

31 

TITLE: Evaluation of a Practice-Based Programme of Health Checks: Financial Cost and 

Success at Risk Detection. Sacks, G.; Marsden, R. Journal of the Royal College of General 

Practitioners. 39(326): 369-372. September 1989. 

OBJECTIVE: To evaluate the efficacy and cost of a screening program for cardiovascular 

risk factors among patients in a large group practice in Oxford, England. 

CATEGORY: Secondary intervention. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The screening program increased recording of risk factors but its cost was 

not fully met by reimbursement for salaries or services. 

RECOMMENDATION: To avoid the financial disincentive to general practitioners to 

provide such preventive medicine programs, salaries for program staff should be completely 

reimbursed by the government. 

ABSTRACT: The authors evaluated the efficacy and cost of a screening program to identify 

patients at risk for cardiovascular disease in a large suburban group practice in Oxford, 

England. Costs for the unfunded program were to be recouped through fees generated by 

referrals for tetanus and polio shots and cervical cytology exams. Of 1,470 patients invited to 
participate in the nurse-run health checks, 1,382 (94.0 percent) participated. In this group, 66 

cases of previously undiagnosed hypertension and 11 cases of previously undiagnosed 

diabetes were identified. Just over one-third (34.9 percent) of patients were overweight and 

27.0 percent smoked. Total cost of the program was £ 11,785, of which £ 11,510 was for 

staff salaries. Estimated service fees generated totaled only £ 1,167, which was adjusted to £ 

1,342 to reflect patients who had died or left the area. With £ 8,057 of income added to this 

amount from 70 percent reimbursement of salaries, the screening program operated at a net 

cost to the practice of £ 2,386, or £ 1.73 per patient. This outcome casts doubt on the results 

of other studies that have suggested that the costs of government-recommended prevention 

programs can be fully recouped through item-of-service payments. 1 figure, 2 tables, 14 

references. 

32 

TITLE: The Feasibility of a Potentially "Ideal" System of Integrated Diabetes Care and 

Education Based on a Day Centre. Day, J.L.; Johnson, P.; Rayman, G.; Walker, R. Diabetic 

Medicine. 5(1): 70-75. January 1988. 

OBJECTIVE: To evaluate the feasibility of a new system of clinical and educational care 

designed to replace traditional diabetes clinics. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The new integrated diabetes care system improved quality of care of 

patients without incurring major costs. 

RECOMMENDATION: None. 

ABSTRACT: The authors evaluated a new, integrated diabetes care and education program 

in Ipswich, England, at a new day facility. Staff from a traditional hospital clinic were 

reorganized and the role of the specialist nurse changed to providing primary counseling 

(physicians also provided care in the new center). Clinic hours were revised and a new 

appointment system created. After 1 year, the new program was found to have provided a 

pleasant environment for diabetes care and education, largely eliminated excessive waiting 

time, established continuity in consultation, and made available a more comprehensive and 

systematized educational program. Mean glycosylated hemoglobin levels of patients did not 

differ significantly by whether they saw the physician or specialist nurse. These results were 

achieved without major additional expenses: building maintenance, £ 3,000; nursing staff, £ 

2,275; phlebotomist services, £ 300; and receptionist services, £ 2,476. Most costs were 

within original financial targets. In addition, the British Diabetic Association provided a 3-year 

support grant of £ 17,129. Capital costs of the new building and equipment (total of £ 88,000) 

were considered small when spread over the potential lifetime of the building. 6 tables, 12 
references. 

33 

TITLE: Fructosamine or Glycated Haemoglobin as a Measure of Diabetic Control? Allgrove, 

J.; Cockrill, B.L. Archives of Disease in Childhood. 63(4): 418-422. April 1988. 

OBJECTIVE: To determine whether measuring fructosamine concentration is a suitable 

alternative or useful adjunct to the measurement of glycated hemoglobin A1 (HbA1C) in the 

routine management of children with diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: In children with diabetes, fructosamine values were well correlated with 

HbA1C levels, but only when values outside the normal range were not excluded. Measuring 

fructosamine is not a direct substitute for assaying HbA1C. 

RECOMMENDATION: Use of fructosamine concentration for routine diabetes control 

monitoring, with HbA1C assayed under select conditions, should be considered a cost-saving 

alternative to routine HbA1C monitoring. 

ABSTRACT: The authors evaluated the potential of measuring fructosamine concentration 

as an alternative or adjunct to HbA1C measurement in routinely managed children with 

diabetes. HbA1C, fructosamine, and total proteins were assayed in 61 children with diabetes 

and 30 normal children. Linear regression analysis showed a highly significant correlation in 

children with diabetes between HbA1C and fructosamine; however, when values outside the 

normal range were excluded, the significant relation- ship disappeared. The same results were 

obtained when HbA1C values were plotted against the fructosamine:protein ratio. In three 

newly diagnosed patients whose disease was being brought under control, fructosamine 

concentrations were lower than expected; in one deteriorating patient, values were higher than 

expected. The authors conclude that fructosamine is not a direct substitute for HbA1C. The 

routine addition of a fructosamine test to a HbA1C measurement would increase overall costs 

of assessing diabetic control (by 10 to 15 percent if the reagents are made up in the 

laboratory) and cannot be justified. Conversely, substituting fructosamine for HbA1C 

monitoring would provide only small savings in a pediatric clinic and cannot be justified on 

clinical grounds. Using fructosamine for most routine monitoring, with HbA1C assayed on 

selected occasions, would reduce overall costs of assessing diabetic control while retaining the 
flexibility of having both assays available. 2 tables, 4 figures, 12 references. 

34 

TITLE: Importance of Outpatient Supervision in the Prognosis of Juvenile Diabetes Mellitus: 

A Cost/Benefit Analysis. Deckert, T.; Poulsen, J.E.; Larsen, M. Diabetes Care. 1(5): 281284. 

September/October 1978. 

OBJECTIVE: To investigate whether outpatient follow-up visits to a subspecialized clinic 

have a favorable effect on survival of patients with type 1 diabetes, and to evaluate whether 

the cost of this effort is in reasonable proportion to the benefit obtained. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: A clear relationship was found between the frequency of outpatient visits to 

a subspecialized clinic and the duration of survival with diabetes. Outpatient supervision in a 

subspecialized clinic involves relatively little cost compared with the benefit derived. 

RECOMMENDATION: None. 

ABSTRACT: The study consisted of 180 insulin-treated patients with diabetes (89 females, 

91 males) who had been referred for admission to the Steno Memorial Hospital in Denmark 

before their 15th year of diabetes. Sixteen patients could not be traced after 40 years of 

diabetes; the others were followed until death or until 40 years of diabetes. Subsequent to the 

first hospital admission, 77 patients never attended follow-up in the outpatient clinic; the 

others attended 1 to 145 times in the course of their first 20 years of diabetes. (Only 

outpatient visits that took place within these first 20 years were included in the authors' 

analysis.) The aim of the outpatient supervision was to keep the patient symptom free and 

socially well adapted, to avoid long periods of poor metabolic regulation, to prevent insulin 

reactions, and to adapt the treatment to intercurrent diseases. The authors found a clear 

correlation between the number of outpatient visits and the duration of survival with diabetes: 

patients seen more than 20 times in the outpatient clinic in the course of their first 20 years of 

diabetes had a longer survival with diabetes (mean, 38.5 years) than patients who did not have 

outpatient follow-up (mean, 26.6 years); this difference was highly significant (p = 0.0001). 

Those in the first group averaged 4.4 outpatient follow-up visits annually over a 12.5-year 

period (first visit was at an average of 7.5 years of follow-up). If regular follow-up for these 

patients produced 11.9 additional years of work, total benefit from years gained working 

(1976 earnings of an unskilled laborer were used) and hospital admissions eliminated was 

estimated to be $100,656. In contrast, cost per patient (1976 prices) of running the clinic for 

40 years was estimated at $10,468. 1 figure, 1 table, 2 references. 
35 

TITLE: Inpatient or Outpatient Initiation of Insulin Therapy: Experience and Cost Effective 

Analysis in a Suboptimal Clinical Setting. Mengistu, M.; Lungi, Y.; Mamo, F. Tropical and 

Geographical Medicine. 43(1-2): 180-183. January-April 1991. 

OBJECTIVE: To assess the safety, feasibility, and cost-effectiveness of initiating insulin 

therapy in an outpatient setting in an area where day-care centers for persons with diabetes do 

not exist. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Initiation of insulin therapy in the outpatient setting was safe, feasible, and 

cost effective even though the setting was suboptimal. 

RECOMMENDATION: None. 

ABSTRACT: The authors report initiation of insulin therapy in a suboptimal clinical setting 

in Ethiopia for patients with newly diagnosed diabetes mellitus. Between 1985 and 1989, 53 

patients with diabetes and no impending or established ketoacidosis began insulin therapy as 

outpatients. Treatment began on a Monday to allow sufficient working days for patient 

education. Patients returned to the outpatient clinic for 3 to 4 weekly visits, then were 

followed every 2 to 3 months. Outpatient costs included clinic staff salaries and taxi fare; 

examining room rent was excluded as minimal. Results were compared with 51 retrospectively 

chosen inpatients hospitalized for insulin initiation because of distance from the clinic or 

existing practice. Inpatient costs included medical and nonmedical staff and the declarable cost 

of beds, which included food and other utilities. Costs for third-class (n = 46), second-class (n 

= 4), and first-class (n = 1) beds were 2.2, 12.0, and 30.0 Birr, respectively (2.07 Birr = $1 

U.S.). Mean blood glucose levels before and after treatment were 357.9 and 197.6 mg/dl, 

respectively, for inpatients and 325.4 and 205.8 mg/dl, respectively, for outpatients. Mean 

weight before and after treatment was 44.8 and 49.1 kg, respectively, for inpatients and 53.3 

and 56.4 kg, respectively, for outpatients. Mean insulin dose for inpatients and outpatients 

was 29.4 " 14.7 units and 28.7 " 9.2 units, respectively. Mean duration of hospitalization for 

inpatients was 24.3 " 9.2 days. Total cost per outpatient visit was 6.8 Birr; total cost per 

inpatient day was 24.3 Birr. Total outpatient and inpatient costs were 1,346.2 and 30,115.0 

Birr, respectively. The savings realized with outpatient care equaled $14,000 (U.S. dollars). 

Outpatient initiation of insulin therapy is safe, acceptable, and cost effective. 3 tables, 10 

references. 

36 
TITLE: Insulin Injection Technique Can Be Taught without Hospitalization. Lester, F.T.; 

Demissie, Y.; Negash, A. Ethiopian Medical Journal. 28(4): 191-195. October 1990. 

OBJECTIVE: To assess the feasibility of outpatient instruction in insulin injection technique 

for patients with diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Outpatient instruction in insulin injection technique is safe and feasible. 

RECOMMENDATION: None. 

ABSTRACT: The authors assessed the feasibility of outpatient instruction in insulin injection 

technique as an alternative to the traditional Ethiopian practice of inpatient instruction for 

patients with diabetes. A total of 144 patients were instructed in insulin injection technique 

over a 1-year period at an Addis Ababa hospital; 85 of these patients were instructed while 

hospitalized and 59 were instructed as outpatients. Patients were instructed in a single group 

by two nurses; sessions were held 6 days a week. Outpatients needed an average of 4.7 days 

to learn the technique; an additional 3 to 4 weeks of frequent monitoring was needed to attain 

control. No severe hypoglycemic reactions were seen among the outpatients. Instruction was 

unsuccessful for two very symptomatic outpatients. Six to 16 months after the instruction 

period, 62.7 percent of the outpatients but only 50.6 percent of the inpatients were still 

attending the clinic. Hospitalization is disruptive and costly and diabetic control achieved there 

is artificial, i.e., control has not been achieved in the patient's natural environment. 3 tables, 6 

references. 

37 

TITLE: Insulin-Glyburide Combination Therapy for Non-Insulin-Dependent Diabetes 

Mellitus: A Long-Term Double-Blind, Placebo-Controlled Trial. Casner, P.R. Clinical 

Pharmacology and Therapeutics. 44(5): 594-603. November 1988. 

OBJECTIVE: To determine whether the combination of a sulfonylurea agent and insulin can 

improve glycemic control in patients with type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Statistical analysis. 

Perspective: Health care system. 
CONCLUSION: The combination of a sulfonylurea agent and insulin did not improve 

glycemic control during the study year, and the extra cost and inconvenience of combination 

therapy would not make it worthwhile except in a few select patients. 

RECOMMENDATION: Providing combination therapy in a pulse form instead of 

continually may be more effective and may need to be studied; insulin clamp studies are 

required to address insulin sensitivity. 

ABSTRACT: Sixty-four patients with insulin-treated type 2 diabetes were treated with a 

combination of insulin and oral sulfonylurea therapy or insulin and a placebo in a double-blind 

controlled trial conducted over 12 months. There were no significant differences between the 

two groups of patients except for age; the control group was 4.2 years older. In the treatment 

group, fasting blood glucose concentrations were significantly below those for the control 

group only at 3 and 4 months. Insulin dose for the treatment group was significantly below the 

dose for the control group at month 8 only. In comparisons of the two groups, 

glycohemoglobin values were significantly lower for the control group at months 3 and 6 only; 

C-peptide levels were significantly higher in the treatment group at 3 and 9 months only. At 

each visit, placebo or glyburide was titrated to higher doses, with both groups attaining 

maximal dosage (20 mg/day). Oral glucose tolerance test results did not significantly differ 

between groups except at 3 months, when the control group's were higher. The treatment 

group was divided into responders (a fasting blood glucose concentration # 140mg/dL on at 

least 3 visits and a 25 percent reduction in total daily insulin requirements sometime during the 

study) and nonresponders. Forty-two percent were responders; 29 percent of these responders 

received a > 50 percent reduction of insulin dose at some time during the study. By the end of 

the study, the daily insulin dose for responders was about 50 percent lower than that of the 

control group and non-responders, suggesting that combination therapy may improve insulin 

sensitivity and enhance insulin secretion. Patients in the treatment group experienced no 

serious side effects from the combination of insulin and glyburide. Combination therapy may 

increase the cost of treatment by nearly 50 percent, and its effect appears to be transitory in 

most patients. Patients most likely to benefit are those who show an increase in C-peptide 

levels when taking oral hypoglycemics. 6 figures, 2 tables, 41 references. 

38 

TITLE: Less Expensive, Reliable Blood Glucose Self-Monitoring. Spraul, M.; Sonnenberg, 

G.E.; Berger, M. Diabetes Care. 10(3): 357-359. May-June 1987. 

OBJECTIVE: To determine whether splitting test strips for capillary blood glucose selfmonitoring will permit reliable measurement of blood glucose levels. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 
CONCLUSION: Cutting capillary blood glucose test strips (Chemstrips bG) in half had no 

effect on the reliability of self-assessment of blood glucose levels and halved the cost of the 

test. 

RECOMMENDATION: All patients should be advised to split their test strips (Chemstrips 

bG) to reduce the costs of blood glucose self-monitoring. 

ABSTRACT: The authors tested the reliability of using split test strips to self-assess blood 

glucose levels by experimenting with Haemoglukotest 20-800 (Chemstrips bG) test strips. Ten 

participants (patients and laboratory personnel) who were trained in reading test strips but had 

never used split test strips were each asked to test blood samples using 10 full-size strips, 10 

strips halved mechanically with a splitting device, and 10 strips halved manually with scissors. 

Results were compared with plasma glucose concentrations measured in a Beckman glucose 

analyzer. The correlation coefficients (r) values for uncorrected plasma glucose concentrations 

were 0.95 for full-thickness strips, 0.966 for mechanically split strips, and 0.966 for manually 

split strips, respectively. The mean absolute deviation from the reference value and standard 

error (in mg/dl) was 17 " 2 for full strips, 17 " 1 for mechanically split strips, and 17 " 1 for 

manually split strips. There was no significant difference between the three self tests and the 

laboratory analyzer by analysis of variance (p = .98), variance between participants (p = .12), 

or interrelationship between participants' readings and the three methods (p = .61). Test strips 

reliably monitor blood glucose concentrations, and halving the strips with scissors cuts the 

cost of monitoring in half without reducing reliability. Patients should be advised to use split 

test strips to save money. 1 figure, 1 table, 5 references. 

39 

TITLE: Lifetime Benefits and Costs of Intensive Therapy as Practiced in the Diabetes 

Control and Complications Trial. The Diabetes Control and Complications Trial Research 

Group. Journal of the American Medical Association (JAMA). 276(17): 14091415. 

November 6, 1996. 

OBJECTIVE: To examine the costs and benefits of intensive treatment of type 1 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Intensive therapy for those meeting eligibility criteria would improve quality 

and length of life and represents a good monetary value. 

RECOMMENDATION: None. 
ABSTRACT: The authors developed a Monte Carlo simulation model to estimate the lifetime 

benefits and costs of conventional and intensive insulin therapy for patients with type 1 

diabetes. The intensive therapy regimen was designed to achieve blood glucose levels as close 

to the nondiabetic range as possible with three or more daily insulin injections or with 

treatment with an insulin pump, self-monitoring of blood glucose levels four times daily, and 

monthly outpatient visits with a multidisciplinary team. Conventional therapy consisted of one 

or two injections each day, daily self-monitoring, and quarterly visits. Data were collected as 

part of the Diabetes Control and Complications Trial (DCCT) and supplemented with data 

from other clinical trials and epidemiologic studies. The authors assumed that approximately 

17 percent of the U.S. population with type 1 diabetes (120,000 persons) would qualify for 

enrollment in the DCCT. They included all direct medical costs for the Cost-effectiveness 

analysis but did not include direct nonmedical costs (e.g., transportation, lodging) or potential 

production losses arising from disease related absence from work, long-term disability, or 

premature death. The costs of conventional and intensive therapy were based on actual 

resources used in the DCCT. The Monte Carlo model simulated the course of the patient's 

disease over his or her expected lifetime. The authors found that implementing intensive rather 

than conventional therapy among the 120,000 persons meeting DCCT criteria would gain 

920,000 years of sight, 691,000 years free from end stage renal disease, 678,000 years free 

from lower extremity amputation, and 611,000 years of life, at an additional cost of $4 billion 

(1994 U.S. dollars with future costs and effects discounted 3 percent) over the lifetime of the 

group. The incremental cost per year of life gained was $28,661. The incremental cost per 

quality-adjusted life-year gained with intensive treatment was $19,987. 2 figures, 4 tables, 49 

references. 

40 

TITLE: Management of Patients with Diabetes by Nurses with Support of Subspecialists. 

Peters, A.L.; Davidson, M.; Ossorio, R.C. HMO Practice. 9(1): 8-13. March 1995. 

OBJECTIVE: To describe a program for managing patients with diabetes via diabetes nurses 

within a health maintenance organization (HMO) system, and to report on the costeffectiveness of the program. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Patients achieved significant decreases in glycated hemoglobin levels; the 

program appears to have achieved substantial cost savings by avoiding acute hospitalizations 

for diabetes in 244 patients. 

RECOMMENDATION: None. 
ABSTRACT: Staff at the Cedars-Sinai Medical Center in Los Angeles developed a program 

to manage diabetes patients called the Comprehensive Diabetes Care Service. Diabetes nurse 

specialists, supervised by diabetologists, provide diabetes and lipid management per protocols. 

Staffing ratios are one nurse and one staff assistant for each 250 patients with diabetes and 

one diabetologist for each 1,000 patients. An independent practice association at the hospital 

with approximately 150 physicians and a capitation contract with 12 HMOs (as of 1986) was 

persuaded to participate in the diabetes program. The program began in February 1987 with a 

capitated population of approximately 8,000; in July 1994, that population was approximately 

65,000. Actual patients with diabetes followed in the program numbered 236 in January 1990 

and 754 in December 1993. A diabetologist sees the patient in conjunction with the nurse 

initially and annually. The nurse sees the patient quarterly and follows a defined format at each 

visit. Patients are referred to a dietitian at entry and are seen by an ophthalmologist at their 

first visit. A computer system was designed to improve patient management. The authors 

found that glycated hemoglobin levels improved significantly (p < 0.01) in a subset of all 

patients and a subset of compliant patients but not in noncompliant patients. The authors 

estimated that over a 4-year period (1990 to 1993), 244 patients who would probably have 

been hospitalized by other physicians at the hospital were not because of the intensive 

outpatient follow-up available. The authors estimated the potential net cost savings to be 

$568,721 over the 4 years. 1 figure, 2 tables, 9 references. 

41 

TITLE: Nursing Case Management: An Innovative Model of Care for Hospitalized Patients 

with Diabetes. Edelstein, E.L.; Cesta, T.G. Diabetes Educator. 19(6): 517-521. NovemberDecember 1993. 

OBJECTIVE: To evaluate the effect of using a diabetes team with a case management 

approach to quality of care and length of hospital stay. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Length of hospital stay was reduced for patients with a primary and 

secondary diagnosis of diabetes whose care was managed by the team. Blood glucose control 

before discharge was at least fair in more than 98 percent of team patients before discharge. 

RECOMMENDATION: None. 

ABSTRACT: The authors reported on 160 patients admitted to Beth Israel Medical Center 

in New York City who did not have private physicians. Eighty-five patients had a principal 

diagnosis of diabetes; 49, a secondary diagnosis of diabetes; and 26 were antepartum patients 

admitted for blood glucose control. A team consisting of a case manager, diabetes nurse 
educator, diabetologist, and nutritionist managed the care of these patients. Consultations per 

patient totaled 7.5; average length of stay of the patients with a principal diagnosis of diabetes 

was 4.14 days, 58 percent lower than the hospital's 1990 average for such patients. For 

patients with a secondary diagnosis of diabetes, the average length of stay was 14 percent 

below the 1990 Beth Israel average. The study readmission rate was 7.33 percent within 30 

days of discharge, but readmissions were unrelated to diabetes. The team patients had 

excellent (28.7 percent), good (26.9 percent), or fair (42.7 percent) blood glucose control 

prior to discharge. 3 figures, 14 references. 

42 

TITLE: Pointers to Preventing Hyperglycaemic Emergencies in Soweto. Buch, E.; Irwig, 

L.M.; Huddle, K.R.; Krige, L.P.; Krut, L.H.; Kuyl, J.M. South African Medical Journal. 64 

(18): 705-709. October 22, 1983. 

OBJECTIVE: To analyze emergency hospital admissions for hyperglycemia in Soweto, 

South Africa, including associated costs; to assess the use of health services by emergency 

patients before and after hospital admission. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Health service costs for admissions for hyperglycemic emergencies in 

Soweto were estimated as at least 462,000 rand (South African currency) in 1981; many 

admissions were preventable, and patient use of health resources and self-monitoring prior to 

and after admission were inadequate. 

RECOMMENDATION: Ambulatory services for patients with diabetes should be developed 

and upgraded in Soweto, with the following specific considerations: improved patient 

education, allocation of special staff for hyperglycemic emergencies, establishment of a 

registry for such emergencies, improved records systems, and application of complianceimproving strategies. 

ABSTRACT: The authors reviewed the incidence of admissions for hyperglycemic 

emergencies during a 2-month period in 1981 at Baragwanath Hospital in Soweto, the 

associated costs, and the use of health services by patients with diabetes prior to and following 

admission. Problems related to providing diabetes care are compounded in Soweto by poor 

socioeconomic conditions. During the study period, 60 patients were admitted for 

hyperglycemic emergencies; 15 (25 percent) died in the hospital; just 3 of the deaths may have 

been unrelated to the emergency. Of 56 patients interviewed, 7 percent were previously 

undiagnosed with diabetes. Average hospital stay was 20 days, and the estimated cost of 

treating the emergency admissions during the study period was 77,000 rand. Of the 49 

patients known to have diabetes prior to admission, only 19 (39 percent) had attended any 
health services 3 or more times during the 3 months before admission, and 25 percent had not 

attended a health service at all. (Three attendances would be the minimum to receive adequate 

medication.) Of the 36 patients with whom follow-up interviews were conducted 3 months 

after discharge, 12 (33 percent) had been readmitted. Extrapolating from the study sample, the 

cost of hyperglycemic emergencies to Soweto's health services was estimated as at least 

462,000 rand for 1981. 5 figures, 3 tables, 7 references. 

43 

TITLE: Precision and Costs of Techniques for Self-Monitoring of Serum Glucose Levels. 

Chiasson, J.L.; Morrisset, R.; Hamet, P. Canadian Medical Association Journal. 130(1): 38-

43. January 1984. 

OBJECTIVE: To evaluate the accuracy and cost of blood glucose monitoring techniques 

involving a glucose oxidase reagent strip with or without a reflectance meter. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The techniques evaluated, particularly those involving reflectance meters, 

compared favorably with standard laboratory methods, were easy to perform, and were less 

expensive. 

RECOMMENDATION: Blood glucose monitoring using a glucose oxidase reagent strip 

and reflectance meter should be considered a feasible, cost-effective alternative to standard 

laboratory testing. 

ABSTRACT: The authors evaluated the accuracy and cost of seven blood glucose 

monitoring techniques available for patient self-monitoring; they also examined the correlation 

between serum glucose concentrations obtained. The blood glucose techniques, which 

involved a glucose oxidase reagent strip with or without a reflectance meter, were evaluated 

in more than 100 patients with or without diabetes. Two of the techniques were tested by 

members of a rotating staff of hospital nurses, all seven by a nurse specifically trained for the 

task, and four of the seven by the patients themselves. Results were compared with reference 

values determined by the hexokinase method in a hospital biochemistry laboratory using the 

Simultaneous Multiple Analysis, Computerized (SMAC) or Autoanalyzer II (AAII) 

(Technicon Instruments Corporation, Tarrytown, New York) assays. Costs were evaluated 

via a survey of drugstore prices. Techniques involving a reflectance meter showed excellent 

correlation with the laboratory reference method (r2 = 0.85 to 0.96) for all three types of 

testers. Correlation with the reference standard was poorer for techniques not involving a 

reflectance meter (r2 = 0.69 to 0.90); correlation improved when the techniques were 

performed by a specially trained nurse. Reflectance meters ranged in price (Canadian dollars) 

from $290 to $565. Costs for bottles of 25 reagent strips ranged from $13 to $19.80. Costs 
for each determination using the self-monitoring techniques ranged from $0.46 to $0.99; these 

values were up to three times less expensive than the laboratory methods ($1.86 for the 

SMAC and $1.04 for the AAII). These blood glucose monitoring techniques, particularly 

those using a reflectance meter, were reliable, easily performed by patients, and less expensive 

per determination when compared with laboratory testing. In contrast, the correlation between 

urine and glucose levels was poor (r2 = 0.21). 4 figures, 12 tables, 19 references. 

44 

TITLE: Randomized Controlled Multicentre Evaluation of an Education Programme for 

Insulin-Treated Diabetic Patients: Effects on Metabolic Control, Quality of Life, and Costs of 

Therapy. de Weerdt, I.; Visser, A.P.; Kok, G.J.; de Weerdt, O.; van der Veen, E.A. Diabetic 

Medicine. 8(4): 338-345. May 1991. 

OBJECTIVE: To assess the effect of an education program for insulin-treated patients with 

diabetes on their metabolic control, quality of life, and costs of therapy. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The education program had no effect on metabolic control, quality of life, 

and costs of therapy, although the patients significantly increased their level of self-monitoring 

blood glucose and diabetes knowledge. The authors suggest various reasons for the failure to 

find effects. 

RECOMMENDATION: None. 

ABSTRACT: This study was conducted in 15 randomly selected hospitals in The 

Netherlands. Control patients were taken from 5 hospitals and intervention patients 

(experimental) from the other 10. In five of the experimental hospitals the program was led by 

a health care worker; in the other five, by a fellow patient. A total of 625 patients were asked 

to participate, 558 (89 percent) of whom agreed. Each group had 40 to 50 patients. The 

patient characteristics of the groups (age, occupational status, duration of diabetes, duration 

of insulin use, and number of daily injections) did not differ significantly. Patients in the 

experimental group were evaluated immediately before and after the education program and at 

1 and 6 months following the program's conclusion. Patients in the control group were 

assessed twice (at 6- to 7-month intervals). At each evaluation, participants completed a 

questionnaire and a blood sample was taken. The effect of the program on metabolic control 

(glycosylated hemoglobin, serum fructosamine concentration, number and severity of 

hypoglycemic reactions, and clinical signs of poor control), quality of life (Affect-Balance 

Scale and subjective social indicators), and costs of therapy (hospitalizations, doctor visits, 

medication, self-testing, sick days, and cost of education program) was assessed. No 

significant effect from the education program on any one of these variables could be found, 
although there was significant improvement in self-care and diabetes knowledge. This lack of 

effect could be due to the quality of the education program, short follow-up of the study, the 

lack of integration of the education program in standard therapy, the lack of follow-up of the 

education given, or the lack of concurrent changes in diabetes therapy. 4 tables, 30 references. 

45 

TITLE: A Risk-Benefit Assessment of Conventional versus Intensive Insulin Therapy. 

Reichard, P. Drug Safety. 10(3): 196202. March 1994. 

OBJECTIVE: To assess the benefits of intensive insulin therapy for type 1 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Intensified insulin therapy leads to a slowing down or halting of 

microvascular complications in patients with type 1 diabetes, including those with diabetes of 

short duration and those with longer term diabetes and nonproliferative retinopathy. 

RECOMMENDATION: An intensified treatment program is generally indicated for the 

majority of adults with type 1 diabetes; such treatment should start before the complications 

become too advanced. 

ABSTRACT: The author explores whether intensified insulin treatment to lower blood 

glucose concentrations is effective in reducing diabetes complications by addressing five 

questions: (1) Is there an association between blood glucose concentrations and 

complications? (2) Is the association causal? (3) Are there any adverse effects of intensified 

treatment? (4) Is intensified treatment acceptable? and (5) How great could the gains be with 

general acceptance and execution of the treatment program? By reviewing various studies, 

most notably the Stockholm Diabetes Intervention Study and the Diabetes Control and 

Complications Trial, the author finds the following: Lower blood glucose concentrations are 

associated with reduction of complications affecting the eyes, kidneys, and nerves. 

Prospective, randomized studies are needed to answer the question of a causal association. 

The chief adverse effects of intensified insulin treatment are weight gain and an increased 

frequency of serious hypoglycemic episodes. Intensified treatment is acceptable to patients. 

The gains are very large, not only for the individual patient, but also for society as a whole. 

The author speculates that if 400,000 patients were put on an intensive treatment program, 

64,000 who would develop nephropathy if conventionally treated would not do so, and 

100,000 would not need laser treatment for retinopathy who otherwise would. Implementing 

an intensified treatment program for type 1 diabetes would bring a significant reduction of 

serious complications and a gain in terms of patient discomfort and cost. 2 figures, 32 

references. 
46 

TITLE: Utility of Serum Fructosamine as a Measure of Glycemia in Young and Old Diabetic 

and Non-Diabetic Subjects. Negoro, H.; Morley, J.E.; Rosenthal, M.J. American Journal of 

Medicine. 85(3): 360-364. September 1988. 

OBJECTIVE: To determine the utility of a serum fructosamine assay as a measure of 

glycemia. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Serum fructosamine was comparable to other measures of glycemia. 

RECOMMENDATION: Serum fructosamine should be considered superior to measures of 

other glycosylated proteins because of its automaticity, reproducibility, and lower cost. 

ABSTRACT: The authors evaluated the utility of serum fructosamine as a measure of 

glycemia by comparing it with other standard glycemic indices: glycosylated hemoglobin, 

glycosylated albumin, and fasting glucose. Participants were 145 adults in six categories, 

including two groups of healthy persons (aged 22 to 50 and 64 to 86) without diabetes; one 

group with chronic debilitating illness (aged 60 to 91); otherwise healthy persons in a 

maintenance methadone program; and two groups (mean ages: 48 and 70 years) of patients 

with diabetes. Blood samples were collected at 8 a.m. after a 12-hour fast. Serum 

fructosamine detected glycemia as well as the established tests, and fructosamine 

concentrations correlated well with serum glycosylated hemoglobin, glycosylated albumin, and 

fasting glucose. Fructosamine concentrations were not significantly affected by any of a large 

battery of medications or by large differences in plasma lipid levels. Age did not affect serum 

fructosamine concentration, which makes this a particularly useful test for older persons with 

diabetes. Serum fructosamine is also amenable to automated determination and is far simpler 

and less expensive than assays for glycosylated proteins. The current charge to patients for 

assays is $6.50 for plasma glucose, $8.00 for fructosamine, $26.00 for glycosylated 

hemoglobin, and $31.00 for glycosylated albumin. 2 figures, 3 tables, 27 references. 

47 

TITLE: Variation in Office-Based Quality: A Claims-Based Profile of Care Provided to 

Medicare Patients with Diabetes. Weiner, J.P.; Parente, S.T.; Garnick, D.W.; Fowles, J.; 

Lawthers, A.G.; Palmer, R.H. Journal of the American Medical Association (JAMA). 273 

(19): 1503-1508. May 17, 1995. 
OBJECTIVE: To demonstrate that profiling of claims data can be used as an ongoing 

method to support ambulatory care quality improvement, to measure the quality of officebased care provided to elderly patients with diabetes, and to identify factors associated with 

higher or lower conformance to recommended criteria of care. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Claims review. 

Perspective: Health care system. 

CONCLUSION: The care of elderly patients with diabetes is not meeting nationally 

recommended guidelines; screening rates are particularly low in rural areas. Examining 

Medicare claims has great potential for measuring patterns of care. 

RECOMMENDATION: Programs should be established to disseminate clinical practice 

guidelines relevant to primary care of diabetes and further research should be conducted to 

delineate variations in office practice patterns. 

ABSTRACT: The authors assessed the quality of office-based care provided to elderly 

patients with diabetes. Data were derived from review of all Medicare claims (Parts A and B) 

in Alabama, Iowa, and Maryland for July 1990 to June 1991 for patients aged 65 years and 

over. Four services/procedures were identified as quality indicators for diabetes: three 

(hemoglobin A1c measurement, ophthalmologic exam, and total cholesterol measurement) 

were to be performed at least annually; the fourth, blood glucose measurement, was identified 

as a limited-use procedure. Across the three states, only 16.3 percent of patients with diabetes 

underwent hemoglobin A1c measurement, 45.9 percent received an ophthalmologic exam, and 

55.1 percent underwent cholesterol measurement at least once during the year. In contrast, 

four-fifths (80.5 percent) of patients underwent blood glucose measurement. In almost all 

instances, practice patterns varied significantly across the three states, even after controlling 

for practice and patient characteristics. With the exception of ophthalmologic exams, rates of 

procedures were significantly lower in rural areas. Results demonstrate that elderly patients 

with diabetes are not receiving optimal care; a large gap exists between national practice 

guidelines and actual primary care practice. Clinical practice guidelines need to be more 

widely disseminated. Further research is needed to identify the causes of variation across 

office practices in order to design quality improvement programs. 3 tables, 38 references. 

Nutrition Care 

48 

TITLE: Cost-Effectiveness of Medical Nutrition Therapy Provided by Dietitians for Persons 

with Non-Insulin-Dependent Diabetes Mellitus. Franz, M.J.; Splett, P.L.; Monk, A.; Barry, B.; 

McClain, K.; Weaver, T.; Upham, P.; Bergenstal, R.; Mazze, R.S. Journal of the American 
Dietetic Association. 95(9): 1018-1024. September 1995. 

OBJECTIVE: To report on the cost-effectiveness of nutrition care by practice guidelines for 

patients with type 2 diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The implementation of nutrition guidelines in type 2 diabetes can be met 

with a reasonable investment of resources and improvement in metabolic control. 

RECOMMENDATION: Additional research should be conducted before more intensive 

nutrition intervention can be recommended as the preferred approach for patients with type 2 

diabetes. 

ABSTRACT: The authors conducted a cost-effectiveness analysis of 179 adult patients with 

type 2 diabetes randomized to basic nutrition care (n = 85) or nutrition care following practice 

guidelines (n = 94). Basic care included just one visit from the dietitian; practice guidelines, 

three or more. The defined outcome for the cost-effectiveness analysis was the effect of 

nutrition care on glycemic control at 6 months as measured by changes from baseline in levels 

of fasting plasma glucose and glycated hemoglobin. Costs were limited to those for direct 

health care as documented through an accounting approach. The per-patient cost (1993 

dollars) of providing basic care was $41.95; the comparable cost for guidelines care was 

$112.07. Each mg/dL of change in the fasting plasma glucose concentration after 6 months of 

intervention required an investment of $5.75 in the basic group and $5.84 in the guidelines 

group. When net costs were considered (per-patient costs minus cost savings due to changes 

in therapy), the required investments were $5.32 and $4.20 for the basic and guidelines 

groups, respectively. Changes in medical therapy resulted in a per-patient cost savings over 12 

months of $31.49 in the guidelines group and $3.13 in the basic group. Sensitivity analysis 

showed that the relative cost-effectiveness of guidelines care versus basic care was unchanged 

by dietitian salary or additional laboratory testing. Results show that nutrition therapy can be 

provided in a cost-effective manner. Additional information is needed, however, before more 

intensive nutrition intervention can be recommended as the preferred approach for type 2 

patients. 5 tables, 26 references. 

49 

TITLE: Effects of Diet and Exercise Interventions on Control and Quality of Life in NonInsulin-Dependent Diabetes. Kaplan, R.M.; Hartwell, S.L.; Wilson, D.K.; Wallace, J.P. 

Journal of General Internal Medicine. 2(4): 220-228. July-August 1987. 

OBJECTIVE: To assess the impact of diet and exercise on glycemic control and quality of 

life in patients with type 2 diabetes. 
CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Patients in the diet-plus-exercise group significantly improved their quality 

of life and significantly decreased their glycosylated hemoglobin (HbA1C) over 18 months. 

RECOMMENDATION: Additional studies of nonpharmacologic intervention for patients 

with type 2 diabetes are needed using larger sample sizes. 

ABSTRACT: The authors report a study of 70 volunteers with type 2 diabetes who were 

randomized to one of four types of nonpharmacologic management: diet, exercise, diet and 

exercise, or education (control group). All participants were given the same diet (the 

exchange diet recommended by the American Diabetes Association) and asked to attend 10 

consecutive weekly meetings; exercise routines were prescribed individually based on graded 

exercise tests. The intervention groups underwent behavioral modification sessions that 

included goal-setting and diet and/or exercise plans. The control group received lectures from 

a variety of health care specialists but no specific behavior modification plans. After 3 and 6 

months, the diet group had significantly greater weight loss than the control group (2.52 kg 

loss versus a gain of 1.37 kg), but at 18 months, the diet group had regained an average of 

1.81 kg. Also at 18 months, the diet-plus-exercise group had reduced its HbA1C levels from 

9.18 to 7.70 percent, versus an increase from 8.21 to 8.57 percent for the controls (p < 0.05). 

Changes in HbA1C in the diet-only and exercise-only groups were not significant compared 

with controls. Over 18 months, quality of life improved for participants in the combined 

intervention group, improved less markedly for the diet group, remained relatively static in the 

exercise group, and deteriorated for the control group. Estimated direct cost of the diet-plusexercise intervention was $1,000 per participant per year; this program yielded 0.092 years of 

well-being over that obtained by the control group, which was actually less than zero. Thus, 

the cost of producing a well year was $10,870. 2 figures, 4 tables, 19 references. 

50 

TITLE: Reliability and Cost of Diabetic Diets. Tunbridge, R.; Wetherill, J.H. British Medical 

Journal. 2(701): 78-80. April 11, 1970. 

OBJECTIVE: To ascertain the adherence of patients with diabetes mellitus to the 

recommended diet, and to calculate the cost of maintaining the recommended diet. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 
Perspective: Health care system. 

CONCLUSION: Thirty percent of patients adhered to within 10 percent of their 

recommended diet. The cost of the recommended diet was higher than the cost of food for the 

general population. 

RECOMMENDATION: None. 

ABSTRACT: The authors reported on adherence to prescribed diets for 63 patients attending 

the diabetes clinic at the General Infirmary in Leeds, England, for a single week in the spring 

of 1968. Dietary control was satisfactory (90 to 100 percent within guidelines) for 30 percent 

of patients, tolerable (80 to 89 percent within guidelines) for 38 percent, and "hopeless" (less 

than 80 percent within guidelines) for 32 percent. Less than one-third of women (n = 35) and 

men (n = 28) followed satisfactory diets. Adherence was best among participants aged 40 

years and under and worst among those aged over 60 years. Dietary control was poorer 

among participants treated by diet plus oral hypoglycemic agents than in those treated by 

dietary control with or without insulin; it was poorer among those diagnosed within 10 years 

than among those diagnosed for more than 10 years. Dietary control was best with diets of 

1,201 to 1,999 calories and worst with 1,200 calories or less. Diabetes control was 

satisfactory (blood glucose between 50 and 200 mg/ml, no ketonuria, weight steady) in 42 

percent of patients with satisfactory diets, 33 percent of those with tolerable diets, and 40 

percent of those with hopeless diets. The estimated cost per patient per week to follow an 

ideal diet was 44 shillings and 1 penny, versus 38 shillings, 4 pennies for the general 

population. Low-income patients continue to have difficulty purchasing the food to maintain a 

correct diet. 7 tables, 5 references. 

51 

TITLE: Spin-Off Cost/Benefits of Expanded Nutritional Care. Davidson, J.; Delcher, H.; 

Englund, A. Journal of the American Dietetic Association. 75(3): 250-257. September 1979. 

OBJECTIVE: To describe and evaluate an expanded nutrition care program developed in a 

hospital diabetes unit; to compare projected costs of continuing the preintervention program 

with actual costs incurred with the expanded intervention. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Over an 8-year period, the expanded nutrition care program saved the 

hospital $379,988 from reduced use of insulin (1973 to 1978 only) and no use of oral agents 

and over $3,700,000 from decreased incidence of lower extremity amputations and severe 

diabetic ketoacidosis. Net savings for the year 1978 were $216,699. 
RECOMMENDATION: Registered dietitians should collaborate with physicians and nurses 

to organize health care teams that will provide expanded nutrition care programs for all 

Americans who have diabetes. 

ABSTRACT: The authors describe the outcome of an expanded nutrition care program 

developed over an 8-year period (1971-1978) in the Grady Memorial Hospital Diabetes Unit 

in Atlanta, Georgia; Grady is the primary teaching hospital of the Emory University School of 

Medicine. Projected costs of continuing the pre-1971 program, which consisted of basic 

nutrition care with high use of insulin and oral agents, were compared with actual costs of the 

expanded program. The latter program emphasized short-term fasts, hypocaloric diets, patient 

education and follow-up, discontinued oral agents, and limited use of insulin. Total costs of 

the pre-1971 program were estimated at $125,863 per year, including $43,176 for oral agents, 

$23,723 for insulin, $23,963 for the basic nutrition program, and $35,000 for personnel, 

facilities, and supplies. Estimated total cost of the expanded nutrition care program for the 

year 1978 was $615,164, including approximately $500,000 for personnel, facilities, and 

equipment; $73,391 for expanded nutrition care; and $41,774 for insulin. Despite these 

increased costs, the hospital had an estimated net savings of $216,699 for that year, as it saved 

more than $706,000 because of decreased prevalence of severe diabetic ketoacidosis and 

severe lower extremity amputations. During the 8-year study period, decreased hospitalization 

for severe diabetic ketoacidosis and lower extremity amputation provided the hospital with 

gross savings of more than $3.7 million. 2 figures, 9 tables, 15 references. 

Educational Programs 

52 

TITLE: Comparison of Five Glucose Meters for Self-Monitoring of Blood Glucose by 

Diabetic Patients. Gifford-Jorgensen, R.A.; Borchert, J.; Hassanein, R.; Tilzer, L.; Eaks, G.A.; 

Moore, W.V. Diabetes Care. 9(1): 70-76. January-February 1986. 

OBJECTIVE: To compare the accuracy, ease of operation, and cost of five self-monitoring 

blood glucose meters. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: For four of the five meters, adjusted blood glucose values were not 

significantly different from laboratory values. Various advantages and disadvantages were 

found relative to price, calibration, strip utilization, and ease of operation. 

RECOMMENDATION: Patient education is absolutely necessary for accurate use of the 
blood glucose meters. 

ABSTRACT: The authors assessed five kinds of currently marketed meters for home use: 

Accu-Chek (Bio-Dynamics, Inc.); Glucochek II bG (Medistron/Larken), with Chemstrip bG 

reagent strips; Glucochek II-Dextro (Medistron/Larken), with Dextrostix reagent strips; two 

Glucometer (Ames Division, Miles Laboratories) reflectance photometers, with calibration 

either by fluids or special chips; and Glucoscan II (LifeScan, Inc.). Fasting blood samples were 

taken from patients (n = 37) at the University of Kansas College of Health Sciences and 

Hospital and tested immediately on the meters. Blood samples were also taken to the 

laboratory for serum testing according to the glucose-oxidase method. When unadjusted 

meter readings of whole blood glucose were plotted against laboratory values, three of the 

meters had a 35-49 percent inaccuracy rate; for the other two, inaccuracy rates were 65 and 

70 percent. After adjustment of the whole blood glucose values to match the serum values, 

only the Glucochek II-Dextro with Dextrostix reagent strips had significantly different values. 

(A technical revision by the manufacturers may have changed this meter's performance.) For 

blood glucose ranges of both 60-180 mg/dL and 181-300 mg/dL, all meters except Glucoscan 

II were at least 95 percent accurate. For values of 301-400 mg/dL, both the Glucometer (with 

"CHIP" calibration) and the Glucoscan II were less than 95 percent accurate. Prices 

approximated $150 for the Accu-Chek and the Glucometers, $140 for the Glucochek models, 

and $178 for the Glucoscan II; 404 to 704 for reagent strips. The Glucoscan II and the two 

Glucochek models were factory calibrated; the other models required periodic recalibration. 7 

figures, 3 tables, 32 references. 

53 

TITLE: Conference Report: Approaches to the Treatment of Type II Diabetes and 

Developments in Glucose Monitoring and Insulin Administration. Bloomgarden, Z.T. 

Diabetes Care. 19(8): 906-909. August 1996. 

OBJECTIVE: To review presentations at conferences held in 1996 concerning treatment of 

type 2 diabetes and developments in glucose monitoring systems and insulin administration. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Conference summary. 

Perspective: Health care system. 

CONCLUSION: None. 

RECOMMENDATION: None. 

ABSTRACT: The author reviews 1996 conference presentations concerning treatment of 

type 2 diabetes, glucose monitoring, and insulin administration. In 1992, medical costs for 

diabetes were 12 percent of total health care costs, but only 8 percent of patient visits were to 
diabetes specialists. For each 1 percent fall in hemoglobin A1c (HbA1C), development of 

proliferative retinopathy and nephropathy falls 50 percent. Diet and exercise are effective in 

controlling blood glucose and in decreasing the risk of developing type 2 diabetes. Elizabeth 

Barrett-Connor suggested that achieving glycemic control is not a key to decreasing mortality. 

A speaker on managed care stated that protocol-based care is needed, and that outcomes and 

costs should be followed. Researchers in England are looking at the effect that controlling 

blood glucose and hypertension has on outcome for patients with type 2 diabetes. A new 

study of the effects of obesity and exercise on development of type 2 diabetes is about to start. 

According to one speaker, Julio Santiago, most self-glucose monitoring is a waste of money. 

He indicated that an annual investment of $2,000 per patient would decrease mortality 

substantially in patients with diabetes (supporting data are available). Santiago proposed that 

therapeutic programs use algorithms based on the HbA1C, the fasting blood glucose value, 

and the avoidance of hypoglycemia. Another speaker stated that home blood glucose meters 

are inaccurate, especially at glucose concentrations less than 75 mg/dL. An implantable insulin 

pump was found to decrease blood glucose and HbA1C, but infections, mechanical failures, 

and cost were problems. Inhalation, trans-dermal delivery, and sonophoresis are being 

investigated, as is the use of computer programs for records management and treatment 

advice. 4 references. 

54 

TITLE: The Diabetes Education Study: A Controlled Trial of the Effects of Diabetes Patient 

Education. Mazzuca, S.A.; Moorman, N.H.; Wheeler, M.L.; Norton, J.A.; Fineberg, N.S.; 

Vinicor, F.; Cohen, S.J.; Clark, C.M. Diabetes Care. 9(1): 1-10. January-February 1986. 

OBJECTIVE: To assess, in the context of a randomized clinical trial, the impact of an 

education program for adult patients with diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Patients in the intervention education group made lasting changes in skills 

and self-care behavior and achieved modest improvement in glycemic control. 

RECOMMENDATION: More research in similar and different settings is needed to 

determine whether the patients from this study are truly representative of patients with type 2 

diabetes. 

ABSTRACT: The authors report the results of the Diabetes Education Study (DIABEDS) 

developed by the Indiana University School of Medicine. The DIABEDS is a randomized, 

controlled trial of patient and physician education in managing diabetes. The 532 patients 

recruited from a clinic population into the study were primarily elderly, female, black, and 
obese; 95 percent had type 2 diabetes. Patients could be assigned to intervention groups 

(patient education, physician plus patient education) or control groups (control group, 

physician education group). Staff were randomly assigned to care groups. Patients in the 

intervention groups (n = 263) received interactive instruction over an 8-week period on 

diabetes and its complications, use of medications, the effects of diet and exercise, foot care, 

urine testing, and behavior modification; they also received meal plans and menus as well as a 

home visit. Patients in the control groups (n = 269) received the standard institutional patient 

education. Patients were assessed at entry into the study and at postintervention periods 

ranging from 6 to 14 months. Two hundred seventy-five patients took part in postintervention 

assessment. On most knowledge items, there was little difference between intervention and 

control groups; intervention patients did better in listing causes of hyperglycemia, knowledge 

of urine test implications, and knowing the diabetes exchange list system. Intervention patients 

were significantly better on two of four urine testing skills as well as on food partitioning 

and/or weighing. In addition, they made more improvement in fasting glucose concentrations, 

glycosylated hemoglobin, body weight, diastolic and systolic blood pressure, and serum 

creatinine concentrations. Intervention patients also had statistically better diet compliance and 

safety habits. 8 tables, 13 references. 

55 

TITLE: Effect of Diabetes Education on Self-Care Metabolic Control and Emotional WellBeing. Flack, J.R. Diabetes Care. 13(10): 1094. October 1990. 

OBJECTIVE: To rebut the assertion by Rubin et al. (Diabetes Care. 12:673-679. 1989) that 

educational programs with a few sessions spread over a long time period are probably less 

effective than a program of 5 consecutive days. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Diabetes education programs that spread the education process over a 

period of time (up to 6 weeks) may be more effective than five consecutive-day programs. 

RECOMMENDATION: Future studies on diabetes programs need to focus on who should 

teach what, when and how it should be taught, and how to assess outcome. 

ABSTRACT: The author questions the contention of Rubin et al. that educational 

interventions for persons with diabetes that consist of a few sessions spread over a long period 

will probably be less effective than the 5 consecutive-day program of Rubin et al. A study 

presented by Beeney et al. (1988) at the 13th International Diabetes Federation meeting 

compared four diabetes education programs over 3 years. At 12 months after entry, 

knowledge improvement was independent of the program format. Psychological adjustment 

was better in patients for whom the program was prolonged for up to 6 weeks. Beeney et al. 
concluded that the demonstrated benefits of extended formats must be rationalized with the 

size and requirements of the population served to determine the most cost-effective program. 

They noted that shorter programs have higher patient turnover. The author suggests that 

diabetes education needs more study in terms of who is to teach what, when and how it 

should be taught, and how to assess a suitable outcome. In a reply, Rubin et al. agree that 

extended education programs can be effective. They state that the content and time devoted to 

teaching are the most important factors in a program, but they indicate that the point of 

diminishing return for the amount of education has not been identified. They recommend that 

future studies seek to identify the content and format that produce the best results. 6 

references. 

56 

TITLE: Effect of Diabetes Education on Self-Care, Metabolic Control, and Emotional WellBeing. Rubin, R.R.; Peyrot, M.; Saudek, C.D. Diabetes Care. 12(10): 673-679. NovemberDecember 1989. 

OBJECTIVE: To determine whether an intensive comprehensive educational program will 

improve emotional well-being, self-care practices, and metabolic control in patients with 

diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Prospective trial. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: An intensive comprehensive educational program improves emotional wellbeing, self-care practices, and metabolic control, especially in patients whose functional status 

in these areas is poor. 

RECOMMENDATION: Randomized, controlled studies are needed to assess more 

definitively the effectiveness of diabetes education programs. 

ABSTRACT: Participants (n = 165) in this study at the Johns Hopkins Diabetes Center were 

enrolled in a week-long outpatient diabetes education program designed to improve self-care 

practices, emotional well-being, and metabolic control. The study population was 70 percent 

white, mean age was 47.4 " 16.5 years, and 59 percent had some college education; most 

participants were overweight. Sixty-three percent were taking insulin, and 62 percent had type 

2 diabetes. Disease complications in the study group included neuropathies, retinopathy, 

vascular complications, and infections. Baseline data were collected on emotional status, selfcare behaviors, diabetes knowledge levels, and glycemic control as measured by hemoglobin 

A1c tests (HbA1C). One hundred twenty-four (75 percent) of the participants completed a 6-

month follow-up questionnaire, and 71 (43 percent) had HbA1C tests at 6-month follow-up. 

At both program end and 6-month follow-up, participants had significantly improved from 
baseline on all measures of emotional well-being as well as on knowledge. At 6 months 

(versus baseline), bingeing was lower (p < 0.01), exercise was more frequent (p < 0.001), selfmonitoring of blood glucose was more frequent (p < 0.001), and HbA1C was lower (p < 

0.001). Program effects were unrelated to demographic or disease characteristics but were 

strongly related to initial status. On six different measures, participants who entered the 

program in the worst condition improved the most; those who entered in the best condition 

improved little, if at all. 1 figure, 3 tables, 28 references. 

57 

TITLE: The Effectiveness of Diabetes Education for Non-Insulin-Dependent Diabetic 

Persons. Scott, R.S.; Beaven, D.W.; Stafford, J.M. Diabetes Educator. 10(1): 36-39. Spring 

1984. 

OBJECTIVE: To determine the effectiveness of a patient education program for patients 

with type 2 diabetes in improving their understanding and management of the disease and their 

use of hospital and specialist services. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: The patient education program did not result in sustained improvement in 

glycemic control or long-term behavior change. 

RECOMMENDATION: The effectiveness of any education program for people with type 2 

diabetes should be carefully assessed, as considerable investment of time by health 

professionals may not result in substantial benefits. 

ABSTRACT: This two-part study was carried out at the Christchurch Diabetes Center in 

New Zealand. In the first part, individuals with type 2 diabetes were referred to a diabetes 

education program where they were randomly assigned to a treatment (n = 32) or control (n = 

28) group. The treatment group entered an education program immediately, while the control 

group entered it four weeks later. Researchers assessed participants' knowledge and anxiety 

levels and glycemic control at the time of referral and 4 weeks later, before the control group 

had begun the education program. At the latter time, assessment indices (plasma glucose; 

urinary glucose; glycosylated hemoglobin; and knowledge, anxiety, and depression levels) in 

the control group showed no significant improvement except for a small increase in the 

knowledge score (p < .05). In the treatment group, knowledge (p < .001), plasma glucose (p 

< .01), glycosylated hemoglobin (p < .1), and anxiety score (p < .1) had all improved, but the 

urinary glucose score had increased (p < .05). Comparison of improvement in the control and 

treatment groups found significant differences in favor of the treatment group for knowledge, 

plasma glucose, glycosylated hemoglobin, and anxiety. In the second part of the study, 30 
patients received education at referral and 26 patients received education after a 4-week delay. 

Glycemic control was assessed at referral, at the end of the program, and 4 weeks after the 

program's completion. In both groups, the mean values for blood glucose and glycosylated 

hemoglobin were not significantly different 4 weeks after program conclusion from the values 

at referral. 2 tables, 7 references. 

58 

TITLE: Effects of Educational Interventions in Diabetes Care: A Meta-Analysis of Findings. 

Brown, S.A. Nursing Research. 37(4): 223-230. July-August 1988. 

OBJECTIVE: To assess the effects of educating patients with diabetes on their knowledge, 

self-care behavior, and metabolic control. 

CATEGORY: Secondary intervention. 

Type of Study: Formal meta-analysis of randomized controlled trials. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Patient education has positive outcomes in adults with diabetes. 

RECOMMENDATION: More research is needed to develop the statistical basis for metaanalysis, and researchers must make data available in a form that permits comparisons with 

other studies. 

ABSTRACT: The author used meta-analysis to explore several issues: What is the magnitude 

of the effect of patient teaching in adults with diabetes? What outcomes from teaching in this 

population have been documented in terms of patient knowledge, self-care, and metabolic 

control? Is there a relationship between outcome effects and various study characteristics 

(e.g., research design, type of instruction)? Data were derived from published and unpublished 

sources; studies had to have a control group (n = 27) or a preintervention control phase (n = 

20) for comparison of results. Studies had been published between 1954 and 1986 (50 percent 

after 1982). The studies included 3,605 patients (range: 8 to 373), 236 effect sizes, and 52 

pooled effect sizes. (An effect size is the difference between the experimental and control 

group in standard score form.) The author found that patient teaching appears to enhance 

patient outcomes in diabetes management; she determined that the weighted mean effect size 

across all studies was 0.33 (i.e., outcomes that are 0.33 standard deviation units higher than 

those for the comparison group). The effect of teaching on patient knowledge was moderate 

to large; on skill performance it was small to low-moderate. There was a small effect of 

teaching on weight loss and a large effect on dietary compliance. Teaching also had a positive 

effect on metabolic control. The only study characteristic to be correlated with overall 

weighted mean effect size was attrition. 3 tables, 59 references. 

59 
TITLE: Evaluating the Costs and Benefits of Outpatient Diabetes Education and Nutrition 

Counseling. Kaplan, R.M.; Davis, W.K. Diabetes Care. 9(1): 81-86. January-February 1986. 

OBJECTIVE: To analyze the studies that supported the resolution of the American Diabetes 

Association recommending third party payment for outpatient education and nutrition 

counseling of patients with diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: The reports cited by the American Diabetes Association in support of third 

party reimbursement for outpatient education and nutrition counseling of patients with 

diabetes do not meet criteria to measure benefits and rarely include the full costs of such 

programs. 

RECOMMENDATION: The first criterion for evaluating education and nutrition counseling 

should be evidence that they improve health status. Scientifically sound experiments 

evaluating education of patients with diabetes should be undertaken. 

ABSTRACT: The authors analyzed the scientific validity of 13 studies cited by the American 

Diabetes Association in support of its recommendation for third party coverage of outpatient 

education and nutrition counseling of patients with diabetes. Only two of the reports 

mentioned control or comparison groups, and in neither case were the patients randomly 

assigned to such groups. Only four studies provided health care cost accounting, and two of 

these studies did not include the intervention costs. Some of the studies seemed to show an 

increase in costs with intervention. None of the studies included discount analyses and most 

failed to report net differences in costs. Some studies did not report costs of related services 

or program implementation costs. In some cases, apparent savings were in fact cost shifting, 

which may not equate to cost reduction. None of the studies estimated indirect patient costs, 

such as travel time, changes in diet, and lost work. Only one study reported costs of 

medications and educational materials. Costs of continuing intervention were not estimated. 

Attrition was high in the five studies that reported it, and follow-up was nonexistent or not 

reported in half of the studies. Researchers extrapolated limited results nationwide, and the 

programs varied widely. None of the reports meets accepted criteria to establish the cause and 

effect of education intervention. Well-designed experiments are needed to assess the direct 

and indirect program costs, the savings attributable to the program, and the net program 

benefits. Costs must be based on all patients who receive service, adequate patient follow-up, 

and discounted future benefits. 1 table, 23 references. 

60 

TITLE: Evaluation of a Structured Treatment and Teaching Program for Non-Insulin-
Treated Type II Diabetic Outpatients in Germany after the Nationwide Introduction of 

Reimbursement Policy for Physicians. Gruesser, M.; Bott, U.; Ellermann, P.; Kronsbein, P.; 

Joergens, V. Diabetes Care. 16(9): 1268-1275. September 1993. 

OBJECTIVE: To evaluate the practicability and efficacy of a structured treatment and 

teaching program for patients with type 2 diabetes in a routine primary care office setting. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The structured treatment and teaching program improved the quality of 

care, as evidenced by decreased patient weight, less use of oral antidiabetic agents, and 

improved metabolic control. 

RECOMMENDATION: The participating physicians recommended a higher reimbursement 

rate for providing a structured treatment and patient education program for their type 2 

diabetes patients. 

ABSTRACT: In 1991, nationwide insurance coverage of a standard treatment and teaching 

program for outpatients with type 2 diabetes was introduced in Germany. Physicians' fees and 

the costs of teaching materials were reimbursed. Physicians and office staff were required to 

complete a training course to obtain reimbursement. The authors interviewed 127 office-based 

physicians in Hamburg who had completed the training course (42 percent were internists and 

58 percent were general practitioners) 12 months after the training, and information was 

collected on 179 patients who participated in group treatment and teaching programs, which 

were provided in 17 randomly selected office practices. Of the 127 physicians, 122 (96 

percent) rated the training course content as good and useful, 2 reported they learned nothing 

new, and 3 rated the content as useless or poor. Sixty-one percent of the physicians had 

implemented at least one treatment and teaching course in their practice at the time of the 

evaluation (median: 12 months after completing the training course). Information on patients 

completing the program showed substantial improvements in quality of treatment and self-care 

practices. The number of patients who tested their urine for glucose at least twice a week rose 

from 3 percent to 70 percent. Improved dietary habits led to a reduction in body weight, 

which resulted in decreased use of oral antidiabetic agents and improved metabolic control. 

The net cost for the program was $35.80 (U.S. dollars) per patient in year 1, with an expected 

savings of $13.20 per patient per year beginning in year 2. These savings do not include 

anticipated reductions in the costs associated with treating long-term complications of 

diabetes. Most of the physicians found reimbursement for offering the program to be either 

"extremely inadequate"or "inadequate." 1 figure, 4 tables, 40 references. 

61 

TITLE: Obesity and the U.S. Navy [letter]. Yowell, S.K. Military Medicine. 156(12): A10. 
December 1991. 

OBJECTIVE: To show that the authors of an earlier article (Hoiberg, A.; McNally, M.S. 

Military Medicine. 156(2): 76-82 [abstract 222]) did not provide support for the Health and 

Physical Readiness Program of the U.S. Navy. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Review of study. 

Perspective: Health care system. 

CONCLUSION: The referenced authors' support for the Navy's Health and Physical 

Readiness Program was not justified by their study. 

RECOMMENDATION: A weight control program's efficacy, potential benefits, and 

adverse effects should be examined, as should its cost of screening and monitoring. 

ABSTRACT: This letter to the editor offers several criticisms of Hoiberg and McNally's 

article on overweight patients in the U.S. Navy. The author points out that obesity was not 

defined in Hoiberg and McNally's article and that data were obtained from sources that did not 

verify diagnoses. Furthermore, the control group was not age-matched with the obese group. 

The author also questions diagnoses of gout, hypertension, gallbladder disorders, and diabetes 

on admissions of obese patients. He points out that admissions for a diagnosis like diabetes are 

more likely to have obesity mentioned in the workup than are admissions for diagnoses where 

weight is thought to be irrelevant. Referring to the authors' finding of a high concordance of 

alcoholism and obesity, the writer notes that during the study period almost all obesity therapy 

was offered by alcohol rehabilitation staff; a co-diagnosis of alcoholism was often needed to 

gain admission. Before implementing weight control programs and examining their potential 

savings in hospitalization, he suggests looking at their efficacy, potential benefit, adverse 

effects, and the cost of screening and monitoring. 

62 

TITLE: A Randomized Study of the Effects of a Home Diabetes Education Program. Rettig, 

B.A.; Shrauger, D.G.; Recker, R.R.; Gallagher, T.F.; Wiltse, H. Diabetes Care. 9(2): 173-

178. March-April 1986. 

OBJECTIVE: To determine the effectiveness of a home-based individualized instruction 

program in diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Statistical analysis. 
Perspective: Health care system. 

CONCLUSION: Six months following enrollment, patients in the intervention group (home 

teaching) had significantly greater knowledge and skill scores than the control group (no 

teaching). Hospitalization rates, diabetes-related emergency room visits, physician visits, and 

sick days did not differ significantly by group at 12-month follow-up. 

RECOMMENDATION: Because diabetes is a chronic disease, new guidelines for diabetes 

patient education should incorporate a long-term management plan in conjunction with 

periodic reinforcement of self-care knowledge and skills. 

ABSTRACT: In this Nebraska-based study, home health nurses provided up to 12 

educational visits for 193 patients randomly assigned to the intervention group. The 180 

patients in the control group, while not receiving home visits, were free to participate in other 

types of health education. The two groups did not vary in terms of demographic composition, 

diabetes duration, diabetes type, or previous diabetes education. A survey instrument 

developed by the Nebraska Diabetes Demonstration Project was used to measure self-care 

knowledge and skills. At 6-month follow-up, total mean knowledge scores were 60.2 for the 

intervention group, 51.6 for controls (p = 0.001); total mean skill scores were 74.8 for the 

intervention group and 72.6 for controls, a difference that was statistically significant (p = 

0.04) but not considered meaningful. At 12-month follow-up, hospitalization rates did not 

differ by group on any of three types of admission: nondiabetes-related, nonpreventable 

diabetes-related, and preventable diabetes-related. There was no difference between the 

groups in mean foot appearance score at 6-month follow-up. The authors warn of possible 

bias in the selection of study participants, as those who chose to participate may have been 

more highly motivated than those who did not (about 70 percent of patients who were asked 

to participate actually did). Such a bias could have resulted in recruiting patients for whom 

teaching would have added little to present knowledge and skill levels. In addition, persons 

hospitalized with a diabetes-related condition were more likely to have been identified as 

eligible to participate than those hospitalized with a condition not overtly related to diabetes. 5 

tables, 13 references. 

63 

TITLE: Reduced Hospital Utilization and Cost Savings Associated with Diabetes Patient 

Education. Sinnock, P. Journal of Insurance Medicine. 18(3): 24-30. Summer 1986. 

OBJECTIVE: To review data demonstrating the impact of patient education programs on 

health care services used by patients with diabetes; to review the system for assuring the 

quality of such programs and the current status of reimbursement by third party payers for 

diabetes outpatient education. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 
Perspective: Health care system. 

CONCLUSION: Diabetes patient education programs can dramatically reduce the physical 

and economic costs of diabetes. 

RECOMMENDATION: The insurance industry and diabetes community should work 

together to monitor and improve diabetes patient education programs. 

ABSTRACT: Numerous studies have demonstrated an association between diabetes patient 

education and reduction in hospitalizations, resulting in cost savings. A 2-year study of 6,000 

persons with diabetes who participated in a patient education program at Los Angeles County 

Hospital demonstrated a 73 percent decrease in hospitalizations; cost savings over the study 

period were estimated at $1.8 million. A program at Grady Memorial Hospital in Atlanta 

showed a 65 percent decrease in admissions for diabetic ketoacidosis and an estimated savings 

of $3.5 million over 8 years. In Maine, a Centers for Disease Control state-based program 

demonstrated a 32 percent reduction in hospitalizations among 1,000 participants, with net 

savings estimated at $293 per participant per year. A 51 percent reduction in hospitalization 

from diabetic acidosis and infection and a 63 percent reduction in emergency room visits were 

seen in a Rhode Island program. Estimated cost savings associated with this intervention were 

$355 per participant per year. The quality of diabetes education programs in the United States 

has varied, but it is hoped that the implementation of the National Standards for Diabetes 

Patient Education Programs (National Diabetes Advisory Board 1983) will improve this 

situation. Blue Cross and/or Blue Shield and selected private insurers reimburse for outpatient 

education in 14 states, Medicare in 15 states, and Medicaid in 6 states. Several states are 

considering legislation that would mandate coverage for self-management education programs 

for diabetes outpatients. 1 figure, 2 tables, 30 references. 

64 

TITLE: Third Party Reimbursement for Diabetes Mellitus: Outpatient Education: A Year's 

Progress. Peddicord, M.; Lyons, A.; Tobin, C.; Vinicor, F. Diabetes Spectrum. 3(1): 9-12. 

January-February 1990. 

OBJECTIVE: To determine the progress made in obtaining third party reimbursement for 

outpatient education programs for patients with diabetes. 

CATEGORY: Secondary intervention. 

Type of Study: Patient management. 

Methodology: Survey. 

Perspective: Health care system. 

CONCLUSION: Between 1986 and 1989, the number of states reporting reimbursement for 

diabetes outpatient education increased. Medicare reimbursement increased because of a 

national policy statement from the Health Care Financing Administration (HCFA). An 

increase in private insurer reimbursement is credited to consumer demand and Medicare 
policies. There was little change in Medicaid programs. 

RECOMMENDATION: Continued consumer advocacy, emphasis on quality, providing 

additional cost and cost-savings information, and ongoing exploration of strategies and 

alternatives are recommended to continue the progress made in reimbursement policies. 

ABSTRACT: Reimbursement for outpatient education programs for patients with diabetes is 

increasing across the United States. Four states have enacted legislation covering 

reimbursement of these programs. Medicare reimbursement has increased for outpatient 

education programs because of a national policy statement issued by the HCFA defining 

Medicare's criteria for reimbursement of prevention, including diabetes education. Private 

insurers, including HMOs, have shown the greatest increase in third party reimbursement for 

outpatient education programs, primarily because of consumer demand and Medicare policies. 

Medicaid programs, which are regulated by the states, have shown the least change toward 

third party reimbursement. Among many insurers there is an acceptance of education as a part 

of treatment, and not solely as a preventive measure. Most reimbursed outpatient education 

programs are either hospital-based or based in rural health clinics. Programs formally 

recognized by an accrediting or recognition body at the state or national level are more likely 

to be reimbursed. Concerns regarding reimbursement for outpatient education for patients 

with diabetes include the fact that only one or two education programs per state currently 

receive reimbursement, that the prospective payment system is causing more programs to shift 

from an inpatient to outpatient setting, and that little progress has been made in 

reimbursement for free-standing education programs. 1 figure, 3 tables, 3 references. 

Tertiary Intervention 

Eye Care 

65 

TITLE: Cost Savings Associated with Detection and Treatment of Diabetic Eye Disease. 

Javitt, J.C. PharmacoEconomics. 8 (Supplement 1): 33-39. 1995. 

OBJECTIVE: To estimate current and potential savings in the United States and Sweden 

from screening and treating retinopathy in persons with diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: Treatment of retinopathy in patients with diabetes mellitus yields substantial 

savings of sight years and money. 
RECOMMENDATION: Eye care for patients with diabetes must emphasize patient 

identification, carefully maintained follow-up, and prompt, appropriate treatment. 

ABSTRACT: The author describes the use of the PROPHET modeling system, a program 

designed to model the progression of a chronic, irreversible disease, to estimate savings from 

recruiting, screening, and treatment programs for diabetic eye disease. Data from crosssectional and longitudinal studies and clinical trials are used in the model. The analysis derives 

the costs of screening and treatment from average Medicare charges for 1990; savings as well 

as costs are expressed in 1990 U.S. dollars using a discount rate of 5 percent. An annual 

federal expenditure of $14,296 is predicted for blind persons with diabetes under 65 years of 

age, just $32 (not counting Medicare, Social Security, income tax exemption) for those 65 

and over. Based on studies by Klein et al. (1987) in Wisconsin, the implementation rate of eye 

screening is currently 60 percent. Even at this suboptimal level, screening and treatment for 

eye disease in patients with diabetes generates annual savings of $350 million to the federal 

budget and 100,000 person-years of sight. Each additional person (beyond the 60 percent 

level) enrolled in appropriate screening and treatment is associated with net lifetime savings of 

$9,571 (type 1 diabetes) or $973 (type 2 diabetes). The Swedish Council on Technology 

Assessment in Health Care repeated this analysis and found that 60 percent implementation of 

screening could potentially save 22 million SEK. Their analysis found that savings associated 

with detection and treatment were 10 times greater than costs. The authors of the present 

study found that changing the frequency of screening for patients with no or mild background 

retinopathy from 1 to 2 years does not reduce years of sight saved and reduces screening costs 

if the sensitivity of eye screening is 80 percent or greater. 3 figures, 43 references. 

66 

TITLE: Cost-Benefit Analysis of Diabetic Eye Disease. Matz, H.; Falk, M.; Gottinger, W.; 

Kieselbach, G. Ophthalmologica. 210(6): 348-353. 1996. 

OBJECTIVE: To compare the costs of blindness caused by diabetes with the costs of 

screening and treatment of retinopathy associated with diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Screening for blindness saves more money than it costs. 

RECOMMENDATION: All patients with diabetes should be screened for retinopathy and 

optimal therapy should be initiated. 

ABSTRACT: The authors calculated the cost-benefit of screening and testing of diabetes-
associated eye disease in the state of Tyrol, Austria. Current and new cases of severe 

retinopathy (proliferative retinopathy or clinically significant macular edema) were calculated 

to be 2,147 and 252, respectively. Without proper intervention, all 252 persons with incident 

cases would be expected to go blind within 10 years, vision could be retained in at least one 

eye in 179 cases with proper treatment, and blindness could be delayed an average of 3 years 

in patients for whom it is unavoidable. Costs of blindness included disability payments and 

allowances; exemptions from telephone, television, and radio fees; tax exemptions; financial 

aid based on reduced earnings and disability; and early retirement pensions. The anticipated 

costs of blindness were ATS 19 million overall, of which ATS 14.6 million was considered 

preventable, assuming 100 percent ability to diagnose severe retinopathy and macular edema 

and 100 percent ability to treat these conditions at an optimal time. Cost was based on 10-year 

life expectancy at onset of severe retinopathy, duration of blindness ranging from 2.5 to 8.5 

years, sex, age, employment status, type of diabetes, and correlation of minimum retirement 

age with life expectancy. In Tyrol, 16,913 persons would require annual eye examinations 

(cost: ATS 5,191,445) and 2,147 persons would require examinations 4 times per year (ATS 

3,022,547). Laser coagulation or vitrectomy plus examinations would cost the national health 

care system ATS 8,560,089 and private insurance ATS 2,119,566 (only 17.7 percent of the 

population has supplemental private insurance). Up to ATS 3.9 million can be saved through 

adequate screening and treatment to prevent blindness. 1 figure, 5 tables, 25 references. 

67 

TITLE: Cost-Effective Screening for Retinopathy Using a Nonmydriatic Retinal Camera in a 

Pre-paid Health-Care Setting. Peters, A.L.; Davidson, M.B.; Ziel, F.H. Diabetes Care. 16(8): 

1193-1195. August 1993. 

OBJECTIVE: To evaluate the effectiveness of a nonmydriatic retinal camera as a screening 

tool for serious retinopathy. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: The nonmydriatic retinal camera was highly sensitive in detecting serious 

retinopathy. 

RECOMMENDATION: The nonmydriatic retinal camera should be considered an easy-touse, inexpensive component of screening strategies for retinopathy. 

ABSTRACT: The authors evaluated the effectiveness of the Canon CR4-45 nonmydriatic 

retinal camera as a screening tool for retinopathy. Nurse clinicians took retinal photos of the 

522 patients in a diabetes program affiliated with a health maintenance organization at their 

initial and annual visits. The degree of retinopathy as assessed by the reader (a diabetologist) 

of the retinal photos was compared with results of examinations of the patients by retinal 
specialists. These ophthalmologists used direct and indirect ophthalmoscopy as well as slitlamp biomicroscopy. Sensitivity and specificity values for photo interpretation were based on 

189 patients who had gradable photos for both eyes and a retinal examination report available. 

Comparison of any retinopathy noted by the examination with any retinopathy noted by the 

reader yielded a sensitivity and specificity of 85 percent and 93 percent, respectively. The 

reader occasionally missed background retinopathy not requiring treatment. If serious 

retinopathy was seen on the examination, the reader always noted some retinopathy 

(sensitivity: 100 percent; specificity: 82 percent). Results show that the nonmydriatic retinal 

camera, which is easy to use and inexpensive, can be employed as a screening tool for 

detecting serious retinopathy. The camera might identify more patients at risk for serious 

retinopathy than routine referral for ophthalmologic screening, for which compliance rates are 

often poor (74 percent in this study). 1 table, 11 references. 

68 

TITLE: Cost-Effectiveness of Alternative Methods for Retinopathy Screening. Lairson, D.R.; 

Pugh, J.A.; Kapadia, A.S.; Lorimor, R.J.; Jacobson, J.; Velez, R. Diabetes Care. 15(10): 

1369-1377. October 1992. 

OBJECTIVE: To compare the cost-effectiveness of four approaches to screening for 

retinopathy. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Screening with retinal photographs in a primary care setting can be cost 

effective. Cost per true-positive case was lowest for retinal photography with dilation. 

RECOMMENDATION: Screening could be offered as an addition to a routine visit in a 

primary care clinic or on a separate visit. 

ABSTRACT: The four methods of screening for retinopathy compared were (1) 45-degree 

retinal camera photography taken by a physician assistant or nurse practitioner without pupil 

dilation (n = 351), (2) the same kind of photography with pupil dilation (n = 351), (3) direct 

and indirect funduscopic examination (dilated pupils) by an ophthalmologist (n = 347), and (4) 

direct ophthalmoscopic examination (dilated pupils) by a physician assistant or nurse 

practitioner (n = 172). All photographs (methods [1] and [2]) were read by an 

ophthalmologist. Positive retinopathy was considered a level of 40 or greater on the modified 

Airlie House reference standard. Screening costs were incurred through Veterans 

Administration and Department of Defense facilities and included staff salaries and fringe 

benefits; equipment (amortized over expected life); supplies; participants' travel, screening 

time, and transportation; space; overhead; and reading fees. Interest rates were set at 8.24 

percent, based on 1989 long-term government bond rates, and overhead costs were set at 29.7 
percent of ambulatory care health system costs. Patient travel costs were assessed through an 

interview; wages for unemployed patients were calculated at $3.35 per hour. Costeffectiveness was based on the cost per true-positive test. Sensitivity of methods 1-4, 

respectively, was 0.61, 0.81, 0.33, and 0.10; specificity was 0.85, 0.96, 0.99, and 0.99. Total 

cost (health system plus patient) per exam was $70, $74, $48, and $31, respectively. The 

average cost to the health care system only per case of identified retinopathy was $295 

(method 2); $378 (method 1); $390 (method 3); and $794 (method 4). Adding the patient 

costs did not change these rankings. 1 figure, 4 tables, 22 references. 

69 

TITLE: Cost-Effectiveness of Alternative Methods for Retinopathy Screening. Wareham, 

N.J. Diabetes Care. 16(5): 844. May 1993. 

OBJECTIVE: To point out an issue not raised in an article by Lairson et al. on screening 

methods for retinopathy (Diabetes Care. 15:1369-1377. 1992. Abstract 53) and offer 

calculations of sensitivity, specificity, and cost per true-positive for the data presented by 

those authors. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The conclusions of cost-effectiveness drawn by Lairson et al. may not be as 

strong as presented. 

RECOMMENDATION: None. 

ABSTRACT: The author notes that Lairson et al. did not account for error in their sensitivity 

estimates of the four screening tests they compared. He reassesses their data by applying 95 

percent confidence intervals to the sensitivity and specificity of screening patients with 

diabetes for retinopathy by (1) 45-degree retinal photographs without pupil dilation, (2) retinal 

photography with pupil dilation, (3) ophthalmologist examination, or (4) technician 

examination. The sensitivity (with upper and lower 95 percent confidence limits) for 1-4 was 

0.61 (0.72, 0.50), 0.81 (0.90, 0.72), 0.33 (0.44, 0.22), and 0.07 (0.14, 0), respectively. The 

specificity for 1-4 was 0.85 (0.89, 0.81), 0.96 (0.99, 0.94), 1.00 (1.00, 0.99), and 0.99 (1.00, 

0.97), respectively. System cost per true-positive diagnosis with these approaches (with upper 

and lower estimates) was $378 ($463, $330), $295 ($331, $265), $390 ($581, $294), and 

$794 (not given, $379), respectively. Patient cost per true-positive diagnosis was $171 ($209, 

$144), $139 ($156, $125), $306 ($454, $230), and $1,009 (not given, $481), respectively. 

Because of the overlap in confidence intervals, the author points out that conclusions in this 

paper about the cost-effectiveness of these screening methods are weakened. He also points 

out that sensitivity is a major determinant of the cost-effectiveness of screening for retinopathy 

and states that including confidence intervals in the estimate of the cost per true-positive case 
is critical for making policy decisions. 2 tables, 2 references. 

70 

TITLE: Cost-Effectiveness of Current Approaches to the Control of Retinopathy in Type I 

Diabetics. Javitt, J.C.; Canner, J.K.; Sommer, A. Ophthalmology. 96(2): 255-264. February 

1989. 

OBJECTIVE: To estimate the benefits (in terms of preservation of vision) and attendant 

costs of screening, diagnosis, follow-up, and treatment of retinopathy in patients with type 1 

diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: Screening, diagnosis, follow-up, and treatment of retinopathy in patients 

with type 1 diabetes resulted in a cost of $966 per person-year of sight saved, which is only 14 

percent of the direct cost to the federal government of a year of blindness-related disability. 

RECOMMENDATION: The federal government should fund eye care for patients with type 

1 diabetes to avoid the higher cost of disability from blindness. 

ABSTRACT: The authors used a computer model to analyze the benefits (in terms of 

preservation of vision) and attendant costs of screening, diagnosis, follow-up, and treatment 

of retinopathy in patients with juvenile-onset type 1 diabetes. Screening recommendations 

were taken from the Public Health Committee of the American Academy of Ophthalmology. 

Current charges for screening and treatment of retinopathy were compared with current 

federal budgetary expenses for blindness-induced disability under the Social Security Disability 

program. Incidence, disease progression, and mortality data were drawn from several 

population-based studies. The computer model, based on a Monte Carlo simulation, was run 

for a hypothetical cohort of 31,000 patients with type 1 diabetes beginning at age 12.5 years 

and followed over a 60-year period. Model inputs were based on published reports of crosssectional and disease incidence studies, clinical trials, and U.S. statistics. The model predicted 

that by age 60, background retinopathy would have developed in 98 percent of the cohort, 

macular edema in 42 percent, and proliferative retinopathy in 72 percent. Despite appropriate 

screening and treatment, ultimately 28 percent of the cohort, according to the model, would 

suffer severe vision loss. Over the 60 years, costs for ophthalmologic examinations, focal laser 

treatment, and panretinal photocoagulation were $91.0 million, $26.0 million, and $44.0 

million, respectively. A total of 92,700 person-years of sight could be saved at the end of 60 

years by the application of screening and panretinal photocoagulation. The cost of screening 

and panretinal photocoagulation per person-year of sight saved was $966, which is only 14 

percent of the direct cost ($6,900) to the federal government of a year of blindness-related 

disability payments. 8 figures, 2 tables, 35 references. 
71 

TITLE: Cost-Effectiveness of Detecting and Treating Retinopathy. Javitt, J.C.; Aiello, L.P. 

Annals of Internal Medicine. 124 (1 Part 2): 164-169. January 1, 1996. 

OBJECTIVE: To determine from the perspective of health insurers the cost-effectiveness of 

ophthalmologic screening and treatment to prevent vision loss for patients with diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-utility analysis. 

Perspective: Health care system. 

CONCLUSION: Ophthalmologic screening and treatment of eye disease in patients with 

diabetes is a highly cost-effective approach to preventing blindness in people with diabetes. 

RECOMMENDATION: Implementation of current guidelines regarding eye examinations 

for people with diabetes should be encouraged. 

ABSTRACT: Detection and treatment of diabetic eye disease has been shown to result in 

cost savings. Prevention of diabetes-related blindness, on a cost-effectiveness basis, ranks 

above other medical interventions commonly provided. The PROPHET system, based on 

Monte Carlo simulation, was used to model the progression of proliferative retinopathy. 

Monte Carlo simulation, which uses random number generation, allows for a simple, 

probability-based solution of complex disease progression processes over time. Screening and 

treatment costs were derived from average Medicare charges in 1990, using a discount rate of 

5 percent. Previous reports suggest that over 413,200 person-years of sight are currently 

saved, and over 710,800 person-years of sight could be saved, if all patients with diabetes had 

appropriate ophthalmologic screening and treatment. The cost of implementing currently 

recommended guidelines for screening and treatment of retinopathy was calculated to be 

$1,757 per person-year of sight saved. The cost per quality-adjusted life-year (QALY) 

associated with detecting and treating diabetic eye disease was found to range from $1,996 

per QALY for those with type 1 diabetes to $3,530 per QALY for those with type 2 diabetes 

who do not require insulin. Overall cost of detecting and treating disease in patients with 

diabetes was $3,190 per QALY. Despite the high level of efficacy, clinical effectiveness, and 

cost-effectiveness, screening and treatment for diabetic eye disease are not universally 

practiced. Recommendations for annual dilated eye examinations of patients with diabetes 

have now been included in the Health Plan Employer Data and Information Set (HEDIS II) 

quality guidelines adopted throughout the managed care industry. 1 figure, 4 tables, 55 

references. 

72 
TITLE: Cost-Effectiveness of Strategies for Detecting Retinopathy. Dasbach, E.J.; Fryback, 

D.G.; Newcomb, P.A.; Klein, R.; Klein, B.E. Medical Care. 29(1): 20-39. January 1991. 

OBJECTIVE: To evaluate the cost-effectiveness of six different strategies for providing 

ophthalmologic care to patients with diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Screening for retinopathy is generally cost effective in younger-onset 

patients and in those older-onset patients who take insulin. 

RECOMMENDATION: None. 

ABSTRACT: The authors used data from the Wisconsin Epidemiologic Study of 

Retinopathy to create simulation models of the natural progression of retinopathy and the 

effects of detecting and treating retinopathy on this process. Data were modeled (by the 

Markov process) for three groups of 1,000 patients: younger-onset patients (under age 30 

years at diagnosis) with diabetes for 5 years or more, older-onset patients (age 30 years or 

over at diagnosis) who required insulin, and older-onset patients who did not take insulin. The 

six strategies modeled for ophthalmologic care were annual or biannual use of 

ophthalmoscopy, annual or biannual use of fundus photography through physiologic pupil 

dilation (the nonmydriatic camera), and annual or biannual use of fundus photography through 

pharmacologic pupil dilation (mydriatic). Effectiveness was based on sight years saved with 

intervention. Each strategy was modeled over 10 and 60 years, with costs remaining constant; 

savings in years and costs were discounted by 5 percent to represent their present value. 

Except for the older-onset group not taking insulin, net savings for annual or biannual 

screening by all methods were substantial; for 10 years they ranged from $877,656 to 

$997,462 in the younger-onset cohort and from $19,043 to $71,986 in the older-onset group 

taking insulin. The younger-onset group (10-year model) saved more than 200 sight years by 

any of the strategies; the older-onset groups taking insulin saved 45 to 59 years; and those not 

taking insulin, 14 to 19 years. Sixty-year results were similar to those for 10 years; an 

exception was that the younger-onset cohort gained considerably more sight years and cost 

savings. Annual screening with fundus photography using the mydriatic camera was the most 

effective of the six screening strategies; however, the gain in effectiveness was small compared 

with annual screening with the nonmydriatic camera or with an ophthalmoscope. 7 figures, 5 

tables, 32 references. 

73 

TITLE: Cost-Effectiveness of the Screening and Treatment of Retinopathy. What Are the 

Costs of Underutilization? Fendrick, A.M.; Javitt, J.C.; Chiang, Y.P. International Journal of 
Technology Assessment in Health Care. 8(4): 694-707. Fall 1992. 

OBJECTIVE: To determine whether screening and treating retinopathy is cost effective in 

Sweden. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Annual photographic screening to detect early signs of retinal disease 

combined with laser photocoagulation treatment of macular edema and retinopathy leads to 

improved health outcomes in terms of years of sight saved and also to decreased medical 

expenditures. 

RECOMMENDATION: None. 

ABSTRACT: A computer model (PROPHET) was used to simulate the health and economic 

outcomes of an annual screening program for retinal disease in a group of patients with type 1 

diabetes in Sweden. Many Swedish patients with type 1 diabetes do not receive optimal eye 

care because physicians have inconsistent practice patterns, are inexperienced in performing 

the eye exam, and lack knowledge of screening recommendations. Screening for retinopathy 

and macular edema before high-risk lesions become worse is the key to preventing vision loss. 

The study looked at 750 patients newly diagnosed with diabetes over a 60-year life span. 

Fundus photography (3 fields per eye) was used as the screening method and 

photocoagulation (panretinal for proliferative retinopathy and focal retinal for macular edema) 

was employed to treat eye disease. The model predicted that background retinopathy, a 

preclinical state, would be present in 98 percent of the patients after 60 years of diabetes. 

Macular edema and proliferative retinopathy were predicted to occur in more than 50 percent 

of the patients in that period. The number of person-years of vision preserved by annual 

screening was closely linked to patient compliance with screening recommendations. The 

model revealed that with a compliance rate of 70 percent, more than 45,000 screening exams 

were performed over the 60-year study period and 2,306 years of vision were saved. Without 

screening and treatment, 6,500 years of sight would be lost. The model showed that with a 

screening compliance rate of 60 to 100 percent, net savings, including the costs of screening 

and treatment, would range from $3.7 to $6 million (U.S. dollars). Although the program was 

costly in the beginning, its net cost decreased over time as the years of sight saved accrued 

and treatment sessions decreased. Sensitivity analysis was performed to evaluate variables for 

which there was uncertainty. In this model, screening compliance rates correlated positively 

with improved clinical and economic outcomes. 5 figures, 3 tables, 64 references. 

74 

TITLE: Detecting and Treating Retinopathy in Patients with Type I Diabetes Mellitus: A 

Health Policy Model. Javitt, J.C.; Canner, J.K.; Frank, R.G.; Steinwachs, D.M.; Sommer, A. 
Ophthalmology. 97(4): 483-494 (discussion: 494-495). April 1990. 

OBJECTIVE: To estimate the medical and economic implications to the federal government 

of several screening and treatment strategies for retinopathy in patients with type 1 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: All five retinopathy screening and treatment strategies resulted in cost 

savings to the federal government. 

RECOMMENDATION: Public health policy must consider the enormous medical and 

economic benefits that can be realized by detecting and treating diabetic eye disease. 

ABSTRACT: The authors used a cost-benefit model to evaluate the average net savings to 

the federal government of retinopathy screening and treatment in patients with type 1 diabetes. 

Using a PROPHET simulation system, the authors analyzed outcomes for a hypothetical 

cohort of 31,000 patients developing the disease at age 12.5 years; these values represent 

annual incidence and average age of onset for this disorder in the United States. Five 

screening strategies involving various schedules of dilated ophthalmoscopy with and without 

full fundus photographs were tested: (1) ophthalmoscopy (with the eyes dilated) every 2 

years, (2) annual ophthalmoscopic exam, (3) ophthalmoscopic exam annually for patients with 

no retinopathy, every 6 months for those with retinopathy, (4) annual ophthalmoscopic exam 

with full fundus photography, and (5) annual ophthalmoscopic exam with fundus photographs 

for patients with no retinopathy, an exam and photos every 6 months for those with 

retinopathy. The discount rate was set at 5 percent; potential savings (in 1986 dollars) were 

based on the amounts paid by the federal government for blindness-related disability ($6,300 

annually in the model). Undiscounted screening and treatment costs for the five strategies 

varied from $89.2 million to $290.3 million. All of the strategies resulted in substantial net 

annual savings to the federal government, ranging from $62.1 million to $108.6 million. The 

model predicted a clear medical and economic advantage for the strategy of dilated 

ophthalmoscopy performed annually, then semiannually upon diagnosis of retinopathy. This 

strategy had the second highest government savings (annual ophthalmoscopy only had the 

highest), but saved several thousand more person-years of sight than annual ophthalmoscopy. 

Positive returns were seen for all five strategies at discount rates below 10 percent. Screening 

and treatment were cost-saving if the value of a year of sight saved was $2,500 or more. Little 

advantage was demonstrated in adding routine fundus photography to screening exams. 3 

figures, 8 tables, 41 references. 

75 

TITLE: Detecting and Treating Retinopathy in Patients with Type I Diabetes Mellitus: 

Savings Associated with Improved Implementation of Current Guidelines. Javitt, J.C.; Aiello, 
L.P.; Bassi, L.J.; Chiang, Y.P.; Canner, J.K. Ophthalmology. 98(10): 1565-1573 (discussion: 

1574). October 1991. 

OBJECTIVE: To estimate the net federal budgetary savings that might be attained with 

increased enrollment of patients with type 1 diabetes into appropriate ophthalmologic care. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: At current levels of screening and treatment implementation, it is less 

expensive to provide preventive eye care for patients with type 1 diabetes than to support 

subsequent disability. Because each 10 percent improvement in implementation over current 

levels would save $16.5 million annually, significant recruitment efforts could be undertaken 

without diminishing returns. 

RECOMMENDATION: Public education should be expanded so that all possible patients 

are recruited into appropriate screening strategies, and primary care physicians must be 

enlisted to identify patients so that strict ophthalmologic follow-up may be instituted. 

ABSTRACT: The authors analyzed the net federal budgetary savings achieved under current 

American Academy of Ophthalmology screening and treatment conditions for retinopathy in 

patients with type 1 diabetes and estimated savings that might be obtained by increased 

enrollment of patients into appropriate ophthalmologic care. A PROPHET modeling system, 

based on Monte Carlo techniques, was used to analyze events and costs. Disease data in the 

model were derived primarily from reports of cross-sectional studies and clinical trials. 

Screening and treatment costs were derived from average Medicare charges in 1990. The 

authors expressed costs and savings in 1990 U.S. dollars with a discount rate of 5 percent. 

They estimated that 60 percent of patients with type 1 diabetes receive retinopathy treatment 

and screening that meets American Academy of Ophthalmology guidelines. At this level, 

47,374 person-years of sight are salvaged and $101.0 million saved annually. The model 

predicts that for every additional 10 percent of patients who enter screening, more than 7,966 

person-years of sight and $16.5 million in further annual savings would be realized. With 100 

percent screening, 79,236 person-years of sight and $167.0 million would be saved annually. 

Current American Academy of Ophthalmology guidelines recommend initiating retinopathy 

screening 5 years after diagnosis of type 1 diabetes. The additional annual financial burden of 

beginning screening upon diagnosis would be $3.03 million. However, the yearly increase in 

expense would be recovered totally if less than 1 additional patient were recruited to screening 

from every 56 patients with diabetes. The model predicts a loss of $17.4 million and 5,961 

person-years of sight if treatment of retinopathy is delayed 1 year. 8 figures, 3 tables, 41 

references. 

76 
TITLE: Detection of Sight-Threatening Diabetic Eye Disease. Leese, G.P.; Broadbent, D.M.; 

Harding, S.P.; Vora, J.P. Diabetic Medicine. 13(10): 850-853. October 1996. 

OBJECTIVE: To review the feasibility and costs of screening methods to detect 

asymptomatic eye disease in patients with diabetes in the United Kingdom. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Community-based screening programs employing fundus photography or 

slit-lamp biomicroscopy may offer a cost-effective alternative to ophthalmological screening 

for eye diseases in patients with diabetes. 

RECOMMENDATION: Formal research-based measurements of the effectiveness of 

alternative eye disease screening methods are needed, and health services purchasers must be 

persuaded to implement cost-effective community-based screening programs. 

ABSTRACT: The authors review the status of screening for sight-threatening eye disease 

among patients with diabetes in the United Kingdom and assess the feasibility of alternatives 

to ophthalmological examinations. Because the number of ophthalmologists in the United 

Kingdom is not sufficient to allow screening of all patients, other options must be considered. 

Screening for retinopathy and other eye diseases at hospital-based clinics, at general practice 

clinics, in optometry practices, and by mobile fundus photography is discussed. The perpatient cost of screening by direct ophthalmoscopy has been estimated at £ 13 when 

performed by community-based optometrists, £ 15 by general practitioners, and £ 27 by 

hospital physicians. Costs of fundus photography by a mobile unit have been estimated at 

between £ 10 and £ 23 per patient versus £ 19 per screen if the camera is maintained within a 

hospital. When using a mobile van, overall costs per potentially sight-saving treatment have 

been estimated by other researchers at £ 700 to £ 1,000. Screening by fundus photography has 

been demonstrated to be more cost effective than ophthalmoscopy because of its greater 

sensitivity. Screening costs must be evaluated in comparison with the costs of supporting a 

blind person in the community, which were estimated in 1981 to be £ 3,500 per year. 42 

references. 

77 

TITLE: Evaluation of Argon Laser Treatment of Retinopathy and Its Diffusion in The 

Netherlands. Vondeling, H. Health Policy. 23(12): 97111. January 1993. 

OBJECTIVE: To review studies on argon laser treatment for retinopathy, including its costeffectiveness; to discuss the diffusion of this technology. 
CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Review of studies. 

Perspective: Societal. 

CONCLUSION: Screening for and treating retinopathy is cost effective. 

RECOMMENDATION: None. 

ABSTRACT: Clinical trial evidence indicates that immediate argon laser treatment can 

prevent blindness and stabilize retinopathy for at least 10 years in 70 percent of cases. 

Drummond et al. (1990) analyzed the U.S. Retinopathy Study and found a net savings from 

the trial for U.S. society over 22 years of laser photocoagulation of $2,816 million (including 

$2,585 million in lost production). Another model (Javitt and coworkers), for patients with 

type 1 diabetes, predicted a cost (in 1986 dollars) of $966 per person-year of vision saved 

from proliferative retinopathy and $1,118 per person-year of central acuity saved from 

macular edema; in contrast, average annual federal payments to eligible blind recipients were 

$6,900. A model of screening practices indicated that the most cost-effective method is dilated 

ophthalmoscopy performed annually for patients without retinopathy and every 6 months for 

those with retinopathy. Proper screening of 60 percent of persons with type 1 diabetes would 

result in annual savings of 47,374 person-years of sight and $101 million. In The Netherlands, 

the number of argon lasers increased from 10 prior to 1978 to 111 in 1992. Change in clinical 

practice in The Netherlands could have been implemented more quickly with more active 

governmental support. Adequate screening for diabetic eye disease is being promoted by the 

American Academy of Ophthalmology, the U.S. National Eye Institute, the World Health 

Organization, and the International Diabetes Federation. Further studies are needed to 

document accurately the cost-effectiveness of screening and early treatment programs. 3 

figures, 21 references. 

78 

TITLE: The Evaluation of Mobile Screening for Retinopathy. Thompson, C.; Leese, G. 

Scottish Medical Journal. 40(1): 5-7. February 1995. 

OBJECTIVE: To overview the use of mobile screening for retinopathy. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Review of studies. 

Perspective: Health care system. 
CONCLUSION: Mobile retinal cameras, which offer the chance to expand eye screening for 

retinopathy, particularly to remote and rural areas, should be considered a valuable addition to 

current methods. 

RECOMMENDATION: None. 

ABSTRACT: The authors review previous studies on screening for retinopathy in the United 

Kingdom. The ideal screening program for retinopathy, which has yet to be determined, 

should be technically accurate, cost effective, and applicable to the whole population. Mobile 

screening in the community is a possible alternative for patients who do not attend diabetes 

clinics and may be particularly valuable in remote rural areas, where fewer people attend 

specialty diabetes clinics or receive a regular ophthalmic examination. In the great majority of 

cases, mydriatic drops (to increase pupil size) are not required for the retinal cameras used. 

An evaluation of a rural mobile screening program (in Tayside) for persons with diabetes 

found that 20 percent of those not attending diabetic clinics had retinopathy, and 6.5 percent 

needed urgent ophthalmological assessment. It has been estimated that a comprehensive 

screening program that included detection, referral, treatment, and follow-up would reduce 

new blindness by 10 percent in persons under 70 years. A recent multicenter study on 

screening found the cost of diagnosis per true-positive case of sight-threatening retinopathy to 

be 33 to £ 1,079 when the screener was a general practitioner, £ 497 for a mobile communitybased retinal camera, £ 1,546 for a hospital-based retinal camera, £ 1,028 for opticians, and £ 

1,033 for hospital physicians. In the Tayside program, the cost to screen a patient was £ 10; 

the cost per case of newly discovered sight-threatening retinopathy was £ 50. The cost per 

patient receiving laser therapy for retinopathy was £ 1,000. A screening service's costeffectiveness depends on the prior probability of detecting significant retinopathy; after the 

initial impact of the mobile camera it may drop because of the low annual incidence of this 

problem. The development of a strategy for identifying high-risk groups has been advocated. 

24 references. 

79 

TITLE: Local Survey of Optometrists about Dilated Funduscopic Examinations for Patients 

with Diabetes: Making Use of Phone Book Yellow-Page Listings. Foster, D.T.; Wylie-Rosett, 

J.; Walker, E.A. Diabetes Educator. 22(6): 605-608. November-December 1996. 

OBJECTIVE: To assess the knowledge, attitudes, and practices of optometrists in the 

Bronx, New York, area related to providing dilated funduscopic examination for patients with 

diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Telephone survey. 

Perspective: Health care system. 
CONCLUSION: Dilated funduscopic examinations were available at a relatively modest cost 

in over half of the optometry practices listed in the NYNEX yellow pages for the Bronx. 

RECOMMENDATION: Information is needed concerning how to increase education about 

dilated fundoscopic examinations in medically underserved areas such as the South Bronx. 

Campaigns to increase the rate of dilated funduscopy among patients with diabetes should 

consider how optometrists interact with the medical care system to achieve early detection of 

retinopathy and other diabetes-related eye problems. 

ABSTRACT: The authors surveyed optometrists listed in the Bronx, New York, NYNEX 

yellow pages. Telephone interviews were conducted with 23 of the 31 optometry practices 

listed. Dilated funduscopic examinations were performed by 13 of the 23 practices. The 

primary contraindication to performing dilated funduscopy cited by respondents who 

performed the examination was narrow-angle glaucoma; hypertension was also mentioned as a 

contraindication (it is not considered one per se, and this problem is frequently associated with 

diabetes). Estimates by optometrists of the percentage of patients with diabetes who knew of 

the need for dilated funduscopy examinations ranged from 2 percent in the South Bronx to 25 

percent for Westchester County (New York) practices. Billing charges for a general 

examination ranged from $12 to $55. The billing charge for dilated funduscopy ranged from 

no additional charge to a $27 extra charge. Of the 23 practices, Medicaid payment for 

examinations was accepted by 22, credit card by 20, and Medicare by 18. Performing dilated 

funduscopy could be a recruitment strategy for optometrists and might increase the number of 

patients who get this examination annually. 2 tables, 12 references. 

80 

TITLE: Meeting the Challenge of Diabetic Blindness in the 90's. Yeo, K.; Fan, R.; Yong, V. 

Singapore Medical Journal. 34(2): 128-130. April 1993. 

OBJECTIVE: To describe a 5-year screening and education program for diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Blindness from retinopathy is largely preventable. 

RECOMMENDATION: Institute a nationwide program of screening and treatment for 

diabetes. 

ABSTRACT: The prevalence of diabetes in Singapore is rising, and retinopathy is a leading 

cause of blindness among Singapore adults. Hospital-based screening efforts in Singapore will 
reach only a small percentages of those with diabetes. Most Singapore patients with diabetes 

are treated in primary-level services (general practitioners, outpatient departments), where 

direct ophthalmoscopy is widely available. This approach, however, has important technical 

limitations. Many persons with diabetes do not know that diabetes might cause blindness, and 

those with good vision are often not motivated to seek a fundal examination. If blindness can 

be prevented in 10 percent of the people in Singapore who have diabetes, cost savings will be 

significant. A nationwide screening program for public education in diabetes; training of 

medical staff, nursing personnel, and volunteers; and providing adequate treatment and 

follow-up facilities are suggested to reduce blindness from diabetes, with initial screening 

targeting high-risk groups. As a first step, the authors suggest establishing a centralized 

screening clinic in a hospital or diabetic center coupled with a mobile screening service. They 

project that 16,800 patients can be screened the first year, with 10 percent increments each 

year, for a total of 102,564 patients for 5 years. The cost of these two programs is estimated 

at $150,000 (Singapore dollars) for the first year, with equipment accounting for the major 

expenditure in that year. The cost of screening is not excessive and is much below the cost of 

treating late-stage retinopathy and rehabilitating blind patients. The loss of economically 

productive persons with diabetes must also be considered. Education can be carried out 

through mobile exhibits, mass media, talks and seminars, and a diabetes education exhibit in 

the screening center. Additional laser facilities would have to be made available to treat 

patients with sight-threatening retinopathy. 8 references. 

81 

TITLE: Mobile Retinal Photography: A Means of Screening for Retinopathy in Aboriginal 

Communities. Karagiannis, A.; Newland, H. Australian and New Zealand Journal of 

Ophthalmology. 24(4):333-337. November 1996. 

OBJECTIVE: To determine whether interpretable fundus photographs of the eye could be 

taken by specially trained aboriginal health workers in a mobile screening setting. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Quality review. 

Perspective: Health care system. 

CONCLUSION: Of the 390 photographs taken of 47 patients known to have diabetes, 371 

slides were of sufficient clarity to interpret for retinopathy. However, 158 of the 371 slides 

were suboptimal. 

RECOMMENDATION: Mobile retinal photography carried out by aboriginal health 

workers as part of routine health visits could be an efficient, practical approach to eye 

screening of aboriginal diabetes patients living in remote areas and of monitoring patients with 

existing retinopathy. 

ABSTRACT: The prevalence of diabetes in the aboriginal community in Australia is 
estimated to be up to 15 percent. Aborigines and Torres Strait Islanders living in remote areas 

of Australia and New Zealand have limited access to screening services for retinopathy. The 

investigators describe a pilot study to train aboriginal health workers to take fundus 

photographs of the eyes of aborigines with diabetes during routine health clinic visits. The 

health workers received 2 weeks of training from an ophthalmic photographer; 1 week took 

place on-site in an aboriginal community. The photographer then supervised the health 

workers on 2 clinic visits in a 6-month period in the community during which the health 

workers carried out dilated eye examinations in 47 known diabetes patients. The health 

workers took an average of 8 photographs per patient (range: 4 to 27), for a total of 390 

slides. A retinal specialist compared the slides with baseline photographs taken by the 

ophthalmic photographer at the beginning of each clinic visit and graded them for quality and 

interpretability. Nineteen slides, representing 11 patients, could not be read; 371 slides were of 

sufficient quality to detect significant eye disease. The unit cost per photograph was $1.00 

(Australian dollars), not including the cost of the equipment, services of the retinal specialist, 

or mobile screening vehicle. 2 figures, 14 references. 

82 

TITLE: Ophthalmic Screening for Diabetics: The Importance of Physician-Ophthalmologist 

Collaboration in the Prevention of Blindness. Chew, S.J.; Hart, P.M.; Ang, B.C.; Lim, A. 

Singapore Medical Journal. 31(1): 26-29. February 1990. 

OBJECTIVE: To evaluate the efficacy and cost-effectiveness of a screening program for 

retinopathy involving the coordination of primary physician and ophthalmologist services. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: The screening program accurately identified patients with varying degrees 

of retinopathy at a reasonable cost. 

RECOMMENDATION: Screening for retinopathy based on fundus photography performed 

by primary care physicians and interpreted by ophthalmologists should be considered an 

accurate, cost-effective strategy for blindness prevention in patients with diabetes. 

ABSTRACT: The screening program, which was offered in Singapore, included Polaroid 

fundus photography, noncontact tonometry, and blood pressure measurement, with primary 

care physicians and ophthalmologists equally responsible for patient care. Screening 

examinations took place at a retinal clinic, and photographs were reviewed and discussed with 

patients by a retinal specialist. During the first 6 months of the program, 428 patients with 

known diabetes were screened; retinopathy was detected in 161 eyes (18.8 percent). The 

prevalence of retinopathy was closely associated with duration of diabetes; age of onset was 

of lesser importance. Of the 161 eyes with retinopathy, 60 percent exhibited only background 
changes; sight-threatening retinopathy was found in 7.6 percent of all cases (59 of 856 eyes). 

Background retinopathy occurred in 22.5 percent of eyes among patients with type 1 diabetes 

and 9.7 percent of eyes among patients with type 2 diabetes. Proliferative retinopathy was 10 

times more prevalent in the eyes of patients with type 1 than in the eyes of patients with type 2 

diabetes. Patients were charged S$6.00 for the screening service, which included the cost of 

photography. 7 tables, 5 references. 

83 

TITLE: Opportunities for Cost Reduction in Retinopathy Treatment: Case Study From 

Mexico. Phillips, M.; del Rio, I.; Quiroz, H. Bulletin of the Pan American Health 

Organization. 28(1): 50-61. March 1994. 

OBJECTIVE: To measure the costs of treating eye problems in patients with diabetes, to 

find out who bears these costs, and to determine how cost reduction could be accomplished. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: The cost of treating eye problems was quite high, and the individual patient 

bore most of the costs for treatment. Reducing the number of visits could substantially lower 

the economic impact on patients. 

RECOMMENDATION: Further research is needed to clarify the benefits gained by patients 

who have photocoagulation laser therapy. 

ABSTRACT: A randomized study was conducted at the Hospital for the Prevention of 

Blindness in Mexico City to determine the costs of treating patients with diabetes who had 

retinopathy. Clinical records of a random sample of 69 patients were used to collect data on 

demographic and socioeconomic variables, diabetes treatment, initial eye diagnosis, and the 

amount and type of eye treatment provided by the hospital from 1985 to 1991. The cost of the 

resources used for each type of treatment provided was determined. Patient interviews 

provided information about treatment-associated costs incurred by patients and those 

accompanying them. The average age of patients was 59 years; most were poor and had little 

formal education. All lacked private health insurance and none was reimbursed for medical 

care expenses incurred. The cost of treatment per patient over 5 years was $630; the patient 

and family paid 83 percent of the cost. Fees accounted for 45 percent of patient costs, other 

direct expenses (e.g., travel and accommodations) made up another 45 percent, and lost 

income accounted for 10 percent. Suggestions for reducing patient costs without lowering 

quality of care included shortening waiting time, increasing the strength of laser treatments to 

decrease number of visits needed, completing more procedures in a single visit, revising the 

policy on fluoroangiography, and educating patients and at-risk relatives accompanying them 

about the need for early detection and treatment of eye problems. 5 tables, 13 references. 
84 

TITLE: Practical Community Screening for Retinopathy Using the Mobile Retinal Camera: 

Report of a 12 Centre Study. British Diabetic Association Mobile Retinal Screening Group. 

Also, Population-based Screening for Retinopathy: A Promising Start (Comment). 

Greenwood, R.H. Diabetic Medicine. 13(11):925-926, 946-952. November 1996. 

OBJECTIVE: To report the progress of a project involving the use of mobile units equipped 

with retinal cameras to provide eye screening services to diabetes patients in 12 health districts 

in the United Kingdom. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: The mobile units performed 64,905 screenings; analysis of 42,803 

screenings found 2,400 referrals for further evaluation, of which 516 resulted in immediate 

laser therapy for sight-threatening disease. During subsequent years of this multiyear project, 

the number of patients referred and those needing laser therapy declined. 

RECOMMENDATION: Mobile eye screening programs should be designed to fit the 

specific needs of each district, retinal photographers should be personable and well trained, 

and close liaisons with local ophthalmologists should be established. 

ABSTRACT: In 1989, the British Diabetic Association initiated a mobile eye screening 

program designed to reduce morbidity from diabetic eye disease, the leading cause of 

blindness in working-age adults. Twelve health centers, representing urban and rural areas, 

participated in the program. The vans were equipped with retinal cameras, and each center 

was responsible for training an operator/driver, determining how the screening service would 

be used in the district, and setting up systems for reporting results. Most screenings (76.5 

percent) were carried out in primary care settings; the remainder were carried out in hospitalbased settings. The average cost per patient screened and per patient treated was £ 13.11 and 

£ 1,110, respectively. Patient acceptance of the screening process was high, and in 10 of 12 

districts financial responsibility for the program has been taken over by hospital trusts or 

district health authorities. The investigators conclude that the use of mobile vans for retinal 

screening is cost effective and efficient. An accompanying "Comment" notes that performance 

standards need to be developed by a central organization such as the British Diabetic 

Association before the program can be implemented on a wider scale. A table of proposed 

standards developed by the British Diabetic Association Retinal Screening Group is presented 

in the original article. The article also includes an appendix listing reports from district units. 7 

tables, 1 appendix, 19 references in principal article; 15 references in Comment. 
85 

TITLE: Preventive Eye Care in People with Diabetes Is Cost-Saving to the Federal 

Government: Implications for Health Care Reform. Javitt, J.C.; Aiello, L.P.; Chiang, Y.; 

Ferris, F.L.; Canner, J.K. III; Greenfield, S. Diabetes Care. 17(8): 909-917. August 1994. 

OBJECTIVE: To estimate savings to the federal government from screening and treatment 

of retinopathy in patients with type 2 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: Improvement in ophthalmologic screening of patients with type 2 diabetes 

will reduce vision loss and save money for the federal government. 

RECOMMENDATION: Eye care for patients with type 2 diabetes must emphasize patient 

identification, careful follow-up, and prompt, appropriate treatment. 

ABSTRACT: The authors used the PROPHET computer model system to project the 

incidence and the costs of screening and treatment of eye disease resulting from diabetes. 

PROPHET is designed to model the course of a chronic, irreversible disease. Incidence data 

for type 2 diabetes were applied to 1990 Medicare, Social Security Disability Insurance, and 

Social Security Insurance costs for screening and treatment; a 5 percent discount rate was 

used. Costs of screening were based on complete dilated eye examinations ($62 each) at 

diagnosis and every 2, 3, or 4 years or, for those with retinopathy, every 6, 12, 18, or 24 

months. Treatment (photocoagulation for both eyes) cost, including fluorescein angiograms, 

was $1,980. Based on 1988 population figures for the United States, 576,136 patients yearly 

develop type 2 diabetes. Blindness in patients with diabetes costs the federal government 

$14,296 annually per patient under age 65; per patient aged 65 and over, federal expenditures 

are $32 annually (does not include Medicare/Social Security payments or income tax 

exemption). Screening and treatment for eye disease in patients with type 2 diabetes saves 

53,986 person-years of sight at an annual federal budget savings of $247.9 million; these 

results assume that 60 percent of type 2 patients receive appropriate eye care. For patients 

with type 2 diabetes controlled by insulin, however, savings would be $1,715 per person, 

versus $725 for those controlled by other means. Patients with onset prior to age 45 account 

for 89.1 percent of sight savings and 100 percent of cost savings. With recommended eye 

care, 112,730 and 94,304 person-years of sight and $624 and $472.1 million would be saved 

annually in all patients with diabetes and those with type 2 diabetes, respectively. 4 figures, 2 

tables, 52 references. 

86 
TITLE: A Relative Cost-Effectiveness Analysis of Different Methods of Screening for 

Retinopathy. Sculpher, M.J.; Buxton, M.J.; Ferguson, B.A.; Humphreys, J.E.; Altman, J.F.; 

Spiegelhalter, D.J.; Kirby, A.J.; Jacob, J.S.; Bacon, H.; Dudbridge, S.B.; Stead, J.W.; Feest, 

T.G.; Cheng, H.; Franklin, S.L.; Courtney, P.; Talbot, J.F.; Ahmed, R.; Dabbs, T.R. Diabetic 

Medicine. 8(7): 644650. August/September 1991. 

OBJECTIVE: To determine the relative cost effectiveness of various screening methods for 

sight-threatening retinopathy in terms of cost per true-positive case detected. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Cost per true-positive case ranged from £ 633 to £ 1,079 for general 

practitioners; it was £ 1,033 for a hospital physician; £ 784 for an ophthalmic optician; £ 441 

to £ 609 for an ophthalmological clinical assistant; £ 601 to £ 1,546 for a hospital-based 

camera; and £ 497 to £ 747 for a traveling camera. Except for the ophthalmological clinical 

assistant (the reference standard), the sensitivity of all screening methods was low (0.35 to 

0.67). Relative Cost-effectiveness changes if the screening can take place without requiring an 

additional patient visit and is strongly related to the relative sensitivity of the screening 

methods and to the prior probability (prevalence or incidence) of retinopathy in the population 

with diabetes. 

RECOMMENDATION: Approaches to screening, which are discussed in this report, may 

improve sensitivity without reducing specificity or increasing cost per true-positive case 

substantially. 

ABSTRACT: The authors report on screening for sight-threatening retinopathy of five 

patient groups (n = 3,318) in three British centers. Patients' fundi were assessed by a primary 

screener (a hospital physician, a general practitioner, or an ophthalmic optician) using 

ophthalmoscopy with mydriasis. Additionally, all patients had their fundi photographed by a 

nonmydriatic fundus camera, and they received an ophthalmoscopic examination with 

mydriasis by an ophthalmological clinical assistant (the reference standard). The costs per 

true-positive case for the primary screeners ranged from £ 633 to £ 1,079 ( £ 1,033 for the 

hospital physician), for the clinical assistant from £ 441 to £ 609, and for photography from £ 

497 for a camera that is taken to general practices in one center to £ 1,546 for a hospitalbased camera. The cost for true-positive case for hospital physicians would drop from £ 1,033 

to £ 353 if an additional visit to the hospital were not required. Similarly, if ophthalmoscopy is 

part of a general assessment by a general practitioner rather than requiring an additional visit, 

the cost per true-positive case would drop dramatically (to £ 245 to £ 362). Total costs per 

patient screened by primary screeners ranged from £ 19.31 for ophthalmic opticians to £ 37.77 

for hospital physicians. The low sensitivities of primary screeners and of photography (35 to 

67 percent) may indicate that none of these methods would be acceptable in routine clinical 
practice, despite their relatively high specificities (86 to 98 percent). Alternatives that may 

improve sensitivity (while avoiding a reduction in specificity or increase in cost per truepositive case detected) include (1) clinical assistant screening of both hospital and communitybased patients; (2) use of combined screening strategies (e.g., general practitioner, 

ophthalmoscopy and fundus photography); and (3) identification of risk factors for 

retinopathy that could be used, exclusively or in combination with single or joint screening 

methods, as forms of screening in themselves (e.g., patients with 10+ years of type 1 diabetes 

could be referred directly to an ophthalmologist without prior screening). 1 figure, 3 tables, 25 

references. 

87 

TITLE: Retinopathy in the West of Scotland: Its Detection and Prevalence, and the CostEffectiveness of a Proposed Screening Programme. Foulds, W.S.; McCuish, A.; Barrie, T.; 

Green, F.; Scobie, I.N.; Ghafour, I.M.; McClure, E.; Barber, J.H. Health Bulletin. 41(6): 318-

326. November 1983. 

OBJECTIVE: To assess the prevalence of retinopathy as diagnosed by ophthalmoscopy in 

the West of Scotland and to evaluate the financial implications of implementing a screening 

program for retinopathy in that part of Scotland. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Societal. 

CONCLUSION: A projected screening program for retinopathy appeared to be cost savings 

in terms of costs of patient identification and screening relative to savings associated with the 

prevention of blindness. 

RECOMMENDATION: Universal screening for early detection of serious retinopathy 

should be performed. 

ABSTRACT: The authors assessed the prevalence of retinopathy in the West of Scotland. 

Based on ophthalmoscopic examination of 1,147 patients with diabetes, the authors estimated 

the prevalence of retinopathy to be 26 to 35 percent; of serious retinopathy, 9.5 to 11 percent. 

The potential cost-effectiveness of a proposed screening program involving annual 

ophthalmoscopic examination of all patients with diabetes in the West of Scotland (population 

about 2.5 million) was assessed. Projected annual cost associated with 

physician/ophthalmologist examination plus nurse time was £ 51,800. Total annual cost to 

identify those patients with serious retinopathy was estimated to be £ 55,300 , or £ 183 per 

patient with serious retinopathy identified. Total cost per annum of identifying and treating 

patients at risk for blindness was estimated to be £ 387 per patient treated. Costs associated 

with identifying and treating a backlog of patients during the first year of the program were 

estimated to be £ 86 per patient treated. Projected savings in blind welfare services and state 
benefits per case of prevented blindness were calculated to be £ 3,575. It is estimated that 60 

percent of blindness from retinopathy could be prevented by appropriate laser therapy. Total 

savings to the state per annum in treating and preventing blindness in such a percentage of atrisk patients were estimated to be £ 193,050. One-time savings associated with treating the 

backlog of patients with serious retinopathy were estimated to be £ 1.6 million. Appropriate 

laser therapy was estimated to result in a net savings of £ 135,025 annually based on projected 

treatment costs and savings for the state associated with blindness prevention. In addition, the 

90 patients annually prevented from going blind would be expected to earn £ 4.67 million. 1 

table, 10 references. 

88 

TITLE: Retinopathy — Need and Demand for Photocoagulation and Its Cost-Effectiveness: 

Evaluation Based on Services in the United Kingdom. Savolainen, E.A.; Lee, Q.P. 

Diabetologia. 23(2): 138-140. August 1982. 

OBJECTIVE: To assess both need for photocoagulation and the cost-effectiveness of using 

this therapy in patients with retinopathy. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Patient care model. 

Perspective: Societal. 

CONCLUSION: The cost of photocoagulation and follow-up is less than the indirect costs 

to maintain a blind person for 1 year. 

RECOMMENDATION: Criteria for the need for photocoagulation are urgently needed. 

ABSTRACT: The authors used published literature from 1962 to 1978 to estimate the 

number of patients with diabetes needing photocoagulation for retinopathy in two regional 

Health Authorities in England. They also reviewed case notes (only 141 of 272 sampled were 

available) from 9 of 10 photocoagulation centers in the region. Interviews were conducted 

with consultants at the centers, and information on manpower, equipment, and practices with 

different patient groups was obtained to develop a model for estimating consultant hours and 

treatments needed per year. It was estimated that 10,608 eyes were in need of 

photocoagulation, which would require 21,417 consultant hours per year and 14,496 

treatments. The estimated number of actual treatments for 1979 was only 3,080. The annual 

outpatient cost for photocoagulation and follow-up was £ 100 per patient ( £ 170 in 1981 to 

1982 prices). The cost of maintaining one blind person for 1 year (considering lost earnings 

and Social Security payments) was estimated to be £ 1,751 ( £ 2,871 at the end of 1981). As 

two of the nine centers in the sample accept patients from outside the regions, these data 

indicate that fewer than 20 percent of the patient need for photocoagulation was met. Patients 

may be undiagnosed or diagnosed too late for treatment to be effective. Criteria are needed to 

guide early detection, adequate treatment, and follow-up of retinopathy in patients with 
diabetes. Interested physicians, and possibly paramedical staff, will require training in 

photocoagulation to meet the need for this service. 1 figure, 1 table, 10 references. 

89 

TITLE: Screening for Retinopathy in a Clinical Setting: A Comparison of Direct 

Ophthalmoscopy by Primary Care Physicians with Fundus Photography. Griffith, S.P.; 

Freeman, W.L.; Shaw, C.J.; Mitchell, W.H.; Olden, C.R.; Figgs, L.D.; Kinyoun, J.L.; 

Underwood, D.L.; Will, J.C. Journal of Family Practice. 37(1): 49-56. July 1993. 

OBJECTIVE: To compare the accuracy and cost-effectiveness of two approaches to 

screening for retinopathy in a clinical setting: (1) ophthalmoscopy by trained primary care 

physicians followed by referral to ophthalmologists as indicated, and (2) seven-view 

nonstereoscopic, mydriatic fundal photographs read by general ophthalmologists and retinal 

specialists. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Dilated ophthalmoscopic screening by primary care physicians followed by 

referral to an ophthalmologist if indicated was at least as accurate as and more cost effective 

than nonstereoscopic mydriatic fundus photographs read by ophthalmologists in screening for 

retinopathy. 

RECOMMENDATION: Future studies should measure the absolute sensitivity, specificity, 

and predictive value of referral decisions for various diabetic retinal screening strategies and 

should estimate their costs. Similar trials should be conducted in other clinical settings to 

assess physicians' referral decisions. 

ABSTRACT: The two screening strategies were implemented at a rural clinic in Toppenish, 

Washington, that served more than 400 Native Americans with diabetes. During the 2.5-year 

study period, 243 clinic visits were recorded; 93 referrals were made, of which 83 were 

completed. The primary care physicians were first given a 2-hour update about retinopathy 

and their role as screeners; they were told to refer every patient with marked retinopathy to an 

ophthalmologist. The "primary physician method" referred all 17 patients ultimately diagnosed 

with significant retinopathy. Estimated maximum sensitivity in diagnosing retinopathy was 100 

percent for primary physicians; for the general ophthalmologists and retinal specialists reading 

photographs, it was 94 and 100 percent, respectively. Estimated maximum specificity was 93 

percent for the primary physician, 82 percent for the general ophthalmologists, and 64 percent 

for the retinal specialists. Projected costs, including personnel and material costs plus 

examination charges (according to the American Academy of Ophthalmology), for screening 

and diagnosing 100 patients by these methods were $3,132 for ophthalmoscopic screening by 

primary providers, $4,942 to $5,734 for screening by retinal photography, and $8,800 for 
referring all patients for full annual examination by an ophthalmologist. Transportation, 

training, equipment, and other direct or indirect costs were not included. 3 tables, 34 

references. 

90 

TITLE: Screening for Retinopathy in South Africa with 60� Retinal Colour Photography. 

Joannou, J.; Kalk, W.J.; Mahomed, I.; Ntsepo, S.; Berzin, M.; Joffe, B.I.; Raal, F.J.; Sachs, 

E.; Van Der Merwe, M.T.; Wing, J.R. Journal of Internal Medicine. 239(1): 4347. January 

1996. 

OBJECTIVE: To assess the use of a 60� mydriatic fundal camera to screen for retinopathy. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Mydriatic retinal photography with a 60� field was more sensitive and 

diagnostically more accurate than funduscopy by clinic doctors and compared well with 

screening by an ophthalmologist. Screening for treatable retinopathy by 60� mydriatic retinal 

photography is likely to be cost effective. 

RECOMMENDATION: Both retinae should be screened. 

ABSTRACT: Patients attending a diabetes clinic in South Africa were screened for 

retinopathy by mydriatic fundal photography with a 60� camera. Selected eyes were evaluated 

by an ophthalmologist. Randomized photographs were assessed through single or two 

overlapping 45� fields (by masking the slides) and at 60�. The authors found that 92 percent to 

94 percent of photographs were diagnostically useful (80 percent were excellent quality), 

which compares well with nonmydriatic cameras. Compared with an ophthalmologist's 

assessment, retinal photography had a sensitivity of 93 percent and a specificity of 89 percent 

for any retinopathy, and 100 percent and 75 percent, respectively, for severe retinopathy. 

Funduscopy missed 28 percent of affected eyes, compared with only 5.5 percent missed by 

photography. A single 45� field missed 31 percent and two overlapping 45� fields missed 11 

percent of retinopathy as compared with that detected by a 60� field camera. For the 122 eyes 

assessed at the three field areas, the mean scores increased significantly as the field area 

increased (p < 0.0001 for each comparison). The costs of screening were calculated from the 

price of film and processing (but not the camera) and from related staff salaries for the first 

663 patients screened. The basic expenditure (in U.S. dollars) was determined to be $5.85 per 

patient screened, $13.55 per patient with retinopathy (n = 286), and $37.03 for each patient 

referred for formal ophthalmological assessment (n = 103, 15.5 percent). 2 figures, 1 table, 30 

references. 
91 

TITLE: Use of Mobile Screening Unit for Retinopathy in Rural and Urban Areas. Leese, 

G.P.; Ahmed, S.; Newton, R.W.; Jung, R.T.; Ellingford, A.; Baines, P.; Roxburgh, S.; 

Coleiro, J. British Medical Journal. 306(6871): 187-189. January 16, 1993. 

OBJECTIVE: To compare the rate of retinopathy detected by a mobile screening unit 

equipped with a nonmydriatic Polaroid between rural and urban areas; to identify the cost 

associated with the service. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Mobile eye-screening units seem to be particularly effective at identifying 

previously unrecognized advanced retinopathy in rural patients with diabetes; these patients 

were more likely than urban patients to need urgent laser photocoagulation. The cost per 

patient with mobile eye screening units was relatively low. 

RECOMMENDATION: Patients with diabetes living in rural areas are less likely to seek 

help at hospital clinics and would benefit from an expanded mobile-eye-screening program to 

detect and treat retinopathy. 

ABSTRACT: Researchers compared the effective-ness of screening for retinopathy using 

mobile eye-screening units in rural versus urban patients with diabetes during 2 years in the 

Tayside region of Scotland. They estimated that 64 to 77 percent of the population with 

diabetes was screened: 1,225 urban and 961 rural patients were photographed with a 

nonmydriatic fundal camera. Rural patients were less likely to attend a hospital clinic than 

urban patients (46 percent versus 86 percent, p < 0.001) and were less likely to be receiving 

insulin (27 percent versus 34 percent, p < 0.001). Advanced retinopathy was greater among 

rural than urban patients (13 percent versus 7 percent, p < 0.001), and more rural patients 

required urgent laser photocoagulation (1.4 percent versus 0.5 percent, p < 0.02). Direct and 

indirect costs, estimated for screening 1,800 patients a year, included the salary of the 

ophthalmic photographer; the purchasing and processing of film; and the servicing, running, 

and depreciation costs of the van and camera. The cost of the screening program per patient 

was £ 10, which is cheaper than all alternatives. This cost is equivalent to £ 350 per patient 

with previously unrecognized disease and £ 1,000 per patient receiving laser treatment. These 

costs are low compared with alternatives and could be further reduced by screening more 

patients per unit. 5 tables, 23 references. 

Renal Care 
92 

TITLE: Cost Analysis of Kidney-Pancreas and Kidney-Islet Transplant. Lenisa, L.; Castoldi, 

R.; Socci, C.; Motta, F.; Ferrari, G.; Pozza, G.; Di Carlo, V. Transplantation Proceedings. 27 

(6): 3061-3064. December 1995. 

OBJECTIVE: To compare outcomes and costs for patients with diabetes undergoing kidneypancreas or kidney-islet cell transplantation. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Costs for kidney-pancreas and kidney-islet cell transplantation were nearly 

the same. Pancreas grafts had better actuarial survival than islet cell grafts. 

RECOMMENDATION: Improvements are needed in isolation and purification techniques 

for islet cell transplantation, which might lower costs for that approach. 

ABSTRACT: The authors report the costs for 51 kidney-pancreas transplants and 21 kidneyislet cell transplants in patients with type 1 diabetes transplanted at an Italian hospital since 

1989. Among kidney-islet cell patients, 14 received islet cells after kidney transplantation and 

7 received islet cells simultaneously with the kidney. All 72 patients received the same 

immunosuppression and antimicrobial and vascular thrombosis prophylaxis. Actuarial survival 

was calculated from life tables. Expenditures were the actual costs incurred for hospitalization 

from pretransplant evaluation until discharge; kidney-islet cell costs were calculated based on 

using islets from two pancreases per kidney-islet cell transplant and assuming simultaneous 

transplantation of islet cells. Actuarial survival at 48 months was 70 and 52 percent for 

pancreas and islet cell grafts, respectively. Peri-operative mortality, morbidity, and incidence 

of surgical complications were 1.9 and 5 percent, 54 and 29 percent, and 43 and 4.8 percent 

for kidney-pancreas and kidney-islet cell, respectively. Total transplantation costs were 

comparable ($46,085 for kidney-pancreas and $47,550 for kidney-islet cell). Graft retrieval 

cost $1,400 for kidney-pancreas versus $2,260 for kidney-islet cell; islet cell isolation cost 

$15,500. Costs for surgery, hospitalization, and immunosuppression were higher for kidneypancreas than for kidney-islet cell ($5,440 versus $2,580, $30,765 versus $20,790, and $5,640 

versus $3,760, respectively). Patients stayed in intensive care a mean of 7 days for kidneypancreas versus 3 days for kidney-islet cell transplantation and in the medical department a 

mean of 60 versus 50 days, respectively. Hospitalization represented 67 percent of kidneypancreas and 44 percent of kidney-islet cell costs; islet cell isolation represented 32 percent of 

kidney-islet cell costs. The mean length of hospital stay (the major cost for both groups) is 

likely to be lowered. Improvements in islet cell isolation might decrease costs for kidney-islet 

cell transplantation. 2 figures, 2 tables, 6 references. 
93 

TITLE: The Cost of Immunosuppression and Coverage of Immunosuppressive Drugs for 

Kidney Transplant Recipients Under the Medicare Catastrophic Coverage Act. In: Cost and 

Outcome Analysis of Kidney Transplantation: The Implications of Initial Immunosuppressive 

Protocol and Diabetes (Final Report: Volume I). Evans, R.W.; Manninen, D.L.; Thompson, 

C. Battelle Human Affairs Research Centers, Seattle, Washington. 1989. Chapter 13. 

OBJECTIVE: To provide the Health Care Financing Administration with information it 

needs to quantify the economic consequences of the Medicare Catastrophic Coverage Act of 

1988. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: There are likely to be relatively few changes in transplant 

immunosuppression between 1988 and 1995 that will seriously affect the overall costs of 

organ transplantation. 

RECOMMENDATION: None. 

ABSTRACT: The Medicare Catastrophic Coverage Act of 1988 will shield Medicare 

beneficiaries from excessive hospital, doctor, and outpatient prescription drug bills. In this 

chapter, the authors project the number of kidney transplant recipients likely to be eligible for 

Medicare catastrophic coverage through 1995, estimate per-patient annual expenditures for 

immunosuppressive drugs during the year of transplant and subsequent years, and highlight 

future developments in the field of transplant immunosuppression. In 1987, there were 39,585 

living kidney transplant recipients; for 1995 the authors project totals ranging from 63,910 

(base case) to 144,653. The authors note that cyclosporine was approved by the Food and 

Drug Administration in 1983; for 1990 through 1995 they project that 95 percent of 

transplants (cadaver or living related donor) will use this drug as a primary 

immunosuppressive agent. They present cost estimates associated with major 

immunosuppressive protocols in use in the United States; per the "high" estimate, total firstyear costs range from $947 for conventional immunosuppression without antithymocyte 

globulin to $12,819 for quadruple-drug cyclosporine therapy. Subsequent-year annual costs 

range from $793 for conventional immunosuppression to $8,227 for triple-drug cyclosporine 

therapy (U.S. variation); this cost is $6,870 for quadruple-drug cyclosporine therapy. Per the 

National Task Force on Organ Transplantation (1985), the cost-effectiveness of cyclosporine 

therapy is believed to exceed that of conventional therapy, but the Task Force assumed that 

patients on cyclosporine would be converted to conventional therapy within 1 year after 

transplant. The authors state that triple-drug and quadruple-drug cyclosporine therapy appear 

to be equally cost effective. 56 tables, 5 figures. 
94 

TITLE: Cost-Effective Treatment for Diabetic End-Stage Renal Disease: Dialysis, Kidney, or 

Kidney-Pancreas Transplantation? Lenisa, L.; Castoldi, R.; Socci, C.; Motta, F.; Ferrari, G.; 

Spotti, D.; Caldara, R.; Secchi, A.; Pozza, G.; Di Carlo, V. Transplantation Proceedings. 27 

(6): 3108-3113. December 1995. 

OBJECTIVE: To compare the survival, morbidity, and cost of hemodialysis, kidney 

transplantation, and kidney-pancreas transplantation in patients with end-stage renal disease 

associated with type 1 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: In terms of survival rate and financial savings, kidney-pancreas 

transplantation is the most cost effective of the three treatments. 

RECOMMENDATION: None. 

ABSTRACT: The authors report survival, morbidity, and cost data for 122 patients with type 

1 diabetes treated at San Raffaele Hospital in Milan, Italy. All patients had undergone 

hemodialysis (HD); in this study, 48 remained on HD, 23 underwent kidney transplantation 

(K), and 51 had a kidney-pancreas transplant (KP). Survival rates were calculated by life-table 

methods from the beginning of HD for all patients and from the third month after 

transplantation for K and KP. To correct for selection bias, survival curves were also 

calculated from the day of transplantation for the K and KP groups and from 25 months after 

initiation of HD for the HD group (25 months was the mean duration of dialysis at 

transplantation for the transplant groups). Expenditures were the actual costs (undiscounted) 

incurred for hospitalization from pretransplant evaluation until discharge and for consumable 

materials, depreciation of machinery and buildings, and personnel costs. Actuarial survival 96 

months from initial HD for HD, K, and KP was 40 percent, 70 percent, and 87 percent, 

respectively (p < .001 for K and KP compared with HD); 84-month survival from date of 

transplantation or from 25 months after HD initiation (for the HD group) was 36 percent, 65 

percent, and 96 percent, respectively (p < .001 for K and KP compared with HD). In KP, 

there were five kidney transplant failures and one pancreas graft failure; in K, there was one 

graft failure. Peri-operative mortality was 8.7 percent in K and 1.9 percent in KP. The first 

year of HD cost $43,150 for 3 treatments per week, monthly assessment, and vascular access. 

Transplantation costs were $30,090 for K and $46,085 for KP. Surgery, hospitalization, and 

rejection treatment costs were higher for KP than K. Estimated costs for each year after 

transplantation were $13,070 for K and $10,880 for KP, which were 32 percent and 27 

percent of expected yearly HD costs, respectively. 4 figures, 3 tables, 15 references. 
95 

TITLE: Cost-Effectiveness Modeling of Simultaneous Pancreas-Kidney Transplantation. 

Holohan, T.V. International Journal of Technology Assessment in Health Care. 12(3): 416-

424. Summer 1996. 

OBJECTIVE: To compare simultaneous pancreas-kidney transplantation and kidney 

transplantation plus continued insulin therapy in patients with type 1 diabetes using a costeffectiveness model. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The model predicted that simultaneous pancreas-kidney transplantation 

would be less cost effective than a kidney transplant plus continued insulin therapy except for 

patients with complicated diabetes that was poorly responsive to exogenous insulin and whose 

costs of maintaining blood glucose control were high. In that scenario, the two interventions 

were equal in cost-effectiveness. 

RECOMMENDATION: These cost-effectiveness analyses should be reviewed periodically 

as data on pancreas survival after simultaneous pancreas-kidney transplant accumulate and as 

more comprehensive cost information becomes available. 

ABSTRACT: In the authors' cost-effectiveness model, estimated costs for 100 hypothetical 

recipients of simultaneous pancreas-kidney transplants were compared with those for 100 

hypothetical recipients of a kidney transplant only. Cost estimates for transplant procedures 

and for maintaining blood glucose control in those without a normally functioning pancreas as 

well as estimates of the quality of life resulting from transplant were considered. Costs were 

estimated for a 3-year posttransplant period; costs for kidney transplant alone included 

ongoing expenses of treating hyperglycemia or hypoglycemia. The model assumed no renal 

graft loss in either group; pancreas graft survival rates were based on United Network for 

Organ Sharing data. The costs of combined transplant included managing hyperglycemia or 

hypoglycemia in those patients whose pancreas grafts failed over time. Payment data for the 

procedures were obtained from the Health Insurance Association of America, the Health Care 

Financing Administration, and a survey of transplant centers. The cost per quality-adjusted 

life-year of the two procedures was equivalent only when the annual cost of blood glucose 

control was in the range of $28,000 to $40,000. Simultaneous pancreas-kidney transplant was 

therefore likely to be equivalent in cost-effectiveness to kidney transplant plus continued 

insulin therapy only for those patients whose annual direct costs of blood glucose maintenance 

were high, in the range of $15,000 to more than $40,000 per year. Average annual direct 

costs for treating diabetes and its complications have been estimated to be $6,280 by the 

American Diabetes Association. 1 figure, 4 tables, 65 references. 
96 

TITLE: Cost-Effectiveness of Screening and Early Treatment of Nephropathy in Patients 

with Insulin-Dependent Diabetes Mellitus. Siegel, J.E.; Krolewski, A.S.; Warram, J.H.; 

Weinstein, M.C. Journal of the American Society of Nephrology. 3(Suppl 1): S111-S119. 

October 1992. 

OBJECTIVE: To determine the effect of angiotensin-converting enzyme inhibitors (ACEIs) 

on survival and the cost of using these drugs at an early stage of nephropathy; to determine 

what kind of intervention program with ACEIs would be appropriate. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Early treatment of type 1 diabetes with ACEIs can be a very cost-effective 

use of health care resources. 

RECOMMENDATION: None. 

ABSTRACT: Researchers developed a model to simulate the progression of renal 

complications in newly diagnosed type 1 diabetes patients to determine the effectiveness of 

using ACEIs as a treatment modality. Three alternative strategies (programs) were analyzed 

(versus standard antihypertensive treatment); patients were screened twice annually for renal 

complications in each. Overt proteinuria, significant microalbuminuria, and microalbuminuria 

were treatment indicators for ACEIs in programs 1, 2, and 3, respectively. The progression of 

nephropathy and medical care costs incurred with the new programs were compared with 

those for standard treatment. Cost-effectiveness was considered the ratio of the net increase in 

health care costs (discounted by 5 percent per year) to the discounted net improvement in 

health outcome (life expectancy). With standard treatment, a cohort of 15-year-old patients 

with type 1 diabetes had a median life expectancy of 44.9 years (undiscounted) and lifetime 

costs for treatment of $4,706 per person (discounted). Program 1 was used as the baseline to 

calculate cost-effectiveness ratios because it had lower costs and it improved life expectancy 

more than standard treatment. Program 1 lifetime costs were $4,643 per person (discounted) 

and additional life expectancy was 45.1 years (undiscounted), assuming a starting age of 15 

years. Values for program 2 were $5,542 and 45.3 years; program 3, $5,927 and 45.5 years. 

Program 2 offers additional life savings at an additional cost; however, it is not a costeffective option; the substantial increase in screening and treatment costs from this program is 

not offset by a sufficient increase in life expectancy. Program 3 had the highest initial costs but 

avoided twice as many cases of renal failure as program 1; it provided an additional 5 to 8 

months of life expectancy (not discounted) and its incremental cost-effectiveness ratio was 

$7,900 to $16,500 per additional year of life saved. Resources permitting, program 3 would 

be the preferred choice. 1 figure, 6 tables, 23 references. 
97 

TITLE: The Costs of Nephropathy in Type II Diabetes. Borch-Johnsen, B. 

PharmacoEconomics. 8(Supplement 1):40-45. 1995. 

OBJECTIVE: To discuss the problem of nephropathy in patients with diabetes, including the 

social cost of this disorder and the economics of prevention. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Societal. 

CONCLUSION: Screening, intervention, and treatment for nephropathy is cost effective in 

type 1 diabetes patients; more research on this issue is needed for type 2 diabetes. 

RECOMMENDATION: Future controlled clinical trials on the benefits of screening for 

diabetic nephropathy should focus on type 2 diabetes patients. 

ABSTRACT: The lifetime risk of diabetic nephropathy may be as low as 15 to 25 percent in 

type 1 diabetes patients. Studies of the natural history of nephropathy in patients with type 2 

diabetes are difficult to perform, but research in selected high-risk populations has found 

incidence patterns to be similar for types 1 and 2 diabetes. Patients with diabetic nephropathy 

have an increased risk (versus other patients with diabetes) of developing other late diabetic 

complications (e.g., they have a relative risk of 5-10 for acute myocardial infarction and 2-4 

for stroke). Genetic susceptibility appears to be essential for developing nephropathy. 

Important risk factors for nephropathy among type 2 diabetes patients include young age at 

diagnosis, familial predisposition, poor metabolic control, hypertension, retinopathy, and 

microalbuminuria. The author discusses a model for estimating the actual costs of diabetic 

renal disease in a society; epidemiological data, results of controlled clinical trials, and reliable 

cost data are needed for the model. Studies of type 1 diabetes patients show the costs of 

treating end-stage renal failure to be so high that, even for rather expensive screening, 

intervention, and treatment programs, the benefits exceed the costs; a separate analysis would 

be needed for type 2 diabetes patients. In white populations in western Europe and North 

America, most type 2 diabetes patients will die from vascular disease. In nonwhite 

populations, the incidence of type 2 diabetes in patients below age 50 is much higher than in 

whites, and these patients will live long enough to develop diabetic nephropathy. Intervention 

trials targeted at preventing end-stage renal failure in type 2 diabetes patients are urgently 

needed; studies in Asia, the Pacific Islands, and Latin America (high-risk areas for early-onset 

type 2 diabetes) should be encouraged. 1 figure, 4 tables, 21 references. 
98 

TITLE: Economic Analysis of Captopril in the Treatment of Diabetic Nephropathy. Rodby, 

R.A.; Firth, L.M.; Lewis, E.J.; the Collaborative Study Group. Diabetes Care. 19(10): 1051-

1061. October 1996. 

OBJECTIVE: To determine the long-term impact on health care costs of using captopril 

therapy in patients with diabetic nephropathy to delay the progression to end-stage renal 

disease (ESRD) or death. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: The analysis showed that captopril therapy in patients with type 1 or type 2 

diabetes and overt nephropathy saves substantial direct costs and reduces health care 

expenditures for treatment of ESRD. 

RECOMMENDATION: None. 

ABSTRACT: The authors assessed the long-term impact on health care costs of treating 

patients with diabetic nephropathy with captopril, an antihypertensive drug. A medical 

treatment model was developed to compare the costs and benefits of captopril therapy in 

delaying the progression to ESRD or death. The model was based on data derived from a 

prospective, double-blind, multicenter clinical trial of captopril in patients with type 1 diabetes 

and nephropathy. In that model, captopril therapy reduced the risk of both progressive renal 

insufficiency and the combined endpoint of death, dialysis, and transplantation by about 50 

percent. Data for patients with type 2 diabetes were projected from the type 1 study. The 

model assessed the economic impact of captopril therapy over the projected lifespans of 

patients in the study (31 years for patients with type 1 diabetes and 12 years for patients with 

type 2). Projected costs for ESRD included direct costs associated with treatment (dialysis 

and transplantation), including transportation, and indirect costs related to disability and 

premature death. Direct and indirect costs were stated in 1994 dollars; both costs and lifeyears saved were discounted at 5 percent. Direct lifetime cost savings associated with 

captopril use were $32,550 per patient for those with type 1 diabetes and $9,900 per patient 

for those with type 2. Indirect per-patient cost savings were $84,390 and $45,730 for those 

with type 1 and type 2 respectively. These savings included future monies not spent on ESRD 

treatment because of death of some patients from other causes, such as cardiovascular disease. 

According to the model, if captopril therapy were initiated in 1995 for patients with either 

type of diabetes and nephropathy, the aggregate health care costs savings would be $189 

million a year for the year 1999 and $475 million a year in 2004; the present value of 

cumulative health care cost savings over 10 years would be $2.4 billion. 4 figures, 2 tables, 2 

appendixes, 66 references. 
99 

TITLE: Economic Evaluation of the Contribution of Captopril in the Treatment of Diabetic 

Nephropathy: A Cost-Effectiveness Approach. (Article in French with an English abstract.) Le 

Pen, C.; Petitjean, P.; Lévy, P.; Hannedouche, T. Nephrologie. 17(6): 321-326. 1996. 

OBJECTIVE: To evaluate the cost-benefit ratio of the use of captopril to treat nephropathy 

in patients with type 1 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: The use of captopril to treat nephropathy in patients with type 1 diabetes is 

therapeutically and economically efficacious, especially for patients who require 

antihypertensive therapy as well. 

RECOMMENDATION: None. 

ABSTRACT: The authors analyzed the cost benefit of captopril treatment of nephropathy in 

patients with type 1 diabetes, using previously published data from a randomized, doubleblind, clinical trial (Lewis. New England Journal of Medicine 329: 1456-1462. 1993). Patients 

had been diagnosed at least 7 years previously and had proteinuria greater than 500 mg/24 

hours and blood creatinine less than 221 Fmol/L at entry. Serum creatinine doubled in 25 of 

the captopril group (n = 207, 25 mg, 3 times per day for an average of 883 days) and in 43 of 

the placebo group (n = 202, average of 824 days; p < 0.007). The combined death, dialysis, or 

transplantation events numbered 23 (8 deaths) in the treatment group and 42 (14 deaths) in 

the placebo group (p < 0.006). Costs were calculated based on 1993 French health care costs 

and on the Lewis data from which the effects of other antihypertensive treatment could not be 

separated nor costs of screening for admission to the study or follow-up determined. Captopril 

treatment cost 1,263,017 French francs (FFr) for the cohort (FFr 6,101.53 per patient); other 

antihypertensives cost (in FFr) 543,271 in the captopril group and 649,832 in the placebo 

group. In the captopril and placebo groups, hospitalizations cost (in FFr) 630,312.98 and 

712,752.14, respectively, and dialysis/transplantation cost (in FFr) 13,842,500 and 

20,912,500, respectively. Overall, the cost savings in the captopril group was FFr 5,995,983; 

a savings of 131 life-years was also realized in the captopril group. If all patients were treated 

with captopril for nephropathy, the net cost-benefit would be FFr 475 per patient. These 

savings actually underestimate cost-benefit since they do not include, for instance, the 

hospitalization costs for vascular access and initiation of dialysis or pretransplant 

examinations. Further economic benefits from captopril would be expected from a study of 

longer duration. 5 tables, 10 references. 
100 

TITLE: Employment, Work Disability, and Income Support Program Participation. In: A 

Cost and Outcome Analysis of Kidney Transplantation: The Implications of Initial 

Immunosuppressive Protocol and Diabetes (Final Report: Volume I). Evans, R.W.; 

Manninen, D.L.; Thompson, C. Battelle Human Affairs Research Centers, Seattle, 

Washington. 1989. Chapter 8. 

OBJECTIVE: To examine the employment and work disability experience of renal transplant 

patients after their transplant surgery. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Survey. 

Perspective: Societal. 

CONCLUSION: Kidney transplantation is not very effective in allowing previously disabled 

dialysis patients to return to the labor force. 

RECOMMENDATION: None. 

ABSTRACT: In this multicenter observational study (sponsored by the Health Care 

Financing Administration) of patients who underwent kidney transplantation, questionnaires 

were used to find out about employment status in the year prior to transplant and at 3, 6, 9, 

12, and 15 months after the procedure. Sample sizes frequently differed by analysis. Just over 

half (50.7 percent) of patients reported they were employed either full time or part time in the 

year prior to surgery; 3 months after surgery, only 28.7 percent said they were employed. In 

an analysis by primary renal diagnosis, less than half (43.3 percent) of those whose diagnosis 

was not diabetes and 33.3 percent of those with a diabetes diagnosis were employed full time 

before transplant; 23.8 and 20.0 percent, respectively, were employed full time 3 months later. 

On the issue of ability to work (not employment status), rates for the diabetes and nondiabetes 

groups were as follows: not able to work for pay, 63.1 percent and 39.1 percent; limited in 

kind of work, 83.1 percent and 58.6 percent. Three months posttransplant, 43.5 percent of 

transplant patients were receiving Social Security retirement or disability benefits and 17.8 

percent were receiving Supplemental Security Income. More than half (53.8 percent) of 

patients with a primary renal diagnosis of diabetes were receiving Social Security retirement 

or disability benefits at that time. Although 97.2 percent of transplant patients said they 

received assistance (Medicare, State Kidney Program, Medicaid, etc.) in paying for 

immunosuppressive drugs, 22.8 percent said they had difficulty paying for the drugs. Fifteen 

months following transplantation, 43.1 percent of patients reported being employed either full 

or part time, but the number of patients for whom employment status was known was very 

small (n = 51). 27 tables. 
101 

TITLE: Hospital Charges. In: Cost and Outcome Analysis of Kidney Transplantation: The 

Implications of Initial Immunosuppressive Protocol and Diabetes (Final Report: Volume I). 

Evans, R.W.; Manninen, D.L.; Thompson, C. Battelle Human Affairs Research Centers, 

Seattle, Washington. 1989. Chapter 12. 

OBJECTIVE: To analyze costs of the initial hospital stay and follow-up periods for patients 

undergoing kidney transplantation. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Kidney transplantation is an expensive procedure. 

RECOMMENDATION: None. 

ABSTRACT: In this multicenter observational study of kidney transplantation, which was 

sponsored by the Health Care Financing Administration, the authors analyzed hospital charges 

rather than costs. The mean charge for the transplant procedure (the initial hospital stay), 

including professional fees, was $41,046 (range: $18,484 to $727,392); length of stay ranged 

from 6 to 252 days (n = 396). Patients were compared by whether their primary renal 

diagnosis was diabetes: Average transplant charges for the nondiabetes group were $41,587; 

for the diabetes group, they were $39,718. Estimated follow-up hospital charges (not 

including professional fees) in the first year after transplant were $22,098 for the diabetes 

group and $12,533 for those without the diabetes diagnosis. Patients with a diabetes diagnosis 

averaged more follow-up hospital days than other patients in the first four posttransplant 

periods (each 3 months), with the most pronounced difference in the 6-9-month period (5.8 

days versus 1.5 days). For the 24 patients who experienced a graft failure or died between 

initial hospital discharge and the 3-month checkpoint, hospital charges for this period 

(excluding professional fees) averaged $31,049. In contrast, for the 346 patients with 

functioning grafts at 3 months, average charges were $3,835. 13 tables. 

102 (Cross-Reference 161) 

TITLE: Is Screening and Intervention for Microalbuminuria Worthwhile in Patients with 

Insulin Dependent Diabetes? Borch-Johnsen, K.; Wenzel, H.; Viberti, G.C.; Mogensen, C.E. 
British Medical Journal. 306(6894): 1722-1725. June 1993. Correction: 307(6903): 543. 

August 1993. 

OBJECTIVE: To analyze the cost benefit of screening for microalbuminuria and providing 

antihypertensive treatment for early renal disease indicated by microalbuminuria in patients 

with type 1 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Assuming drug treatment effects (delay in normal progression of 

microalbuminuria) of 33 percent or 67 percent, median life expectancy increased by 4 or 14 

years, respectively, and the need for dialysis or transplantation decreased by 21 percent or 63 

percent. Establishing a screening program for microalbuminuria for patients with type 1 

diabetes would be economically neutral at a treatment effect of 11 percent and a discount rate 

of 6 percent. 

RECOMMENDATION: A screening program including annual measurement of urinary 

albumin excretion rate should be implemented to help increase life expectancy and reduce endstage renal failure, and an intervention program of antihypertensive treatment should also be 

considered (it is known to be effective in patients with nephropathy, and its effectiveness for 

microalbuminuria has been suggested by clinical studies). 

ABSTRACT: This cost-benefit analysis of the effects of a screening and antihypertensive 

intervention program for microalbuminuria used a computer simulation of a 30-year program 

involving an imaginary cohort of 8,000 patients with type 1 diabetes, whose urine was 

screened annually beginning 5 years after onset of the disease. Objectives were to estimate 

mortality, incidence of nephropathy, and need for kidney transplantation or dialysis as well as 

the direct costs and savings associated with preventing or postponing the development of 

nephropathy. One scenario described the natural progression of the cohort and another the 

progression of the same cohort with screening and treatment. The economic evaluation was 

based on direct costs (screening, antihypertensive treatment in patients with microalbuminuria 

and nephropathy, dialysis, kidney transplantation, and immunosuppressive agents in patients 

needing transplants). Costs (and savings) were based on 1991 German sickness fund prices 

and were given in Deutschmarks (DM). A progression rate of 20 percent was assumed for 

untreated microalbuminuria. Assuming treatment effects (decrease in progression rate) of 33 

percent or 67 percent, median life expectancy would increase by 4 or 14 years, respectively; 

onset of nephropathy, by 6 or 24 years; and the need for kidney transplantation or dialysis by 

21 percent or 63 percent, respectively. Costs and savings would balance with a real discount 

rate of 6 percent a year and an antihypertensive treatment effect of 11 percent or with a real 

discount rate of 2.5 percent and an 8 percent treatment effect. Savings per patient would 

range from DM 1,500 (U.S. $800) with a discount rate of 6 percent and a treatment effect of 

33 percent to DM 11,000 for a discount rate of 2.5 percent and a 67 percent treatment effect. 

4 figures, 3 tables, 35 references. 
103 

TITLE: Pancreas Transplantation as a Treatment for Diabetes: Indications and Outcome. 

Sutherland, D.E. Current Therapy in Endocrinology and Metabolism. 5: 457-460. 1994. 

OBJECTIVE: To review the indications for various pancreas transplantation options and 

their outcomes and costs. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: It is more expensive to treat diabetes with a pancreas transplant than with 

insulin injections, but if secondary complications are ameliorated, health care costs over a 

lifetime may be less than if the recipient remained diabetic. Improved quality of life in patients 

who have received a pancreas transplant also justifies the cost of the procedure. 

RECOMMENDATION: None. 

ABSTRACT: The author examines pancreas transplantation in terms of medical and quality 

of life outcomes as well as costs. Worldwide, more than 4,000 pancreas transplants had been 

reported by 1992, including 2,600 in the United States. Successful pancreas transplantation 

may stabilize retinopathy over the long term and significantly improve survival probability in 

patients with severe nephropathy. Kidney function is adversely affected by immunosuppressive 

drugs. As long as rejection is prevented, improvement in quality of life for patients with 

transplanted pancreas and kidneys is dramatic, because both insulin dependence and dialysis 

are prevented. Patients with only a pancreas transplant must balance the benefit of relief from 

diabetes with the difficulties of immunosuppression. In a study of 131 patients, 92 percent 

found immunosuppression was easier to manage than diabetes. Standardized well-being 

indices showed that 100 percent and 85 percent of patients with successful and failed grafts, 

respectively, would recommend transplantation. Insurance coverage for kidney transplant is 

routine but highly variable for pancreas transplantation. Pancreas transplants performed as a 

solitary procedure at the University of Minnesota cost $65,000 for hospital care plus the cost 

of immunosuppressive drugs. 27 references. 

104 

TITLE: Simultaneous Pancreas-Kidney Transplantation (SPK): A Cost-Effectiveness 

Analysis Model (abstract). Holohan, T.H. Annual Meeting of the International Society for 

Technology Assessment in Health Care. 1996; 12:25. 
OBJECTIVE: To compare cost per quality-adjusted life-year (QALY) of simultaneous 

pancreas-kidney transplantation and kidney transplant only. 

CATEGORY: Tertiary intervention. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-utility analysis. 

Perspective: Health care system. 

CONCLUSION: Even though the model's assumptions favored the combined transplant, in 

terms of cost per QALY the combined transplant was equivalent to a kidney transplant alone 

only for patients whose annual treatment costs for managing diabetes were quite high 

($15,000 to $40,000) or for patients whose quality of life after a simultaneous transplant has 

been shown to be superior to the quality of life of patients having a kidney transplant alone 

with continued insulin therapy. 

RECOMMENDATION: None. 

ABSTRACT: The author describes a model developed to compare costs associated with a 

combined pancreas-kidney transplant to treat end-stage renal disease in people with type 1 

diabetes with that of a kidney transplant alone. The model assumed that improvement in 

secondary complications (neuropathy, nephropathy, and retinopathy) resulting from a 

combined transplant remained unproven; that a combined transplant resulted in improved 

quality of life, although there are few objective data to support this assumption; that no 

technical failures occurred with the combined transplant; and that there were no renal graft 

failures. The model accounted for a period of 3 years, the length of time for which graft 

survival data were available. Benefit was expressed in terms of QALY, and costs included 

costs or charges related to the transplant operation and those associated with treating 

hypoglycemia or hyperglycemia in patients getting kidney transplant alone and in patients with 

pancreas graft failure. 

105 

TITLE: Therapeutic Interventions in the Progression of Diabetic Nephropathy. Lewis, E.J. 

American Journal of Hypertension. 7 (9 Part 2): 93S95S. September 1994. 

OBJECTIVE: To determine whether the drug captopril exerts kidney-protective effects 

independent of the effects it has on systemic blood pressure. 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 
Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: The protection that captopril offers against deterioration in renal function is 

significantly greater than that attributable to control of blood pressure alone. Captopril is very 

cost effective compared with other therapies and has no costs associated with life-years 

gained. 

RECOMMENDATION: Treatment with captopril can potentially eliminate high annual 

treatment costs for dialysis and kidney transplantation in numerous patients. 

ABSTRACT: A prospective, double-blind, randomized, placebo-controlled multicenter trial 

was conducted in 30 clinical centers in the United States and Canada. Captopril (25 mg 3 

times daily) was compared with a placebo in 409 patients with overt nephropathy associated 

with type 1 diabetes (average age, 35; mean duration of diabetes, 22 years). Three quarters of 

the patients either had hypertension at entry or were already on antihypertensive treatment. In 

both groups (n = 207, captopril group; n = 202, placebo group), the aim was to maintain 

blood pressure below set limits using agents other than an angiotensin-converting enzyme 

(ACE) inhibitor or a calcium antagonist during the median 3year follow-up so that the 

potential kidney-protective effect of ACE inhibition by captopril could be assessed 

independently. The primary outcome measure was a doubling of the baseline serum creatinine 

concentration (among study participants, median time from doubling of serum creatinine to 

requiring dialysis was 9 months). In the placebo group, 43 of 202 patients doubled their serum 

creatinine, versus 25 of 207 in the captopril group, which had a risk reduction of 51 percent. 

The placebo group lost renal function at a rate of nearly 17 percent per year versus 10 percent 

in the captopril group. The combined endpoint of endstage renal disease or death was reached 

by nearly twice as many in the placebo group (n = 42, 21 percent) as in the captopril group (n 

= 23, 11 percent, p = 0.006). Nephroprotective therapy could double the time to dialysis from 

3 years in a patient who has routine blood pressure control to 6 years on captopril. An 

economic model (Rodby R.A. et al., unpublished study) to determine the economic value of 

treating nephropathy patients with captopril to reduce progression to end-stage renal disease 

found significant overall cost savings. Projecting figures from this study yields a savings of 

more than $2.6 billion over 10 years for end-stage renal disease. 2 references. 

106 

TITLE: Type I Diabetic Nephropathy: Clinical Characteristics and Economic Impact. 

Chukwuma, C. Journal of Diabetes and Its Complications. 7(1): 15-27. January-March 1993. 

OBJECTIVE: To examine the incidence, prevalence, pathogenesis, risk factors, and costs of 

nephropathy associated with type 1 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 
Perspective: Health care system. 

CONCLUSION: Direct medical costs are much higher in diabetes than in other diseases. 

Type 1 diabetic nephropathy necessitates kidney replacement in many patients. The cost of 

renal replacement therapy is greater for patients with diabetes. 

RECOMMENDATION: The pathogenesis and treatment of type 1 diabetes nephropathy 

needs to be elucidated to reduce the economic impact of that disorder. 

ABSTRACT: The author reviews the incidence, prevalence, pathogenesis, risk factors, and 

economic impact of diabetic nephropathy in patients with type 1 diabetes. About one-third of 

type 1 patients develop diabetic nephropathy. Several risk factors, including poor metabolic 

control, hypertension, and genetic factors are related to its development. End-stage renal 

disease (ESRD) is a frequent consequence of nephropathy. The incidence of ESRD from 

diabetic nephropathy increased in the United States from 10 percent in 1973 to 30 percent in 

1987. Also in the U.S., Medicare costs in 1982 for ESRD among persons with diabetes were 

$330 million. These costs appear to be increasing at a rate exceeding $800,000 per year. 

ESRD therapy is more costly for patients with diabetes than for other causes because of a 

higher hospitalization rate and poorer treatment outcomes. 

Foot Care 

107 

TITLE: Benefits of Prevention: The Medicare Therapeutic Shoe Demonstration. Wooldridge, 

J.; Handwerger, S. Diabetes Spectrum. 2(6): 390-394. November-December 1989. 

OBJECTIVE: To describe the Medicare Therapeutic Shoe Demonstration, a congressionally 

mandated research initiative into the cost-effectiveness of using Medicare Part B coverage for 

therapeutic shoes in patients with diabetes mellitus who have severe foot disease. 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: None. 

RECOMMENDATION: None. 

ABSTRACT: In the Medicare Therapeutic Shoe Demonstration, physicians (including 

podiatrists) in the demonstration states (California, Florida, and New York) are to certify the 

eligibility of patients with diabetes who have severe foot disease. Patients are to be randomly 

assigned to receive or not receive Medicare Part B coverage for therapeutic shoes (n = 13,700 
patients per group). Cost-effectiveness will be determined by aggregate federal and state 

costs. If costs for patients who receive the benefit exceed costs for those who do not, it will 

not be cost effective. Unless the shoe benefit is not cost effective, it will become permanent in 

1993. Eligible patients will have a past or present history of callus formation with peripheral 

neuropathy, foot ulceration, prior amputation of a foot in whole or in part, foot deformity 

with potential for ulceration, or poor circulation. The legislation limits coverage to one pair of 

depth-inlay or custom-molded shoes; an authorized shoe supplier will bill Medicare directly, 

with annual deductible and copayment costs the responsibility of the patient. The 

demonstration began in August 1989 and will run for 1 to 3 years. 1 table. 

108 

TITLE: Cost-Effectiveness of Early Digit Amputation in the Patient With Diabetes. Benton, 

G.S.; Kerstein, M.D. Surgery, Gynecology and Obstetrics. 161(6): 523-524. December 1985. 

OBJECTIVE: To assess the cost-effectiveness of early versus delayed amputation of the 

osteomyelitic toe in patients with diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Early amputation is the preferred approach for managing osteomyelitis of 

the toe in patients with diabetes. Oral antibiotic use alone is neither clinically nor cost 

effective. 

RECOMMENDATION: Early surgical intervention and rehabilitation would reduce 

hospitalizations for foot lesions among patients with diabetes and have beneficial economic 

effects. 

ABSTRACT: The authors report the costs of treating 14 men and 8 women with diabetes 

who had radiologic confirmation of osteomyelitis of the toe with no systemic sepsis. Cultures 

confirmed the diagnosis, with Staphylococcus aureus the predominant organism. Patients were 

initially treated with 2 grams/day of oral cephalosporin. Average length of antibiotic treatment 

was 108 days for men and 84 days for women. All patients subsequently met minimum criteria 

for local amputation: (1) Gangrene and infection was localized, (2) patient was free of pain, 

(3) patient had minimal or no rubor of the toes on dependency, and (4) venous filling was no 

longer than 20 seconds. All amputations were through the metatarsal phalangeal region. Time 

to complete healing and rehabilitation after surgery was 15 days (range 9 to 31) for men and 

13 days (range 8 to 28) for women. Costs were assessed for antibiotics, local wound care, and 

mean length of hospitalization and did not reflect days lost from work. Per-patient and total 

costs for antibiotics were $350 and $7,700, respectively. Per-day and total hospitalization 

costs were $165 and $2,359, respectively. Postoperative hospitalization averaged 2.6 days, 

and daily costs of medicine, operating room, laboratory, and ancillary services averaged $350. 
The surgeon's fee averaged $250. Oral antibiotic therapy was ineffective and therefore an 

unnecessary cost. Definitive surgery allows the patient to return to work within 2 weeks of 

amputation. 5 references. 

109 

TITLE: Diabetic Foot Care: Financial Implications and Practice Guidelines. Reiber, G. 

Diabetes Care. 15(Supplement 1): S29-S31. March 1992. 

OBJECTIVE: To examine the financial implications of foot care in patients with diabetes and 

to review the implementation of practice guidelines for diabetic foot care. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Diabetic foot problems result in significant morbidity and mortality in the 

United States. Foot care guidelines are emerging, but their role in reducing foot problems in 

diabetes is not well defined. 

RECOMMENDATION: Studies should be conducted to address the impact of current 

guidelines for foot care, the cost-effectiveness of both preventive and therapeutic measures, 

and modes of delivering patient education and foot care. 

ABSTRACT: The author examines the available data on the impact of foot problems in 

patients with diabetes and the status of practice guidelines. Although the actual cost of 

diabetic foot problems in the United States is under debate, the current data show that diabetic 

foot problems result in significant morbidity and mortality. A 1986 study estimated that 

chronic skin ulcers alone accounted for $150 million of the $11.6 billion direct costs of type 2 

diabetes in the United States. California hospital discharge data showed an average cost of 

$20,085 and length of stay of 19.3 days for nontraumatic diabetic amputation in 1987. In 

fiscal year 1987, Medicare reported 31,120 bills submitted for reimbursement of lowerextremity amputation, with reimbursements averaging $12,230 and length of stay averaging 

18.7 days. Average cumulative cost of care for 106 patients (diabetes status unknown) treated 

at a New England medical center for limb-threatening ischemia was $40,769 for a lowerextremity bypass (average follow-up: 2.2 years) and $40,563 for amputation (average followup: 1.8 years). Foot care guidelines for persons with diabetes from several sources are 

reviewed. The author concludes that these guidelines should be viewed by providers as 

recommended minimum practice guidelines that should be modified and adapted according to 

patient pathology, comorbidity, and ability. 20 references. 

110 
TITLE: Diabetic Foot Ulcers in a Multidisciplinary Setting: An Economic Analysis of 

Primary Healing and Healing with Amputation. Apelqvist, J.; Ragnarson-Tennvall, G.; 

Persson, U.; Larsson, J. Journal of Internal Medicine. 235(5): 463-471. May 1994. 

OBJECTIVE: To perform a cost analysis of healing with and without amputation in patients 

with diabetes who had foot ulcers. 

CATEGORY: Tertiary intervention. 

Type of Study: Prospective. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The findings indicate a potential cost savings from preventive, 

multidisciplinary foot care. Treatment for healing without amputation in a multidisciplinary 

system was associated with relatively low costs, while amputation was costly, due mainly to 

multiple and prolonged hospitalization. 

RECOMMENDATION: Early and aggressive intervention in the management of foot ulcers 

is important in keeping treatment costs low. Costs increase dramatically with the severity of 

the lesion, impaired peripheral circulation, and wound-healing time. 

ABSTRACT: A total of 314 consecutively presenting patients with diabetes who had foot 

ulcers were included in a prospective study. Forty patients died before healing occurred; the 

remaining 274 were included in a retrospective economic analysis. In this group, 197 patients 

(72 percent) healed without amputation, and 77 (28 percent) healed after amputation. All 

patients were treated by a combined foot care team (diabetologist, orthopedic surgeon, 

diabetes nurse, podiatrist, orthotist) both as inpatients and outpatients and were followed up 

by the same team until final outcome. Data from the prospective study and from patient 

records were used to estimate direct costs for inpatient care, antibiotics, surgery, outpatient 

care, staff attendance, drugs and material for ulcer dressings, and orthopedic appliances. 

Indirect costs (e.g., loss of production) were not calculated. Costs were calculated in Swedish 

Krona (SEK) in 1990 prices (SEK 6.0 = about $1 U.S.). Costs related to treatment in years 2 

and 3 after diagnosis were discounted by 5 percent to 1990 values. The average direct cost for 

healing with amputation was SEK 344,000; for patients who healed without amputation, SEK 

51,000. Costs for inpatient care accounted for 82 percent of the total average costs for 

patients with amputation and 37 percent for those who healed without amputation. Topical 

treatment of ulcers in the outpatient setting comprised 13 percent of the total average cost for 

patients who underwent amputation; for those who healed without amputation, it made up 45 

percent. Costs for medical visits (45 minutes for the first visit, 20 minutes for subsequent 

visits), antibiotics, and orthopedic appliances were low in relation to total costs. Inpatient stay 

for those who healed with amputation averaged 76 days; for major amputation, 84 days. The 

authors state that treating patients with diabetes who have foot ulcers in a multidisciplinary 

system is associated with a high probability of healing without amputation. 4 tables, 29 

references. 
111 

TITLE: Evaluation of the Costs to Medicare of Covering Therapeutic Shoes for Diabetic 

Patients. Wooldridge, J.; Moreno, L. Diabetes Care. 17(6): 541547. June 1994. 

OBJECTIVE: To evaluate the cost to Medicare of a therapeutic shoe benefit for Medicare 

Part B beneficiaries with severe diabetic foot disease. 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: There is no strong evidence that expanding Medicare Part B to cover 

therapeutic shoes for beneficiaries with severe diabetic foot disease will increase total 

Medicare costs. The demonstration indicated that lowering the cost of therapeutic shoes 

through a Medicare benefit would substantially increase ownership and use of such shoes. 

RECOMMENDATION: A more orderly approach would have been to determine the 

conditions for clinical effectiveness of the shoes before assessing their effect on Medicare 

costs. 

ABSTRACT: Congress mandated a demonstration of a therapeutic shoe benefit for Medicare 

Part B beneficiaries with diabetes. The benefit would be made permanent if it could not be 

shown that the benefit was not cost effective. The authors implemented a 3year demonstration 

in New York, Florida, and California in which they sought to enroll 27,500 eligible 

beneficiaries; only 4,373 applied. Participants were randomly assigned to either a treatment 

group that received the extra therapeutic shoe coverage or a control group that received 

standard Medicare coverage. The authors evaluated the Medicare payments and service use 

for a 12-month period of 3,428 participants (1,711 in the treatment group; 1,717 in the 

control group) who applied by August 25, 1991, and were randomized by September 30, 

1991. Data were collected from the Health Care Financing Administration, the 

demonstration's enrollment form, and a telephone survey of beneficiaries. A onetailed test of 

statistical significance assessed the null hypothesis that Medicare payments for the treatment 

group were # to payments for the control group. Results indicated that cost differences 

between groups were not statistically significant, although Medicare payments for all services 

among the treatment group in the first year of the demonstration were 3.8 percent higher 

($451) than those for the control group. The lower extremity amputation rate during this 

period also did not differ significantly (2.6 percent for the treatment group, 1.8 percent for 

controls). Similarly, during this year, Medicare payments for foot care services were 14.6 

percent ($318) higher among the treatment group, but this was also a statistically insignificant 

difference. At the beginning of the demonstration, 32 percent of both the treatment and 

control groups owned therapeutic shoes; almost 3 years later, 85 percent of the treatment 

group used them, versus 55 percent of controls — this difference was statistically significant. 
2 tables, 14 references. 

112 

TITLE: Foot Infections in Diabetic Patients: Decision and Cost-Effectiveness Analyses. 

Eckman, M.H.; Greenfield, S.; Mackey, W.C.; Wong, J.B.; Kaplan, S.; Sullivan, L.; Dukes, 

K.; Pauker, S.G. Journal of the American Medical Association (JAMA). 273(9): 712-720. 

March 1, 1995. 

OBJECTIVE: To examine the cost-effectiveness of approaches to the diagnosis and 

treatment of foot infections and suspected osteomyelitis in patients with type 2 diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Markov modeling. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Noninvasive testing procedures add significant expense to the treatment of 

patients with type 2 diabetes in whom pedal osteomyelitis is suspected but may result in little 

improvement in health outcomes. 

RECOMMENDATION: For patients with no signs of systemic infection who have adequate 

perfusion, surgical debridement followed by a 10-week course of culture-guided oral 

antibiotics may be as effective as and less costly than other strategies. 

ABSTRACT: The authors performed a decision and cost-effectiveness analysis of strategies 

for the diagnosis and treatment of patients with type 2 diabetes who have foot infections and 

suspected osteomyelitis. Data were drawn from English-language literature by using 

MEDLINE searches and the bibliographies of selected articles. The base case scenario 

specified a 56-year-old man with type 2 diabetes for 7 years. Five interventions were assessed 

following hospitalization for surgical debridement and intravenous antibiotic therapy: (1) 

treatment for presumed soft-tissue infection, (2) culture-guided empiric treatment for 

presumed osteomyelitis, (3) 71 combinations of diagnostic tests prior to antibiotic therapy, (4) 

71 combinations of tests prior to amputation, and (5) immediate amputation. A Markov state 

transition model was constructed to analyze decision trees and perform sensitivity analyses. 

Main outcomes were quality-adjusted life expectancy and average costs (in 1993 dollars). A 

long course of culture-guided antibiotic therapy was the least expensive strategy, with an 

average lifetime cost of approximately $30,880; immediate amputation was the most 

expensive, costing $46,900. Noninvasive testing to select patients for long-term antibiotic 

therapy cost from $31,000 to $33,750. Sensitivity analysis showed that roentgenography 

followed by magnetic resonance imaging cost an average of $120 more than empiric therapy, 

either with no discounting or with cost-discounting of 5 percent, but resulted in no gain in 

quality-adjusted life expectancy. Results show that noninvasive testing adds expense to the 

treatment of patients with type 2 diabetes in whom pedal osteomyelitis is suspected but may 

result in little improvement in health outcomes. A 10-week course of empiric antibiotic 
therapy may be as effective as and less costly than other strategies. 2 figures, 5 tables, 83 

references. 

113 

TITLE: long-term Costs for Foot Ulcers in Diabetic Patients in a Multidisciplinary Setting. 

Apelqvist, J.; Ragnarson-Tennvall, G.; Larsson, J.; Persson, U. Foot and Ankle International. 

16(7): 388394. July 1995. 

OBJECTIVE: To analyze long-term costs for prevention, treatment, home care, and social 

services in patients with diabetes and foot ulcers. 

CATEGORY: Tertiary intervention. 

Type of Study: Prospective. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The expected average annual costs per patient during the first 3 years after 

healing ranged from $5,200 to $11,200 for primarily healed patients and from $14,000 to 

$32,000 for patients healed with amputation. These findings indicate the potential cost savings 

of preventive foot care. 

RECOMMENDATION: When estimating the costs for diabetic foot ulcers, a short-term 

perspective is not sufficient. long-term costs are high and are due mainly to the need for 

increased home care and social services as well as to costs for recurrent ulcers and new 

amputations. 

ABSTRACT: A total of 314 consecutively presenting patients with diabetes and foot ulcers 

were followed to a final outcome; those who healed were followed for an additional 3 years. 

Primary healing occurred in 197 patients (72 percent); healing after amputation, in 77 patients 

(28 percent). The 40 patients who died before healing were excluded from a retrospective 

economic analysis (n = 274) of costs during 3 years after healing. All patients were treated and 

followed, both as inpatients and outpatients, by a foot care team consisting of a diabetologist, 

an orthopedic surgeon, an orthotist, a podiatrist, and a diabetes nurse. Those who healed 

primarily were further divided according to the presence (n = 56) or absence (n = 141) of 

critical ischemia. Healing with amputation was divided according to minor (n = 27) or major 

(n = 50) amputation. Inpatient, outpatient, home care, and social service costs were 

determined for a period of 3 years after healing of the initial ulcer and were calculated in 

Swedish Krona in 1990 prices. Costs related to treatment in years 2 and 3 were discounted by 

5 percent to equal 1990 values. The expected total present value costs per patient during 3 

years of observation for primarily healed patients were $26,700 (U.S. dollars) for those with 

critical ischemia and $16,100 for those without critical ischemia. These calculations account 

for the probability of surviving the first and second year of observation. The corresponding 

figures were $43,100 and $63,100 following minor and major amputation, respectively. The 

highest costs for inpatient care were found during the first year of follow-up for patients who 
had undergone major amputations ($11,900). Similarly, the estimated annual extra costs for 

social service and home care were higher among patients who healed with major amputation 

than in other groups. 1 figure, 3 tables, 29 references, 1 appendix. 

114 

TITLE: Medicare Therapeutic Shoe Demonstration: Report to Congress. Health Care 

Financing Administration, Baltimore, Maryland. 1990. 85 pp. 

OBJECTIVE: To provide a report to Congress on the cost-effectiveness of providing a 

Medicare Part B benefit for therapeutic shoes. 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: It is too early to tell whether the benefit will be cost effective; a 

demonstration to determine cost-effectiveness is ongoing. 

RECOMMENDATION: None. 

ABSTRACT: The Omnibus Reconciliation Act of 1987 mandated a demonstration project in 

which Medicare Part B coverage would be provided for therapeutic shoes. An evaluation was 

also required to determine whether the benefit would be cost effective and should be 

introduced as a regular benefit. To be eligible for the demonstration, Medicare beneficiaries 

with diabetes had to have one or more of five conditions (previous amputation, deformity with 

potential for ulceration, callus formation or history of callus formation with peripheral 

neuropathy, a history of foot ulceration, poor circulation) in one or both feet. A priori, to be 

cost effective the cost to Medicare of therapeutic shoes had to be less than the savings 

resulting from reduced use of other Medicare-covered services attributable to the program. In 

the evaluation, costs to Medicare of a group receiving the experimental benefit are being 

compared with costs for a similar group not receiving the benefit. The authors note that these 

are insufficient data at this point to indicate whether the benefit is cost effective, and that the 

demonstration project is ongoing. Thus, they provide background on the demonstration 

project, present the clinical arguments on coverage, give a legislative history, describe how the 

demonstration was implemented, and discuss what is known about the population at risk and 

how their characteristics affect the likelihood that the benefit will be cost effective. In the 

demonstration project, physicians must certify the eligibility of beneficiaries who meet the 

clinical criteria and prescribe the therapeutic shoes, which must be provided by suppliers 

authorized by the Health Care Financing Administration. Early enrollment has been below 

expectations, and, in the first 4 months, very few primary care practitioners certified patient 

eligibility or prescribed therapeutic shoes. Plans are under way to increase participation during 

early 1990 in cooperation with the clinical community. 2 figures, 11 tables, 10 references. 
115 

TITLE: Medicare Therapeutic Shoes Demonstration: Was the Demonstration Cost Effective? 

Final Comprehensive Report, Volume I. Wooldridge, J.; Bergeron, J.; Moreno, L.; Thornton, 

C. Mathematica Policy Research, Inc., Princeton, NJ, June 30, 1993. 261 pp. 

OBJECTIVE: To evaluate the cost-effectiveness of the Medicare Therapeutic Shoe 

Demonstration. 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The hypothesis that the shoe benefit was cost effective could not be 

rejected statistically. However, because enrollment in the program was below the target level, 

the authors lacked sufficient precision in their estimates to be sure that if the benefit was not 

cost effective, they would have correctly identified it as such. (Medicare added a therapeutic 

shoe benefit [Part B] in May 1993 as a result of the demonstration findings.) 

RECOMMENDATION: The authors recommend several changes in the benefit (e.g., 

provide Medicare coverage for shoe repair) and its procedures as well as regulatory changes. 

ABSTRACT: The Medicare Therapeutic Shoe Demonstration (conducted from August 1989 

to October 1992) enrolled 4,373 Medicare beneficiaries with diabetes and severe foot disease. 

Enrollees were randomly assigned to a benefit group (who received Medicare Part B coverage 

for therapeutic shoes) or a control group (no coverage). The authors refer to two earlier 

reports on the demonstration: the first (1990) found no evidence that the program was cost 

saving; the second (1993) found no statistical basis to conclude that costs had increased. In 

the present report, the authors summarize a more comprehensive evaluation of whether 

providing the benefit was cost effective (Congress had mandated that the shoe benefit be 

enacted nationally unless it was shown not to be cost effective). For this report, a null 

hypothesis was tested to see whether it could be rejected: that under the demonstration, costs 

were lower than or equal to what they would have been without the intervention. For 

evaluation purposes, the shoe benefit would not be cost effective if the net cost to Medicare of 

providing the shoes significantly exceeded zero (i.e., the gross cost of covering the shoes 

significantly exceeded savings from reduced use of Medicare services that might result if the 

shoes helped to prevent new foot problems). The authors state that their approach assured a 

low probability of asserting that costs increased because of the program if they really did not. 

However, they state that their approach also carried the risk of not concluding that costs truly 

increased under the new benefit if the increase in cost was small. For the benefit group's first 

year in the demonstration, the authors found no statistically significant differences from the 

control group in terms of Medicare payments for all services, for Medicare Part A or Part B 

services only, or for all foot care services, although in each instance the figure for the 
treatment group was higher. Hospital admissions for the two groups were also 

indistinguishable statistical. 6 figures, 44 tables, 38 references. 

116 

TITLE: Osteomyelitis in Feet of Diabetics: Clinical Accuracy, Surgical Utility, and CostEffectiveness of MR Imaging. Morrison, W.B.; Schweitzer, M.E.; Wapner, K.L.; Hecht, P.J.; 

Gannon, F.H.; Behm, W.R. Radiology. 196(2): 557564. August 1995. 

OBJECTIVE: To evaluate the sensitivity, specificity, clinical utility, and Cost-effectiveness 

of magnetic resonance imaging (MRI) in the diagnosis of osteomyelitis of the foot in patients 

with diabetes. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: MRI has good sensitivity and specificity for diagnosing osteomyelitis in the 

feet of patients with diabetes, is competitively priced compared with other imaging methods, 

and is clinically useful in accurately delineating the extent of osteomyelitis so that limited 

surgical resection may be achieved. 

RECOMMENDATION: Although the common perception of MRI is that it is a high-tech, 

high-cost modality, in the inpatient setting it may be the best and most cost-effective method 

of diagnosis. 

ABSTRACT: The authors prospectively evaluated 62 MRI studies of the foot in 59 patients 

to detect the presence and extent of osteomyelitis. The population was divided into patients 

with diabetes (study group, n = 27 feet) and patients without diabetes (control group, n = 35 

feet). MRI was performed with a 1.5T unit and an extremity coil; two orthogonal planes were 

imaged in each study. Contrast enhancement was used in 53 of the 62 studies. Biopsy (n = 41 

feet) and clinical follow-up (n = 62 feet) were used to establish the diagnosis, select treatment, 

and determine outcome. Patients were followed up for an average of 6 months after treatment. 

A subgroup of 13 patients who underwent footsparing resection procedures was followed up 

for an average of 9 months; in every case, there was no recurrent infection at the surgical 

margin. Good sensitivity (82 percent) and specificity (80 percent) were obtained with MRI in 

diagnosing osteomyelitis in diabetic feet despite a high frequency of neuropathic 

osteoarthropathy (33 percent) and peripheral vascular disease (19 percent), both of which can 

complicate image interpretation. Sensitivity and specificity were higher in the control group 

(89 percent and 94 percent, respectively), but the differences were not statistically significant. 

Cost analysis revealed that contrast-enhanced MRI is competitively priced compared with the 

combination of two scintigraphic methods, one involving three-phase bone scanning and the 

other, white blood cell scanning. The overall cost of diagnosis, surgical procedures, and 

hospitalization was slightly lower with contrast-enhanced MRI than with the optimal 
(combined) scintigraphic method. 5 figures, 2 tables, 52 references. 

117 

TITLE: Preventing Diabetic Foot Disease: Lessons From the Medicare Therapeutic Shoe 

Demonstration. Wooldridge, J.; Bergeron, J.; Thornton, C. American Journal of Public 

Health. 86(7): 935-938. July 1996. 

OBJECTIVE: To determine why few at-risk patients with diabetes purchased and used 

therapeutic shoes in the Medicare demonstration program (1989 to 1992). 

CATEGORY: Tertiary intervention. 

Type of Study: Randomized clinical trial. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Physicians may not recognize the importance of special foot care for 

patients with diabetes. Only 6 percent of physicians who were notified about the Medicare 

demonstration ever enrolled any patients. 

RECOMMENDATION: Internists and general and family physicians need to receive 

continuing education on preventive care for foot problems in patients with diabetes. Frequent 

reminders to physicians about the Medicare shoe benefit might increase the number of 

participating physicians. A legislative change to allow podiatrists to certify eligibility in the 

national program would facilitate access. 

ABSTRACT: Patients with diabetes often have amputations because of foot ulcers from 

impaired peripheral sensation, circulatory problems, and poorly controlled blood sugar levels. 

In May 1993, Medicare added coverage of therapeutic shoes for beneficiaries with diabetes at 

risk for foot disease after an evaluation did not show that this benefit increased Medicare 

costs. The patient's physician certified patient eligibility, a physician prescribed the shoes, and 

an authorized shoe supplier fit and furnished the shoes. The evaluation took place in 

California, Florida, and New York from August 1989 to October 1992, with few beneficiaries 

applying in the first 6 months despite a publicity campaign in which 43,000 Medicare 

beneficiaries who had a relatively recent admission for a diabetes-related foot problem and 

56,000 physicians or podiatrists as well as clinics were notified. A second campaign, targeted 

at physicians, was mounted in response. Enrollment after 37 months totaled 4,373 

beneficiaries, far below the target of 27,500. Of this group, 2,183 were randomly assigned to 

the treatment (coverage) group, 2,190 to the control group (no coverage). Three years after 

the evaluation began, 85 percent of the treatment group and 55 percent of the control group 

owned therapeutic shoes. Despite the promise of Medicare coverage, only 71 percent of the 

treatment group bought therapeutic shoes through the demonstration. Podiatrists enrolled 

nearly half of the eligible participants; internists and orthopedic surgeons were the next most 

frequent enrollers. Pedorthists supplied 29 percent of the shoes; podiatrists, 23 percent; and 

prosthetists, 22 percent. Only 2 percent of the 43,000 Medicare beneficiaries who were 
notified of the demonstration subsequently enrolled. Podiatrists reported that many patients 

resist wearing custom-molded shoes. 2 tables, 8 references. 

118 

TITLE: A Prospective Evaluation of Transcutaneous Oxygen Measurements in the 

Management of Diabetic Foot Problems. Ballard, J.L.; Eke, C.C.; Bunt, T.J.; Killeen, J.D. 

Journal of Vascular Surgery. 22(4): 485-492. October 1995. 

OBJECTIVE: To determine whether lower extremity transcutaneous measurements of the 

partial pressure of oxygen can accurately predict the severity of foot ischemia and be used to 

select appropriate treatment for patients with diabetes and tissue necrosis or ischemic pain at 

rest. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Mapping of lower-extremity transcutaneous partial pressure of oxygen is an 

accurate, noninvasive, and relatively inexpensive method to prospectively select appropriate 

treatment for patients with diabetes and limb-threatening ischemia, and it may obviate the need 

for arteriography to determine the severity of foot ischemia. 

RECOMMENDATION: An absolute transmetatarsal level for the partial pressure of oxygen 

of 30 mm Hg or greater appears to be an accurate cutoff point for the selection of 

conservative or operative treatment for almost all diabetic foot problems. However, the 

conservative management scheme requires diligent patient follow-up. A higher threshold (40 

mm Hg) may be required to manage calcaneal gangrene or some very severe nonhealing 

ulcerations. 

ABSTRACT: Thirty-four men and 21 women (ages 34 to 87) with diabetes and ischemic 

pain at rest or pedal tissue necrosis (representing 66 threatened feet) were prospectively 

treated from June 1993 to July 1994. Treatment indications included nonhealing ulcer (53 

percent), gangrene (38 percent), and rest pain (9 percent). Noninvasive hemodynamic arterial 

assessment and transcutaneous mapping of the partial pressure of oxygen for the involved 

limb were obtained before treatment was selected. Patients with trans-metatarsal levels of 30 

mm Hg or higher received conservative treatment (e.g., local wound care, debridement, minor 

foot amputation). If the trans-metatarsal level was less than 30 mm Hg, arteriography was 

performed. The endpoints for determining treatment success or failure were complete wound 

healing or relief of ischemic rest pain. Thirty-one of 36 (86 percent) limbs with an initial 

transmetatarsal level of 30 mm Hg or higher were treated successfully with conservative care, 

including 11 of 15 feet without a palpable pedal pulse. After revascularization (16 feet) or 

angioplasty (8 feet), 20 of 24 (83 percent) limbs with initial partial pressure of less than 30 

mm Hg achieved a transmetatarsal level greater than 30 mm Hg. An initial or postintervention 
transmetatarsal level of 30 mm Hg or greater was more accurate (90 percent, p = 0.001) than 

a palpable pulse (65 percent, p = 0.009) in predicting ultimate resolution of pedal gangrene, 

nonhealing ulceration, or ischemic rest pain. The total cost for transmetatarsal mapping of a 

lower extremity was $93.88 per patient, versus $1,052.73 for a diagnostic lower extremity 

arteriogram. If absence of pedal pulses had been the indication for arteriography, 45 limbs in 

this study would have been subjected to this examination, yet only 31 actually required it. The 

authors also found that conservative management is cost effective compared with 

revascularization surgery or angioplasty. 3 tables, 17 references. 

119 

TITLE: Towards Less Amputations in Diabetic Patients: Incidence, Causes, Cost, Treatment, 

and Prevention — A Review. Larsson, J.; Apelqvist, J. Acta Orthopaedica Scandinavica. 66 

(2): 181-192. April 1995. 

OBJECTIVE: To discuss the problem of lower extremity amputation in patients with 

diabetes, and to analyze possibilities for reducing the number of such procedures. 

CATEGORY: Tertiary intervention. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: A comprehensive system that incorporates regular foot examinations, 

preventive foot care, protective footwear, education of patients, a multidisciplinary approach 

to foot ulcers, strict amputation criteria, long-term follow-up after healing, and continuous 

registration of amputations can reduce major amputation in patients with diabetes. 

RECOMMENDATION: None. 

ABSTRACT: Foot ulcers are the most common reason for amputation in the patient with 

diabetes. The most frequent underlying condition is polyneuropathy with sensory, motor, and 

autonomic disturbances. Most often, the foot ulceration is precipitated by trauma, usually 

caused by faulty or incorrectly used footwear. Patients with diabetes with a high probability 

for an amputation include those with polyneuropathy and those with vascular disease without 

evidence of polyneuropathy. Common indications for amputation in patients with diabetes are 

gangrene, infection, and nonhealing ulcer. In 1990, the estimated cost of an amputation in the 

United States (hospital treatment only) was $18,300. When evaluating costs of treatment or 

other therapeutic strategies, it is important to include the costs of hospitalization and 

rehabilitation along with outpatient treatment costs until healing. The first step to minimize the 

risk of amputation is preventing lesions that may develop into gangrene and/or a deep 

infection. An important regimen is regular inspection of feet and footwear of patients with 

diabetes during health care visits; however, previous studies have shown this occurs in only 12 

to 15 percent of checkups. Patients should have early access to a multi-disciplinary team for 

examination and treatment, both as inpatients and outpatients. From a long-term perspective, 
among patients with diabetes, a minor amputation has a lower risk for a new major 

amputation. A minor amputation also has a better rehabilitation potential. 8 tables, 117 

references. 

Diabetes in Pregnancy 

Gestational Diabetes 

120 

TITLE: Capillary Blood Glucose Screening for Gestational Diabetes: A Preliminary 

Investigation. Landon, M.B.; Cembrowski, G.S.; Gabbe, S.G. American Journal of Obstetrics 

and Gynecology. 155(4): 717-721. October 1986. 

OBJECTIVE: To evaluate the utility of capillary blood glucose measurement using a 

reflectance meter as an outpatient screening tool for gestational diabetes. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Capillary blood glucose evaluation using a reflectance meter can provide 

accurate outpatient screening for gestational diabetes with significant cost savings over 

laboratory plasma assays. 

RECOMMENDATION: None. 

ABSTRACT: The authors screened 125 consecutive pregnant women in a high-risk practice 

in a university hospital in Philadelphia, Pennsylvania. All the women underwent a standard 50 

g glucose challenge at 26 to 28 gestational weeks. Capillary glucose values obtained with the 

use of a reflectance meter were highly correlated with plasma venous values obtained by the 

central laboratory, but mean capillary values were significantly higher (136.35 versus 111.74 

mg/dL, p < 0.001) with the reflectance meter. The authors found that a capillary value of 160 

mg/dL was the optimal reference point; its sensitivity and specificity were 93 percent and 96 

percent, respectively, for an abnormal test of venous plasma ($ 135 mg/dL). Costs of 

screening 1,000 patients were estimated to be $5,900 for the laboratory plasma study and 

$1,034 for the capillary reflectance meter assay, with the latter costs including 32 additional 

glucose tolerance tests at $12 each because of a 3.2 percent false-positive rate. The potential 

cost savings associated with capillary blood glucose screening combined with its high 

efficiency make it an economically viable alternative to laboratory plasma assays for the 

detection of gestational diabetes. 2 figures, 2 tables, 16 references. 
121 

TITLE: Capillary Glucose Determination in the Screening of Gestational Diabetes. Meriggi, 

E.; Trossarelli, G.F.; Carta, Q.; Menato, G.; Porta, M.A.; Bordon, R.; Gagliardi, L. Diabetes 

Research and Clinical Practice. 5(1): 55-61. May 19, 1988. 

OBJECTIVE: To determine a threshold for glucose challenge test positivity using capillary 

blood to facilitate use of a reflectance meter in gestational diabetes screening; to verify a 

plasma glucose threshold for glucose challenge test positivity; and to determine the differences 

and correlations between glucose values obtained from plasma and capillary blood with a 

reflectance meter during a glucose challenge test. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: A plasma glucose value of 135 mg/dL and a capillary value of 155 mg/dL 

represent optimal cutoff points for recommending a diagnostic glucose tolerance test. 

RECOMMENDATION: The simplicity, precision, and high efficiency of the reflectance 

meter make it suitable for screening for gestational diabetes in all pregnant women. 

ABSTRACT: Paired capillary-venous blood samples were obtained from 418 pregnant 

women, aged 25 years or older with or without risk factors, who underwent an oral glucose 

challenge test (GCT) to screen for gestational diabetes. Plasma glucose was measured by the 

glucose oxidase method; capillary glucose, by a Reflocheck glucose strip and a Reflocheck 

reflectance meter (both from Boehringer Mannheim Diagnostic, Inc.). The relationship 

between capillary and plasma glucose concentrations was investigated to establish a capillary 

GCT threshold. The receiver operator characteristic curve technique provided a quantitative 

method for determining cutoff points and the level of efficacy to be expected in detecting 

gestational diabetes. A plasma glucose value of 135 mg/dL and a capillary value of 155 mg/dL 

were found to represent optimal cutoff points for recommending the oral glucose tolerance 

test. Values of various plasma thresholds and those of corresponding capillary thresholds (20 

mg/dL higher) were similar in sensitivity, specificity, and predictive values. The differences 

between mean values of plasma and capillary glucose determinations fasting and 1 hour after 

glucose load were 10-12 mg/dL and 22-24 mg/dL, respectively. The authors recommend early 

screening (at 12-16 weeks) in cases with risk factors because one-third of glucose tolerance 

test positive cases can be diagnosed and treated. These investigators believe the reflectance 

meter has advantages over laboratory enzymatic techniques in the screening of gestational 

diabetes. 3 figures, 3 tables, 20 references. 

122 
TITLE: Clinical Experience with a Screening Program for Gestational Diabetes. Lavin, J.; 

Barden, T.; Miodovnik, M. American Journal of Obstetrics and Gynecology. 141(5): 491-

494. November 1981. 

OBJECTIVE: To evaluate the cost and effects of a screening program for gestational 

diabetes in a large population of women attending a prenatal clinic at a university hospital. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The cost per case of gestational diabetes detected was $328.96. 

RECOMMENDATION: Cost-benefit analyses should be included in determinations of the 

sensitivity and specificity of screening tests for gestational diabetes and comparisons of 

perinatal morbidity and mortality in screened and unscreened populations. 

ABSTRACT: The authors determined the cost of screening for gestational diabetes in 2,077 

pregnant women without diabetes attending a university prenatal clinic in Cincinnati over a 2-

year period. Participants were divided into group 1 (959 women who presented with historical 

or clinical risk factors for gestational diabetes) and group 2 (1,118 patients without risk 

factors). Patients in group 1 underwent a glucose challenge test at their initial visit; an oral 

glucose tolerance test was performed if the glucose challenge test was abnormal. Glucose 

challenge and glucose tolerance tests were repeated at 28 weeks if the patient had an initially 

normal glucose challenge test. Group 2 patients underwent a glucose challenge test at 28 to 

32 weeks; a glucose tolerance test was performed if the glucose challenge test was abnormal. 

Direct costs of the screening program were estimated by proration of component costs. The 

incidence of abnormal glucose challenge test and abnormal glucose tolerance test results was 

not statistically different for the two groups. Of the total population, 137 participants (6.6 

percent) had an abnormal glucose challenge test and 30 participants (1.4 percent) had an 

abnormal glucose tolerance test. The total estimated cost for the screening program was 

$9,900, including $5,700 for serum glucose determination, $1,300 for glucose challenge test 

and glucose tolerance test solutions, and $2,900 for the phlebotomist's salary. The cost per 

patient screened was $4.75 and the cost per case of gestational diabetes detected was 

$328.96. These costs are marginally understated. The study confirms the feasibility of routine 

screening for abnormal carbohydrate metabolism in pregnancy in large populations. 4 tables, 

16 references. 

123 

TITLE: Cost Efficacy of Routine Screening for Diabetes in Pregnancy: 1-h versus 2-h 

Specimen. Weiner, C.P.; Fraser, M.M.; Burns, J.M.; Schnoor, D.; Herrig, J.; Whitaker, L.A. 

Diabetes Care. 9(3): 255-259. May-June 1986. 
OBJECTIVE: To compare the specificity and costs of 1-hour and 2-hour oral glucose 

challenge testing to screen patients for gestational diabetes mellitus. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The 2-hour glucose challenge testing was more sensitive and cost effective 

than the 1-hour screening test. 

RECOMMENDATION: Screening for gestational diabetes on the basis of past medical 

history should be abandoned, and all pregnant women should undergo oral glucose challenge 

screening. 

ABSTRACT: This study at the University of Iowa Hospitals and Clinics sought to determine 

whether the specificity of the glucose challenge test for diabetes screening during pregnancy 

could be increased by using a 2-hour rather than a 1-hour glucose challenge. Plasma glucose 

concentrations were measured in 790 women 1 hour after challenge (Trutol, Monoject 

Scientific, 50 g): all the women were asked to give a 2-hour blood sample; 342 complied. 

Abnormal 1-hour glucose challenge tests (above 139 mg/dL) prompted standard oral glucose 

tolerance tests. Costs per glucose challenge test and oral glucose tolerance test were $7.25 

and $64.00, respectively. Of 1-hour glucose challenge tests, 24.3 percent were elevated; 2-

hour glucose challenge tests exceeded 115 and 117 mg/dL in 20.5 and 16.3 percent of 

women, respectively. Oral glucose tolerance tests were positive in 10.8 percent of women 

with an elevated 1-hour glucose challenge test, in 13.0 percent of those with a 2-hour glucose 

challenge test above 115 mg/dL, and in 16.4 percent of women in which the latter test 

exceeded 117 mg/dL. All women with abnormal 1-hour glucose challenge tests and positive 

oral glucose tolerance tests had abnormal ($ 118 mg/dL) 2-hour glucose challenge tests; 28 

women had abnormal 2-hour but normal 1-hour glucose challenge tests. Thirty-four percent 

fewer oral glucose tolerance tests were needed based on 2-hour (versus 1-hour) glucose 

challenge tests (p < .05), and the cost of identifying a case of gestational diabetes mellitus 

would have dropped 24 percent (from $866 to $662) if the 2-hour test were used. With riskfactor screening, 77 percent of gestational diabetes mellitus cases would have been missed, 

and the cost per case would have been $1,805. In a second group (n = 190), the cost per case 

of gestational diabetes mellitus would have declined by 32 percent if the 2-hour screen had 

been used. 6 tables, 9 references. 

124 

TITLE: Cost of Non-Insulin-Dependent Diabetes in Women with a History of Gestational 

Diabetes: Implications for Prevention. Gregory, K.D.; Kjos, S.L.; Peters, R.K. Obstetrics and 

Gynecology. 81(5 Pt 1): 782-786. May 1993. 
OBJECTIVE: To estimate the potential savings in health care costs that would result from 

primary prevention programs targeted at women with gestational diabetes. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Preventive therapy may result in a net savings over 10 years of $32 million 

to $331 million, depending on the assumed percentage reduction in diabetes incidence. 

RECOMMENDATION: A prospective prevention trial should be conducted to evaluate the 

potential health and cost benefits of ongoing postpartum education and cognitive 

reinforcement of lifestyle changes adopted during pregnancy in women with gestational 

diabetes. 

ABSTRACT: The authors estimated potential health care cost savings over 10 years from a 

hypothetical primary prevention program aimed at women with gestational diabetes. An 

economic model was developed based on a series of assumptions about a national cohort: 3 

percent of all live births in 1990 were complicated by gestational diabetes (resulting in 

125,370 cases of gestational diabetes); 50 percent of the women with gestational diabetes 

(62,685) would develop type 2 diabetes; and the rate of progression to diabetes would be 

constant (6.7 percent) over a 10-year period. Average annual health care costs per case for 

women with diabetes were estimated at $2,834 (in 1990 dollars), cumulative net costs for 

caring for all women who developed diabetes over 10 years were estimated at $818 million. 

Calculations discounted future dollars by 5 percent per year. New costs incurred for 

preventive counseling and evaluation were estimated at $39.8 million (in 1990 dollars) for the 

entire cohort over 10 years (these costs included serum glucose determinations and dietary 

consultations). Net potential savings began to accrue if the prevention program reduced the 

incidence of diabetes by 5 percent. Estimated net savings for reductions in the incidence of 

gestational diabetes of 5, 10, 25, and 50 percent were $500,000, $31.9 million, $139.5 million, 

and $331.4 million, respectively, over 10 years. Various limitations of the analysis are 

discussed; for example, evidence suggests that conversion to diabetes is not linear, occurring 

more often in the first 5 years after pregnancy than the second 5 years. For another example, 

the Latina population has a 6 percent rate of gestational diabetes and a higher rate of disease 

progression. 3 tables, 17 references. 

125 

TITLE: Cost-Effective Approach to Office Screening for Gestational Diabetes. Teplick, F.B.; 

Lindenbaum, C.R.; Cohen, A.W. Journal of Perinatology. 10(3): 301-303. September 1990. 

OBJECTIVE: To examine the cost-effectiveness of outpatient office screening for 

gestational diabetes using capillary blood measurements with a reflectance meter. 
CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Use of a glucose reflectance meter offers an accurate, quick, cost-effective 

approach to glucose screening for gestational diabetes. 

RECOMMENDATION: Providers of prenatal care should use screening programs like 

glucose reflectance meters more readily for gestational diabetes, with the understanding that 

cutoff values for each meter must be established for each facility. 

ABSTRACT: Over a 6-month period, 50 patients were screened for gestational diabetes with 

a standard 50 g oral glucose load (Glucola) in the nonfasting state at 27 to 28 weeks 

gestation. One hour later, a capillary blood specimen was evaluated by means of an AccuCheck II (Boehringer-Mannheim, Indianapolis, IN) reflectance meter; a venous sample was 

evaluated in a hospital laboratory. Any patient with a serum glucose value greater than 130 

mg/dL was scheduled for a 3-hour glucose tolerance test. The authors found a significant 

correlation between capillary blood glucose concentration and laboratory serum values (r = 

0.59). Using a reflectance meter cutoff value of greater than 160 mg/dL, the authors did not 

miss any patients who would have required a 3-hour glucose tolerance test via serum 

screening. The sensitivity and specificity of this testing method were very good, and its 

negative predictive value was 100 percent. The authors' findings suggest that by using the 

glucose reflectance meter, 90 percent of patients can be screened without laboratory studies, 

resulting in significant savings. In addition to the cost savings, the immediate results (within 2 

minutes) obtained by a reflectance meter allow for prompt identification of an abnormal screen 

and timely scheduling of the 3-hour glucose tolerance test. 1 figure, 1 table, 11 references. 

126 

TITLE: Cost-Effective Criteria for Glucose Screening. Marquette, G.P.; Klein,V.R.; Repke, 

J.T.; Niebyl, J.T. Obstetrics and Gynecology. 66(2): 181-184. August 1985. 

OBJECTIVE: To identify a cost-effective method of screening for gestational diabetes 

without decreasing sensitivity to a level substantially below that of universal screening. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The cost of screening for gestational diabetes can be reduced without 
substantially compromising sensitivity by restricting screening to patients aged 24 years or 

older and using a glucose screening threshold of 150 mg/dL. 

RECOMMENDATION: Studies are needed to analyze the cost of additional days in the 

hospital caused by maternal or neonatal morbidity secondary to undiagnosed gestational 

diabetes. 

ABSTRACT: The authors conducted a cost-effectiveness analysis of screening criteria for 

gestational diabetes on 1,012 unselected pregnant women registered at Johns Hopkins 

Hospital who were between 26 and 30 weeks of gestation. Direct medical costs included 

glucose tolerance tests and glucose screening. Fasting patients were given a 50 g oral glucose 

load, followed by a 1-hour plasma glucose test. If the glucose concentration was 130 mg/dL 

or greater, a 3-hour oral glucose tolerance test was performed. A total of 24 women (2.4 

percent) were identified as having gestational diabetes; 21 of the 24 women were aged 24 or 

older with glucose concentrations of 150 mg/dL or greater on screening. Increasing the 

glucose screen threshold from 130 to 150 mg/dL with universal screening caused the positive 

predictive value to increase from 10 percent (24 of 235 patients) to 24 percent (23 of 96). 

Screening only patients aged 24 years or older and using the 130 mg/dL threshold had a 

positive predictive value of 14 percent (22 of 153). Increasing the threshold to 150 mg/dL 

while still screening only women aged 24 or older caused the positive predictive value to 

increase to 30 percent, with 21 of 24 cases of gestational diabetes identified. The cost of the 

diagnosis in these latter patients was 40 percent of the cost of diagnosis of universal screening 

using a 130 mg/dL threshold. 2 figures, 3 tables, 10 references. 

127 

TITLE: First Prenatal Visit Glucose Screening. Hong, P.L.; Benjamin, F.; Deutsch, S. 

American Journal of Perinatology. 6(4): 433-436. October 1989. 

OBJECTIVE: To determine the benefit of early glucose screening for gestational diabetes. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Universal screening for gestational diabetes at first prenatal visit detected a 

significant number of cases that would have been missed if current screening 

recommendations were followed. 

RECOMMENDATION: Universal glucose screening for gestational diabetes at first prenatal 

visit is recommended; minor increases in cost associated with universal screening may be 

offset by potential savings from more timely initiation of appropriate antepartum management. 
ABSTRACT: The authors evaluated the benefit of glucose screening at first prenatal visit. 

Nine hundred and ninety-nine new obstetric patients at a New York City hospital who had not 

been previously diagnosed with diabetes underwent a glucose challenge test at their first 

prenatal visit, regardless of gestational age. A total of 228 patients had a gestational age (in 

weeks) of less than 14; 354, 14 to 23; 122, 24 to 28; and 295, greater than 28. Follow-up oral 

glucose tolerance tests were performed for results of 130 mg/dL or higher. Data were 

subdivided by patient age in years (under 24, 24 and over, 25 and over, and 30 and over) to 

allow comparison with other studies and current screening recommendations. Patients under 

24 years of age had a lower mean glucose screening value than older patients (106.1 mg/dL 

versus 117.4 mg/dL, p < 0.05), but 13 percent of cases of diagnosed gestational diabetes 

occurred in this youngest group. One-third of the diagnoses of gestational diabetes were for 

women screened in week 32 or earlier. Total screening program costs were $7,130 for 

universal screening, $4,041 for screening patients 25 years and over, and $2,286 for screening 

patients 30 years and over; costs per diagnosed case of gestational diabetes were $184 

(universal), $122 (25 plus), and $120 (30 plus). The slightly greater cost of universal 

screening for gestational diabetes would be offset by potential savings from more timely 

initiation of appropriate antepartum management. When the criterion for an abnormal glucose 

challenge test was changed to $ 140 mg/dL, costs per diagnosed case dropped to $115, $106, 

and $102. 8 tables, 16 references. 

128 

TITLE: Screening for Gestational Diabetes. Zoller, D.P.; Jurica, J.V.; Gould, S.H.; 

Weinstein-Mayer, S. The Journal of the American Board of Family Practice. 1(2): 98100. 

April-June 1988. 

OBJECTIVE: To determine the validity of screening all pregnant women for gestational 

diabetes mellitus (GDM); to determine the Cost-effectiveness of such a program. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Universal screening of pregnant women for GDM was found to be simple 

and cost effective. There was no difference between women with risk factors and those 

without in rate of abnormal glucose tolerance. 

RECOMMENDATION: Because a history of risk factors for diabetes is an insensitive 

predictor of GDM, it is necessary to screen all pregnant patients; a plasma glucose 

concentration of 140 mg/dL on the glucose challenge test should be a minimum criterion for 

proceeding to the glucose tolerance test. 

ABSTRACT: Three hundred sixty-three consecutive pregnant patients attending obstetrical 
clinics at teaching hospitals of the University of Illinois College of Medicine at Rockford 

underwent screening for GDM by a glucose challenge test that measured plasma glucose 1 

hour after they were fed 50 g of glucose. Most of the women were between 24 and 28 weeks 

of gestation; their average age was 21.3 years; and 41.9 percent were nulliparous. Those 

patients with a plasma glucose greater than 140 mg/dL were given a standard 3hour glucose 

tolerance test using 100 g of oral glucose to confirm GDM. Fifty-two (14.3 percent) of the 

patients had abnormal glucose challenge tests. The average cost per patient screened was 

$14.30, and the cost per case of GDM diagnosed was $519. Patients with one or more risk 

factors (e.g., obesity, family history of diabetes, previous delivery of a macrosomic infant) 

were compared with those without risk factors; there was no significant difference between 

the two groups in percentage of abnormal glucose tolerance tests (2.9 percent in the risk 

factor group; 2.7 percent in the other). The authors concluded that all pregnant patients must 

be screened in order to identify GDM. They noted that the risks associated with screening are 

very low and that patients would not be inappropriately treated because of false-positive tests, 

as all positive glucose challenge tests are followed by a 3hour glucose tolerance test. 1 table, 

26 references. 

129 

TITLE: Screening for Gestational Diabetes: Analysis by Screening Criteria. Reed, B. Journal 

of Family Practice. 19(6): 751-755. December 1984. 

OBJECTIVE: To review the appropriateness and cost-effectiveness of a 1-hour, 50 g 

glucose screening test for gestational diabetes. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Screening for gestational diabetes is sensitive and cost effective. 

RECOMMENDATION: All pregnant women over age 25 years should be screened for 

gestational diabetes with a 1-hour, 50 g glucose test. 

ABSTRACT: The author examined the cost-effectiveness of various approaches to screening 

for gestational diabetes. The initial test consisted of measuring the serum glucose level in a 

pregnant patient 1 hour after ingestion of 50 grams of glucose solution. Five protocol 

strategies were evaluated: (1) glucose screening test for all patients, with an oral glucose 

tolerance test for positive results; (2) glucose screening test only for patients with risk factors, 

with oral glucose tolerance test for positive results; (3) oral glucose tolerance test for patients 

with risk factors; (4) oral glucose tolerance test for all patients; and (5) glucose screening test 

for all patients over age 25 years, followed by an oral glucose tolerance test if the result is 

positive. The costs for utilization of the screening test were calculated using data from 

O'Sullivan et al. (1973) and current local hospital charges. Costs for the glucose screening test 
and the oral glucose tolerance test were assumed to be $10.15 and $24.40, respectively. Cost 

per case of detected gestational diabetes ranged from $386.11 for screening of all patients 

over age 25 to $976.00 for an oral glucose tolerance test for all patients. Screening only 

patients with risk factors for gestational diabetes was not cost effective, costing $683.18 per 

detected case and missing many cases (60 percent rate of false negatives). Performing an oral 

glucose tolerance test on all patients was the most accurate means of detecting gestational 

diabetes (no false negatives) but also the most costly. Screening with the glucose screening 

test for all pregnant women over age 25 years followed by the oral glucose tolerance test 

when indicated is the most cost-effective strategy; its false-negative rate in this analysis was 

24 percent. 2 tables, 17 references. 

130 

TITLE: Screening for Gestational Diabetes: An Analysis of Health Benefits and Costs. 

Everett, W.D. American Journal of Preventive Medicine. 5(1): 38-43. January-February 

1989. 

OBJECTIVE: To determine the health benefits and costs of screening all pregnant women 

for diabetes at 28 weeks of gestation. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: The most cost-benefit outcome of screening all pregnant women for 

gestational diabetes would be a decrease in perinatal mortality rates. The cost of preventing 

cesarean section, death from macrosomia, and certain other outcomes would be so great that 

a decision to screen should not be based on trying to prevent these events. 

RECOMMENDATION: Further research that focuses on decreasing the cost of screening 

pregnant women for gestational diabetes is needed because available data do not clearly 

demonstrate a favorable cost-benefit ratio for universal screening. 

ABSTRACT: The current recommendation to screen all pregnant mothers for diabetes at 28 

weeks of gestation is examined, using known epidemiologic evidence presented in the 

literature, to determine the cost benefit of averting infant death, macrosomia, cesarean section, 

birth injury, shoulder dystocia, and maternal death from cesarean section. The author 

concludes that screening for and treating gestational diabetes may be beneficial, but data are 

not sufficient to determine the full cost and benefits of universal screening. Most of the benefit 

would come from a hoped-for decrease in the perinatal mortality rate. Additional benefits such 

as a decrease in cesarean sections, shoulder dystocia, or birth trauma would have a high cost 

per case presented. Because of ethical considerations, a study of appropriate size to clarify the 

issue of decreased perinatal mortality in treated compared with untreated gestational diabetes 

is unlikely. The Centers for Disease Control recommends that where cost and inconvenience 
make universal screening impractical, women with any of the following risk factors should be 

screened: age 25 years or older, obesity, history of diabetes in a first-degree relative, history 

of pregnancy with stillbirth or infant weighing over 9 pounds, and history of congenital 

malformation in a previous child. 1 figure, 4 tables, 21 references. 

131 

TITLE: Screening for Gestational Diabetes in a High-Risk Population. Massion, C.; 

O'Connor, P.J.; Gorab, R.; Crabtree, B.F.; Nakamura, R.M.; Coulehan, J.L. The Journal of 

Family Practice. 25(6): 569575. December 1987. 

OBJECTIVE: To evaluate the use of the glucose screening test in a well-defined primary 

care population at high risk for gestational diabetes. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: When several variables, including historical factors and the glucose 

screening test result, were analyzed, only the test result was associated with the risk of 

gestational diabetes. 

RECOMMENDATION: Universal screening for gestational diabetes should be conducted 

and oral glucose tolerance tests should be performed when 1-hour blood glucose 

concentrations are $ 130 mg/dL. 

ABSTRACT: A 50 g glucose load was administered to 181 pregnant, nonfasting Navajo 

women during routine prenatal care between 28 and 32 weeks of gestation; plasma glucose 

concentrations were determined 1 hour later. Patients with a plasma glucose concentration of 

130 mg/dL or greater were asked to return for a 3hour oral glucose tolerance test to confirm a 

diagnosis of gestational diabetes. The incidence of gestational diabetes in the study population 

was 6.1 percent. Incidence of gestational diabetes was 10 percent (2 of 21) in patients whose 

screening result was 130 to 149 mg/dL; 39 percent (9 of 23) in patients whose screening 

result was 150 mg/dL or greater. The marginal cost for each case of gestational diabetes 

detected was $114 for universal screening with the 130 mg/dL as the test cutoff point (181 

screening tests and 44 glucose tolerance tests to detect 11 cases of gestational diabetes); for 

this approach, sensitivity approached 1.00, specificity was 0.80, and positive predictive value 

was 0.25. For universal screening with a threshold of 150 mg/dL, the marginal cost per case 

detected was $106 (181 screening tests and 23 glucose tolerance tests to detect 9 cases of 

gestational diabetes). Sensitivity decreased to 0.81, specificity was 0.58, and positive 

predictive value was 0.39. The small differences in cost per case of gestational diabetes 

detected and the increased sensitivity of the universal screening test with the 130 mg/dL 

threshold suggests this approach is preferable to universal screening with a 150mg/dL 

threshold or selective screening based on risk factors. This conclusion depends on cost of 
screening and diagnostic tests, however. By logistic regression analysis, the glucose test 

results were associated with risk of gestational diabetes (p = 0.0004), but historical risk 

factors were not. 3 tables, 26 references. 

132 

TITLE: Screening of High-Risk and General Populations for Gestational Diabetes: Clinical 

Application and Cost Analysis. Lavin, J.P. Diabetes. 34 (Supplement 2): 24-27. June 1985. 

OBJECTIVE: To determine the feasibility and investigate the costs of universal screening for 

abnormal carbohydrate metabolism in pregnancy in a prenatal clinic; to detect the relative 

prevalence of gestational diabetes among populations defined as high and low risk based on 

historic and clinical factors. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient screening. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: A significant number of women with gestational diabetes and their offspring 

will be denied the benefits of improved care if screening is limited to those with a high risk for 

gestational diabetes. Universal screening costs compare favorably with those incurred for 

other screening tests for other diseases during pregnancy. 

RECOMMENDATION: Greater standardization in protocols, presentation, and 

interpretation of data will facilitate selection of an optimal protocol for screening for 

gestational diabetes. 

ABSTRACT: Costs and outcomes of screening 2,077 pregnant women for gestational 

diabetes were analyzed. The women were placed in either high- or low-risk groups, depending 

on whether they had historic or clinical risk factors (Group 1) or none of these factors (Group 

2). Group 1 included 959 women; Group 2 included 1,118 women. All women in Group 2 

underwent an initial glucose challenge test between 28 and 32 weeks of gestation, followed by 

an oral glucose tolerance test if the glucose challenge test was abnormal. Those with an 

abnormal glucose tolerance test were referred to the Pregnancy Special Care Clinic. Group 1 

women underwent a glucose challenge test at their first antepartum visit; those with a normal 

result or a normal glucose tolerance test after an abnormal glucose challenge test received 

routine prenatal care until 28 weeks of gestation, when the testing sequence was repeated. 

Fifty-seven women in Group 1 (5.9 percent) tested positive on the initial glucose challenge 

test; 14 of these women (25 percent, or 1.5 percent of the total group) also tested positive on 

the glucose tolerance test. At week 28, 7.2 percent of these women tested positive on the 

glucose challenge test, but none tested positive on the glucose tolerance test. In Group 2, 6.1 

percent of the women had a positive glucose challenge test; 23 percent of these women (1.4 

percent of the total group) also tested positive on the glucose tolerance test. Differences 

between the groups were not statistically significant. In all, 46.7 percent of the cases of 
gestational diabetes were identified in women with risk factors, and 53.3 percent were 

identified in women with no risk factors. The total estimated direct cost for this screening 

program was $9,869. The cost per patient screening was $4.75 and per case of gestational 

diabetes detected, $328.96. Results support the concept of greater cost efficiency in universal 

screening compared with screening only high-risk populations. 3 tables, 25 references. 

133 

TITLE: Weight Excess Before Pregnancy: Complications and Cost. Galtier-Dereure, F.; 

Montpeyroux, F.; Boulot, P.; Bringer, J.; Jaffiol, C. International Journal of Obesity. 19(7): 

443448. July 1995. 

OBJECTIVE: To study maternal and fetal complications, course of labor, and overall cost of 

pregnancy care in relation to prepregnancy weight. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Hypertension, toxemia, gestational diabetes, insulin treatment, urinary tract 

infections, and macrosomia were positively correlated with maternal excess weight prior to 

pregnancy. Women who were overweight had longer hospital stays and higher costs than 

normal-weight women. 

RECOMMENDATION: Because even moderate excess weight is a significant risk factor 

for obstetrical complications, multidisciplinary management before birth is needed to prevent 

maternal or fetal complications. 

ABSTRACT: Data concerning 112 deliveries at a hospital in Montpellier, France, among 89 

overweight patients from 1980 to 1993 were reviewed and compared with a control group of 

54 normal-weight pregnant patients during the same period. Exclusion criteria were hepatic, 

cardiac, or renal failure; previous diabetes mellitus; height below 145 cm; and age under 18 

years. Patients were placed into four groups according to their pregravid body mass index 

(BMI = kg/m2): normal weight (control group), 18 to 24.9; moderately overweight, 25 to 

29.9; obese, 30 to 34.9; massively obese, 35 or higher. The authors measured the incidence of 

maternal complications (e.g., hypertension, gestational diabetes), complications of labor (e.g., 

macrosomia), and duration of hospitalization. Dysfunctional uterine bleeding was more 

common among obese patients. Hypertensive diseases and glucose tolerance abnormalities 

were strongly correlated with overweight. The incidence of hypertension increased even in 

moderately overweight patients (p = 0.018). The frequency of gestational diabetes mellitus, 

insulin-treated gestational diabetes, and toxemic syndrome was higher in the three overweight 

groups, but it reached statistical significance only for the obese and massively obese. Labor 

complications among obese women included cephalopelvic disproportion (25 percent), fetal 

distress (21 percent), and stagnation of induced labor (17 percent). There was a higher 
frequency of overall cesarean sections (43 percent versus 9 percent, p = 0.002) and first 

cesarean sections (33 percent versus 7 percent, p = 0.006) in the massively obese. The mean 

total duration of hospitalization was correlated with prepregnancy weight. Overall cost 

(including the postpartum period) was more than three times higher in massively obese than in 

normal weight patients (p = 0.0001). In the normal-weight group, 9 percent of patients were 

hospitalized in the antepartum period, versus 33 percent of overweight, 36 percent of obese, 

and 66 percent of massively obese patients. 1 figure, 4 tables, 22 references. 

Pregestational Diabetes 

134 

TITLE: Cost-Benefit Analysis of Preconception Care for Women with Established Diabetes 

Mellitus. Elixhauser, A.; Wechsler, J.M.; Kitzmiller, J.L.; Marks, J.S.; Bennert Jr., H.W.; 

Coustan, D.R.; Gabbe, S.G.; Herman, W.H.; Kaufmann, R.C.; Ogata, E.S.; Sepe, S.J. 

Diabetes Care. 16(8):1146-1157. August 1993. 

OBJECTIVE: To determine whether the costs of pre-conception care in women with 

diabetes are balanced by the savings that result from avoiding complications. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Intensive preconception care for women with diabetes followed by prenatal 

care is cost saving when compared with prenatal care only. 

RECOMMENDATION: None. 

ABSTRACT: Literature review, consensus development, and questionnaires were used to 

compare the costs of preconception care plus prenatal care with the costs of prenatal care only 

for hypothetical groups of 1,000 women each. Preconception care was assumed to require 20 

visits; the model specified that only after glycemic control was achieved and maternal health 

status evaluated would a couple be encouraged to conceive. For the prenatal-care-only group, 

care was assumed to start at gestational age of 12 weeks. The economic consequences of 

adverse outcomes of pregnancy included those for the mother (e.g., a stay in the intensive care 

unit), initial hospitalization for the newborn (costs of congenital anomalies, respiratory distress 

syndrome, etc.), and subsequent care for the newborn. A cost-benefit analysis (all costs in 

1989 dollars) from the perspective of a third party payer was performed in which total 
program costs were compared with the dollar value of maternal and neonatal adverse 

outcomes. Net benefits and a benefit-cost ratio were computed. Net benefits equaled the sum 

of the costs for prenatal care only and the costs of associated adverse outcomes, minus the 

sum of the costs of the preconception-plus-prenatal-care program and the associated adverse 

outcomes. The benefit-cost ratio was calculated by dividing the difference in adverse outcome 

costs between the programs by the difference in program inputs. The model found that the 

preconception-care group incurred costs of $11,294 per enrollee and $17,519 per delivery. In 

contrast, cost per enrollee in the prenatal-care-only program was $12,889 and cost per 

delivery was $13,843 (the cost was higher in the preconception-care group because more 

women received medical services without going on to deliver). Rates of adverse outcomes 

were generally lower for the preconception-care patients. Total costs of adverse outcomes 

were $9,655,079 in the preconception group and $13,372,792 in the group receiving prenatal 

care only. Net benefit of the preconception care program was $1720 per enrollee; the benefitcost ratio was 1.86. 6 tables, 3 appendixes, 44 references. 

135 

TITLE: Cost-Benefit Analysis of Preconception Care for Women with Established Diabetes 

Mellitus. Final Report. Elixhauser, A.; Weschler, J.M. Battelle Medical Technology and Policy 

Research Center, Washington, D.C., 1990. 

OBJECTIVE: To analyze and compare costs and benefits of preconception care plus 

prenatal care versus prenatal care only in preventing adverse fetal and maternal outcomes in 

women with pre-existing diabetes mellitus. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: The program of preconception care plus prenatal care resulted in net 

savings of $1.7 million; the greatest savings were associated with reduction of adverse 

outcomes in mothers and infants. 

RECOMMENDATION: Third party payers can expect to realize cost savings from reduced 

maternal and fetal complications in women with pre-existing diabetes by reimbursing for 

preconception care (including educational and support services provided by allied health care 

providers) according to standards recommended by the American Diabetes Association. 

ABSTRACT: The authors constructed a model, based on literature review, review by an 

expert panel, and questionnaires, to compare among women with diabetes the costs and 
benefits associated with preconception care plus prenatal care with those for prenatal care 

only. The theoretical study population included 1,000 women in the preconception care 

program, of whom 785 became pregnant and entered prenatal care; and 1,000 women in the 

prenatal-care-only program, of whom 900 became pregnant. The preconception component of 

the program was 17 weeks long and included an initial preconception evaluation and 20 visits 

for medical evaluation; laboratory tests; and education, dietary, and counseling services. 

Women in the program were assumed to enter prenatal care six weeks after their last 

menstrual period. The prenatal-care-only program assumed that all women would have 

appropriate care and enter the prenatal program at a later stage of pregnancy (10 to 12 weeks 

after the last menstrual period), that 60 percent would enter the program in less than optimal 

control and 25 percent would require hospitalization to improve control, and that those in 

poor control would require more intensive medical and dietary management. Cost-benefit 

analysis showed that the total costs of care for women in the preconception plus prenatal care 

group were $11,294,100 (not including nonmedical costs); total costs for women in the 

prenatal-care-only group were $9,296,900. Costs associated with adverse outcomes totaled 

$9,655,079 for the first group and $13,372,676 for the second. Total costs for women in the 

second group were $1,720,397 ($1,720 per woman) higher than total costs for women 

receiving preconception care, resulting in a cost-benefit ratio of 1.86. 14 tables, 3 figures, 4 

appendices, 80 references. 

136 

TITLE: Financial Implications of Implementing Standards of Care for Diabetes and 

Pregnancy. Elixhauser, A.; Weschler, J.; Kitzmiller, J.; Bennert, H.; Coustan, D.; Gabbe, S.; 

Herman, W.; Kauffmann, R.; Ogata, E.; Marks, J.; et al. Diabetes Care. 15 (Supplement 1): 

S22-S28. March 1992. 

OBJECTIVE: To examine the financial implications of implementing standards of care for 

pregnancy among women with diabetes. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient management. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Implementing standards of care for pregnancy among women with diabetes 

will represent a greater use of health care resources for outpatient preconception and prenatal 

care but can lead to avoided costs for maternal and fetal complications of pregnancy. 

RECOMMENDATION: Reimbursement should be provided by third party payers for 

comprehensive diabetes and pregnancy care to ensure that women with diabetes have access 

to the care they require to prevent adverse outcomes for themselves and their infants. 

ABSTRACT: The authors examine the financial implications of implementing standards of 

care for pregnancy among women with diabetes. The standards of interest were developed by 
the American Diabetes Association and address four main areas of care: preconception care, 

blood glucose control, frequent visits, and specialized laboratory and diagnostic tests. As 

these standards did not specify the resources required for preconception and prenatal care, the 

authors convened a panel of physicians to outline more precise guidelines. The 

recommendations of the panel were examined for their economic implications. Adherence to 

these standards may represent additional costs to patients or third party payers for initial 

outpatient treatment. However, treatment-related costs of adverse outcomes of pregnancy can 

be enormous, particularly those due to poor maternal glucose control. Corrective surgery for 

infants with congenital heart malformations secondary to poor glucose control may cost up to 

$145,000 (1989 dollars) per survivor; lifetime care costs for infants born with severe spina 

bifida are estimated at $330,000, including both direct and indirect costs. In addition to 

avoiding costs related to poor fetal outcomes, intensive preconception and prenatal care can 

help to avoid expensive hospitalizations for maternal complications; hospitalization for a single 

episode of ketoacidosis averages $4,500. Two recent cost-benefit studies are cited that 

demonstrate that the savings resulting from avoided adverse pregnancy outcomes in women 

with diabetes outweigh the added costs of preconception care. Reimbursement of 

comprehensive diabetes and pregnancy care by third party payers is crucial for ensuring the 

care necessary to prevent adverse outcomes for these women and their infants. 1 figure, 49 

references. 

137 

TITLE: Prevention: The Cost-Effectiveness of the California Diabetes and Pregnancy 

Program. Scheffler, R.M.; Feuchtbaum, L.B.; Phibbs, C.S. American Journal of Public 

Health. 82(2): 168-175. February 1992. 

OBJECTIVE: To determine the cost-effectiveness of a California program aimed at 

improving pregnancy outcomes through intensive diabetes management. 

CATEGORY: Tertiary intervention. 

Type of Study: Retrospective. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: The program significantly reduced hospital charges and length of stay; it 

returned over $5 for every $1 spent. 

RECOMMENDATION: None. 

ABSTRACT: The California Diabetes and Pregnancy Program focuses on improving 

maternal and infant perinatal outcomes in pregnancies complicated by diabetes. Women in the 

program receive comprehensive preconception and prenatal care, including nutrition, 

education, and support services. Data for 102 California Diabetes and Pregnancy Program 

cases were collected from July 1, 1986, to July 30, 1988, from three hospitals with wellestablished programs, each with a level 3 neonatal intensive care unit. Data for 218 control 
cases were collected from five other hospitals, each with at least a level 2 neonatal intensive 

care unit. The demographic characteristics and health status indicators of mothers and babies 

at case and control hospitals were similar. Program participants and control cases of the same 

age, ethnicity, and diabetes classification were randomly matched, yielding a data set of 90 

program cases and 90 control cases. In this data set, mean adjusted charges were $15,344 for 

cases, $21,699 for controls. Mean length of stay (mother and baby combined) was 15.1 days 

for the program cases, 18.0 days for controls. After adjustment for inflation and differences in 

hospital charges, for every $1 of program costs, estimated savings were $5.19. The authors' 

conservative assumptions suggest that actual savings are even larger than their estimates. If 

2,598 babies were born to women with overt diabetes in 1990 (as estimated), yearly savings 

attributable to the California Diabetes and Pregnancy Program would have been $14 million to 

$19 million. In addition to short-term economic savings, mothers will likely have better future 

health status, and there should be long-term savings from fewer anomalies and other 

handicaps. With more normal pregnancies and healthy babies, mothers can stay in the 

workforce longer and return to work sooner. 6 tables, 27 references. 

138 

TITLE: Women with Diabetes During Pregnancy: Sociodemographics, Outcomes, and Costs 

of Care. York, R.; Brown, L.P. Public Health Nursing. 12(5): 290-293. October 1995. 

OBJECTIVE: To provide sociodemographic, outcome, and cost data for pregnancy through 

the postpartum period for predominantly low-income women with diabetes who were 

hospitalized during pregnancy for glucose control. 

CATEGORY: Diabetes in pregnancy. 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Women in the study were three times as likely as those in the general 

Pennsylvania population to deliver low-birthweight infants; mean hospital charges for these 

infants were $39,787. 

RECOMMENDATION: Monies must be targeted to provide a broad spectrum of health 

care services that will meet the unique needs of low-income, childbearing women with 

diabetes. 

ABSTRACT: The authors evaluated data for 55 women with diabetes who received care at 

the University of Pennsylvania Medical Center in Philadelphia between August 1988 and 

December 1992. Fourteen of the women had pregestational diabetes; 41, gestational diabetes. 

Of the 55 women, 63 percent reported annual family income of under $12,500. Data 

collection methods included maternal interviews, review of maternal and infant hospital charts, 

and postpartum telephone interviews. Mean hospital charges for antepartum initial 

hospitalization for glucose control, evaluation, and education were $4,665 (mean length of 
stay: 4.3 days). For women who required rehospitalization for glucose control, mean hospital 

charges were $6,371 (mean length of stay: 5.9 days). Mean charges for postpartum 

hospitalization were $7,793 (mean length of stay: 4.3 days). Of the 54 infants born to the 

study participants, 2 were stillborn and 11 were low birthweight. Mean hospital charges per 

infant were $12,991; for the low-birthweight infants, $39,787. Compared with Pennsylvania 

women as a whole, women in this study were twice as likely not to have had first-trimester 

care (43 percent versus 20.4 percent) and three times more likely to deliver a low-birthweight 

infant (20 percent versus 7.2 percent). The results provide significant evidence of the 

complexity of these women's health care needs and the need for monies targeted at addressing 

these needs. 1 table, 13 references. 

The Economics of Diabetes Mellitus 

Secondary Intervention 

The Economics of Diabetes Mellitus 

Tertiary Intervention 

The Economics of Diabetes Mellitus 

Diabetes in Pregnancy 

Direct Medical Costs 

Inpatient Care 

139 

TITLE: Amputations in the Surgical Budget. Solomon, C.; van Rij, A.M.; Barnett, R.; 

Packer, S.G.; Lewis-Barned, N.J. New Zealand Medical Journal. 107(973): 78-80. March 9, 

1994. 

OBJECTIVE: To describe the extent and distribution of inpatient costs for nontraumatic 

lower limb amputations and to identify areas for cost-saving strategies. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Length of hospital stay was the largest determinant of cost. The need for 
long preoperative management and postoperative rehabilitation hospital time might be 

achieved more economically in less costly settings. Most amputations among patients with 

diabetes were of the minor type; among patients without diabetes, most were major. 

RECOMMENDATION: Greater use of outpatient facilities and providing increased 

resources for screening, preventive education, podiatry, and early intervention may offer both 

limb- and cost-saving opportunities. Free flow and integration of clinical and cost information 

could provide the physician with a more adequate basis for best use of resources. 

ABSTRACT: Investigators reviewed data on 134 hospital admissions for nontraumatic lower 

limb amputations from July 1989 to April 1992 at Otago (New Zealand) Health Board 

hospitals in order to assess potential cost-saving options. Detailed information on costs, 

clinical activity, and length of hospital stay was available for analysis. Statistical analysis used 

the Mann-Whitney U test and the chi-square test. Total in-hospital cost was $1.09 million 

(New Zealand dollars), with an annual cost of $388,000. The mean cost for general surgical 

admission was $11,342 (median $21,367), which was significantly higher (p < 0.001) than that 

for orthopedic patients, whose mean cost was $2,318 (median $6,277). General surgical 

patients, compared with orthopedic patients, required major amputation (above and below the 

knee) more frequently (46.5 percent versus 10.4 percent) and had concomitant diabetes more 

frequently (36.0 percent versus 4.2 percent). Of amputations among patients with diabetes, 

73.9 percent were minor (forefoot and toe), versus 29.0 percent for nondiabetic patients (p < 

0.005). For all admissions, ward costs accounted for 55.6 percent of in-hospital costs per 

admission, making length of stay the most important determinant of admission cost. The long 

preoperative stay spent to avoid amputation might be decreased by greater use of outpatient 

facilities for investigation and initial management. The longest portion of hospital stay is for 

accommodating major amputees until they are fully mobile using an artificial limb; use of less 

costly facilities outside acute hospital wards may achieve the same ends more economically. 3 

figures, 19 references. 

140 

TITLE: Amputations in the Surgical Budget (letter). Simmons, D.; Thomson, C.; Scott, D. 

New Zealand Medical Journal. 107 (978): 208-209. May 25, 1994. 

OBJECTIVE: To report cost findings about patients with diabetes who underwent 

amputation. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Costs of about $21,000 for the year in which amputation took place were 

very close to costs reported in a similar study. 
RECOMMENDATION: With education on foot care, daily self-inspection of the feet, and 

effective monitoring and early intervention, at least 50 percent of amputations should be 

preventable. 

ABSTRACT: The authors determined the mean 1-year cost of $20,881 (in 1987 dollars) for 

treating 20 patients with diabetes during the year of their amputation(s). This figure is close to 

the figure of $21,439 for a more recent study in Dunedin, New Zealand. The authors point out 

that using diabetes codes to identify patients with diabetes has been shown to miss 45 percent 

of these patients. In the present study, many surgical patients with diabetes remained 

undiagnosed throughout their admissions. The authors found in their own study that 40 

percent of patients with diabetes had not had their feet inspected by their diabetes care 

attendant in the previous 12 months and that 57 percent had poor nail or skin care. The 

authors suggest that a team approach makes early intervention more likely and state that this 

would involve close liaison between the diabetes nurse, physician, podiatrist, and preferably a 

surgical team with skills in vascular surgery and a special interest in the diabetic foot. 6 

references. 

141 

TITLE: The Burden of Diabetes: The Cost of Diabetes Hospitalizations in Wisconsin, 1994. 

Ford, E.J.; Remington, P.L. Wisconsin Medical Journal. 95(3): 168-169. March 1996. 

OBJECTIVE: To determine for Wisconsin in 1994 the cost of all hospitalizations in which 

diabetes was listed as a diagnosis; to analyze these hospitalizations and their costs. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Diabetes cost Wisconsin residents $545 million, or $150 per person, in 

1994. 

RECOMMENDATION: Efforts should be made to prevent or delay diabetes and to reduce 

its complications. Interventions that reduce diabetes-related health care costs will benefit all 

citizens. 

ABSTRACT: The state of Wisconsin maintains a database of information on all 

hospitalizations, including costs. For 1994, hospital discharge data revealed 53,791 admissions 

in Wisconsin for which diabetes was listed as a primary or secondary diagnosis. Total costs 

were $545 million; costs of individual admissions ranged from $150 to $1.5 million (median, 

$6,280; mean, $10,120). For 8 percent (4,234) of admissions, diabetes was listed as the 

principal diagnosis; the cost of these admissions was $42 million. For the remaining 92 
percent, diabetes was listed as a secondary diagnosis. Among these events, costs by principal 

diagnosis were $208 million for circulatory diseases (38 percent of total costs); $42 million for 

digestive diseases (8 percent); $35 million for respiratory diseases (6 percent); $32 million for 

musculoskeletal conditions (6 percent); $30 million for complications of medical care (5 

percent); $28 million for neoplasms (5 percent); $21 million for injury and poisoning (4 

percent); $16 million for genitourinary conditions (3 percent); and $81 million for all other 

causes (15 percent). By age, costs were $213 million for persons under age 65 (39 percent), 

$176 million for those aged 65-74 (32 percent), and $156 million for persons aged 75 and 

over (29 percent). Medicare was billed for 68 percent of the costs; other governmentsupported reimbursement, including Medicaid, brought the total supported by taxpayers to 

over 75 percent. Private insurance accounted for 23 percent. 1 figure, 1 table, 7 references. 

142 

TITLE: Clinical Features and Health-Care Costs of Diabetic Nephropathy. Narins, B.E.; 

Narins, R.G. Diabetes Care. 11 (10): 833-839. November/December 1988. 

OBJECTIVE: To review the natural history, treatment, and costs of treating nephropathy 

associated with diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Diabetes-associated nephropathy is rapidly becoming the largest cause of 

renal replacement therapy. 

RECOMMENDATION: Further study of the pathogenesis and treatment of diabetes and 

diabetic nephropathy is needed. 

ABSTRACT: The authors review the incidence, course, prognosis, and treatment of 

diabetes-related nephropathy. Of patients with type 1 diabetes, 40 to 50 percent develop 

clinically evident renal disease; two-thirds of those who do (30 percent overall) require 

replacement therapy for end-stage renal disease (ESRD). From 1973 to 1980, the percentage 

of ESRD attributable to diabetes tripled. ESRD from diabetes is disproportionally common 

among blacks (versus whites). Microalbuminuria and macroalbuminuria develop 5 to 10 years 

and 10 to 15 years, respectively, after initial diagnosis of diabetes. Glomerular filtration rate 

and serum creatinine generally remain constant during the first 10 to 15 years of insulin 

dependence. ESRD occurs approximately 5 years after persistent proteinuria and azotemia 

develop. Among patients with type 1 diabetes-related nephropathy, almost two-thirds die from 

renal failure, 25 to 30 percent from cardiovascular complications, and 5 to 15 percent from 

other disorders; patients with type 2 diabetes die more frequently from cardiovascular 

complications. After 5 years, survival is about 75 percent for patients who receive kidney 

transplants from living related donors, versus 40 to 50 percent for patients who receive other 
ESRD therapy. In 1982, average hospital days for patients with diabetes receiving dialysis 

were 37 percent greater than for ESRD patients without diabetes. In the first posttransplantation year, patients with diabetes averaged 45 percent more days than those without 

diabetes. Respective annual per capita costs for all patients with ESRD and for patients with 

diabetic ESRD were $23,833 and $35,616 for hemodialysis, $23,076 and $36,585 for 

peritoneal dialysis, and $32,075 and $43,010 for kidney transplantation. 6 figures, 30 

references. 

143 

TITLE: The Cost of Hospitalization for the Late Complications of Diabetes in the United 

States. Jacobs, J.; Sena, M.; Fox, N. Diabetic Medicine. 8 (Symposium): S23S29. 1991. 

OBJECTIVE: To calculate for U.S. patients with diabetes the risk of hospitalization for late 

complications (e.g., cardiovascular and kidney disorders). 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based costs. 

Perspective: Health care system. 

CONCLUSION: Late complications of diabetes accounted for 2 percent of the total hospital 

admissions in the United States in 1987. The total cost of treating these complications was 

estimated at $5.091 billion (cardiovascular, 74 percent; renal diseases, 10 percent; neuropathy, 

3.6 percent; ophthalmic disorders, 1.5 percent; and unspecified diseases, 10 percent). 

RECOMMENDATION: None. 

ABSTRACT: The cost of health care in the United States is usually attributed to a disease 

according to the primary diagnosis on the patient's medical record. This method 

underestimates the cost of hospital care for patients with diabetes, which often contributes to 

a variety of other diseases or complications. The authors used the 1987 National Hospital 

Discharge Survey to determine hospitalization rates for patients with diabetes and a matched 

control group; excess hospitalizations and associated costs were attributed to diabetes. Only 

those hospitalizations with a diagnosis-related group that matched a late complication were 

included in the analysis. Average cost per day for complications was obtained from the Pracon 

Med PROs Audit, a Medicare database. For neuropathy, the highest hospitalization rate 

among persons with diabetes occurred in the 45- to 54-year age group, 6.74 per 1.000; the 

highest rate for controls (1.80) was in the group 75 years of age and over. Patients with 

diabetes aged 45 or younger were 46 times as likely to be hospitalized due to neuropathy as 

those in the control group (95 percent CI, 45.0 to 47.4). Those with diabetes were 21.8 times 

as likely to be admitted for skin ulcers/gangrene (95 percent CI, 21.6 to 22.0), 15 times as 

likely for peripheral vascular disease, 10 times as likely for congestive heart failure, and almost 

10 times as likely for atherosclerosis. The risk of cerebrovascular accident and heart disease 

was 6 to 10 times greater for diabetic patients than for controls. Hospitalization from renal 
complications was much more common at younger ages for those with diabetes. Late 

complications of diabetes resulted in nearly 7 million hospital days; inpatient hospitalization 

costs were estimated to be $5.091 billion. 1 figure, 5 tables, 16 references. 

144 

TITLE: The Costs of Diabetes-Related Lower Extremity Amputations in the Netherlands. 

van Houtum, W.H.; Lavery, L.A.; Harkless, L.B. Diabetic Medicine. 12(9): 777781. 

September 1995. 

OBJECTIVE: To identify for 1992 the duration of hospitalization for diabetesrelated lower 

extremity amputations and their associated costs in The Netherlands. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Days in the hospital for lower extremity amputations in the population with 

diabetes totaled 65,778 (41.8 days per hospitalization); mean cost per hospitalization was £ 

10,531. 

RECOMMENDATION: The direct cost of prevention strategies for high-risk patients with 

diabetes should be analyzed to determine the financial impact of the multidisciplinary clinics 

that provide these preventive services. 

ABSTRACT: The authors used 1992 data from the Dutch organization SIG Health Care 

Information to identify all lower extremity amputations in The Netherlands. Using average 

costs associated with such amputations obtained from the National Health Tariffs Authority, 

Netherlands, the authors were able to determine the average cost of hospitalizations. Total 

direct costs included those associated with hospital stay and the average procedure-specific 

costs (for surgeon and anesthetist fees and the operating room) for the specific level of 

amputation. Patient-specific charges were not available. In 1992, there were 1,810 

diabetesrelated lower extremity amputations involving 1,575 hospitalizations. The mean 

hospital stay was 41.8 days, with a mean cost of £ 10,531. The total direct cost associated 

with hospitalization and surgery for diabetesrelated amputations was £ 16.59 million, and 

more than 65,000 hospital days were used. Hospital days for amputation among persons 

without diabetes totaled almost 46,000. Hospital stays in this group were significantly shorter 

(mean: 31.8 days, p < 0.001) than in persons with diabetes. When outcomes were adjusted for 

age, more multiple amputations were performed in persons with diabetes (13.6 percent) than 

in those without diabetes (6.6 percent, p < 0.001). Indirect costs and costs of continued 

medical care at rehabilitation centers and other medical facilities were not taken into account 

in this study, and, thus, the actual costs associated with lower extremity amputations in the 

population with diabetes were even higher than this study reported. Studies have shown that 

lower extremity amputations are at least partly preventable with multidisciplinary treatment 
programs. 1 figure, 4 tables, 19 references. 

145 

TITLE: Counting the Cost of Diabetic Hospital Admissions From a Multi-Ethnic Population 

in Trinidad. Gulliford, M.C.; Ariyanayagam-Baksh, S.M.; Bickram, L.; Picou, D.; Mahabir, D. 

Diabetic Medicine. 12(12): 1077-1085. December 1995. 

OBJECTIVE: To measure the impact of diabetes on a major hospital in northern Trinidad 

and to evaluate the relationship between ethnicity and morbidity from diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Costs of admission for diabetes in the hospital wards surveyed accounted 

for at least 8 percent of total expenditures at the hospital and 23 percent of bed occupancy. 

RECOMMENDATION: Investment in better-quality community care for patients with 

diabetes would be economically advantageous for countries such as Trinidad and Tobago. 

ABSTRACT: Admission records at Port of Spain Hospital in Trinidad were reviewed for all 

patients with diabetes admitted to any of seven medical wards, five general surgical wards, or 

two ophthalmology wards over a 26-week period beginning in October 1993. During the 

study period, 1,722 (13.6 percent) of a total of 12,673 admissions involved patients (n = 

1,447) with diabetes. One hundred seventy-eight of these patients had more than one 

admission; 1,269 had a single admission. Admission rates increased with age and were 

approximately 40 percent higher in the population of Indian descent than in those of African 

origin. Diabetes prevalence in the population had a primary influence on admission rates, with 

level of admissions and morbidity also influenced by accessibility to hospital services and 

quality of care in the community. Conditions frequently present on admission included 

disorders of blood glucose control, foot diseases, renal impairment, cardiac failure, angina, 

and myocardial infarction and stroke. The fatality rate among admissions was 8.9 percent (154 

deaths), and the mean length of stay was 4 days. The presence of renal impairment on 

admission was associated with a fatality rate of 21 percent. The annual number of bed days 

occupied by persons with diabetes was 26,659, which represented 23 percent of all bed days 

on the study wards. Annual financial cost for all patients admitted with diabetes was TT$10.7 

million, including TT$3.1 million for patients admitted with foot problems, TT$2.5 million for 

those with glucose control problems, and TT$5.1 million for those with other diagnoses. The 

mean cost of 1 patient admission with diabetes was TT$3,096. 1 figure, 5 tables, 28 

references. 

146 
TITLE: Diabetes - Inpatient Utilisation, Costs and Data Validity: Dunedin 1985-9. Phillips, 

D.E.; Mann, J.I. New Zealand Medical Journal. 105(939): 313-315. August 1992. 

OBJECTIVE: To describe the impact of diabetes on public hospital inpatient services in an 

urban New Zealand 450-bed university teaching hospital from 1985 through 1989. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Admission, bed utilization rates, and associated costs for diabetes rose by 

factors of 3.2, 3.8, and 2.8, respectively, during the study period. Most utilization increases 

were accounted for by admissions in which diabetes was a subsidiary diagnosis. At $16,000 

(New Zealand dollars) per patient, admissions for diabetic peripheral vascular disease were the 

most costly. 

RECOMMENDATION: Because diabetes consumes many hospital resources in this region, 

especially for the growing elderly population, alternative options for providing care are 

needed. Data audits must be performed or restricted to well-defined groups (e.g., diabetes as 

principal diagnosis only) to achieve an accurate analysis. 

ABSTRACT: Hospital discharge data were collected to describe trends in utilization and 

costs of admissions for diabetes and associated conditions in an urban teaching hospital in 

New Zealand from 1985 through 1989. A validation study was performed to assess the impact 

of underreporting or nonreporting and misclassification of diabetes as a discharge diagnosis. 

Admissions for diabetes-related conditions represented 5 percent of all hospital inpatient costs 

in 1989, but 45 percent of admissions where diabetes should have been a subsidiary diagnosis 

were omitted from the discharge data. During the study period, an average 4.6 percent of total 

hospital bed utilization was for diabetes admissions, 1.9 percent as the principal, and 2.7 

percent as the subsidiary diagnosis. Length of stay averaged 12.3 days for admissions with 

diabetes as the principal diagnosis and 15.4 days for diabetes as a subsidiary diagnosis. The 

highest daily cost was for diabetic eye disease (90 percent of these costs were for operative 

treatment of cataracts, 10 per-cent for treatment of retinopathy), and the highest total and 

mean per-patient costs were for peripheral vascular disease. Annual bed utilization where 

diabetes was a subsidiary diagnosis rose from 1,580 to 5,972 days during the study period, but 

utilization days where diabetes was the principal diagnosis declined from 2,036 to 1,860. 

Macrovascular disease accounted for most admissions and bed utilization when diabetes was 

the subsidiary diagnosis. Patients with diabetes are surviving to an age where vascular disease 

becomes common. Admission rates averaged 3/1,000 for the 0 to 44 age group and 60/1,000 

for the $ 75 age group; bed utilization rates were similar, and costs for the two groups rose 

from $2,400/1,000 to $181,900/1,000. Increased admissions and bed utilization rates are 

likely due to an increase in available facilities and changes in treatment practices; the 

validation study suggests that changes in recording practice by doctors is unlikely to be a 
major factor. The accuracy of aggregate costs depends on the accuracy of the discharge data, 

and diabetes has been significantly underreported. 4 tables, 23 references. 

147 

TITLE: Diabetes-Related Hospitalization and Hospital Utilization. Aubert, R.E.; Geiss, L.S.; 

Ballard, D.J.; Cocanougher, B.; Herman, W.H. In: Diabetes in America. 2nd edition. National 

Diabetes Data Group, ed. National Institute of Diabetes and Digestive and Kidney Diseases. 

NIH Publication No. 95-1468. 1995: 553-569. 

OBJECTIVE: To describe rates and trends for hospitalization of persons with diabetes using 

data from the National Hospital Discharge Survey (NHDS) and the National Health Interview 

Survey (NHIS). 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based costs. 

Perspective: Health care system. 

CONCLUSION: Persons with diabetes have higher rates of hospitalization than persons 

without diabetes. 

RECOMMENDATION: None. 

ABSTRACT: The authors assessed rates and trends of hospitalization for persons with 

diabetes between 1980 and 1990. Per the NHDS, in 1990, diabetes was listed as a primary or 

secondary diagnosis for 2.8 million hospitalizations (24.5 million hospital days); the 

proportion of such hospitalizations for which diabetes was listed as the primary diagnosis 

declined from 29 percent in 1980 to about 15 percent in 1990. In the latter year, for 

discharges that listed diabetes, only diseases of the circulatory system exceeded diabetes as a 

primary diagnosis. Per the 1989 NHIS, among adults with diabetes, 8.3 percent reported 

multiple hospital admissions and 15.5 percent reported a single admission. In the population 

aged 18 years and over, persons with diabetes were 3 times more likely than those without 

diabetes to report hospitalization in the previous year. Women with diabetes were 6 to 18 

percent more likely to report being hospitalized than their male counterparts. Reported single 

and multiple hospitalization rates were proportionally higher with more diabetes-related 

complications. In 1990, per the NHDS, 89 percent of admissions with diabetes as a listed 

diagnosis were of patients aged 45 years or older. Hospitalizations that listed diabetic 

ketoacidosis increased 27 percent from 1980 to 1990 (age adjusted); hospitalizations for 

lower extremity amputations related to diabetes rose from about 36,000 to about 54,000 

during the period. From 1980 to 1990, the average length of stay when diabetes was the 

primary diagnosis decreased from 10.5 to 7.8 days. The American Diabetes Association 

estimated costs associated with hospital care for diabetes to be $37.2 billion in 1992; an 

estimate by Rubin et al. (1994) put the figure at $55 billion. 19 figures, 8 tables, 32 references. 
148 

TITLE: Diagnosis Related Groups, Resource Utilization, Age, and Outcome for Hospitalized 

Nephrology Patients. Muñoz, E.; Thies, H.; Maesaka, J.K.; Angus, G.; Goldstein, J.; Wise, L. 

American Journal of Kidney Diseases. 11(6): 481-488. June 1988. 

OBJECTIVE: To examine hospital costs and outcome by age of patients for all nephrology 

diagnosis-related groups at an academic medical center outside New York City. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Nephrology patients with diabetes generated significantly higher hospital 

costs than nephrology patients without diabetes due to greater resource consumption. 

Nephrology patients with diabetes generated a mean net loss per admission of $2,353 relative 

to diagnosis-related group (DRG) payments. 

RECOMMENDATION: Reimbursement of nephrology patients with diabetes should be 

made more equitable under the DRG system. 

ABSTRACT: The authors analyzed hospital cost and outcome for 784 adult and pediatric 

nephrology admissions over a 2-year period at an academic medical center. Seventy-eight of 

these patients had diabetes mellitus. Hospital costs (excluding physician fees) were calculated 

by using per-patient charge data and converting charges to costs via the cost-to-charge ratio 

data used by the hospital. These costs were then compared with DRG reimbursement for all 

patients using the DRG payment methodology and DRG case-mix index. The 784 nephrology 

admissions generated approximately $5 million in hospital costs. Patients with diabetes 

generated significantly higher mean hospital costs, $8,893, than those without diabetes, 

$6,153 (p < 0.03). For nephrology patients overall, those in age groups 55 years and over 

would have generated losses relative to DRG payment, peaking at a mean loss of $5,343 for 

patients aged 85 and over. The deficit was due primarily to more expensive care provided to 

patients 65 and over. Reimbursement under the DRG system should be made more equitable 

for patients with diabetes. 5 figures, 8 tables, 7 references. 

149 

TITLE: The First Two Years of Type I Diabetes in Children: Length of the Initial Hospital 

Stay Affects Costs but not Effectiveness of Care. Simell, T.; Simell, O.; Sintonen, H. Diabetic 

Medicine. 10(9): 855-862. November 1993. 

OBJECTIVE: To compare 1-week and 4-week initial hospital stays for children with type 1 
diabetes in terms of cost and outcomes during a 2-year follow-up. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective trial. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Total costs for children who had a 4-week initial hospital stay were 1.6-fold 

higher during the 2-year follow-up, but outcomes for the two groups were similar. 

RECOMMENDATION: The main findings from this analysis can be applied to diabetes care 

centers in Finland and other countries. 

ABSTRACT: Sixty-one newly diagnosed children with type 1 diabetes took part in this 

Finnish study, which was based at two Helsinki hospitals: Children's Hospital, University of 

Helsinki; and the Avrore City Hospital. Thirty-one children were assigned to the short-term 

group (1-week initial hospital stay) and 30 children to the long-term group (4-week initial 

hospital stay). Metabolic control, psychosocial adjustment, and direct and indirect costs of 

care were compared during the 2-year follow-up. First-month costs accounted for 74 percent 

of total costs in the long-term group and 59 percent of total costs in the short-term group. 

The major first-month expenses were for hospital costs (82 percent in the long-term group 

and 78 percent in the short-term group). The indirect costs of parents' lost work time, 

traveling costs, children's living expenses at home, and housekeeping and babysitter assistance, 

although minimal, were substantially higher during the first month in the long-term group. 

Other direct costs considered during the 2-year follow-up, including outpatient visits, insulin 

treatment, home monitoring of blood glucose and urine tests, and diabetic diet, did not differ 

significantly by group. Overall, total costs were 1.6 times greater in the long-term group. The 

researchers found no significant differences between the two groups in metabolic control, 

family adjustment to diabetes, psychosocial measures, or satisfaction with patient education 

during the 2-year follow-up period. They concluded that shortening the average initial hospital 

stay of children newly diagnosed with diabetes from 23 days to 9 days achieved a savings of 

36 percent in costs during the first 2 years of the disease without influencing the metabolic or 

psychosocial outcome of care. 3 tables, 34 references. 

150 

TITLE: Hospitalization and Expenditures for the Treatment of General Medical Conditions 

among the U.S. Diabetic Population in 1991. Ray, N.F.; Thamer, M.; Taylor, T.; Fehrenbach, 

S.N.; Ratner, R. Journal of Clinical Endocrinology and Metabolism. 81 (10): 36713679. 

October 1996. 

OBJECTIVE: To estimate the risk of hospitalization for general medical conditions among 

patients with diabetes aged 45 years and over; to estimate how much of the cost of these 

hospitalizations was attributable to diabetes. 
CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based costs. 

Perspective: Health care system. 

CONCLUSION: Hospitalizations and expenses among patients with diabetes for conditions 

that are neither acute nor chronic complications of diabetes are greater than hospitalizations 

and expenses for these conditions among patients without diabetes. 

RECOMMENDATION: Additional research is needed to identify medical reasons for 

increased risk of selected general conditions among patients with diabetes and to identify 

appropriate interventions for the care of these problems. 

ABSTRACT: The authors studied hospitalization for general medical conditions in patients 

with diabetes aged 45 years and over. Data were derived from the 1991 National Hospital 

Discharge Survey and the 1987 National Medical Expenditure Survey. Expenditures 

attributable to diabetes were estimated by multiplying the excess number of inpatient days for 

persons with diabetes by the mean per-day inpatient cost. Identification of patients with 

diabetes was based on primary or secondary diagnosis codes for diabetes; general medical 

conditions were all those not considered to be acute or chronic complications of diabetes. 

Costs were inflated to 1991 dollars. Mean expenditures per inpatient day per patient with 

diabetes were $1,673 for those 45 to 64 years old and $1,192 for those 65 and over. Middleaged persons with diabetes were 60 percent more likely (relative risk, 1.6, 95 percent 

confidence interval, 1.2-2.0) to be hospitalized for general medical conditions than were 

persons without diabetes; the greatest relative risks were for peritonitis/intestinal abscess, 

respiratory failure, liver disease, and male genital disorders. Among the elderly, there was no 

significant difference between the groups in overall risk of hospitalization for general medical 

conditions; those with diabetes had elevated risks for liver disease, septicemia, diseases of 

pulmonary circulation, and various other problems. Middle-aged and elderly persons with 

diabetes were hospitalized longer than those without diabetes (8.1 versus 6.3 days for Middleaged and 10.1 versus 8.9 days for elderly patients). Inpatient expenditures attributable to 

diabetes were $4.12 billion (52.3 percent of this total was for elderly persons). These costs 

may be understated because they do not account for undiagnosed diabetes among hospitalized 

patients. 5 tables, 55 references. 

151 

TITLE: Hospitals Adopt Intensive Programs for Diabetic Patients to Avoid High Inpatient 

Costs. Conklin, M.S. Health Care Strategic Management. 12(6): 1113. June 1994. 

OBJECTIVE: To review methods used by some managed care organizations and hospitals to 

reduce inpatient costs for patients with diabetes. 

CATEGORY: Cost of diabetes (direct). 
Type of Study: Patient management. 

Methodology: Survey. 

Perspective: Health care system. 

CONCLUSION: Successful diabetes management programs have reduced inpatient stays by 

1 to 2 days. 

RECOMMENDATION: None. 

ABSTRACT: The author reviews efforts to reduce expensive inpatient care for people with 

diabetes. According to one national study, $9,493 was expended per patient with diabetes in 

1992, of which $5,885 (more than 63 percent) was for inpatient care; corresponding figures 

for patients without diabetes were $2,604 and $1,222, respectively. The author describes 

several programs that have been implemented to reduce inpatient costs for diabetes. Kaiser 

Permanente of Northern California has developed a database for all patients with diabetes 

(68,000 in May 1994) that will track costs, compliance, and complication rates. Palmyra 

Medical Centers in Georgia markets an intensive diabetes intervention and prevention plan to 

employers, which costs $1,000 per patient with diabetes for the first year and $400 per year 

thereafter; the program is based on the findings of the Diabetes Control and Complications 

Trial. Control of blood glucose concentrations is stressed, and the program begins with a 2day 

intensive education program for newly diagnosed patients. Hemoglobin A1c is tested every 3 

months, and additional education is provided if concentrations indicate control problems; 

blood glucose concentrations have decreased in 99 percent of patients. Support groups meet 

monthly. Rose Medical Center in Denver has reduced the average length of hospitalization by 

1 day per patient with diabetes, for a savings of over $500,000, by implementing intensive 

case management at admission. The hospital uses its computer system to identify patients with 

diabetes, then involves a member of the diabetes program in the care of the patient. In Macon, 

Georgia, a similar program at the Medical Center of Central Georgia that emphasizes inpatient 

education has reduced length of stay by 1.7 days in 3 years. In Louisville, Kentucky, at Saints 

Mary and Elizabeth Hospital, nurses from all units meet monthly with diabetes nurse 

educators to discuss diabetes management problems; hospital stays for patients with diabetes 

have been reduced by 1.92 days in 2 years. 1 figure. 

152 

TITLE: Operations, Total Hospital Stay and Costs of Critical Leg Ischemia. A PopulationBased Longitudinal Outcome Study of 321 Patients. Eneroth, M.; Apelqvist, J.; Troeng, T.; 

Persson, B.M. Acta Orthopaedica Scandinavica. 67(5): 459-465. October 1996. 

OBJECTIVE: To estimate costs over time for a population of patients with critical leg 

ischemia, including many with diabetes mellitus, who underwent surgery in Sweden. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective. 
Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Mean total costs were $47,000 per patient. Patients with diabetes mellitus 

more often underwent major amputation, had longer hospital stays, and incurred higher 

medical costs than those without diabetes. 

RECOMMENDATION: None. 

ABSTRACT: The authors conducted a longitudinal analysis of costs (in 1996 U.S. dollars) 

incurred by 321 patients, including 118 with diabetes mellitus, who had surgery for critical leg 

ischemia in 1987 or 1988 in Malmohus county, Sweden. Surgical procedures, hospitalizations, 

and hospital treatment costs were assessed from the first procedure until death or for at least 

six years postoperatively. Only those admissions directly caused by arterial occlusive disease 

in the lower limbs were included. Admissions to rehabilitation clinics and nursing homes were 

included, but nursing home stays for those who lived in a nursing home before the surgery and 

returned to one after the procedure were not. The costs of angiography, implants, intensive 

care, outpatient care, and orthopedic appliances as well as indirect costs were not included. 

The initial operation during the inclusion year was a reconstructive vascular procedure for 96 

patients, a restorative or other vascular procedure for 111, and a major amputation for 114. 

Total hospitalization until follow-up in all patients was 37,638 days, of which only 44 percent 

was in surgical departments. Estimated overall cost for hospital stays was $12.87 million, a 

mean per-patient cost of $40,103. Overall cost of surgery was estimated to be $2.25 million, a 

per-patient cost of $7,050. Patients with diabetes had a longer mean total hospital stay (134 

versus 108 days, p = 0.009) and a higher estimated mean total hospital cost ($52,000 versus 

$44,000, p = 0.01) than patients without diabetes. Both groups had a mean of three 

operations. Patients with diabetes were more likely than those without diabetes to undergo 

major amputation as the operation (50 percent versus 27 percent) and more often became 

bilateral amputees than patients without diabetes (28 percent versus 12 percent). 3 tables, 33 

references. 

153 

TITLE: Patterns of Hospitalization in a Pediatric Diabetes Clinic in Sydney. Sutton, D.L.; 

Greenacre, P.; Howard, N.J.; Cowell, C.T.; Silink, M. Diabetes Research and Clinical 

Practice. 7(4): 271-276. November 6, 1989. 

OBJECTIVE: To ascertain the number of children with diabetes admitted to Children's 

Hospital in Sydney between 1985 and 1987 and to analyze their admissions. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 
CONCLUSION: For the 351 admissions of 241 children with type 1 diabetes admitted 

during the period, the median stay was 10 days (12 for newly diagnosed children, 7 for 

others). Costs for newly diagnosed admissions were projected at $Aust 3,658.00; of other 

admissions, $Aust 2,681.55. 

RECOMMENDATION: Patients' use of existing education and dietary services should be 

maximized, and additional services should be developed. 

ABSTRACT: Medical files were obtained retrospectively on all patients with type 1 diabetes 

admitted to Children's Hospital from 1985 to 1987. Information was collected on sex, age, 

number of bed days per admission, and reasons for admission. The direct cost of a bed day 

and an admission for diabetes in this hospital were calculated using a small sample. Two 

hundred forty-one children with type 1 diabetes had 351 admissions over the 3 years; 105 

stays were for newly diagnosed children. Of these 105 children, 14 (13.3 percent) had 

additional admissions during this period. Of the 246 admissions for previously diagnosed 

children, stabilization of high blood glucose was a cause for 145 (59.0 percent); other leading 

causes were a medical reason (32.5 percent) and education (25.6 percent). The cost of a bed 

day for a child with diabetes was $Aust 295.00. 3 figures, 1 table, 12 references. 

154 

TITLE: Precipitants of Hospitalization in Insulin-Dependent Diabetes Mellitus (IDDM): A 

Statewide Perspective. Fishbein, H.A. Diabetes Care. 8 (Supplement 1): 61-S64. SeptemberOctober 1985. 

OBJECTIVE: To describe the epidemiology of precipitants of hospitalization for type 1 

diabetes in Rhode Island; to evaluate the effectiveness of outpatient education in reducing 

hospitalizations for patients with diabetes; and to estimate potential cost savings of the 

education program. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Poor diabetes control and infection accounted for nearly one-half of all 

hospital admissions in Rhode Island among patients known to have diabetes. An outpatient 

education program significantly reduced the incidence of acute hospitalizations among 

participants and resulted in substantial savings. 

RECOMMENDATION: Other investigators may want to consider a registry system for 

diabetes. 
ABSTRACT: The author evaluated the epidemiology of precipitants of hospitalization for 

type 1 diabetes in Rhode Island and the effectiveness of outpatient education in reducing 

hospitalizations. A statewide registry of patients with type 1 diabetes was used to identify and 

characterize the epidemiology of patients admitted to Rhode Island hospitals. Data on 

precipitating factors were obtained via a review of medical records and physician interviews. 

During the study period (April 1978 through March 1983), there were 1,344 hospital 

admissions for type 1 diabetes among 887 persons below age 30. Patients with known 

diabetes accounted for 1,123 admissions (691 persons). Poor diabetes control (noncompliance 

with diet/medication) or infection accounted for 54 percent and 44 percent of single and 

multiple admissions, respectively. Admissions for pregnancy care and for various conditions 

(e.g., myocardial infarction, stroke) were the next most frequent precipitants of 

hospitalization. An intensive 10-hour outpatient education program with two follow-up 

sessions was evaluated in 100 patients; the program reduced the number of hospitalizations by 

51 percent. Based on a direct cost for hospitalization of $2,400, the potential savings of the 

educational intervention for those admitted with known diabetes were estimated at $674,000 

(cost of admission x admissions for poor diabetes control or infection x 50 percent for 

educational effect). The cost of the education program was only about $100 per patient. 2 

tables, 1 figure, 10 references. 

155 

TITLE: Public Cost and Access to Primary Care for Hyperglycemic Emergencies, Clark 

County, Nevada. Wilson, B.; Sharma, A. Journal of Community Health. 20(3): 249-256. June 

1995. 

OBJECTIVE: To determine the cost and major causes of hospitalizations for emergency 

admissions for diabetic hyperglycemia at a large public hospital in Clark County, Nevada; to 

determine the effect of insurance coverage on the availability of primary care providers, 

hospitalization costs, and precipitators of admissions in the study population. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Uninsured patients accounted for 49 percent of hyperglycemic admissions 

during the study period. Hospital medications and/or charges were lower for uninsured 

patients, who were more likely than insured patients to be hospitalized because they lacked 

access to primary care. 

RECOMMENDATION: Public funding or universal insurance coverage and more 

comprehensive employer-funded insurance programs to provide primary care access for 

diabetes mellitus management should be evaluated as cost-savings measures in areas with 

large populations of people with diabetes. 
ABSTRACT: The authors evaluated hospital charges and major causes of hospitalization for 

diabetic ketoacidosis and nonketotic hyperosmolar state, the major acute emergencies of 

diabetes mellitus, at a large public hospital. Medical insurance coverage associations with 

availability of primary care and hospitalization charges were also examined. Data were derived 

from a retrospective search of hospital admissions for diabetic ketoacidosis and nonketotic 

hyperosmolar state over a 30-month period from 1989-1991. Hospitalization and emergency 

room charges were compiled from medical records review. Over the study period, 247 

admissions for diabetic ketoacidosis and nonketotic hyperosmolar state were identified; 

uninsured admissions accounted for 49 percent. Only 6 percent of patients in the uninsured 

group identified a primary care provider, as compared with 85 percent of the insured group. 

Un-insured patients accounted for a majority of emergency room visits and 52 percent of 

emergency room charges. However, average hospital charges (exclusive of physician fees) 

were significantly less in the uninsured group ($4,049) than in the insured group ($7,222). 

Uninsured patients were much more likely to have been hospitalized because they lacked 

access to medication and much less likely to be hospitalized because of late complications of 

diabetes mellitus. These patients had milder acute and chronic disease processes potentially 

responsive to appropriate out-patient management. 1 figure, 3 tables, 6 references. 

156 

TITLE: Relative Risk and Economic Consequences of Inpatient Care Among Patients With 

Renal Failure. Thamer, M.; Ray, N.F.; Fehrenbach, S.N.; Richard, C.; Kimmel, P.L. Journal 

of the American Society of Nephrology. 7(5): 751-762. May 1996. 

OBJECTIVE: To identify the leading causes of hospitalization for people with renal failure; 

to compare the risks of hospitalization associated with these causes and with other chronic 

progressive diseases; and to quantify total inpatient days, excess length of stay, and associated 

costs attributable to renal failure. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based cost. 

Perspective: Health care system. 

CONCLUSION: Chronic renal disease is associated with significant morbidity and medical 

costs. 

RECOMMENDATION: None. 

ABSTRACT: The authors studied inpatient care for persons with chronic renal failure, 

including those with end-stage renal disease as well as those who had not reached that stage, 

using 1991 data from the Medicare End-Stage Renal Disease program, the National Health 

Interview Survey, the U.S. Census, and the National Hospital Discharge Survey. If chronic 

renal failure was the primary discharge diagnosis, all charges were included; a portion of the 
charges was included if chronic renal failure was a secondary diagnosis. In 1991, patients with 

renal failure had 348,962 hospitalizations, of which 64 percent were for either chronic renal 

failure or 1 of 15 comorbid conditions (e.g., vascular access problems, congestive heart 

failure). Patients aged 65 years and older accounted for 57.6 percent of these hospitalizations 

but 63.0 percent of the inpatient days. The renal failure population averaged 1.4 

hospitalizations in 1991. Compared with persons without renal failure, the age-adjusted 

relative risk of hospitalization for persons with renal failure was 10 for all causes, 201.5 for 

vascular access problems, 32.4 for congestive heart failure, 31.3 for pulmonary 

edema/respiratory failure, 23.4 for gastrointestinal hemorrhage, 21.7 for diabetes, 19.2 for 

sepsis/septicemia, 15.6 for electrolyte disorders, 12.4 for hypertension, 10.4 for anemia, and 

10.3 for myocardial infarction. Length of stay was significantly longer (mean difference: 0.9 

days) than in those without renal failure. Patients with renal failure consumed 1.5 million 

hospital days, for a total cost of $2.2 billion; of this amount, $291 million was directly for 

chronic renal failure. Hospitalization for vascular access problems cost $168 million; for 

congestive heart failure, $142 million. 6 tables, 46 references. 

157 

TITLE: Resource Utilization in Treatment of Diabetic Ketoacidosis in Adults. May, M.E.; 

Young, C.; King, J. American Journal of the Medical Sciences. 306(5): 287-294. November 

1993. 

OBJECTIVE: To determine the specific care practices that correlate with decreased hospital 

stay for adult patients with ketoacidosis related to diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Optimizing hospital care and reducing the incidence of ketoacidosis in 

women would markedly affect health care costs. 

RECOMMENDATION: Future studies of ketoacidosis in adults should focus on criteria for 

admission to the intensive care unit (ICU), optimum time to move patients out of the ICU, 

and the etiology and prevention of recurrent ketoacidosis in women. 

ABSTRACT: The authors examined the records of 40 women and 25 men with diabetes who 

were hospitalized a total of 92 times with ketoacidosis (serum glucose greater than 200 

mg/dL, positive serum or urine ketones, and evidence of metabolic acidosis). The cases were 

analyzed by initial level of nursing care (ICU, stepdown, general); the three fatalities were 

excluded from analysis of the correlates of length of stay or cost. Mean days of hospitalization 

and total costs (with standard deviations) were 6.3 (5.3) and $12,286 ($12,096) for the ICU 

group, 4.4 (3.0) and $6,804 ($3,759) for intermediate care, and 6.0 (6.0) and $7,357 ($6,902) 

for general care. Patients with concurrent infection had significantly longer stays than those 
who were culture-negative (9.1 " 6.8 days versus 4.5 " 3.2 days). Shorter length of stay was 

correlated with care by a diabetologist, shorter interval from presentation until time to 

administration of an intermediate- or long-acting insulin, and time of day of the initial 

presentation. In-hospital recurrences of ketoacidosis occurred less frequently in patients 

managed by a diabetologist (30 versus 47 percent of cases) and were correlated with longer 

hospitalization. Rapid initial correction of hyperglycemia and acidemia did not correlate with 

reduced resource usage. Level of care did not affect outcome; if all cases were treated at the 

intermediate level, an overall savings of $2,292 per case would have been realized. The 

authors conclude that admission to the ICU is indicated for patients with a concurrent 

diagnosis that would require intensive care (e.g., myocardial infarction) or if the ketoacidosis 

is grade 4 (the highest grade). They project resource savings of $60 to $90 million yearly from 

reducing the level of diabetic ketoacidosis in females to the level in males. 4 tables, 33 

references. 

Oupatient Care (Hospital, Physician, Emergency) 

158 

TITLE: ACE Inhibition in Diabetic Patients: Economic Implications. Rodby, R.A.; Lewis, 

E.J. PharmacoEconomics. 10(Supplement 4): 315-320. October 10, 1996. 

OBJECTIVE: To discuss angiotensin-converting enzyme (ACE) inhibitors, their role in 

slowing the progression of diabetic nephropathy to end-stage renal disease (ESRD), and their 

consequent influence on health care expenditures. To project the economic impact of this class 

of antihypertensive agents on diabetes mellitus. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Epidemiological cohort model. 

Methodology: Cost-effectiveness analysis. 

Perspective: Health care system. 

CONCLUSION: Use of captopril, an ACE inhibitor, in patients with diabetes mellitus and 

overt nephropathy produces substantial cost savings and prolongs life. 

RECOMMENDATION: Continuing attention must be given to the cost-effectiveness of all 

therapies, but a therapy need not save money to be justified. 

ABSTRACT: In patients with type 1 diabetes, histological changes from diabetic 

nephropathy are present within 5 years of diagnosis; overt nephropathy usually occurs after 15 

to 25 years of diabetes. Treatment with ACE inhibitors is one of the therapies that appear to 

influence development and progression of nephropathy in patients with type 1 diabetes in a 

beneficial way. The authors explore the issue of whether treatment with the ACE inhibitor 

captopril to delay the onset of renal failure is cost effective. They point out that unless ESRD 

therapy is avoided altogether for some patients, captopril will not save money. Complete 
avoidance of ESRD could occur if captopril halts the progression of diabetic nephropathy 

entirely in some patients (which has not been shown in overt nephropathy) or if it prevents 

ESRD long enough for a patient to succumb to another illness first. The authors discuss their 

medical treatment model of the cost-benefit and cost-effectiveness of captopril therapy in 

patients with type 1 diabetes and diabetic nephropathy. In the model, patients receive either 

captopril or placebo and are followed as they progress to ESRD, receive ESRD therapies, and 

eventually die. Each year, the model predicts costs for the two study groups. In each of the 

second through 16th years, placebo patients cost more than those receiving captopril. In the 

17th and succeeding years, captopril patients cost more than their placebo counterparts. 

However, the lower cost per captopril patient in the early years more than offsets the higher 

cost for the captopril group in the later years, resulting in overall cost savings. Captopril 

prolongs life and simultaneously saves money because progression to ESRD is delayed long 

enough for some patients taking captopril to die before ESRD develops. The authors' model 

predicts per-patient savings from using captopril of $7,800 over 5 years, $30,110 over 12 

years, and $32,550 over 31 years. 3 figures, 1 table, 11 references. 

159 

TITLE: Closing the Gap: The Problem of Diabetes Mellitus in the United States. Herman, 

W.H.; Teutsch, S.M.; Geiss, L.S. Diabetes Care. 8 (4): 391-406. July-August 1985. 

OBJECTIVE: To review the epidemiology and costs of diabetes and its complications; to 

discuss methods of reducing the burden of diabetes on the health care system. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Societal. 

CONCLUSION: Both type 2 diabetes mellitus and the complications of diabetes are often 

preventable. 

RECOMMENDATION: Continuing to promote public health and Diabetes Research, 

assuring that public health programs follow current standards for diabetes care, and providing 

third party coverage of educational programs and preventive screening for complications 

should all be used to reduce the morbidity and mortality of diabetes. 

ABSTRACT: The authors review data on diabetes from population-based studies and 

surveys of the National Center for Health Statistics. Among racial/ethnic groups, the 

prevalence of type 1 diabetes mellitus is highest in whites, and its peak onset is in children 

aged 10 to 14 years. The risk of type 2 diabetes increases with age, and the disease is 

relatively more common among women and nonwhites. The risk of gestational diabetes 

increases with maternal age. Genetic, familial, and environmental factors; obesity; and 

inactivity are discussed as risk factors. The prevalence (number of cases) of type 1 diabetes in 

1980 was 435,000, and the prevalence of type 2 diabetes was about 5.1 million. Mortality in 
1980 from diabetes was estimated at 154 per 100,000 persons in the general population. 

About 86,000 women develop gestational diabetes annually. The major cause of death in 

people with type 2 diabetes is cardiovascular disease; the major causes of death for those with 

type 1 diabetes are renal and cardiovascular diseases. People with diabetes are more than 

twice as likely to require hospital services as those without diabetes, and in 1977, 15 percent 

of people in nursing homes had diabetes. In 1980, the direct costs of diabetes were $652 

million for physician visits, $6,157 million for hospitalization, $663 million for nursing home 

care, and $380 million for insulin and hypoglycemic agents. Indirect costs were estimated at 

$10 billion per year. The authors state that control of obesity, glycemia, and hypertension; 

patient education; and smoking cessation could annually reduce the prevalence of diabetes or 

its complications by the following amounts: type 2 diabetes, 293,000; gestational diabetes, 

28,000; ketoacidosis, 52,000; congenital malformations, 500; stroke, 19,000; coronary heart 

disease, 38,000; peripheral vascular disease, 24,000; blindness, 3,500; end-stage renal disease, 

2,000; and amputations, 15,000. 23 tables, 105 references. 

160 

TITLE: Direct Costs of Diabetes Care: A Survey in Ottawa, Ontario 1986. McKendry, J.B. 

Canadian Journal of Public Health. 80 (2): 124-128. March/April 1989. 

OBJECTIVE: To determine the annual direct costs of care for patients with diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Of the costs of routine diabetic care, 23.4 percent were for at-home testing; 

45.3 percent, treatment supplies; 20.9 percent, physician's services; and 10.4 percent, 

miscellaneous items. Of direct nonroutine costs, 64.4 percent were for hospital services, 13.9 

percent for treatment supplies, 9.6 percent for physician services, and 7.7 percent for testing 

supplies. 

RECOMMENDATION: Periodic cost-of-care surveys, with help from volunteers of the 

diabetes association, offer an affordable means to monitor utilization trends and costs of 

supplies and services in caring for patients with diabetes. 

ABSTRACT: A total of 205 Ottawa-area patients with diabetes completed questionnaires 

designed to assess their annual use of equipment, supplies, and professional and institutional 

services. Average age of respondents was 47.3 years; their average duration of diabetes was 

18.3 years. Indirect costs, such as loss of time from work, were not addressed. Direct costs 

were divided into routine (supplies and equipment for self-treatment and testing and 

professional services during routine encounters) and nonroutine (nonroutine emergency room 

and hospital services) categories. The costs of goods and services were estimated using 

current fee schedules and local pharmacy prices. Methods used for glucose monitoring at 
home included blood tests only (64.9 percent), urine tests only (16.6 percent), urine and blood 

tests (7.8 percent), and no testing (10.7 percent). Annual costs for treatment regimens were as 

follows: diet only, no cost (4.4 percent); oral medication, $236.40 (9.3 percent); insulin 

injections, $362.34 (79 percent); and insulin by pump, $1,603.20 (7.3 percent). Assuming six 

or fewer visits to a family physician or diabetologist, two or less to an ophthalmologist, and no 

visits to a nephrologist or neurologist, annual costs for physician services were estimated to be 

$201.47. Annual costs for routine care included 23.4 percent for test supplies, 45.3 percent 

for treatment supplies, 20.9 percent for physicians' services, and 10.4 percent for 

miscellaneous items, for a total of $962.01. Nonroutine costs averaged $45.84 for emergency 

room visits and $1,936.40 for inpatient hospital care. When expressed in terms of routine plus 

nonroutine cost, hospital care accounted for 64.4 percent; treatment supplies, 13.9 percent; 

physician services, 9.6 percent; test supplies, 7.7 percent; miscellaneous, 3.4 percent; and 

emergency care, 1 percent, for a total of $2,944.25. 7 tables, 2 figures. 

161(Cross-Reference 102) 

TITLE: The Economics of Screening for Microalbuminuria in Patients with InsulinDependent Diabetes Mellitus. Borch-Johnsen, K. PharmacoEconomics. 5(5): 357-360. May 

1994. 

OBJECTIVE: To discuss the cost benefit of screening for microalbuminuria followed by 

antihypertensive treatment of early renal disease indicated by microalbuminuria in patients 

with type 1 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient screening. 

Methodology: Cost-benefit analysis. 

Perspective: Health care system. 

CONCLUSION: Screening and intervention for microalbuminuria in patients with type 1 

diabetes appears to increase life expectancy significantly and improve quality of life for 

patients while providing considerable savings for health care providers. 

RECOMMENDATION: A screening program, including an annual measurement of the 

urinary albumin excretion rate, should be instituted for all patients with type 1 diabetes. 

ABSTRACT: Patients with type 1 diabetes are at risk of developing diabetic nephropathy, a 

condition in which the urinary albumin excretion rate exceeds 300 mg/day, which can lead to 

end-stage renal failure, dialysis or kidney transplantation, or death. Patients with 

microalbuminuria (i.e., a slightly elevated excretion rate of 30 to 300 mg/day) have a much 

increased risk of developing diabetic nephropathy. The Diabetes Control and Complication 

Trial Research Group study (1993) showed that metabolic control could reduce the risk of 

developing microalbuminuria by 39 percent. Intensive antihypertensive treatment may be 

effective for microalbuminuria and is known to delay the onset of end-stage renal failure if 

used in early clinical nephropathy. Semiannual screening for microalbuminuria is sufficient for 
early detection using albumin assays or less expensive reagent strips. Prevention by metabolic 

control is possible but costly to maintain. Two studies evaluating screening for 

microalbuminuria and intervention with antihypertensive drugs showed that the monetary 

benefits of screening outweighed the costs, even with a limited treatment effect. One study 

found that reducing the urinary albumin excretion rate from 20 percent to 18 percent annually 

would result in a net savings because the annual costs per patient for treating end-stage renal 

failure were very high (dialysis: $35,000 to $55,000; transplantation: $14,000 to $35,000 

initially and $7,000 subsequently), compared with screening ($9) and antihypertensive 

treatment ($350). If, as indicated by recent trials, antihypertensive treatment can reduce the 

progression of the urinary albumin excretion rate by 33 percent or 67 percent, median life 

expectancy would increase by 4 or 14 years, and the need for dialysis and transplantation 

would decrease by 20 percent to 60 percent. 1 table, 25 references. 

162 

TITLE: "Educating" the Person with Diabetes in an Ambulatory Setting. Travis, L.B. Texas 

Medicine. 88(7): 69-71. July 1992. 

OBJECTIVE: To raise questions about the distribution of savings accruing from the 

transition to the outpatient setting for educating and managing patients with newly diagnosed 

diabetes; to discuss underwriting the cost of ambulatory education programs. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Outpatient education and management of patients with diabetes results in 

savings, but these savings are not necessarily returned to the health care system. Health 

centers themselves under-write the diabetes program. 

RECOMMENDATION: None. 

ABSTRACT: The author comments on the benefits of outpatient management and education 

of patients with type 1 diabetes. Increased public awareness of the symptoms of diabetes, 

earlier detection by the medical profession, and efforts to reduce health care costs have helped 

to move diabetes education to the outpatient setting. At the Barbara Davis Center in 

Colorado, 60 percent of patients received all their care as outpatients from 1980 through 

1986. In a Texas hospital, the percentage of those receiving only outpatient services increased 

from 0 to 38 percent in just over 2 years. Outpatient education reduces the disruption of the 

disease for patients and their families. Although reports of cost savings are no doubt authentic, 

these savings have not resulted in reduced health insurance premiums or lower taxes. The 

author reports that outpatient education services at the Children's Diabetes Management 

Center (University of Texas Medical Branch, Galveston) require, per patient, 2 to 4 hours 

from the physician, 10 to 12 hours from the nurse educator, and 2 to 4 hours from the 
dietitian. Using a conservative estimate of 12 hours of professional time, total costs (salaries, 

fringe benefits, clinic and laboratory fees, and supplies and education materials) range from 

$500 to $800 per patient. Private insurance reimburses less than 50 percent of costs, if any. In 

Texas, diabetes education is not a reimbursable expense; the health care center pays for 

outpatient education costs. Impediments to outpatient diabetes management and education 

outside a medical center include the comfort level of practitioners in managing new-onset 

diabetes, the availability of adequate instructional services, and the cost to practitioners. 5 

references. 

163 

TITLE: Health Insurance and the Financial Impact of IDDM in Families with a Child with 

IDDM. Songer, T.J.; LaPorte, R.E.; Lave, J.R.; Dorman, J.S.; Becker, D.J. Diabetes Care 20 

(4):577-584. April 1997. 

OBJECTIVE: To examine health insurance experience and out-of-pocket costs of families 

with and without a child with type 1 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective. 

Methodology: Statistical analysis. 

Perspective: Societal. 

CONCLUSION: Having a child with diabetes exerts a substantial economic impact on the 

family. 

RECOMMENDATION: The issue of whether limited access to insurance, limited coverage, 

or high out-of-pocket costs have any long-term health effect on people with diabetes remains 

to be investigated. 

ABSTRACT: The study included 197 families having a child with type 1 diabetes (identified 

by the Allegheny County [Pennsylvania] IDDM Registry) and 142 control families who did 

not have such a child. In addition to health insurance issues, three measures of out-of-pocket 

costs were examined: (1) money spent on health care services and supplies not reimbursed by 

insurance, (2) reported out-of-pocket costs plus out-of-pocket insurance premiums, and (3) 

out-of-pocket costs (including insurance premiums) as a share of household income. Out-ofpocket costs were categorized in intervals of $250 up to more than $2,750 (1990 dollars). 

Case families were older than control families and more likely to be headed by a single parent. 

About 90 percent of case and control families reported full-year insurance coverage. Case 

families, however, were more likely to report being denied coverage (8.4 percent versus 1.7 

percent for controls, p = 0.03). In addition, case families reported significantly higher out-ofpocket expenses (p < 0.001), and the median amount of these expenses plus the out-of-pocket 

costs for insurance premiums was also significantly higher in case families ($1,125 versus 

$625, p = 0.03). The case families spent 5.6 percent of their income on health care, versus 3.1 

percent for the control families (p = 0.004). The authors note that there is some uncertainty 
about the future availability of insurance and care for individuals and families who use health 

services frequently. 2 figures, 6 tables, 38 references. 

164 

TITLE: Hospital Costs, Use of Resources, and Dynamics of Death Associated with Diabetes 

Mellitus. Muñoz, E.; Chalfin, D.; Birnbaum, E.; Goldstein, J.; Cohen, J.; Wise, L. Southern 

Medical Journal. 82 (3): 300-304. March 1989. 

OBJECTIVE: To analyze the use of hospital resources for patients with diabetes mellitus 

admitted to a teaching hospital in a suburb of New York City. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The diagnosis-related group hospital payment system is inequitable for 

reimbursing the care of patients who die in the hospital from diabetes-related causes. 

RECOMMENDATION: Physicians must be advocates for equitable reimbursement and for 

further study of the economics of patient death in the hospital. 

ABSTRACT: The authors analyzed resource use and diagnosis-related group payment for 

patients with diabetes at an 805-bed teaching hospital outside New York City. Patients had 

type 1 or type 2 diabetes as a primary or secondary diagnosis. Variables for which 

nonsurvivors had higher values than survivors included mean age, mean diagnosis-related 

group weight index (by 5.9 percent), length of stay (by 67.7 percent), number of diagnoses 

(89.5 percent), procedures (28.2 percent), and severity of illness (56.2 percent); the last value 

was calculated as the total number of diagnostic codes. Total daily hospital cost was 129.7 

percent greater for nonsurvivors; this group generated a $9,910 loss per patient versus a $141 

profit for survivors. Nonsurvivors had much higher rates of emergency admission, admission 

to ICU, and requirements for blood or plasma. The only profitable group of nonsurvivors 

when these patients were defined by length of stay were those who died within 7 days of 

admission. All age categories of nonsurvivors except for those aged 25 to 34 years generated 

financial losses to the hospital. Diabetes-related deaths after a nonemergency admission 

created a much greater financial risk to the hospital than did such deaths after an emergency 

admission. 5 tables, 2 figures, 12 references. 

165 

TITLE: Medical and Financial Implications of Discontinuing a Statewide Free Insulin 

Program Involving 3,720 People. Nicholas, W.; Watson, R. Southern Medical Journal. 82(1): 

13-17. January 1989. 
OBJECTIVE: To assess the effects of discontinuing a state program that provided free 

insulin to people with diabetes for almost 20 years. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Discontinuing the program did not affect recipients negatively, as measured 

by physician or emergency room visits or hospitalizations. 

RECOMMENDATION: None. 

ABSTRACT: For almost 20 years, the Mississippi State Department of Health provided free 

insulin to several thousand people with diabetes; the program was discontinued in 1981. The 

authors hypothesized that discontinuation would adversely affect the people involved. The 

periods studied were the 18 months before (period 1) and the 18 months after (period 2) 

discontinuation. Most of the 351 sample patients interviewed were black; the majority were 

female. Mean age at interview was 58.6 years. Fifty-seven percent had Medicaid or Medicare 

coverage; 43 percent were uninsured. Mean daily insulin dose, body weight, and blood 

glucose value did not differ significantly between the study periods, although in period 2 there 

was a trend among those aged 45 or over for a smaller percentage of patients to have fasting 

serum glucose values higher than 300 mg/dL. About three-fifths of patients indicated they 

were not doing without essentials to purchase insulin after program discontinuation. Patients 

with Medicaid or Medicare coverage had significantly fewer hospitalizations in period 2. For 

the overall sample, 17 patients were admitted for ketoacidosis in period 1; 7 during period 2. 

Visits to physicians averaged 8.4 for period 1; 8.9 for period 2. Emergency room visits, which 

were infrequent, did not differ significantly by period. Diabetes-related hospital admissions 

decreased from 45.2 to 34.9 per 100 persons, but again the difference was not significant. 

Using data from the Medicaid Commission and the Mississippi Health Care Commission, the 

authors extrapolated the decreased hospital admissions to a savings of $85,618 for the sample 

group as a whole. The small (statistically insignificant) increase in physician visits was 

projected to cost $2,250. The authors concluded that discontinuing the free insulin program 

did not have a measurable negative effect on the patients studied. The authors also found that 

the 3,720 patients who had comprised the complete group of patients receiving free insulin 

had fewer hospitalizations in period 2, a projected cost savings of $907,404 ($244 per 

person). A slight increase in physician visits produced a cost increase of $23,846 ($6.40 per 

person). Overall savings were $883,558 ($237.13 per person). The program had cost the state 

$550,000 annually. 6 tables, 3 figures, 1 reference. 

166 

TITLE: An Outpatient-Focused Program for Childhood Diabetes: Design, Implementation, 

and Effectiveness. Lee, P.D. Texas Medicine. 88(7): 64-68. July 1992. 
OBJECTIVE: To determine the impact of an outpatient program for management and 

education of patients with newly diagnosed diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Program evaluation. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Outpatient management and education of patients with new-onset diabetes 

reduced costs, total days of stay, and length of hospitalizations for diabetes-related problems. 

RECOMMENDATION: Third party payers of health care should adjust coverage to 

encourage more cost-effective health care delivery through outpatient programs for diabetes. 

ABSTRACT: The author analyzes the impact of implementing, in mid-1988 at Texas 

Children's Hospital, outpatient management and education for children with newly diagnosed 

diabetes mellitus. Patient records from 1985 to 1990 provided comparative data. A pediatric 

endocrinologist, two nurse educators, a dietitian, and a social worker provided outpatient 

care; initial sessions usually lasted a total of 8 to 12 hours over 2 to 3 days. Hospitalization for 

rehydration and initiation of insulin therapy was based on degree of illness rather than specific 

laboratory criteria; patients entered outpatient care when medically stable. Follow-up visits 

occurred 1 to 2 weeks and 1 month later. Thirty to 50 new cases of diabetes were seen yearly. 

Yearly inpatient admissions (1985 to 1990) were 82, 114, 102, 88, 59, and 51; yearly 

outpatient visits (1986 to 1990) totaled 660, 837, 957, 816, and 964. The proportion of newonset patients who were never hospitalized increased from 0 to 38 percent between 1987 and 

1990. Hospitalizations for new-onset diabetes in 1987 and 1990 totaled 42 and 32, 

respectively, with an average duration of 5.6 and 4.0 days, respectively (p < .05). 

Readmissions for diabetes-related problems equaled 84 in 1986 and 20 in 1990; average 

length of stay for these admissions was 4.4 days in 1987 and 2.6 days in 1990 (p < .05). An 

analysis of readmissions from 1989 to 1990 found that none of the readmitted patients had 

received their initial care as outpatients. Average hospitalization costs (excluding physician, 

nursing, and dietitian fees) for the last 23 consecutive new-onset patients at the hospital were 

approximately $1,000 per day. With the outpatient program, average per-patient costs were 

reduced approximately $100,000 per year, and the average costs of all admissions declined. 

Outpatient management of new-onset diabetes reduces initial costs and subsequent need for 

hospitalization. 4 figures, 12 references. 

167 

TITLE: Resource Utilization and Costs of Care in the Diabetes Control and Complications 

Trial. The Diabetes Control and Complications Trial Research Group. Diabetes Care. 18(11): 

1468-1478. November 1995. 

OBJECTIVE: To detail the resources used and associated costs of care for patients in the 
Diabetes Control and Complications Trial (DCCT). 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Intensive therapy to lower blood glucose concentrations as practiced in the 

DCCT is associated with a substantial increment in cost. 

RECOMMENDATION: The costs of intensive therapy to treat type 1 diabetes should be 

balanced against the cost savings related to reduction of long-term complications of diabetes. 

ABSTRACT: The resources used and associated costs of care of patients in the DCCT are 

detailed. Researchers calculated resources used for intensive and conventional therapy, 

including health care professionals' time and services, hospitalizations, outpatient care, and 

equipment and supplies, as well as for managing the side effects of therapy. Most data were 

derived from information routinely collected as part of the trial; a questionnaire was used to 

gather data not available from existing sources. Costs were calculated as the product of the 

resources used and the unit cost of those resources. The annual cost of intensive therapy with 

multiple daily insulin injections (approximately $4,000 per year) was $2,300, or 2.4 times, 

greater than the cost of conventional therapy (approximately $1,700 per year). Most of the 

difference in cost was attributable to differences in the frequency of outpatient visits and selfmonitoring of blood glucose. The annual cost of intensive therapy with continuous 

subcutaneous insulin infusion (approximately $5,800 per year) was $1,800, or 1.4 times, 

greater than the cost of intensive therapy with multiple daily insulin injections. The higher 

expense was due entirely to the cost of the pump and pump-related supplies. The costs ($210 

per year) associated with the major side effects of intensive therapy, excessive weight gain and 

severe hypoglycemia, were three times the cost of treating the side effects of conventional 

therapy ($70 per year), but as a percentage of the total there was little difference between the 

groups (5 percent versus 4 percent). The authors point out that costs associated with intensive 

therapy in the DCCT, which was carried out in academic settings following a research 

protocol, would probably be higher than the cost of such therapy in the general health care 

setting. 8 tables, 11 references. 

Prescription Drug 

168 

TITLE: Conversion from Glipizide to Glyburide: A Prospective Cost-Impact Survey. Alexis, 

G.; Henault, R.; Sparr, H.B. Clinical Therapeutics 14(3): 409-417. May-June 1992. 

OBJECTIVE: To assess the feasibility and cost of converting patients with type 2 diabetes 

from glipizide to glyburide. 
CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Conversion of a large number of patients from glipizide to glyburide was 

found to be feasible and resulted in substantial cost savings. 

RECOMMENDATION: None. 

ABSTRACT: Researchers studied the cost of converting 211 men with type 2 diabetes from 

glipizide to glyburide; both are oral hypoglycemic agents. Patients had to be receiving stable 

doses of glipizide and not require insulin at study entry. Programs were designed to educate 

both prescribers and patients. Mean patient age was 66.0 " 8.24 years (range 42 to 82 years). 

Mean daily glipizide dose at conversion was 18.7 " 12.32 mg (range 2.5 to 40 mg), and mean 

duration of glipizide therapy was 8.8 " 2.07 months (range 4 to 13 months). After conversion, 

patients were followed for up to 12 months. Mean daily glyburide dose was 8.3 " 5.68 mg 

initially and 9.9 " 6.52 mg at 7 months; mean change in daily dose thereafter was less than 1 

mg. The ratio of mean daily dose of glyburide to glipizide was 1:2.3 initially and 1:1.9 at 7 

months. Eight patients stopped glyburide and began using insulin; nine patients had insulin 

added to the glyburide regimen. Daily dose was significantly lower with glyburide than with 

glipizide in patients analyzed in all six subsets of glipizide dose. The average wholesale price 

for a 5-mg dose was $0.289 for glipizide and $0.446 for glyburide. The daily costs per patient 

were $1.08 (glipizide) and $0.88 (glyburide), respectively, and the average annual costs of 

treatment for all patients were $83,242.43 and $68,010.41, respectively, based on the average 

wholesale price. Costs based on Veterans Administration discounts were $0.144 versus 

$0.156 per 5-mg dose, $0.54 versus $0.31 per day per patient, and $41,477.20 versus 

$23,788.39 per year for all patients, respectively. Conversion from glipizide to glyburide was 

well tolerated and resulted in substantial cost savings. Potential savings were understated by 

limiting the study group to the subset of patients who were stabilized on glipizide and had 

sufficient follow-up data after conversion. 3 figures, 2 tables, 7 references. 

169 

TITLE: Drug Consumption in Elderly Diabetics. Gram, J.; Damsgaard, E.M. Diabetes 

Research and Clinical Practice. 7(4): 293-298. November 6, 1989. 

OBJECTIVE: To compare drug consumption for patients with diabetes versus a control 

group. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 
Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: More than 80 percent of patients with diabetes used drugs daily, versus 55 

percent of controls. Patients with diabetes used more doses of cardiovascular drugs than 

controls. 

RECOMMENDATION: Resources need to be allocated for preventing type 2 diabetes 

instead of treating its complications. 

ABSTRACT: Drug use was studied in 228 patients with diabetes who resided in Fredericia, 

Denmark; 52 were treated with insulin, 101 with oral hypoglycemic agents, 66 with diet only, 

and 9 were not treated. An age- and sex-matched control group was selected (n = 223); both 

groups ranged in age from 60 to 74 years. Information on drug use was obtained through a 

questionnaire, an interview, and inspection of the drugs. Daily use of prescribed and 

nonprescribed drugs (antidiabetics excluded) was significantly more common in patients with 

diabetes (82 percent) than in controls (55.6 percent). The median number of different drugs 

used by patients with diabetes who took drugs daily was 3.1; the corresponding number for 

the control group was 2.4. When patients were analyzed by antidiabetic treatment (diet only, 

insulin, no treatment, oral hypoglycemic agents), no significant differences were found in the 

percentage who used drugs daily. However, as measured by defined daily dose (DDD), drug 

use among those taking oral agents was about 20 percent below that of the insulin-treated 

group and 30 percent under the diet-only group. (Defined daily dose considers the average 

dose per day when the drug is used for its main indication.) Among daily users, patients with 

diabetes used 70 percent more DDDs of drug than controls (antidiabetics excluded). The most 

used drugs (other than antidiabetics) for both patients with diabetes and controls were from 

the cardiovascular, central nervous system, and musculoskeletal groups. Patients with diabetes 

in all treatment groups used significantly more DDDs of cardiovascular drugs than controls. 

Patients treated with oral antidiabetics used significantly fewer DDDs of cardiovascular drugs 

than the insulin and diet-only groups. The authors previously found in the same study 

population that patients with diabetes use primary health care services 2 to 3 times as often as 

controls, have a hospital bed-day occupancy rate 2 to 3 times greater than the general 

population of the same age, and have an estimated cost of drug therapy more than 2.5 times 

higher than do controls. 3 tables, 14 references. 

170 

TITLE: The Economics of Pharmacotherapy for Diabetes Mellitus. Costa, B.; Arroyo, J.; 

Sabate, A. PharmacoEconomics. 11(Supplement 2): 139-158. February 1997. 

OBJECTIVE: To review the economics of drug therapy, including insulin treatment, for type 

1 and type 2 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 
Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: It is essential to consider individual and social costs of diabetes and to 

search for reliable indicators of the effectiveness of care for the disease. Educational programs 

for patients and professionals are the most logical way of rationalizing the use of drugs. 

RECOMMENDATION: Prescribers of drug therapy should follow experts' 

recommendations, even if they do not seem efficient in the short term, as the implications of 

diabetes must be viewed in the long term. 

ABSTRACT: Seventy to 75 percent of patients with type 2 diabetes take oral hypoglycemic 

agents or antihyperglycemics, 20 to 25 percent take insulin (in some countries these ranges are 

much different). Among the oral hypoglycemics, sulfonylureas are the most widely used 

agents; the effectiveness of these drugs decreases progressively, usually 5 to 10 years after 

initiation. Antihyperglycemic agents cannot cause hypoglycemia. Insulin is essential in type 1 

diabetes and may be used in type 2. While expensive, its cost-benefit relationship in type 1 is 

excellent. Most developed countries have two mechanized systems for delivering insulin: 

injector pens and preloaded syringes. Self-monitoring devices and glucagon (for hypoglycemic 

emergencies) are also part of diabetes management. Optimal treatment of type 2 diabetes 

probably requires diet, exercise, and education initially, with drugs secondary. In obese 

patients with type 2, an initial trial with antihyperglycemic drugs has been recommended. The 

authors review prescription trends and drug consumption; in Spain, drug consumption grew 

72.6 percent from 1988 to 1994. A study (Rubin, et al. 1994) in the United States concluded 

that in 1992 drugs and self-monitoring devices accounted for 9 percent of all diabetes mellitus 

costs. Insulin is not easily available in poorer countries, but it is generally free there. In 

underdeveloped countries, diabetes-related mortality rates are similar to Western rates 75 

years earlier. The authors point out that at present there is no effective drug treatment for 

specific long-term complications of diabetes, such as retinopathy, neuropathy, and vascular 

diseases. The authors also state that health education reduces costs of drug therapy. 3 tables, 

4 figures, 124 references. 

171 

TITLE: Hypoglycemic Drugs in the Treatment of Non Insulin Dependent Diabetes Mellitus 

(NIDDM) in Klong Toey Slum (abstract). Sitthi-amorn, C.; Chiamwongpaet, S. Abstracts of 

the International Society for Technology Assessment in Health Care. 1992:30. 

OBJECTIVE: To compare locally produced oral hypoglycemic agents with more expensive 

imported agents in terms of their efficacy in treating patients with type 2 diabetes living in a 

slum area in Thailand. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective. 

Methodology: Cost analysis. 
Perspective: Health care system. 

CONCLUSION: The imported oral hypoglycemic drugs were more effective in lowering 

blood glucose concentrations than locally produced agents, but at almost double the cost. 

RECOMMENDATION: Locally produced oral hypoglycemic agents have a role in the 

treatment of type 2 diabetes patients living in this area. 

ABSTRACT: The researchers randomly selected 67 patients with type 2 diabetes living in a 

slum area in Thailand who were being treated with imported oral hypoglycemic drugs. The 

patients were randomized into two groups: one group (n = 34) took locally produced agents 

for 6 months, then imported agents with the same generic name and dosage for another 6 

months. The second group (n = 33) reversed the process. Fasting blood glucose tests and 

assessments of glycosolated hemoglobin were performed on all patients every 1 to 3 months 

throughout the 12-month study. Direct medical costs were assessed by the costs of the 

medication, and direct nonmedical and indirect costs were obtained through interviews. 

Patients had greater reductions in fasting blood glucose and in glycosolated hemoglobin while 

on imported drugs. However, the cost to achieve a 1 percent reduction in glycosolated 

hemoglobin was almost twice as great using imported agents (41.2 Baht for imported drugs 

versus 22.4 Baht for domestically produced drugs. 

172 

TITLE: Labour Productivity Effects of Prescribed Medicines for Chronically Ill Workers. 

Rizzo, J.A.; Abbott, T.A.; Pashko, S. Health Economics. 5(3): 249265. May-June 1996. 

OBJECTIVE: To estimate the costs and benefits to employers of covering prescription drugs 

for workers with hypertension, heart disease, type 2 diabetes, or depression. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost-benefit analysis. 

Perspective: Societal. 

CONCLUSION: The net benefits to employers from covering prescription medicines for 

these chronic illnesses are substantial. 

RECOMMENDATION: None. 

ABSTRACT: The authors used data from the 1987 National Medical Expenditure Survey to 

estimate the costs and benefits of providing prescription coverage for individuals aged 18 to 

64 years afflicted with hypertension, heart disease, depression, or type 2 diabetes. Benefits 

were measured by the extent to which prescription medications decreased productivity losses 

resulting from employee disability days. Assuming average compliance rates, estimated 
average annual days saved from drug treatment were 3.5 for hypertension, 7.3 for heart 

disease, 9.1 for depression, and 16.1 for diabetes. Employer costs of providing drug benefits 

were estimated as the difference between total costs of the drugs and patients' out-of-pocket 

costs. The value of days saved was computed by multiplying days saved by a wage rate of 

$9.32 per hour (8-hour day assumed) times 1.25 to reflect fringe benefits. With average 

compliance rates, estimated net benefits per employee (in 1987 dollars) by disease were $286 

for hypertension, $633 for heart disease, $822 for depression, and $1,475 for diabetes. When 

capital costs were included, average net benefits to employers were even greater, ranging from 

$503 for hypertension to $2,485 for diabetes. Additional benefits could accrue if employees 

complied fully with their medications. 6 tables, 20 references. 

173 

TITLE: Medication Cost Savings Associated with Weight Loss for Obese Non-InsulinDependent Diabetic Men and Women. Collins, R.W.; Anderson, J.W. Preventive Medicine. 

24(4): 369-374. July 1995. 

OBJECTIVE: To determine the savings in prescription costs associated with a weight loss 

reduction program in obese patients with type 2 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Significant short- and long-term savings in prescription costs were obtained 

following a 12-week hypocaloric weight reduction program for obese individuals with type 2 

diabetes. 

RECOMMENDATION: In deciding upon the most appropriate treatment strategy for 

patients with type 2 diabetes, careful consideration should be given to the treatment's potential 

long-term medical and economic benefits. 

ABSTRACT: The authors determined the prescription cost savings associated with a weight 

reduction program in obese patients with type 2 diabetes. Adult patients with a history of type 

2 diabetes of more than 1 year and a body mass index of 30-40 kg/m2 were randomized to 

one of two 800-kcal, 12-week weight loss interventions: five dietary supplements/day with no 

food (n = 20) or two supplements per day and an evening meal (n = 20). Medication usage 

was documented upon initiation of the program, after 12 weeks, and 1 year after completion 

of the diet. Participants' drug profiles were costed through data from local pharmacies; 

insurance coverage was not taken into account. A refundable fee of $100 (far below usual 

cost) was paid for the weight loss program. Participants paid $25 weekly (nonrefundable) for 

dietary supplements. Cost analysis was performed in the 32 patients who took antidiabetes 

and/or antihypertensive medications. Patients lost an average of 14.8 percent of their pre-diet 

body weight over the 12-week study period; an average of 58.8 percent of the weight loss was 
maintained at the 1-year follow-up. At the beginning of the diet, all antidiabetes medications 

were reduced by 50 percent, and all diuretics (for hypertension) were discontinued totally. 

Other antihypertensive medications were decreased in various ways. Prior to the dietary 

interventions, total monthly prescription costs for all medications and supplies averaged 

$82.00 per patient, or $984 annually. Average monthly saving in prescription costs per patient 

was $36.90 at midyear of the follow-up, corresponding to an estimated average cost savings 

over the year of $442.80 per patient. Average monthly pre-diet cost for antidiabetes and 

antihypertensive medications was $63.30 at follow-up (p < 0.001). After 1 year, average 

monthly costs for insulin and oral hypoglycemic agents decreased to 59 percent and 88 

percent of their pre-diet values, respectively. 1 figure, 1 table, 12 references. 

174 

TITLE: Oral Hypoglycemic Agents in the Treatment of Type II Diabetes. Tal, A. American 

Family Physician. 48(6): 1089-1095. November 1993. 

OBJECTIVE: To review the pharmacologic properties, mechanism of action, therapeutic 

effects, side effects, drug interactions, and costs associated with first- and second-generation 

hypoglycemic agents. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: First-generation sulfonylureas are less expensive but less active than 

second-generation sulfonylureas. 

RECOMMENDATION: None. 

ABSTRACT: The author reviewed and compared the properties of first- and secondgeneration oral sulfonylureas used to treat patients with type 2 diabetes. Sulfonylureas provide 

adequate glycemic control in approximately two-thirds of patients, but about 50 percent of 

initially responsive patients have inadequate control after 10 years. The average wholesale 

price per month (1992) for equivalent therapeutic doses of the first-generation drugs 

tolbutamide, acetohexamide, tolazamide, and chlorpropamide was $14.40, $12.40, $15.00, 

and $19.20, respectively; their average generic cost per month was $2.70, $11.90, $6.45, and 

$1.85, respectively. The corresponding average wholesale prices per month for the secondgeneration drugs glipizide and glyburide were $16.70 and $14.70, respectively. Overall, side 

effects occur in 3 to 4 percent of patients taking these drugs. Hypoglycemia is the major 

complication; elderly patients may be at particularly high risk for severe hypoglycemia. 

Twenty to 30 percent of severe hypoglycemic episodes are related to drug interactions. New 

types of drugs are undergoing clinical trials. 3 tables, 27 references. 
175 

TITLE: Use of Health Maintenance Organization Data Bases to Study Pharmacy Resource 

Usage in Diabetes Mellitus. Glauber, H.S.; Brown, J.B. Diabetes Care. 15(7): 870-876. July 

1992. 

OBJECTIVE: To analyze pharmaceutical drug use by patients with diabetes enrolled in a 

health maintenance organization (HMO) and estimate its cost. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Patients with diabetes received significantly more medication at a greater 

total cost than patients without diabetes. Computerized pharmacy databases are useful for 

studying the epidemiology, patterns of care, and costs of chronic disease. 

RECOMMENDATION: None. 

ABSTRACT: The authors analyzed data in the Kaiser Permanente Northwest pharmacy 

database on medication usage by 871 patients with diabetes who were members of the Kaiser 

plan for the entire year. Patients with diabetes were identified from hospital discharge records, 

registration in diabetes education programs, referral to specialists in diabetes or diabetes eye 

care, and prescriptions for products used exclusively by patients with diabetes. Specificity of 

patient identification was greater than 99 percent; sensitivity was 85 to 90 percent; prevalence 

of diabetes was 25.4 per 1,000 members. 1,002 patients were randomly selected from the 

identified group; a total of 131 with no drug insurance were excluded. A control group 

without diabetes was matched for age, sex, and pharmacy insurance status. Mean number of 

outpatient visits for patients with and without diabetes was 11.3 and 6.5 and the 

hospitalization rate was 366 and 105 admissions per year, respectively. Costs were based on 

1988 standard values, retail nonmember price, dispensing cost, and overhead. Statistically, a 

higher percentage of patients with diabetes received cardiovascular, antibiotic, nonsteroidal 

anti-inflammatory, dermatologic, gastrointestinal, narcotic, vitamin, respiratory, psychoactive, 

and hypolipidemic medications. Patients with diabetes also received more than twice the 

number of prescriptions (31.5 vs. 14.4/yr, p < 0.001). Annual pharmacy expenses per patient 

per year were statistically greater for patients with diabetes: $627.93 versus $259.28, p 

< .001. Pharmacy costs accounted for approximately 17 percent of the annual direct cost of 

care for patients with diabetes. 6 tables, 18 references. 

Comprehensive Care(Inpatient and Outpatient) 

176 
TITLE: The Charges for ESRD Treatment of Diabetics. Smith, D.G.; Harlan, L.C.; 

Hawthorne, V.M. Journal of Clinical Epidemiology. 42(2): 111-118. 1989. 

OBJECTIVE: To compare hospital charges for treatment of end-stage renal disease (ESRD) 

in patients with diabetes and those without diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Treatment charges for ESRD were higher for patients with diabetes than 

for other patients. The majority of the difference was attributable to higher inpatient hospital 

charges. 

RECOMMENDATION: None. 

ABSTRACT: The authors report on charges for treatment of ESRD. Data were from 

patients with diabetes (n = 243) and without diabetes (n = 903) treated in Michigan in 1982 to 

1984, with onset of ESRD from 1981 to 1983. Charges were derived solely from Medicare 

reimbursement amounts and patient copayments and deductibles. Because Medicare allowable 

charges do not reflect increased intensity of treatment due to diabetes, use of such charges 

may lead to an underestimate of the additional costs of treating ESRD in patients with 

diabetes. The authors adjusted for ESRD treatment modality and differences in patient 

characteristics. Charges for 12 months (1983) were estimated assuming that average age, sex, 

race, time since onset of ESRD, and proportion dying were the same for patients with and 

without diabetes. Overall, patients with diabetes had estimated annual charges of $29,671, 

significantly higher (by $4,695, p < 0.01) than estimated charges for patients without diabetes. 

Most (84.3 percent) of the total difference in estimated charges was explained by differences 

in inpatient hospital charges, the remainder by differences in charges for physician services and 

medical supplies (14.5 percent) and outpatient services (1.2 percent). Estimated charges were 

similar for the various dialysis modalities for patients with diabetes. However, in the year that 

a cadaver transplant took place, estimated charges for patients with diabetes were significantly 

higher than for those without diabetes ($61,493 versus $42,074). 4 tables, 19 references. 

177 

TITLE: Diabetes and Long-Term Care. Mayfield, J.; Deb, P.; Potter, D. In: Diabetes in 

America. 2nd edition. National Diabetes Data Group, ed. National Institute of Diabetes and 

Digestive and Kidney Diseases. NIH Publication No. 95-1468. 1995: 571-590. 

OBJECTIVE: To present information about nursing home residents with diabetes and 

compare these persons with residents not known to have diabetes. 
CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based costs. 

Perspective: Health care system. 

CONCLUSION: In 1987, 18.3 percent of nursing home residents aged 55 years or more 

were known to have diabetes. Expenditures for residents with known diabetes were about the 

same as for those not known to have diabetes. 

RECOMMENDATION: None. 

ABSTRACT: The authors relied heavily on the Institutional Component of the 1987 National 

Medical Expenditure Survey to develop this report. In 1987, 388,656 persons with diabetes 

aged 55 years and over resided in nursing facilities; these individuals constituted 98 percent of 

all nursing facility residents with diabetes. Approximately 18.3 percent of all nursing home 

residents were known to have diabetes, but the true prevalence may have been much higher. 

Nursing home residents with diabetes were more likely to be nonwhite and to have a low 

income than were residents without (i.e., not known to have) diabetes. Total expenditures for 

1987 were similar for residents with diabetes and those without ($13,045 versus $13,203). 

Mean expenditure per day was $57 for both groups. Medicaid's contribution for expenditures 

of residents with diabetes was $1,226 higher than it was for those without diabetes, which was 

probably related to the higher rate of Medicaid eligibility in the diabetes population. It is 

expected that demographic shifts in the United States will result in a dramatic increase in both 

the proportion and number of persons who will need long-term care over the next several 

decades. Diabetes care will assume an increasingly important role in nursing facilities. 6 

figures, 11 tables, 4 appendices, 68 references. 

178 

TITLE: Diabetic Ketoacidosis Charges Relative to Medical Charges of Adult Patients with 

Type 1 Diabetes. Javor, K.A.; Kotsanos, J.G.; McDonald, R.C.; Baron, A.D.; Kesterson, J.G.; 

Tierney, W.M. Diabetes Care. 20(3):349-354. March 1997. 

OBJECTIVE: To provide information on direct medical care charges for episodes of diabetic 

ketoacidosis relative to all direct care charges for adults with type 1 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Diabetic ketoacidosis accounted for more than one-fourth of direct health 
care charges for the study patients. 

RECOMMENDATION: By designing interventions to reduce recurrent diabetic 

ketoacidosis episodes in patients with type 1 diabetes, health care organizations could save 

substantial costs. 

ABSTRACT: This study focused on 200 adult patients with type 1 diabetes who had 

received inpatient or outpatient care at least twice from January 1993 through June 1994 at a 

facility served by the Regenstrief Medical Record System, which includes Wishard Memorial 

Hospital in Indianapolis. Of this group, 72 (36.0 percent) experienced at least 1 episode (total: 

161) of diabetic ketoacidosis during a 2.5-year observation period that ended in June 1995. 

All 161 episodes resulted in hospitalization; for 150 (93.2 percent) of these hospitalizations 

diabetic ketoacidosis was listed as both the primary admission diagnosis and the primary 

discharge diagnosis. Mean age of the 200 study patients was 43.3 " 15.3 years; the two study 

subpopulations (ketoacidosis, no ketoacidosis) did not differ significantly by age, sex, or race. 

Charges were adjusted to 1995 dollars. Mean charge per ketoacidosis episode was $6,444; 

mean charge for these episodes was $6,055. The overall charges of $1,037,549 for episodes 

of diabetic ketoacidosis accounted for 28.1 percent of all direct medical charges for the 200 

patients in the study. Mean annual charges per patient by number of ketoacidosis episodes 

were as follows: none, $4,907; one or more, $13,096; two or more, $21,430; three or more, 

$29,074; and four or more, $32,872. The authors note that the hospitalization rate for diabetic 

ketoacidosis and the fraction of costs attributable to that disorder may be higher in their study 

cohort (predominantly indigent, inner city) than in another population. 4 tables, 26 references. 

179 

TITLE: Diabetic Ketoacidosis Costs Relative to Medical Costs of Patients with Type 1 

Diabetes [abstract]. Javor, K.; Kotsanos, J.; McDonald, R.; Baron, A.; Kesterson, J.; Tierney, 

W. AHSR FHSR Annual Meeting Abstract Book. 1996;13:94. 

OBJECTIVE: To determine, among patients with type 1 diabetes, the medical costs of 

treating episodes of diabetic ketoacidosis relative to the total medical costs of these patients; 

to assess the medical costs of patients experiencing multiple ketotic episodes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Episodes of diabetic ketoacidosis accounted for one-fourth of medical care 

expenditures for patients in the study group. 

RECOMMENDATION: Interventions that could reduce even modestly the episodes of 

diabetic ketoacidosis could yield significant cost savings in the health care system. 
ABSTRACT: Two hundred twenty-eight patients with type 1 diabetes who had received 

inpatient or outpatient care at least twice between January 1, 1993, and June 30, 1994, were 

included in the study. Resources and charges were recorded for hospitalizations, emergency 

room visits, and outpatient and pharmacy visits. An additional year of information was 

collected on patients with multiple episodes of diabetic ketoacidosis. Seventy-two (31.6 

percent) of the 228 patients experienced 1 or more episodes (total equals 163). Charges for 

these episodes equaled 25 percent of the medical charges for the study group as a whole. 

Annual charges per patient were estimated at $7,965 ($13,152 for those experiencing an 

episode of ketoacidosis, $5,750 for those not experiencing an episode). Twenty-four (10.5 

percent) of the study patients experienced multiple (two or more) episodes, which accounted 

for 56 percent of total medical charges for these patients. 

180 

TITLE: Digging Out Savings in Diabetes Care: Costing Out Care. Finder, S.F.; Smith, M.D.; 

McGhan, W.F. Business and Health. 14(9):69-70, 72. September 1996. 

OBJECTIVE: To provide an overview of diabetes and its complications, to report cost data 

on the disease, including the cost of various care elements, and to suggest opportunities for 

controlling costs. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The true opportunity for controlling the costs of diabetes lies in early 

identification and treatment of this disease. 

RECOMMENDATION: Various recommendations are made for controlling costs. 

ABSTRACT: The authors present an overview of diabetes, including its prevalence, etiology, 

and pathology; acute and chronic complications; and a detailed account of costs. 

Hospitalization of people with diabetes accounts for more than 80 percent of diabetes-related 

costs. Annual inpatient costs per patient with diabetes average $7,150, compared with $1,220 

for a person without diabetes. The corresponding averages for annual outpatient costs are 

$1,225 and $330. The authors detail expenses for diabetes medications, blood glucose 

monitoring, laboratory tests, and screening and diagnostic tests for diabetes and related 

complications. Several opportunities exist for cost savings: (1) workplace screening of 

employees with one or more risk factors so as to identify and treat the disease early, (2) 

disease management programs that identify and focus on patients most likely to experience 

complications, (3) programs that foster improved adherence to diabetes management 

regimens, (4) programs that demand accountability from health care providers to reduce acute 

complications associated with poor control, and (5) determining the most cost-effective 
options for treatment and glucose monitoring. 

181 

TITLE: Economic Impact of Diabetes Mellitus in the Elderly. Weinberger, M.; Cowper, 

P.A.; Kirkman, M.S.; Vinicor, F. Clinics in Geriatric Medicine. 6(4): 959-970. November 

1990. 

OBJECTIVE: To estimate the economic impact of diabetes mellitus among the elderly. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Health care services provided to Americans aged 65 years and older cost an 

estimated $5.16 billion annually (based on 1987 data), with nearly 80 percent due to 

hospitalization. The average yearly expenditure per patient with diabetes was estimated to be 

$4,265, of which $900 was for out-of-pocket expenses. 

RECOMMENDATION: Increased vigilance to prevent or delay the incidence of morbidity 

leading to hospital admissions must be given priority in caring for patients with diabetes. 

Intensifying outpatient care may offer the opportunity to accomplish this goal. 

ABSTRACT: Investigators combined 1987 data on consumer (or third party) prices for 

hospital stays, nursing home stays, physician visits, laboratory tests, prescriptions, supplies, 

and self-monitoring tests with estimates of resource use (inpatient, outpatient, and nursing 

home) attributable to diabetes mellitus to estimate the economic impact of this disease in the 

elderly. The data were restricted to persons aged 65 and older and to cases of type 2 diabetes. 

Only direct costs were used and estimates were conservative because many of the data 

sources excluded people over 74. The authors attributed 400,000 admissions and 3.9 million 

hospital days to diabetes mellitus or its complications (renal, ophthalmic, neurologic, 

cardiovascular, and other). Increased length of hospital stay for patients with diabetes who 

were admitted for other reasons added another 1.5 million patient days. Hospitalization plus 

inpatient physician visits produced total inpatient expenditures of $4.1 billion (79.7 percent of 

the expenditures). Nursing home costs totaled $306 million (5.9 percent). Another $742 

million (14.4 percent) resulted from outpatient care (office and non-office-based physician 

visits, laboratory tests, prescriptions, etc.). Total 1987 direct annual expenditures were 

estimated to be $5.16 billion. Expenses per person (excluding nursing home care) averaged 

$4,265, about 50 percent higher than age-matched counterparts without diabetes; 

approximately $900 represented out-of-pocket expenses. Study results suggest that 

preventing or delaying morbidity leading to hospital admission must take priority in caring for 

patients with diabetes mellitus. Intensifying outpatient care may offer the opportunity to 

accomplish this end. 4 tables, 22 references. 
182 

TITLE: Effect of Third Party Reimbursement on the Utilization of Services and Indices of 

Diabetes Management among Inner City Diabetic Patients. Nordberg, B.; Barlow, M.; 

Chalew, S.A. Poster Presentations at the American Diabetes Association, 52d Annual Meeting 

and Scientific Sessions. San Antonio, Texas. June 20-23, 1992. 

OBJECTIVE: To assess the impact of third party reimbursement on the use of health care 

services by low-income inner-city patients with diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Patients with full or partial reimbursement used health care services more 

often than patients with no reimbursement benefits. 

RECOMMENDATION: None. 

ABSTRACT: Low-income adult patients with diabetes (111 women and 56 men) from an 

inner-city clinic were categorized by their level of medical coverage: full (64), partial (73), or 

none (30). The patients were followed for 13 months, and data were collected on the number 

of clinic visits, emergency room visits, hospital admissions, and use of a free daytime hot line, 

as well as on changes in glycated hemoglobin (HbA1C), blood pressure, and weight, from the 

beginning to the end of the study. Patients included 141 with type 2 diabetes and 26 with type 

1 diabetes. The number of clinic visits, percentage of kept appointments, average number of 

admissions, and average number of emergency room visits were higher for the fullreimbursement group than for the no-reimbursement group, and older patients in all groups 

tended to use services more frequently. Use of the free telephone hot line did not differ by 

reimbursement group. Weight and blood pressure remained the same during the study for all 

groups, but researchers noted a trend for worsening of HbA1C in the group without third 

party reimbursement. 

183 

TITLE: Health Care Expenditures for People with Diabetes Mellitus, 1992. Rubin, R.J.; 

Altman, W.M.; Mendelson, D.N. Journal of Clinical Endocrinology and Metabolism. 78(4): 

809A-809F. April 1994. 

OBJECTIVE: To estimate the prevalence of diabetes and the health care costs for people 

with diabetes in the United States, to compare these costs to costs for people without 
diabetes, and to estimate the fraction of health care expenditures incurred by people with 

diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based costs. 

Perspective: Health care system. 

CONCLUSION: Health care expenses in 1992 for people with diabetes ranged from 11.9 

percent to 14.6 percent of all health care costs, depending on the prevalence estimate used. 

RECOMMENDATION: Health care reformers and insurers should promote benefits that 

will reduce the costs of caring for patients with diabetes. 

ABSTRACT: The authors compared health care expenditures for people with diabetes, for 

those with diabetes confirmed by medical history, and people without diabetes. Health care 

costs incurred by people with diabetes that may not be related to the disease were included. 

Data were based on the 1987 National Medical Expenditure Survey and extrapolated to 1992 

based on United States Census demographic data and government-derived inflation factors. 

The estimated prevalence of confirmed diabetes among all ages was 31.1 per 1,000 people, or 

7.7 million people. Total U.S. health care expenditures were approximately $720.5 billion, of 

which approximately $105.2 billion (14.6 percent) was for persons with diabetes, with $85.7 

billion (11.9 percent) for persons with confirmed diabetes. Per capita expenditures were 

significantly higher (p < .01) for patients with confirmed diabetes than for those who did not 

have diabetes for inpatient care ($7,153 versus $1,222), office visits ($1,045 versus $554), 

outpatient care ($1,225 versus $330), drugs and durable medical equipment ($1,056 versus 

$201), home health ($438 versus $67), and emergency room care ($131 versus $84). Per 

capita annual health care expenditures for persons with diabetes were significantly higher (p 

< .01) than for persons without diabetes for all age groups combined and for all age groups 

aged 35 years and over. Annual expenditures by payer for persons with diabetes and those 

without diabetes were, respectively, 27 and 13 percent for Medicare, 15 and 10 percent for 

Medicaid, 9 and 7 percent for other public programs, 20 and 29 percent for employmentbased insurance, 19 and 26 percent for other private insurance, and 12 and 15 percent for selfpay. These data confirm the high cost of health care for patients with diabetes. Policies of 

prevention and more effective management of diabetes are needed to help control these costs. 

3 tables, 2 figures, 34 references. 

184 

TITLE: Medical Expenditures and Insurance Coverage for People with Diabetes: Estimates 

from the National Medical Care Expenditure Survey. Taylor, A.K. Diabetes Care. 10(1): 87-

94. January-February 1987. 

OBJECTIVE: To provide information on public and private health insurance coverage of 

patients with diabetes and on health care services and costs for these patients. 
CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Prevalence-based costs. 

Perspective: Health care system. 

CONCLUSION: Private insurance coverage for persons with diabetes was similar to that for 

the remainder of the population. However, persons with diabetes used medical care services 

more frequently and, as a result, had higher average medical expenses. 

RECOMMENDATION: None. 

ABSTRACT: The author reports data from the 1977 National Medical Care Expenditure 

Survey on the health insurance coverage, health services usage, and health care expenditures 

related to diabetes. Approximately 4.5 million Americans had diabetes in 1977. Among 

persons with diabetes under 65 years old (2.525 million people), approximately 12 percent had 

no health insurance and 70 percent had private insurance. Uninsured persons tended to be 

black or Hispanic, and to be poorer and younger, in better health, living in the South and 

West, and residing outside large cities. Persons covered only by Medicaid tended to be female, 

black or Hispanic, and in poor health. Almost all persons aged 65 and over were covered by 

Medicare; 67 percent carried supplemental private insurance; 15 percent also had Medicaid. 

Persons with diabetes visited doctors more often, were hospitalized more often, had longer 

hospitalizations, accessed nonphysician services more, and purchased medical equipment and 

supplies more than other people. Per capita expenses (for those with any expense) for persons 

with and without diabetes were $1,514 and $548, respectively; over two-thirds of expenses 

for the former were related to hospital care. Reimbursement was approximately 22 percent 

out of pocket, 24 percent through private insurance, 32 percent through Medicare, 12 percent 

through Medicaid, and 10 percent through other sources. Private insurance coverage was 

comparable in persons with and without diabetes; more persons with diabetes lacked coverage 

of physician office visits and major medical expenses. Trends in public and private third party 

coverage of medical costs will have a large impact on persons with diabetes. 7 tables, 10 

references. 

185 

TITLE: Must Diabetes Be a Fatal Disease in Africa? Study of Costs of Treatment. Chale, S.; 

Swai, A.; Mujinja, P.; McLarty, D. British Medical Journal. 304(6836): 1215-1218. May 9, 

1992. 

OBJECTIVE: To estimate the cost of diagnosing and treating patients with diabetes in the 

African country of Tanzania. 

CATEGORY: Cost of diabetes (direct). 
Type of Study: Prospective. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Of total 1-year outpatient costs, about 32 percent was for insulin, 31 

percent to treat complications, and 24 percent to purchase oral hypoglycemic drugs. 

Estimated costs (U.S. dollars) for inpatients and outpatients combined were about $4 million. 

RECOMMENDATION: Because per capita annual income in Tanzania ranges from $160 to 

$200 and an insulin dependent patient requires $156 per year to purchase insulin, patients 

must continue to be exempted from paying for these items. 

ABSTRACT: Tanzania, a very poor country with health expenditures in 1989 (U.S. dollars) 

of $2 per person, has one of the lowest rates of diabetes in the world. To estimate costs at the 

national level, the authors studied two groups of patients seen at Tanzania's largest hospital. 

Group 1 consisted of 262 consecutive new patients seen at the hospital's diabetic clinic and in 

the inpatient wards from September 1989 to August 1990. Group 2 included 202 patients first 

seen in June 1981 to May 1982. Patients in both groups were monitored until October 1990. 

Costs of insulin, syringes, and other items not purchased by the patient were calculated from 

1989 to 1990 prices charged by central medical stores of the government and by estimates 

from the hospital's budget. Market prices were used for supplies patients had to buy; prices 

charged by private hospitals were used for treatment and investigations at those institutions. 

For physician time, the authors assumed 7 minutes per outpatient visit and 10 minutes each 

day for inpatients; for nurse time, 10 minutes for an outpatient visit and 90 minutes daily for 

inpatients. Average salary for a physician was assumed to be 30 cents (U.S.) for a working 

hour; for a nurse, 4 cents. A prevalence of 0.2 percent was assumed for patients aged 15 years 

or over with diabetes requiring insulin or oral hypoglycemic drugs. For patient groups 1 and 2 

combined, annual outpatient costs were $229 for those requiring insulin and $69 for those not 

requiring insulin. Thirty-two percent of total outpatient costs were for purchasing insulin, 31 

percent for treatment of complications, and 24 percent for purchase of oral hypoglycemic 

drugs. Direct diabetes costs of nearly $4 million represented almost 8 percent of the Tanzania 

government's health budget. 1 table, 16 references. 

186 

TITLE: Prospective Reimbursement and Diabetes Mellitus: Impact upon Glycemic Control 

and Utilization of Health Services. Weinberger, M.; Ault, K.A.; Vinicor, F. Medical Care. 26 

(1): 77-83. January 1988. 

OBJECTIVE: To compare costs of patient care prior to and after implementation of 

reimbursement based on diagnosis-related groups (DRGs) in patients with type 2 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 
Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Short-term cost-cutting goals have probably been met with reimbursement 

based on DRGs, but the long-term consequences (e.g., poorer glycemic control) may offset 

potential cost savings. 

RECOMMENDATION: Larger studies that include other diagnostic groups are needed to 

assess inpatient and outpatient care at other sites. 

ABSTRACT: The authors investigated the effect of changing Medicare reimbursement to a 

method based on DRGs by comparing outcomes for patients with type 2 diabetes who were 

hospitalized for regulation of glycemia before (n = 53) and after (n = 31) implementation of 

DRGs. Patients and their health care use were identified from medical records at Wishard 

Memorial Hospital, a county hospital in Indianapolis, for all admissions in 1981 (pre-DRG) 

and for 1 year beginning in July 1983 (post-DRG). Primary care was delivered to the patients 

in a general medicine clinic staffed by Indiana University School of Medicine. Age, sex, and 

plasma glucose levels at admission for initial glycemic control were similar in the two groups; 

significantly more pre-DRG patients were black. Post-DRG patients had significantly fewer of 

several tests: plasma and urine glucose, serum calcium, serum phosphate, SMA-12, routine 

urinalysis, urine culture, and serum uric acid. Post-DRG patients were relatively less likely to 

have an education session with a registered nurse (0 versus 21 percent) and a dietitian (71 

versus 96 percent); they had significantly fewer rehabilitation medicine consultations (0 versus 

25 percent) as well. Hospital stay was significantly shorter in the post-DRG group (5.6 " 4.7 

days versus 8.3 " 2.7 days; p < 0.001). Plasma glucose concentrations at discharge were 

similar in the two groups. Among patients for whom information was available for the year 

following initial hospitalization, both blacks and whites in the post-DRG group had 

significantly more visits to the general medicine clinic than their pre-DRG counterparts. 

Random plasma glucose concentrations were significantly higher in post-DRG patients. 3 

tables, 17 references. 

187 

TITLE: A RCT of Community Clinic Versus Hospital Outpatient Care in the Treatment of 

Non Insulin Dependent Diabetes Mellitus (NIDDM): Abstract. Sitthi-amorn, C.; 

Chaimwongpaet, S. Abstracts of International Society of Technology Assessment in Health 

Care. 1992:7-8. 

OBJECTIVE: To determine whether structured community clinic care was as good as 

routine hospital outpatient treatment in controlling uncomplicated type 2 diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Prospective. 

Methodology: Cost analysis. 

Perspective: Health care system. 
CONCLUSION: Adherence rates were higher in the clinic, which was also more cost 

effective. 

RECOMMENDATION: The distinguishing features of care in the community clinic should 

be used to redirect diabetes care in the community. 

ABSTRACT: In this study of 132 patients with type 2 diabetes residing in Klong Toey Slum 

in Thailand, half were randomized to structured community clinic care and half to hospital 

outpatient care. Patients were stratified by age, sex, and body mass index. Glycosylated 

hemoglobin, the main outcome measure, was measured at the end of the third, sixth, ninth, 

and twelfth months. Clinic adherence, treatment compliance, satisfaction, fasting plasma 

glucose, hospital admission, mortality, and cost of care were also assessed. Patients in the two 

groups had comparable reductions of fasting plasma glucose and glycosylated hemoglobin; 

these decreases were significant. The adherence rate for the hospital clinic at 3, 6, 9, and 12 

months was 64 percent, 54 percent, 50 percent, and 22 percent, respectively. After 12 months 

the community clinic adherence rate was 90 percent. Treatment at the community clinic was 

more cost effective. 

188 

TITLE: A Simple Economic Evaluation Model for Selecting Diabetes Health Care Strategies. 

Gagliardino, J.J.; Olivera, E.M.; Barragán, H.; Puppo, R.A. Diabetic Medicine. 10(4): 351-

354. May 1993. 

OBJECTIVE: To compare the cost of providing complete care to patients with diabetes who 

have no com-plications with costs of treating selected complications. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Providing complete care for patients with uncomplicated diabetes is a better 

allocation of resources than covering the treatment of complications. 

RECOMMENDATION: None. 

ABSTRACT: To perform their estimates, the authors surveyed the files of 60 diabetologists 

from various provinces of Argentina; physicians from both the public and private health 

sectors were surveyed. Based on survey records, the authors created a standardized patient's 

record reflecting common physician practice; economic costs were obtained from values 

published by Argentina's National Insurance Institute. The authors also used hospital inpatient 

files to create standardized records for treating ketoacidosis and acute myocardial infarction as 
well as the amputation of two toes. The authors estimate the annual outpatient cost for 

treating patients free of chronic complications to be $1,221.47 (U.S. dollars) for those with 

type 1 diabetes and $330.26 for patients with type 2 diabetes. They estimate the cost to treat 

one episode of ketoacidosis to be $632.09; of myocardial infarction, $3,415.47; and of 

amputation of two toes of a lower limb, $1,707.22. Preventing one of these episodes would 

provide enough funds to cover either the total or partial annual cost of controlling and treating 

several patients with uncomplicated diabetes. The authors acknowledge the possible weakness 

of their model's assumption that well-controlled patients would not develop chronic 

complications. They stress that their preliminary investigation does not seek to offer definitive 

proof that prevention pays for itself but that it points out that covering health care costs of 

patients with uncomplicated diabetes would be more efficient than covering the usual 

treatment of their complications. 3 tables, 20 references. 

189 

TITLE: Tallying the Cost Of Diabetes. Caruthers, C. Business and Health. 14(1A): 

SR8SR13. January 15, 1996. 

OBJECTIVE: To review the problems experienced by the government and employers in 

assessing the costs of diabetes; to review approaches used by some employers and insurers to 

reduce costs through preventive programs. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Assessing the true costs of diabetes is difficult, but more insurers and 

employers are supporting preventive measures to reduce the costs from diabetes and improve 

patient quality of life. 

RECOMMENDATION: None. 

ABSTRACT: The author reviews data on the total cost of diabetes in the United States and 

the effect of good diabetes management on costs. Costs are difficult to calculate because 

diabetes involves multiple organ systems, often is not reflected in the primary diagnosis, and 

results in longer hospitalizations for nondiabetes-related illnesses than those required for 

patients with the same diagnosis but no diabetes. In a study by Lewis-VHI using data from the 

1987 National Medical Expenditure Survey, per capita medical costs were found to be 3.5 

times higher for persons with diabetes than for those without diabetes ($9,493 versus $2,604); 

differences were statistically significant at all ages but were greatest for persons aged 45 to 54 

years ($11,000 versus $3,698). This study, which estimated the total cost of diabetes to be 

$112 billion, used a higher estimate of diabetes prevalence than a 1992 report by the American 

Diabetes Association, which put the cost of diabetes at $92 billion, and also included all 

medical charges incurred by persons with diabetes, whether or not they were diabetes-related. 
In terms of patient care, the Diabetes Control and Complications Trial proved that 

comprehensive diabetes management to improve blood glucose control can reduce some 

complications from diabetes by more than 50 percent. However, most primary care physicians 

are unable to provide comprehensive diabetes management, and many insurance companies do 

not provide adequate coverage for such services, including patient education. Although 

addition of diabetes management programs including diabetes education to health insurance 

plans may cost employers an estimated $1,100 to $2,500 per year per person with diabetes, 

comprehensive education programs may reduce hospitalizations by 13 to 74 percent. A study 

of a diabetes management program found, after 1 year, reductions of 72 percent in 

hospitalization, 71 percent in emergency unit visits, and 63 percent in lost work days. 4 

figures, 2 references. 

190 

TITLE: Trends in Medicare Reimbursement for End-Stage Renal Disease: 1974-1979. 

Eggers, P.W. Health Care Financing Review. 6(1): 31-38. Fall 1984. 

OBJECTIVE: To examine expenditures in the Medicare program for end-stage renal disease 

(ESRD). 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Per capita costs to Medicare for reimbursement of ESRD rose at a modest 

7 percent per year from 1974 to 1981. Costs for diabetic nephropathy were slightly higher 

than those for other conditions. Some of this difference can be attributed to the higher 

mortality rate among diabetic patients. 

RECOMMENDATION: None. 

ABSTRACT: Reimbursement through Medicare for ESRD rose from $229 million for 

16,000 enrollees ($14.3 thousand per capita) in 1974 to $1.471 billion for 64,100 enrollees 

($23 thousand per capita) in 1981, a 7 percent increase in per capita reimbursement per year. 

From 1974 to 1975, total reimbursement increased 58 percent; from 1980 to 1981, just 17.7 

percent. Enrollment grew 41.9 percent from 1974 to 1975 but only 10.9 percent from 1980 to 

1981. Distribution of reimbursement by type of service was relatively stable over the 7-year 

period; outpatient ranged from 49.7 to 59.3 percent; inpatient, 25.6 to 29.2 percent; and 

physician/supplier services, 12.1 to 20.6 percent. Between 1974 and 1979, hospitalization 

rates and length of stay for inpatient dialysis decreased while per capita reimbursements 

remained stable. In 1979, reimbursement for dialysis was lowest in persons 65 years of age 

and older, was slightly higher for women than men, and was nearly the same for whites and 

blacks; reimbursement for transplant increased with patient age and was slightly higher for 

blacks. Per-patient dialysis reimbursement in 1979 was $22,770 for patients with diabetic 
nephropathy; for other major diagnoses, it ranged from $20,396 to $21,248. Among dialysis 

patients, reimbursement was 45 percent higher for those who died than for those who 

survived. The introduction of continuous ambulatory peritoneal dialysis and the drug 

cyclosporin for immunosuppression in transplant patients could affect program expenditures 

after the period covered. 10 tables, 9 references. 

191 

TITLE: Why Do Elderly Diabetics Burden the Health Care System More Than NonDiabetics? Damsgaard, E.M. Danish Medical Bulletin. 36(1): 89-92. February 1989. 

OBJECTIVE: To determine why elderly patients with diabetes use the health care system 

more than elderly patients without diabetes. 

CATEGORY: Cost of diabetes (direct). 

Type of Study: Patient management. 

Methodology: Statistical analysis. 

Perspective: Health care system. 

CONCLUSION: Elderly patients with diabetes scored higher on subjective symptoms and 

had a greater frequency of objective findings; they also had more visits to a general 

practitioner or clinic. 

RECOMMENDATION: Some of the cost of treating elderly patients with diabetes may be 

reduced if these patients are treated more vigorously by diet and oral hypoglycemic agents in 

general practice, thereby avoiding time-consuming and costly insulin treatment. 

ABSTRACT: This Danish study focused on 228 patients with diabetes and 223 sex- and agematched controls without diabetes; median age for both groups was 68 years. Of the patients 

with diabetes, 52 were treated with insulin, 101 with oral hypoglycemic agents plus diet, 66 

with diet only, and 9 were untreated. The study period was the 12 months preceding the 

month in which the participant was examined for the screening; data were taken from local 

and national registers. All participants underwent an examination and responded to a 

questionnaire covering subjective symptoms during the preceding year, education, and marital 

status. Visits to a general practitioner or outpatient clinic were made by 93 percent of patients 

with diabetes and 72.1 percent of controls (p < 0.0001). Fifty percent of the control group had 

two or more visits in a year; 50 percent of the patients with diabetes had seven visits or more. 

Twenty-six percent of the patients with diabetes and 10 percent of controls had more than 10 

visits in a year; 56 percent of patients with diabetes who were treated with insulin had at least 

10 visits. The increased number of physician visits by insulin-treated patients may have been 

due simply to control of insulin treatment; these patients had the same prevalence of subjective 

symptoms and objective findings (except for retinopathy) as other patients with diabetes. All 

objective findings were more frequent in patients with diabetes than in controls; hypertension, 

ischemic heart disease, and nephropathy were the most common objective findings in patients 

with diabetes. More than half of the visits made by patients treated with insulin were to 
hospital clinics; other patients with diabetes made only a few visits to these clinics. 3 figures, 4 

tables, 10 references. 

Direct and Indirect Costs 

192 

TITLE: The Burden of Diabetes in North Carolina. Kegler, M.; Lengerich, E.; Norman, M.; 

Sullivan, L.; Stoodt, G. North Carolina Medical Journal. 56(4): 141-144. April 1995. 

OBJECTIVE: To assess the true burden of diabetes in North Carolina using prevalence, 

hospitalization rate, multiple-cause mortality, and economic cost figures. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: The burden of diabetes in North Carolina, as reflected by its listing on death 

certificates as the underlying cause, is underestimated. The total cost of diabetes in the state in 

1990 was estimated to be $1.2 billion, 46 percent attributable to inpatient or outpatient care 

and 54 percent to indirect costs. 

RECOMMENDATION: Regular collection, analysis, and reporting of data about diabetes in 

North Carolina is needed to enable decision makers to plan for and allocate scarce health 

resources. 

ABSTRACT: The authors applied prevalence, hospitalization rate, multiple-cause mortality, 

and economic cost data to the calculation of the true burden of diabetes in North Carolina. 

Prevalence data, based on the Behavioral Risk Factor Surveillance System survey, indicated 

that 290,000 adult North Carolinians had diabetes (5.8 percent of the total population). 

Between 1980 and 1989, 41,676 North Carolina decedents had diabetes listed as a 

contributing cause of death, but it was listed as the underlying cause of death for only 9,771 

decedents. Diabetes was mentioned as a diagnosis in 66,067 hospitalizations but as a primary 

cause for these hospitalizations in only 15 percent of cases. Charges for diabetes-related 

hospitalizations during 1988 to 1989 totaled $490 million, or $73 per resident. The total cost 

of diabetes in North Carolina during 1990, however, was estimated at $1.2 billion based on a 

Centers for Disease Control model. Approximately 46 percent of this total was attributed to 

inpatient and outpatient care ($574 million). The remaining 54 percent ($664 million) reflected 

indirect costs, including forgone wages due to short-term morbidity, long-term disability, and 

death. Because of the large burden of diabetes in North Carolina and the potential to prevent 

complications from diabetes, regular collection, analysis, and reporting of data about diabetes 

is needed so that decision makers can accurately plan for and allocate scarce health resources. 

4 tables, 15 references. 
193 

TITLE: The Cost of Diabetes. Gerard, K.; Donaldson, C.; Maynard, A.K. Diabetic 

Medicine. 6(2): 164-170. March 1989. 

OBJECTIVE: To estimate the cost of diabetes in England and Wales in 1984, and to outline 

problems in ascertaining the true costs of diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: The total indirect and direct costs of diabetes in England and Wales ranged 

from £ 259.5 million to £ 602.5 million, depending on the rate of absenteeism from work. 

RECOMMENDATION: The epidemiological base on which the cost of diabetes estimate 

was based must be improved by using prospective studies with long follow-up periods. 

ABSTRACT: The authors estimated both direct and indirect costs of diabetes; direct costs 

were associated with preventing, detecting, and treating diabetes; indirect costs to lost 

productivity due to absenteeism, early retirement, and premature mortality. The cost of 

welfare effects attributable to deterioration in quality of life was not included. Total direct 

costs were estimated at £ 238.9 million, including £ 74.0 million and £ 86.0 million for 

inpatient treatment of diabetes as a primary and secondary diagnosis, respectively; £ 22.8 

million for outpatient care; and £ 56.1 million for family practitioner services. Lost earnings 

were estimated at £ 20.6 million. Losses due to absenteeism varied based on the assumed rate 

of absenteeism relative to the normal population, ranging from £ 0.0 (absenteeism equal to 

that of the normal population) to £ 343.0 million (absenteeism equivalent to three times that of 

the normal population). Total costs associated with diabetes ranged from £ 259.5 million to £ 

602.5 million. The authors state that existing data are deficient in quality (in particular, no 

distinction is drawn between patients treated by insulin and those not so treated). More 

detailed epidemiological data are needed to accurately assess the economic burden of diabetes. 

To set priorities, economic evaluation (e.g., cost-effectiveness, cost-benefit analysis) rather 

than cost-of-illness studies, such as this one, is needed. 5 tables, 22 references. 

194 

TITLE: Cost of Diabetes in France. Triomphe, A.; Flori, Y.A.; Costagliola, D.; Eschwege, E. 

Health Policy. 9(1): 39-48. February 1988. 

OBJECTIVE: To determine direct costs for patients with type 1 and type 2 diabetes residing 

in Paris. 
CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The direct cost for type 1 patients was 19 percent greater than the average 

direct cost of medical care for France's general population, while the direct cost of the type 2 

group was somewhat below the national average. 

RECOMMENDATION: None. 

ABSTRACT: Of 109 patients studied, 27 had type 1 diabetes and 82 had type 2 diabetes. 

The type 1 group was 56 percent female and had an average age of 48 years; the type 2 group 

was 62 percent male and had an average age of 59 years. Mean duration of disease was 10 

years for both groups. Costs (for hospitalization, laboratory studies, drugs, visits or 

consultations, sick leave, and other) for the type 1 group averaged 12,178 French francs 

(FFr); for the type 2 group, 6,908 FFr. Not including sick leave, mean costs were 7,711 FFr 

for the type 1 group and 5,892 FFr for the type 2 group, versus mean medical care costs of 

6,462 FFr for the general French population. Two areas accounted for most of the non-sick 

leave costs: drugs (44.7 percent in the type 1 group and 34.3 percent in the type 2 group) and 

hospitalization (33.9 percent in the type 1 group and 40.1 percent in the type 2 group). In the 

general French population, drugs accounted for 17.9 percent of costs. The frequency of 

hospitalization was similar for the type 1 group and the general population. Compared with 

findings from a 1978 study, hospitalization was higher and visits or consultations lower. 5 

tables, 13 references. 

195 

TITLE: Costs of Diabetes in Texas, 1992. Warner, D.C.; McCandless, R.R.; De Nino, L.A.; 

Cornell, J.E.; Pugh, J.A.; Marsh, G.M. Diabetes Care. 19(12): 1416-1419. December 1996. 

OBJECTIVE: To estimate the direct and indirect costs of diabetes in Texas for 1992. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Costs were conservatively estimated at $4.0 billion. 

RECOMMENDATION: The databases consulted for this research study could assist state 

and local planning efforts in diabetes. 
ABSTRACT: For this study, several billing databases were searched to find individuals with 

diabetes or hypoglycemia as a primary or secondary diagnosis. Unique individual identifiers 

were used to capture all incidents of health care use by persons with the diagnoses identified. 

For most direct medical costs, the authors relied on third party or provider databases, which 

included Texas Medicare and Medicaid; selected Veterans Affairs and public hospitals; the 

state's Department of Health, Rehabilitation Commission, and Commission for the Blind; a 

commercial pharmaceutical database; and a migrant/community health center. Costs were 

defined in terms of allowed charges or payments. Three categories of direct costs were 

estimated — clearly attributable to diabetes, clearly attributable plus probably attributable to 

diabetes, and all costs for people with diabetes. Survey data were used to estimate private 

insurance claims and associated out-of-pocket costs. For nursing home costs, the finding of a 

1992 American Diabetes Association study on days attributable to diabetes was applied to 

Texas experience. National Health Interview Survey and U.S. Department of Labor data were 

used to estimate costs of short- and long-term disability. For the cost of premature mortality, 

1992 Texas death records were searched for persons with diagnoses of diabetes or 

hypoglycemia; present value of lost future productivity was calculated with a discount rate of 

3 percent. The authors estimated that $2.4 billion in indirect costs and $1.6 billion in direct 

costs were clearly or probably attributable to diabetes. Almost half of direct costs were paid 

by Medicare. 2 tables, 14 references. 

196 

TITLE: The Cost of Diabetic Foot Problems. Ward, J.D. PharmacoEconomics. 8 

(Supplement 1):55-57. 1995. 

OBJECTIVE: To discuss the prevalence and incidence of diabetic foot problems, their 

economic cost, and strategies for improvement. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Vigilant identification of those at risk for diabetic foot problems, supported 

by education, care, and appropriate clinical services, will dramatically lower the incidence of 

foot ulceration and its associated costs. 

RECOMMENDATION: All diabetes clinic services should provide a foot care specialist. 

ABSTRACT: Peripheral vascular disease, neuropathy, and social factors are important 

precursors of foot ulceration and amputation. In 50 percent of cases of the diabetic foot, 

vascular disease and neuropathy will both be present. The authors report their impression that 

few patients with diabetes who have foot problems are employed. According to a British study 

(Robinson et al. 1990), hospital admissions with peripheral vascular disease and neuropathy 
accounted for 20.8 percent of total bed days associated with diabetes in a recent period. 

Estimated total cost for these admissions was £ 12.9 million. According to Caddick et al. 

(1994), there is a very significant correlation between residing in an economically deprived 

area and being admitted to the hospital for diabetes; it is 2.5 times more common for those 

from deprived areas to be admitted. The author of the present article cites studies showing 

that provision of a foot care specialist reduces the incidence of diabetic foot ulceration and 

recommends offering a regular session for diabetic foot problems with a team consisting of a 

physician, diabetes specialist nurse, chiropodist (podiatrist), and orthotist. The author states 

that there is no reason that the objective included in the St. Vincent Declaration (1990) of 

reducing amputation in diabetes by 50 percent over 5 years cannot be achieved. In the United 

Kingdom, local diabetes services advisory groups have been set up in every health district to 

oversee, organize, and improve the provision of diabetes care. 17 references. 

197 

TITLE: The Cost of Diabetic Neuropathy. Ward, J.D. PharmacoEconomics. 8 (Supplement 

1):52-54. 1995. 

OBJECTIVE: To discuss diabetic neuropathy and its economic implications. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Health care system. 

CONCLUSION: Assuming that up to 20 percent of patients in a diabetic clinic will have 

neuropathic problems, numb feet, predisposition to ulcers, or impotence, a great deal of time 

should be spent with such patients (much more than currently available in many clinics). 

RECOMMENDATION: Measures of quality of life need to be developed to prove the 

efficacy of treatments in patients with diabetic neuropathy. 

ABSTRACT: No available economic studies actually state the economic price of diabetic 

neuropathy, a term with no precise definition. The author suggests defining diabetic 

neuropathy as a state of nerve damage leading to unpleasant symptoms mainly in the distal 

lower limbs that will lead the patient to consult a physician or the detection of physical signs 

indicating severely damaged nerves likely to result in clinical problems (diabetic foot 

ulceration). This definition includes 20 percent of patients; many epidemiological studies 

quote a prevalence of 28 to 38 percent. The most common syndrome of diabetic neuropathy is 

chronic sensory neuropathy of insidious onset (83 percent of cases). Autonomic neuropathy is 

relatively rare. Among men with diabetes aged 55 or over, 50 percent are impotent — the 

cause is primarily neuropathic, with vascular sclerosis and psychological factors also 

contributing. Although the role of neuropathic disease in developing foot ulceration is well 

recognized, the great amount of suffering among those with other forms of neuropathy is not. 

As a consequence, these other forms of neuropathy are not recognized as costly. 15 
references. 

198 

TITLE: The Cost of Education (Editorial). Siddons, H. Diabetic Medicine. 11(3): 239240. 

April 1994. 

OBJECTIVE: To point out the benefit of education for patients with diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Not educating patients with diabetes is very expensive. 

RECOMMENDATION: Convince health service authorities that diabetes education is worth 

the investment. 

ABSTRACT: The editorialist points out that the 1993 Diabetes Control and Complications 

Trial in the United States clearly demonstrated that intensive education and good blood 

glucose control can improve outcomes for people with diabetes. She notes the conflict 

between the Diabetes Control and Complications Trial recommendation of 20 minutes of 

education monthly for each patient with the British Diabetic Association's recommendation of 

one diabetes nurse per thousand patients. She also points out that nurse specialists are 

considered expensive and notes that many people are looking to practice nurses to take on this 

role. Practice nurses, however, are under pressure and their time is often used inappropriately. 

The editorialist states that it is well documented that education can reduce the cost of 

complications and hospital admissions for persons with diabetes. She notes that the cost of not 

educating patients is extremely high — about £ 300 for an overnight stay at the Manchester 

Royal Infirmary (before treatment) and £ 5,000 for inpatient treatment alone for a below-knee 

amputation at that institution. The health service is currently driven by financial implications, 

but this may not be bad. The authorities must be convinced that it is worthwhile to invest in 

diabetes. 2 references. 

199 

TITLE: The Cost of Insulin-Dependent Diabetes Mellitus (IDDM) in England and Wales. 

Gray, A.; Fenn, P.; McGuire, A. Diabetic Medicine. 12(12): 1068-1076. December 1995. 

OBJECTIVE: To estimate the direct and indirect costs of type 1 diabetes in England and 

Wales in 1992 using a cost-of-illness approach. 

CATEGORY: Cost of diabetes (direct and indirect). 
Type of Study: Epidemiological cohort model. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: The estimated direct medical costs related to type 1 diabetes were £ 95.6 

million; indirect costs (lost earnings) were estimated at £ 113 million. 

RECOMMENDATION: Cost-of-illness studies such as this one should provide a framework 

for cost-effectiveness analyses to determine appropriate levels of expenditures for diabetes 

treatment programs. 

ABSTRACT: The authors performed a cost-of-illness study of type 1 diabetes in England 

and Wales in 1992 using an incidence-based approach. The total number of persons with type 

1 diabetes in 1992 was estimated at 93,581. Using available information on mortality risk, 

2,014 deaths were estimated per year from type 1 diabetes for this imaginary cohort, resulting 

in an annual loss of 50,993 life-years and 23,691 potential working years. Estimated direct 

costs were £ 95.6 million; per sensitivity analysis, the range was £ 77 million to £ 113 million, 

depending on disease incidence. About half ( £ 47.3 million) of these costs were those directly 

attributable to diabetes. Almost half of those costs were associated with routine insulin 

maintenance, including glucose monitoring and routine outpatient care. The second most 

important direct expenditure category was renal complications, which accounted for £ 30.2 

million. Most of these expenses ( £ 26.5 million) were for renal replacement therapy. Vascular 

complications accounted for nearly 5 percent of direct costs; ophthalmic and neurological 

complications each accounted for about 1 percent. Costs of social security payments 

attributable to type 1 diabetes were estimated at £ 11 million annually. Potential earnings 

losses (discounted at 6 percent per year) due to premature mortality were estimated at £ 113 

million annually. 6 tables, 33 references. 

200 

TITLE: The Cost of Obesity: The US Perspective. Wolf, A.M.; Colditz, G.A. 

PharmacoEconomics. 5 (Supplement 1): 34-37. 1994. 

OBJECTIVE: To estimate the economic impact of obesity in the United States by examining 

the economic costs attributable to obesity for major chronic disorders, including type 2 

diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: The estimated direct cost of obesity-associated disease in 1990 was $45.8 
billion; the indirect cost was estimated to be $23.0 billion. The cost of type 2 diabetes 

attributable to obesity was 12.7 billion dollars ($8.835 billion for direct costs and $3.890 

billion for indirect costs associated with lost productivity resulting from excess mortality). 

RECOMMENDATION: Programs aimed at preventing weight gain in children and adults 

may help contain rapidly rising health care costs. 

ABSTRACT: The authors estimated the economic impact of obesity (body mass index $ 27.8 

kg/m2 for men or 27.3 kg/m2 for women) in 1990 U.S. dollars. Direct costs were derived 

from estimates for five major chronic disorders (type 2 diabetes, gallbladder disease, 

cardiovascular disease, cancer, and musculoskeletal disease) for which obesity increases risk. 

The authors estimated the percentage of costs attributable to obesity for these disorders to be 

57, 30, 19, 2.3, and 10, respectively. For diabetes, direct costs included routine care, cost of 

complications, and costs from an increased prevalence of other conditions (e.g., peripheral 

vascular disease, cerebrovascular disease). The authors used a published estimate of the 1980 

U.S. health care expenditure for type 2 diabetes as the basis for making the cost estimate for 

this disorder. They estimated that, for 1990, direct costs for type 2 diabetes that were 

attributable to obesity were $8.8 billion. Indirect costs in this study were divided by causes: 

(a) lost productivity as a result of obesity-related illness and (b) excess mortality. The authors 

estimated that 52.59 million work days were lost in 1988 because of obesity-related disease; 

they estimated the cost of this lost productivity to be $4.06 billion. They did not, however, 

allocate this cost to the five diseases studied. Costs of lost productivity from excess mortality 

for the five diseases were estimated at $18.94 billion, including $3.89 billion for type 2 

diabetes. 

201 

TITLE: Costs of Insulin-Dependent Diabetes Mellitus. Simell, T.T.; Sintonen, H.; Hahl, J.; 

Simell, O.G. PharmacoEconomics. 9(1): 24-38. January 1996. 

OBJECTIVE: To review the costs to the individual and society of initial treatment, followup, and late treatment for type 1 diabetes; to assess the potential for decreasing these costs. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Societal 

CONCLUSION: The costs of type 1 diabetes peak at the diagnosis of the disease and again 

with the development of complications. Intensive patient education, shortened hospitalizations 

for initial treatment, and maintenance of good metabolic control and mental health are the 

primary means of containing or reducing costs associated with type 1 diabetes until primary 

prevention is available. 

RECOMMENDATION: None. 
ABSTRACT: The authors review the epidemiology and the direct and indirect costs of type 1 

diabetes. Their review considers total costs as well as costs associated with three clinical 

stages: initial treatment, follow-up after initial treatment, and late treatment. The incidence 

and prevalence of type 1 diabetes vary, with the highest rates occurring in Scandinavia and the 

lowest rates in the Far East. Costs are difficult to ascertain because there are no prospective 

or longitudinal studies of the total long-term costs of type 1 diabetes. Available data suggest 

that the highest costs of type 1 diabetes are associated with initial and late treatment stages of 

the disease. The mean length of initial hospitalization at the clinical onset of type 1 diabetes 

ranges from 2 days in the United States to 6 weeks in northern and eastern Europe. A Finnish 

study found that shortening the initial hospitalization from 23 to 9 days had no effect on 

patient outcome at 2 years. Costs accumulate slowly after initial treatment; for children with 

type 1 diabetes in one study, total costs of self-care over a 2-year period were less than the 

cost of 1 inpatient day at a university hospital. Late-phase treatment is characterized by a 

rapid increase in costs because of complications, including retinopathy requiring laser 

treatment; renal disease, requiring dialysis; cardiovascular disease, which is responsible for 

more than 20 percent of deaths among type 1 patients; and neuropathy, which can lead to 

amputation. The estimated cost to provide tight metabolic control in type 1 patients in the 

Diabetes Control and Complications Trial was $3,700 (U.S.) per year, which would increase 

current control costs by 120 percent. However, the authors assert that the potential long-term 

personal and economic savings of continuing tight control and reducing complications are 

enormous. 121 references. 

202 

TITLE: Costs of Temporary and Permanent Dis-ability Induced by Diabetes. Olivera, E.M.; 

Duhalde, E.P.; Gagliardino, J.J. Diabetes Care. 14 (7): 593596. July 1991. 

OBJECTIVE: To evaluate indirect costs of diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Retrospective. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Persons with diabetes but without complications and a control group of 

persons without diabetes had similar rates of absenteeism and yearly cost. In contrast, the 

costs of overall absenteeism and permanent disability were much higher in persons with 

diabetes and chronic complications. 

RECOMMENDATION: Secondary prevention of diabetic complications might be an 

optimal approach to reducing the burden of diabetes. 

ABSTRACT: From 1984 to 1986, the cost of temporary disability for patients with diabetes 

was studied in a group of La Plata University (Argentina) employees (n = 42 for both control 
group and group with diabetes); the cost of permanent disability for patients with diabetes was 

studied in a larger group (n = 2,763) of Buenos Aires government employees. The La Plata 

University group with diabetes was divided into those without complications (31 percent) and 

those with chronic complications (69 percent). Complications consisted of macroangiopathy 

(42 percent peripheral, 22 percent coronary, and 5 percent cerebral), peripheral neuropathy 

(33 percent), retinopathy (25 percent), and kidney lesions (11 percent). The number and 

causes of working days lost during the calendar year were determined for each individual. For 

temporary disability, average days per year lost in patients without complications did not differ 

significantly from the number for the age- and sex-matched control group. However, patients 

with chronic complications had a considerably higher rate (p < 0.05) of days lost than the 

control group or patients with diabetes without complications. The costs of permanent 

disability for the government employees were estimated by calculating the expected number of 

years to retirement age for each early retiree. Work production loss was discounted at a 6 

percent rate. Average work production lost for 115 patients disabled by diabetes was 11 years 

(n = 115; 48 women, 67 men). At an annual cost of $23,660 (U.S. dollars), the total cost for 

these employees was $2,720,900. 3 tables, 17 references. 

203 

TITLE: Diabetes. Vaughan, J.P.; Gilson, L.; Mills, A. In: Disease Control Priorities in 

Developing Countries. Jamison, D.T; Mosley, W.H.; Measham, A.R.; Bobadilla, J.L.; eds. 

New York: Oxford University Press. 1993. pp. 561-576. 

OBJECTIVE: To summarize information for developing countries on the incidence and 

development over time of diabetes as well as the direct and indirect costs of this disease. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Literature review. 

Perspective: Societal. 

CONCLUSION: Resource allocation to improve the diagnosis and treatment of diabetes in 

developing countries needs to be fitted to the public policy and needs of individual countries. 

RECOMMENDATION: Further research is needed to assess the incidence and prevalence 

of type 1 and type 2 diabetes in developing countries, to evaluate possible interventions to 

prevent type 2 diabetes, and to assess case management and financing strategies. 

ABSTRACT: The authors review the epidemiology and economic burden of diabetes 

worldwide and especially in developing countries. Detection and reporting of new cases of 

diabetes depends on the availability and use of health care services, or on the result of largescale population-based surveys. The authors briefly review the evidence for genetic and 

environmental factors in the development of type 1 and type 2 diabetes. The incidence of type 

1 diabetes may be rising, but it is considered a rare disease in most developing countries and 

the very poor database makes the situation there uncertain. The incidence of type 2 diabetes 
has risen in the United States, Singapore, and Taipei, Taiwan; for Africa and Latin America, 

there are fewer data on incidence of this disease. Poor epidemiologic data and the failure to 

separate type 2 from type 1 diabetes makes it difficult to determine indirect costs in 

developing countries. In most of these countries, direct costs for diabetes are likely to be low. 

Reducing the incidence of new cases requires primary prevention strategies, and reducing 

complications requires early detection and improved case management. Prevention needs to 

include modification of behavior, improvement in health services and health education, and 

government regulation. However, the success of attempts to modify behavior is debated, and 

improvement in health services is expensive, especially for developing countries. The authors 

suggest strategies for developing countries based on both incidence of diabetes and income. 

Further research is needed to assess the incidence and prevalence of type 1 and type 2 diabetes 

in developing countries, to conduct studies of possible interventions for preventing type 2 

diabetes (including broad-based noncommunicable disease control), to assess case 

management, and to consider financing mechanisms. 

204 

TITLE: Diabetes Care in a UK Health Region: Activity, Facilities and Costs. Alexander, 

W.D. South East Thames Diabetes Physicians Group. Diabetic Medicine. 5(6): 577-581. 

September 1988. 

OBJECTIVE: To compare facilities and staffing for diabetes care in the Southeast Thames 

region with recommendations from the Royal College of Physicians and the British Diabetic 

Association, and to assess the cost of diabetes care for the region. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Total cost of diabetes was estimated at £ 21.6 million per year for the 

South-east Thames region. Physician staffing, patient education, and an ineffectual system of 

care have resulted in an unacceptably high hospitalization rate for uncomplicated diabetes and 

metabolic imbalances. 

RECOMMENDATION: Regional and District Health Authorities need to give priority to 

establishing effective, formal diabetes care strategies. 

ABSTRACT: The authors reported facilities and services available to patients with diabetes 

mellitus in 15 districts of the Southeast Thames Regional Health Authority and estimated the 

basic hospitalization costs for patients with diabetes based on 1985 Hospital Activity Analysis 

data. Cost estimates were £ 100 per day for inpatient care and £ 20 per visit for outpatient 

care, and estimates for insulin, sulphonylurea, and modified diet were £ 165, £ 80, and £ 13 

per patient per year, respectively. Using recommendations from the Royal College of 

Physicians and the British Diabetic Association as a standard, mean deficits (with ranges) in 
the number of consultant physicians, consultant sessions per week, and nurse specialists were 

0.9 (0 to 2.2), 6.6 (0 to 15), and 3.1 (0.4 to 6.0), respectively. Many districts provided no 

retinopathy screening, education program, computerized records, secretaries, or diabetes day 

unit. Of 11,857 hospitalizations for patients with diabetes, 4,185 had diabetes given as the 

principal cause; mean stay for all cases was 4.4 days. Among stays where diabetes was the 

principal cause, 76 percent had no mention of complications or were for ketoacidosis or coma, 

and 7.6 percent were for peripheral circulatory disorders (mean stay of 35.3 days) or 

neurologic complications. Estimated total out-patient costs were £ 4,489,320 ( £ 1,432,000 

for visits, £ 1,772,100 for insulin, £ 1,145,600 for sulphonylurea, £ 139,620 for dietary 

intervention, and £ 3,057,320 for supplies); estimated inpatient costs, £ 17,074,080 ( £ 

6,026,400 for patients admitted primarily for diabetes). Estimated excess inpatient costs for all 

patients with diabetes, using hospitalization costs of the whole population as a comparison, 

were £ 13,460,800. Investment of approximately 11 percent of excess costs would bring 

staffing to recommended levels and improve chiropody and dietetic services. The authors 

recommend that all regional and district health authorities adopt a strategic plan for diabetes 

care. 4 tables, 12 references. 

205 

TITLE: Diabetes Mellitus in Egypt. Arab, M. World Health Statistics Quarterly (Rapport 

Trimestriel de Statistiques Sanitaires Mondiales). 45(4): 334-337. 1992. 

OBJECTIVE: To report findings from a series of surveys of the epidemiology of diabetes 

mellitus in Egypt; to discuss the cost of diabetes, its interaction with other health problems, 

and health care delivery in that country. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: The direct and indirect costs of diabetes mellitus constitute a great burden 

on the economy of Egypt; a national program cannot provide free care for all Egyptians with 

diabetes. 

RECOMMENDATION: Improvements in health care delivery in Egypt are needed to 

reduce the morbidity and mortality of diabetes mellitus. 

ABSTRACT: The author reports that average prevalence of diabetes mellitus in Egypt is 4.3 

percent, with distinct geographical variations. The incidence of type 1 diabetes per 100,000 in 

children below age 15 was found to be 8.3 in an urban population and 7.6 in a rural 

population. Socioeconomic factors, including religion, may have an impact on the prevalence 

of diabetes in Egypt. For example, Islam calls for healthy behaviors, including the limitation of 

food intake to meet one's real needs and encouragement of exercise. Schistosomiasis, a 

parasitic disease, affects an estimated 20 million Egyptians; this disorder affects metabolism 
and may be reflected as hypoglycemia or hyperglycemia or as insulin resistance or other 

problems. Total 1990 direct costs for treatment of diabetes were approximately $74.3 million 

(U.S. dollars). Average monthly costs for medication were $1.12 for oral hypoglycemic 

agents, $2.44 for insulin, and $2.90 for glucose self-monitoring supplies. Laboratory assays 

cost $22.20 per year, and private physician fees ranged from $9.00 to $60.00 per year. There 

are substantial government subsidies for basic medication. The costs of treatment for 

complications of diabetes were much higher, ranging from $2.90 per month for hypertension 

to $555.00 per month for advanced nephropathy. Basic hospital costs ranged from $0.88 to 

$3.80 per day for uncomplicated cases. Indirect costs of diabetes mellitus were estimated at 

$11.8 million per year for the effects of absenteeism on productivity; indirect costs due to 

premature death were not estimated. 2 tables, 7 references, French summary. 

206 

TITLE: Diabetes - The Cost of Illness and the Cost of Control: An Estimate for Sweden 

1978. Jonsson, B. Acta Medica Scandinavica. 671 (Supplement): 19-27. 1983. 

OBJECTIVE: To estimate the economic cost of diabetes mellitus in Sweden in 1978, and to 

address the question of possible savings from improved metabolic control. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: Total direct and indirect costs for diabetes mellitus in Sweden in 1978 were 

estimated at 568 million and 749 million SEK, respectively. Management and control costs 

were estimated at 313 million SEK, while the cost of treatment of complications was 

estimated to be 1 billion SEK. There are great potential benefits to be expected from 

improved metabolic control. 

RECOMMENDATION: Cost-beneficial improvements in management and control of 

diabetes should be undertaken to lessen the economic burden of diabetes. 

ABSTRACT: For this study, direct costs for inpatients were estimated by multiplying number 

of hospital bed days for patients with a principal diagnosis of diabetes by average cost per bed 

day. Outpatient costs were developed from estimates of physician visits; cost estimates took 

into account differences between general practice and hospital outpatient departments. The 

cost of drugs was estimated from data on drug sales. Indirect costs were estimated separately 

for short-term illness, permanent disability, and premature death. Direct costs were estimated 

at 568 million SEK, including 358 million and 210 million SEK for institutional and 

noninstitutional care, respectively. Persons aged 65 years and older accounted for more than 

50 percent of the direct costs and nearly 66 percent of the institutional costs. Total indirect 

costs were estimated at 749 million SEK, including 134 million SEK from short-term illness, 

438 million SEK from permanent disability, and 176 million SEK from premature mortality. 
Lost production due to permanent disability accounted for 60 percent of the indirect costs and 

one-third of the total costs. Complications were more costly than management or control: The 

latter costs were estimated at 313 million SEK; estimated costs associated with complications 

were 1 billion SEK, including 255 million SEK in direct costs and 749 million SEK in indirect 

costs. Models that estimate potential savings from improved metabolic control are discussed. 

Simulations show that even with modest assumptions for beneficial outcomes, investment in 

improved control of diabetes will be cost beneficial. Limiting cases to those with a primary 

diagnosis of diabetes leads to an underestimate of the economic consequences of this disease. 

2 figures, 14 tables, 18 references. 

207 

TITLE: Direct and Indirect Costs of Cardiovascular and Cerebrovascular Complications of 

Type II Diabetes. MacLeod, K.M.; Tooke, J.E. PharmacoEconomics. 8(Supplement 1): 46-

51. 1995. 

OBJECTIVE: To review the literature on the economic impact of macrovascular 

complications on diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Societal. 

CONCLUSION: Much of the cost of type 2 diabetes is attributable to accelerated 

atherosclerosis and macroangiopathy. 

RECOMMENDATION: None. 

ABSTRACT: The authors review various studies on the economic impact of diabetes. In a 

U.S. study (Rendell et al. 1993), persons with diabetes accounted for 3.1 percent of the study 

group but 8.3 percent of overall health care charges. Adjusted odds ratios for various 

diagnoses for those with diabetes (versus those without) were 3.32 for ischemic heart disease, 

3.14 for peripheral vascular disease, 2.83 for hypertension, and 2.26 for cerebrovascular 

disease. In a Finnish study (Aro et al. 1994), 50.7 percent of those with diabetes and 12.4 

percent of a control population were hospitalized annually. In a Danish study of elderly 

patients (Damsgaard et al. 1987), macro-vascular disorders (cardiac, cerebrovascular, and 

peripheral vascular disease) accounted for 87.4 percent of bed days used for diabetic 

complications. In a U.S. study reported in the same year, Jacobs et al. found the risk of acute 

myocardial infarction and chronic ischemic heart disease to be 8.3 and 7.2 times as great 

among patients with diabetes as it was in the general population. In that study, which used 

patient records identified from the 1987 U.S. National Hospital Discharge Survey, 

cardiovascular complications accounted for 74 percent of hospitalization costs for the 

treatment of the late complications of diabetes. Huse et al. (1986) found that circulatory 

disorders (hypertension, ischemic heart disease, and cerebrovascular disease) accounted for 
33.3 percent of U.S. direct costs for type 2 disease in 1986. These authors estimated the 

national economic cost of type 2 diabetes to be $19.8 billion for that year, with macrovascular 

disease accounting for 47 percent. 1 figure, 4 tables, 17 references. 

208 

TITLE: Direct and Indirect Costs of Diabetes in Minnesota in 1988. Roesler, J.; Walseth, J.; 

Bishop, D. Minnesota Department of Health, Minnesota Diabetes Surveillance Project. 18 pp. 

September 1990. 

OBJECTIVE: To assess the total economic burden of diabetes in Minnesota in 1988. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: Diabetes represented a significant economic burden in Minnesota in 1988, 

with total costs estimated at more than $300 million. 

RECOMMENDATION: To reduce the economic burden of diabetes; interventions designed 

to prevent the complications of diabetes should be expanded. 

ABSTRACT: The authors estimated costs in Minnesota for diabetes by applying the cost 

estimates from a study by the Center for Economic Studies in Medicine for the American 

Diabetes Association (1988) to the state's population with diabetes. For 1988, the incidence 

and prevalence of diabetes in Minnesota were estimated at 9,695 and 87,109 cases, 

respectively. A total of 1,119 deaths were attributed to diabetes. Total direct costs were 

estimated at $189.4 million. Of this amount, $154.0 million was for hospital-related costs and 

$11.9 million for nursing home costs; outpatient costs were estimated at $23.5 million. 

Estimates of components of hospital costs included $30.5 million for diabetes, $75.6 million 

for its chronic complications, $7.3 million for increased intensity of care, $36.1 million for 

additional length of stay, and $4.4 million for physician visits to inpatients. Indirect costs were 

estimated at $112.2 million; those associated with short-term morbidity were estimated at 

$2.0 million; with long-term disability, $44.6 million. Lost earnings due to premature death 

were estimated at $65.5 million. Total costs were therefore estimated at $301.5 million, of 

which direct costs accounted for 62.8 percent and indirect costs, 37.2 percent. 12 tables, 23 

references. 

209 

TITLE: Direct and Indirect Costs of Diabetes in the United States in 1987. Center for 

Economic Studies in Medicine, Pracon Incorporated. American Diabetes Association, 

Alexandria, VA. 20 pp. 1988. 
OBJECTIVE: To update previous estimates of the incidence and prevalence of diabetes in 

the United States; to measure health care use for diabetes in 1987 and associated direct costs; 

and to estimate for that year morbidity and mortality resulting from diabetes and their 

associated indirect costs. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: Diabetes represents a significant economic burden in the United States, 

with total economic costs estimated at $20.4 billion for 1987. 

RECOMMENDATION: As most of the costs of diabetes are due to its chronic 

complications, programs designed to increase the early diagnosis and treatment of this 

disorder and enhance accessibility to care should be expanded with a goal of preventing 

complications. 

ABSTRACT: The authors used the human capital approach of D.P. Rice et al. (1985) to 

estimate costs associated with diabetes. Data sources for the study included several 

government surveys: the National Health Interview Survey, National Hospital Discharge 

Survey, National Nursing Home Survey, and National Ambulatory Medical Care Survey. 

Prices were specified in 1987 dollars. There were an estimated 6.51 million patients with 

diabetes in the United States in 1987, and 564,868 cases of diabetes were newly diagnosed 

during the year. Total costs of diabetes in 1987 were estimated at $20.4 billion. Direct costs, 

which accounted for 47.1 percent of the total, were composed of $7.9 billion in hospitalization 

and nursing home expenses and $1.7 billion for outpatient care. Indirect costs, 52.9 percent of 

the total, were composed of $142 million attributable to short-term morbidity, $3.14 billion 

attributable to long-term disability, and $7.5 billion associated with premature mortality. 2 

exhibits, 12 tables, 33 references, 1 appendix. 

210 

TITLE: Direct and Indirect Costs of Diabetes in the United States in 1992. Medical 

Technology and Practice Patterns Institute, Washington, DC. American Diabetes Association, 

Alexandria, VA. 27 pp. 1993. 

OBJECTIVE: To report prevalence and incidence estimates for diabetes; to estimate health 

care use and expenditures for treating diabetes; and to estimate morbidity and mortality costs 

as well as associated indirect costs for diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 
Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: The total economic cost of diabetes in the United States in 1992 was 

estimated to be $91.8 billion. 

RECOMMENDATION: The economic burden of diabetes may be reduced by programs 

aimed at increasing the use of preventive and diagnostic services, improving patient education, 

and increasing access to maintenance therapies and screening for complications. 

ABSTRACT: The authors used a prevalence-based and human capital approach to estimate 

costs associated with diabetes. Data sources used to determine the prevalence of diabetes and 

the use of health services included the Centers for Disease Control, the National Hospital 

Discharge Survey, the National Nursing Home Survey, the National Ambulatory Care Survey, 

and the National Medical Expenditure Survey. Costs were expressed in 1992 dollars. In that 

year, an estimated 7.2 million persons had diagnosed diabetes. Total costs (direct plus 

indirect) for diabetes in 1992 were estimated at $91.8 billion. Direct costs accounted for 49.2 

percent ($45.2 billion), with hospital, nursing home, and outpatient costs estimated at $37.2, 

$1.8, and $6.2 billion, respectively. (Outpatient costs included $2.9 billion in hospital 

outpatient visits, $1.2 billion in prescription drugs, $1.0 billion in physician visits, and $0.5 

billion for medical equipment.) Indirect costs, which comprised 50.8 percent ($46.6 billion) of 

total costs, included $8.5 billion for short-term morbidity, $11.2 billion for long-term 

morbidity, and $27.0 billion for premature mortality. Persons aged 45 to 64 years accounted 

for 62.3 percent of total mortality costs (the value of productivity foregone because of 

diabetes). The authors note that although 40.5 percent of all expenditures for diabetes were 

attributed to inpatient hospital care, only 0.03 percent of expenditures went toward 

diet/nutrition counseling and only 1.0 percent to diagnostic testing. They describe several 

ways in which the direct medical costs were likely to be underestimated in the report. 17 

tables, 40 references, 1 appendix. 

211 

TITLE: Economic Consequences of Diabetes Mellitus in the U.S. in 1997. Alexandria, VA: 

American Diabetes Association, 1998. 

OBJECTIVE: To estimate both direct medical and indirect costs attributable to diabetes and 

to calculate total and per capita expenditures for people with and without diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 
CONCLUSION: Estimated direct medical and in-direct costs were $44 billion and $54 

billion, respectively. 

RECOMMENDATION: None. 

ABSTRACT: The authors used prevalence-based cost-of-illness methods and data from 

national health care expenditure surveys to determine costs attributable to diabetes. Direct 

medical costs were calculated as both the medical expenditures attributable to diabetes (i.e., 

cost from excess prevalence of both diabetes-related chronic complications [e.g., neurological 

disease, renal disease] and general medical conditions [e.g., liver disease, respiratory failure, 

malignant neoplasms] and total cost of all services for people with diabetes). Indirect costs 

were those related to foregone earnings because of disability and diabetes-attributable 

mortality. The 1987 National Medical Expenditure Survey was used to estimate mean 

expenditures for encounters where the primary diagnosis was diabetes; this survey was also 

used to estimate diabetes prevalence as well as chronic complications and general medical 

conditions. For 1997, 2.3 million hospital discharges were attributed to diabetes (287.2 per 

1,000 people with diabetes). Of an estimated $44.1 billion in direct medical expenditures 

attributable to diabetes in that year, $27.5 billion was for inpatient care, $10.9 billion for 

outpatient services and home health care, $5.5 billion for nursing home care, and $0.2 billion 

for hospice care. Of the total direct expenditures, treating diabetes and its acute metabolic 

complications accounted for 17.4 percent; chronic complications, 26.8 percent. Of an 

estimated $54.1 billion in attributable indirect costs, premature mortality accounted for $17.0 

billion and disability, $37.1 billion. Total medical expenditures for people with diabetes were 

estimated at $77.7 billion ($10,071 per capita), versus $540.6 billion ($2,669 per capita) for 

people without diabetes. 44 references. 

212 

TITLE: Economic Cost of Diabetes Mellitus: Minnesota, 1988. Minnesota Department of 

Health. Centers for Disease Control. Morbidity and Mortality Weekly Report (MMWR). 40 

(14): 229-231. April 12, 1991. 

OBJECTIVE: To describe the economic impact of diabetes mellitus on the state of 

Minnesota for the year 1988. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: During 1988 in Minnesota, direct and indirect costs for diabetes mellitus 

approximated $189 million and $112 million, respectively. Chronic complications of diabetes 

mellitus accounted for more than half of the hospital days and cost more than $75 million. 
RECOMMENDATION: To reduce the costs of diabetes mellitus, effort should be directed 

at preventing its chronic complications. 

ABSTRACT: The author summarizes an analysis prepared by the Minnesota Diabetes 

Surveillance Project that estimated the economic impact of diabetes mellitus on Minnesota in 

1988. Prevalence of diabetes mellitus was obtained from a previous population-based study; 

national sources were used to estimate hospitalizations, physician visits, nursing home stays, 

laboratory tests, outpatient care, and disability compensation. In 1988, the total cost of 

diabetes mellitus in the state was $301 million. The direct cost of diabetes mellitus, including 

diagnosis, treatment, hospitalizations, nursing home care, and outpatient care, was $189 

million. Chronic complications accounted for 78,304 hospital days, more than half of total 

hospital days for diabetes mellitus. Hospitalizations for chronic complications of diabetes 

mellitus cost more than $75 million, and the indirect cost of diabetes mellitus was calculated at 

$112 million, with $2 million, $44.6 million, and $65.5 million attributable to short-term 

morbidity, long-term disability, and mortality, respectively. Prevention of some of the chronic 

complications of diabetes mellitus should result in a major reduction in its cost. Minnesota has 

developed a multifaceted plan to reduce the morbidity and disability that result from lower 

extremity amputations, diabetic eye disease, uncontrolled hypertension, and adverse 

pregnancy outcomes; the project includes measuring the burden of diabetes mellitus, 

implementing a statewide plan, and monitoring that plan's impact. 1 table, 10 references. 

213 

TITLE: The Economic Cost of Obesity: The French Situation. Levy, E.; Levy, P.; Le Pen, 

C.; Basdevant, A. International Journal of Obesity and Related Metabolic Disorders. 19(11): 

788-792. November 1995. 

OBJECTIVE: To estimate for France the direct and indirect costs of obesity as well as 

excess mortality from this condition. 

CATEGORY: Expert opinion. 

CONCLUSION: The economic cost of obesity in France is approximately 2 percent of all 

health care costs. 

RECOMMENDATION: Prospective studies of the costs of obesity are needed that will 

measure relative risks adjusted for age, sex, socioeconomic conditions, and country-specific 

epidemiologic data. 

ABSTRACT: The authors used a prevalence-based analysis of 1992 data to estimate the 

direct and indirect costs of obesity in France. Indirect costs were based on lost production due 

to obesity as indicated by Health Insurance System reimbursements for obesity-related causes. 

The prevalence of obesity (body mass index 27 Kg/m2 or greater) and morbid obesity (body 

mass index 30 Kg/m2 or greater) in the population aged 20 to 49 was 16.7 and 6.2 percent, 

respectively. Direct costs, based on prevalence of obesity and the relative risk of an obese 
person contracting a disease, were calculated for obesity, hypertension, myocardial infarction, 

angina pectoris, stroke, venous thrombosis, type 2 diabetes, hyperlipidemia, gout, 

osteoarthritis, gall bladder disease, colorectal cancer, breast cancer, genitourinary cancer, and 

hip fractures (this last disorder was considered cost-saving). The lowest estimates for relative 

risk were used. Total direct costs were French francs 66 billion or approximately 11 percent 

of French Health Care System costs, 20 percent of which were for type 2 diabetes health 

services. Obesity and related diseases accounted for 65, 25, and 10 percent of drug, physician, 

and laboratory expenditures, respectively. Total indirect costs were FF 575 million, versus FF 

3.5 billion from all causes. A savings of FF 190 million was found because of fewer hip 

fractures. One-year mortality from obesity was 180,000 persons. Total direct costs of obesity 

amounted to about 2 percent of French Health Care System costs, a finding that accords with 

results of studies in other western countries. This estimate is conservative, in part because not 

all obesity-related diseases were included and the lowest values for relative risk were used. 

Prospective studies of the costs of obesity are needed that will measure relative risks adjusted 

for age, sex, socioeconomic conditions, and epidemiology for each country. 3 tables, 42 

references. 

214 

TITLE: The Economic Costs of Non-Insulin-Dependent Diabetes Mellitus. Huse, D.; Oster, 

G.; Kilen, A.; Lacey, M.; Colditz, G. Journal of the American Medical Association (JAMA). 

262(19): 2708-2713. November 17, 1989. 

OBJECTIVE: To estimate the 1986 costs of morbidity and mortality attributable to type 2 

diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: The estimated total economic cost of type 2 diabetes in 1986 was $19.8 

billion, including $11.6 billion in health care expenditures and $8.2 billion in foregone 

productivity. Of type 2 diabetes-related health care expenditures, 59 percent were attributable 

to diabetes or its complications, and 41 percent to an excess prevalence of related conditions, 

for the most part circulatory disorders. 

RECOMMENDATION: The significance of the public health and clinical problems 

associated with type 2 diabetes-related conditions must be recognized. 

ABSTRACT: The authors estimated the total economic burden of type 2 diabetes using 

conventional prevalence-based cost-of-illness techniques and data from government surveys. 

The total economic cost of type 2 diabetes in 1986 was $19.8 billion, including $11.6 billion in 

health care expenditures and $8.2 billion in foregone productivity due to morbidity or 

mortality. Approximately $4.8 billion of these health care costs were attributable to treatment 
of other diseases, principally circulatory disorders ($3.8 billion) that were attributable to type 

2 diabetes. Men younger than 65 years accounted for $7.0 billion in economic costs; women 

aged 65 years and older, $5.9 billion; men over 65, $3.5 billion; and women under 60, $3.4 

billion. Per case, annual health care expenditures attributable to type 2 diabetes ranged from 

$1,274 among men younger than 65 years to $3,078 among women 65 aged years and older. 

In addition to the significant economic burden of type 2 diabetes, the human toll of type 2 

diabetes was staggering: 144,000 premature deaths were attributable to this disorder in 1986, 

representing 6.8 percent of all U.S. mortality and a loss of 1,445,000 years of life. This 

mortality estimate is more than four times greater than the previously reported estimate of 

35,000 deaths due to all kinds of diabetes. Of the 144,000 deaths, cardiovascular disease was 

the cause in 124,000. 3 figures, 5 tables, 33 references. 

215 

TITLE: Economic Costs of Obesity. Colditz, G.A. American Journal of Clinical Nutrition. 

55(2 Suppl): 503S-507S. February 1992. 

OBJECTIVE: To estimate costs attributable to obesity for type 2 diabetes, hypertension, 

cardiovascular disease, gall bladder disease, colon cancer, and breast cancer. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: Estimated 1986 costs for the six diseases studied totaled $39.3 billion, 

representing 5.5 percent of the cost of illness in that year. 

RECOMMENDATION: Programs that target weight gain avoidance in middle and older 

age should be implemented. 

ABSTRACT: For this prevalence-based estimate of the economic cost of obesity (a body 

mass index $ 27.8 kg/m2 for men or 27.3 kg/m2 for women), the author includes both direct 

and indirect costs. A discount rate of 4 percent was applied to indirect costs. The cost for type 

2 diabetes included routine care for uncomplicated illness, costs related to morbidity and 

mortality from complications, and costs from excess prevalence of other diseases (e.g., renal 

disorders). A published estimate of the 1980 cost of type 2 diabetes was adjusted to 1986; 

direct costs for the latter year were estimated at $11.6 billion; indirect costs, at $8.2 billion. 

Using information from the Nurses' Health Study, the author estimated that 57 percent of 

these costs ($11.3 billion) were attributable to obesity. Total estimated 1986 costs attributable 

to obesity for the 6 diseases studied were $39.3 billion. If the costs of obesity related to 

musculoskeletal disorders (about 50 percent of total costs for those problems) were included, 

another $17 billion would be added to this total. 5 figures, 36 references. 
216 

TITLE: Economic Evaluations of Type II Diabetes. Leese, B. PharmacoEconomics. 8 

(Supplement 1): 23-27. 1995. 

OBJECTIVE: To discuss the cost-of-illness methodology as an approach to studying the 

costs of diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Societal. 

CONCLUSION: Existing studies highlight the difficulties involved in comparing diabetes 

costs between countries with different health care systems and the importance of defining the 

study population and the sources of costs. Relatively few studies make suggestions about how 

their cost estimates might be used. 

RECOMMENDATION: None. 

ABSTRACT: Most economic analyses of diabetes mellitus have been descriptive and used a 

cost-of-illness methodology. Evaluative studies, in contrast, use cost-effectiveness, costbenefit, or cost-utility methodologies. Cost-of-illness studies bring together three kinds of 

costs — direct, indirect, and intangible — to measure the economic burden on society of a 

disease. These studies are usually based on disease prevalence, less often on its incidence. 

Incidence-based studies, which show where cost savings could be obtained from changes in 

treatment, are preferable but harder to perform. Direct costs are the easiest of the three kinds 

of costs to collect, but relevant costs may be excluded, or these costs may be incorrectly 

estimated or valued inappropriately. Indirect costs, which are the subject of considerable 

debate, measure the cost to society of illness, disability, and premature mortality. Intangible 

costs, which are more subjective, have rarely been considered in cost-of-illness studies 

because of difficulties in assigning costs to factors such as stress, pain, and anxiety. The 

valuation of life necessary to derive indirect costs is the main area of debate about the cost-ofillness methodology. One way of valuing life is to consider market earnings; here the human 

capital method is the most widely used approach. However, this method is biased (e.g., 

toward the unemployed). Willingness to pay is another approach, but it has found little 

acceptance. The friction method is a third approach, in which only production losses during 

the period required to replace the sick worker are costed. The most serious criticism of costof-illness studies is that they do not indicate where resources should be devoted to a particular 

disease. The author reviews various studies of the direct costs of type 2 diabetes and notes 

that most studies of the costs of diabetes have not distinguished between type 1 and type 2. 37 

references. 
217 

TITLE: Economic Impact of Diabetes. Entmacher, P.S.; Sinnock, P.; Bostic, E.; Harris, M.I. 

In: Diabetes in America: National Diabetes Data Group. Chapter 32. U.S. Department of 

Health and Human Services, 1984. 

OBJECTIVE: To review estimates of the direct and indirect costs of diabetes in the United 

States. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: Diabetes represents a significant economic burden in the United States, 

with the estimated total cost of diabetes in 1984 equaling $13.75 billion. 

RECOMMENDATION: None. 

ABSTRACT: The authors discuss the direct and indirect costs of diabetes in the United 

States. Using the human capital approach of Rice (1966) and data derived from surveys of the 

National Center for Health Statistics, they estimate that the cost of diabetes rose from $2.6 

billion in 1969 to $13.75 billion in 1984. They state that this increase was largely due to 

inflation and the increasing number of persons with diabetes. In 1984, estimated direct costs 

for medical and health care services were $7.4 billion; estimated indirect costs attributable to 

disability were $4.4 billion and $1.9 billion to premature death. An estimated $3.5 billion in 

direct costs were attributable to care in short-stay hospitals. The increase in total expenditures 

for diabetes from 1969 to 1984 was proportionate to the rise in overall health care 

expenditures during that time. The proportion of the total cost of diabetes attributable to 

direct medical care expenditures rose during the time period from 38 percent to 54 percent; 

the prevalence of diagnosed diabetes rose from 3.2 million in 1969 to 5.5 million in 1980 (no 

figures were given for 1984). In a 1977 national survey, 99 percent of persons with diabetes 

had a direct medical care expense versus 87 percent for those without diabetes. Per capita 

expenses for persons with diabetes who had an expense were 2.7 times higher than those for 

persons without diabetes. 8 tables, 2 appendices, 10 references. 

218 

TITLE: Economic Impact of Diabetes. Javitt, J.C.; Chiang, Y-P. In: Diabetes in America: 

National Diabetes Data Group, 2nd Edition. Chapter 30, 11 pages. 1995. 

OBJECTIVE: To review studies of the economic costs of diabetes and examine 

methodological differences between published analyses. 
CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost of illness. 

Perspective: Societal. 

CONCLUSION: The economic costs of diabetes are substantial, with estimates of total costs 

as high as $92 billion per year. However, comparisons between the estimates of this study and 

others are made difficult by several methodological issues. 

RECOMMENDATION: As health care expenses escalate, the cost of treating diabetes 

should be considered from the perspective of transfer payments and tax losses. 

ABSTRACT: The authors review recent published estimates of the economic cost of diabetes 

in the United States, update and synthesize them, and discuss methodological differences 

between these studies. Most studies of the economic costs of diabetes conducted in the 1980s 

used the human capital approach to valuing human life and relied on prevalence-based annual 

cost estimates. Methodological issues discussed by the authors include the attribution of cost 

to underlying conditions, valuing human life and health, and estimating volume of medical 

services; variation in these methodologies makes comparisons between studies difficult. In 

four 1980 studies, estimates (in 1990 dollars) of the total direct cost of diabetes ranged from 

$9.3 to $13.8 billion; indirect cost estimates ranged from $7.9 to $15.8 billion. Hospitalization 

accounted for most of the direct costs in all four studies. The American Diabetes Association 

published a study for the year 1992 in which it estimated direct medical costs of diabetes and 

its complications at $45.2 billion and indirect costs due to disability and premature death at 

$46.6 billion, for a total economic cost of $91.8 billion. This total, more than three times as 

great as the highest of the four earlier studies described, in part reflects increases in medical 

care costs above the inflation index used as well as more intensive and expensive technology. 

Important differences in the methodology of the 1992 analysis were the inclusion of cost 

components (e.g., home health visits, glucose monitors) not included in other studies, more 

comprehensive ascertainment of services due to systemic comorbid conditions attributed to 

diabetes, and morbidity databases that better capture contributing causes of death. The study 

attributed 344,914 deaths to diabetes in 1992 (80,339 were attributed to the disease in an 

analysis for 1987). Studies indicate that patients with diabetes use a much higher proportion of 

medical services and incur much higher expenses than do persons without diabetes 5 tables, 22 

references. 

219 

TITLE: Economic Impact of Type II Diabetes Mellitus. Krosnick, A. Primary Care: Clinics 

in Office Practice. 15(2): 423-432. June 1988. 

OBJECTIVE: To document the direct and indirect costs associated with type 2 diabetes in 

the United States. 
CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Review of studies. 

Perspective: Societal. 

CONCLUSION: For 1988, total costs associated with type 2 diabetes were estimated at $20 

billion: $10.5 billion for direct costs due to diagnosis and treatment and $9.5 billion for 

indirect costs associated with disability and mortality. 

RECOMMENDATION: A concerted national effort is needed to address the morbidity, 

mortality, and economic burden of type 2 diabetes. 

ABSTRACT: The author reviews recent studies of the direct and indirect costs associated 

with type 2 diabetes in the United States. Type 2 diabetes represents 85 to 90 percent of all 

diabetes cases; an estimated 50 percent of persons with type 2 diabetes are undiagnosed 

and/or untreated. In addition, the prevalence of diagnosed type 2 diabetes is rising steadily. In 

1983, diabetes accounted for 7.2 percent of all hospitalizations nationally, up from 4.6 percent 

in 1971. In 1980, patients with diabetes made approximately 13 million to 16 million physician 

visits and 3 million additional contacts in clinics or emergency rooms or by telephone. Patients 

with diabetes currently average approximately $1,200 in pharmacy purchases annually, which 

is 3 to 8 times higher per year than persons without diabetes. Nursing home care for patients 

with diabetes is estimated to cost between $5 and $6 billion annually; the estimated total cost 

for hospital care in 1980 was $2.2 to $6.5 billion. Diabetes is the leading cause of blindness 

for persons aged 20 to 74; the annual cost of blindness due to diabetes is estimated at $75 

million for lost income and welfare benefits. 1 table, 16 references. 

220 

TITLE: Financing the Care of Diabetes Mellitus in the U.S.: Background, Problems, and 

Challenges. Bran-some, E.D. Diabetes Care. 15(Supplement 1): 1-5. March 1992. 

OBJECTIVE: To review the concerns of the diabetes community that led to the Second 

National Conference on Financing the Care of Diabetes Mellitus in the 1990s and to review 

topics included in that conference. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Commentary. 

Methodology: None. 

Perspective: Health care system. 

CONCLUSION: Papers presented at the conference focused on the demographics of 

diabetes in the United States, standards of care, economic issues, and related topics. 
RECOMMENDATION: None. 

ABSTRACT: The author reports that the concerns that led to the conference included 

inadequate reimbursement for outpatient care interventions, below-standard quality of care of 

patients with diabetes, and confusion among patients and health care professionals about 

reimbursement changes. The author reviews the issues of the demographics of diabetes, the 

economic impact of diabetes, quality care, and reimbursement; he also briefly discusses papers 

presented at the conference. Approximately 6.6 percent of the population has diabetes. The 

American Diabetes Association estimated direct costs of diabetes care in 1987 to be about 

$9.6 billion, of which almost $7 billion was for inpatient care in acute short-stay hospitals. 

Indirect costs associated with short-term morbidity, long-term disability, and premature 

mortality were estimated at $10.8 billion. Reimbursement remains inadequate for preventive 

services and patient education, and there is evidence that limited access to care contributes to 

premature mortality in young adults with type 1 diabetes. The diabetes community has had 

difficulty convincing third parties that preventive care is cost effective. Quality assurance is 

emerging as a concern of accrediting organizations and the Health Care Financing 

Administration. Reimbursement procedures relevant to managed care programs and the 

Medicare Revised Fee Schedule are addressed. 2 figures, 3 tables, 12 references. 

221 

TITLE: The Indirect Costs of Morbidity in Type II Diabetic Patients. Persson, U. 

PharmacoEconomics. 8(Supplement 1):28-32. 1995. 

OBJECTIVE: To estimate the indirect costs of type 2 diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Excess indirect costs (value of lost production) averaged $7,000 (US 

dollars) per person with diabetes. 

RECOMMENDATION: Estimates of the economic burden of diabetes must take into 

account the excess risk of diabetes-related illness, not just the costs of diseases that are related 

to diabetes. 

ABSTRACT: The author reports estimates of indirect costs developed by Olsson et al. 

(1994). The population of Vetlanda, a town in southern Sweden, served as the study site; the 

age- and sex-adjusted prevalence of diabetes was 3.0 percent. The records of all diabetes 

patients aged 20 to 64 years (n = 285) were included (general retirement age in Sweden is 65). 

Of this group, 139 were treated with insulin (all 86 patients with type 1 and 53 of the 199 
patients with type 2). To estimate the excess prevalence of sick days and early retirement in 

the study population, data for the 285 study patients were compared with data for the town's 

entire population aged 20 to 64 (including the study patients). The expected number of sick 

days for the study population was determined by multiplying annual sick days for each sex and 

age group in the general population by the number of insulin-treated and noninsulin-treated 

men and women with diabetes. Similar calculations were carried out for permanent disability 

(premature retirement). The cost of production losses was measured by multiplying lost time 

by average wages plus social security contributions, in 10-year age and sex groups. In an 

analysis adjusted by age and sex, insulin-treated men had 75 percent more sick days and 

insulin-treated women 31 percent had more sick days than expected. Among those not treated 

by insulin, sick days were near the expected number among women and slightly below 

expected among men. For subjects aged 40 years and above, the number of permanently 

disabled individuals was three times higher than expected for diabetic men. The annual perpatient excess cost of lost production due to short-term illness and permanent disability was 

estimated to be SEK 40,000 (US $7,000). Permanent disability among patients aged 40 to 64 

years accounted for 92 percent of these costs. 3 tables, 6 references. 

222 

TITLE: Profiling Overweight Patients in the U.S. Navy: Health Conditions and Costs. 

Hoiberg, A.; McNally, M.S. Military Medicine. 156(2): 76-82. February 1991. 

OBJECTIVE: To identify the health conditions in a sample of Navy men hospitalized in 1974 

to 1984; to compare these disorders with those reported in the literature; and to examine 

obesity-related costs in terms of days hospitalized and career outcomes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Societal. 

CONCLUSION: Conditions common among the obese patients included hypertension, 

alcoholism, and diabetes. 

RECOMMENDATION: Assign overweight individuals to a weight reduction program at an 

early stage of their obesity. 

ABSTRACT: Researchers studied 518 enlisted Navy men with a primary diagnosis of obesity 

and 1,092 Navy men with a secondary or additional diagnosis of obesity who had hospital 

stays in 1974 to 1984. A 10 percent sample of male Navy patients who had not been 

diagnosed as obese served as the comparison group. The most common diagnoses in the 

obese group were hypertension, alcoholism, diabetes mellitus, respiratory system symptoms, 

and chronic ischemic heart disease. In the comparison group, alcoholism, hernia, personality 

disorders, internal derangement of joint, and other cellulitis/abscess were the most common. 

For 20.2 percent of hospital days in the obese group, obesity was listed as the primary 
diagnosis. At $200 per day, the cost of treatment over the 11-year period would have been 

$2,115,000. About 25 percent of separations and retirements in the obese group were 

attributed to a disability (primarily diabetes mellitus), to chronic ischemic heart disease, or to 

hypertension. According to the authors, the study supports implementation of weight 

reduction programs. With stricter adherence to assigning overweight personnel to weight 

reduction programs, they assert that the Navy Medical Department can expect to reduce costs 

associated with obesity-related hospitalizations and physical disability separations. 5 tables, 19 

references. 

223 

TITLE: Social and Economic Costs of Diabetes: An Estimate for 1979. Platt, W.G.; 

Sudovar, S.G. Pracon Incorporated, Washington, D.C. Home Health Care Group, Ames 

Division, Miles Laboratories, Inc. 20 pp. 1979. 

OBJECTIVE: To provide detailed estimates of the direct and indirect costs associated with 

diabetes mellitus in the United States in 1979. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost-of-illness. 

Perspective: Societal. 

CONCLUSION: The authors estimated that 8.3 million persons had diabetes in 1979 and 

that they generated total costs (direct and indirect) of $15.7 billion in that year. 

RECOMMENDATION: None. 

ABSTRACT: The authors derived cost estimates for 1979 from earlier governmental and 

commercial statistics. The authors estimated there were 8.26 million persons with diabetes in 

the United States in 1979, 1.94 million with type 1 diabetes, 2.91 million with type 2 diabetes 

controlled by medication, 1.62 million with type 2 diabetes controlled by diet, and 1.78 million 

with undiagnosed diabetes. Total costs generated by these patients were estimated at $15.7 

billion. Direct economic costs accounted for 36 percent of this total, with $1.95 billion 

associated with short-stay hospital and nursing home costs, $3.28 billion associated with 

noninstitutional costs, and $0.41 billion associated with complications. Indirect costs due to 

morbidity, mortality, and complications were estimated to be $10.03 billion, 64 percent of 

total costs. Morbidity (measured in work disruption) accounted for most of the indirect costs. 

Total costs for the 1.94 million patients with type 1 diabetes were estimated to be $4.8 billion. 

Direct costs accounted for 37 percent and indirect costs for 63 percent of total costs for these 

patients, for whom estimated per capita costs were $2,453. 7 figures, 5 tables, 4 appendices, 

10 references. 

224 
TITLE: The SocioEconomic Cost of Diabetic Complications in France. Triomphe, A. 

Diabetic Medicine. 8 Symposium: S30-S32. 1991. 

OBJECTIVE: To measure the direct cost of diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: Average per-patient medical costs (in French francs [FFr]) in 1984 were 

12,178 for type 1 diabetes and 6,908 for type 2 diabetes. 

RECOMMENDATION: None. 

ABSTRACT: An evaluation of the direct costs of diabetes was conducted in 1984. One 

hundred and nine sample patients with diabetes who resided in Paris were assessed; direct 

costs (e.g., home visits, laboratory tests, drugs, hospitalization, paramedical services) were 

analyzed. The average value (in FFr) of the total medical services used was 12,178 for 

patients with type 1 diabetes, 6,908 for patients with type 2 diabetes. Omitting sick leave, the 

figures were 7,711 for type 1 and 5,892 for type 2 diabetes; the average cost for a sample of 

the general French population was 6,462. The higher figure for type 1 (versus type 2 diabetes) 

patients was principally due to higher drug costs among type 1 patients. Hospitalization 

accounted for 34 percent of medical costs incurred by type 1 patients, 40 percent by type 2 

diabetes patients, and 51 percent by patients in the national sample. The costs of diabetic 

complications were not assessed in this study because they were not well documented. 

Reports from the United States and Sweden indicate that hospitalization accounted for a 

relatively higher percentage of medical costs for patients with diabetes in those countries than 

in this study. 4 tables, 10 references. 

225 

TITLE: Structure and Costs of Health Care of Diabetic Patients in Finland. Kangas, T.; Aro, 

S.; Koivisto, V.A.; Salinto, M.; Laakso, M.; Reunanen, A. Diabetes Care. 19(5): 494-497. 

May 1996. 

OBJECTIVE: To examine the structure and direct costs of health care for Finnish patients 

with drug-treated diabetes. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 
Perspective: Health care system. 

CONCLUSION: Direct medical costs (including insulin) for these patients accounted for 6 

percent of all health care budgets in Finland in 1989 and 13 percent of total inpatient hospital 

days; direct costs per patient ($3,941) were three times higher than for patients without 

diabetes ($1,323). 

RECOMMENDATION: Treatment strategies for diabetes should emphasize high-quality 

ambulatory care to improve blood glucose control, thereby reducing both the personal and 

economic burden of this disease. 

ABSTRACT: Outpatient care was evaluated by analyzing 30,266 questionnaires completed 

by patients with diabetes who obtained their medications through pharmacies during a 7-week 

period in 1989. Data on hospital inpatient care were derived by linking data from the Hospital 

Discharge Register covering the years 1987 to 1989 and the Central Drug Register to 

identification numbers assigned to each Finnish citizen. Analysis of the questionnaires showed 

that 31 percent of survey respondents were treated by insulin alone, 63 percent by oral 

medication alone, and 6 percent by a combination of the two. The mean number of physician 

visits for diabetes among respondents was 3.6. During the study period, patients with diabetes 

used an average of 1.5 million inpatient hospital days, which represented 13 percent of the 

total hospital days in Finland. Total direct cost of health care for patients with diabetes 

averaged $3,941 per year. Of this, 80.8 percent was for hospital inpatient care, 8.8 percent for 

diabetes medications, 8.0 percent for ambulatory care, 2.1 percent for self-care equipment, 

and 0.3 percent for medical rehabilitation. The value of self-care was estimated at up to 

48,282 working months per year, equivalent to $980 (U.S. dollars) per patient per year; 

however, this cost was not included in the calculation of ambulatory costs. The direct costs of 

health care for patients with diabetes represented 5.8 percent of the total health care costs in 

Finland in 1989 and were three times higher than the average costs of care for patients 

without diabetes. 1 figure, 1 table, 22 references. 

226 

TITLE: Systematic Care of Diabetic Patients in One General Practice: How Much Does It 

Cost? Koperski, M. British Journal of General Practice. 42(362): 370-372. September 1992. 

OBJECTIVE: To assess the cost of conducting a monthly health promotion session focused 

on diabetes within a general practice consisting of seven physicians, two trainees, and two 

nurses. 

CATEGORY: Cost of diabetes (direct and indirect). 

Type of Study: Economic assessment. 

Methodology: Cost analysis. 

Perspective: Health care system. 

CONCLUSION: The costs of running a diabetic care day in a London general practice were 
greater than remuneration. 

RECOMMENDATION: An adequate remuneration package for general practitioners could 

improve care for many patients with diabetes. 

ABSTRACT: The author analyzed the direct costs for a London, England, general practice 

of seven physicians, two trainees, and two nurses for monthly "diabetic days" that emphasized 

care of patients with diabetes. To calculate the cost of physician time, the number of targeted 

consultations in 1987 was multiplied by the scheduled consultation time, then divided by the 

total number of office hours booked for 1 year for a full-time general practitioner. The result 

was multiplied by £ 31,105, the average net remuneration established by the Doctors and 

Dentists Review Body in 1989. The hours worked by nurses and clerical staff on diabetic days 

were divided by the total hours worked per year, then multiplied by their annual salary plus 

employer's contributions. Without family health service authority reimbursement, costs for 77 

patients to make a total of 117 visits on diabetic days were £ 1,340.97 for physicians, £ 

1,214.93 for nurses, £ 357.66 for clerical staff, £ 41.32 for 16.8 square meters of building 

space, £ 45.10 for stationery, and £ 1,465.66 for dietitian and chiropodist consultation, for a 

total of £ 4,465.66. With family health service authority reimbursement, costs for nurses and 

clerical staff were reduced to £ 330.01 and £ 97.13, respectively, lowering the total cost to £ 

1,854.53. Thus, the cost per patient visit was £ 38.17 to the National Health Service and £ 

15.85 to the practice. Diabetic days earn a practice £ 1,080.00 annually (1991 prices) through 

a health promotion incentive, well below the cost to the practice surveyed. Furthermore, there 

is no payment for setting up these clinics. The present system encourages low-quality, lowcost care. 1 table, 18 references. 

POLICY/POSITION STATEMENTS 

RELATED TO DIABETES 

227 

TITLE: American Diabetes Association Annual Meeting 1996: Managed Care and Change in 

Medicine. Bloomgarden, Z.T. Diabetes Care. 19(10): 1169-1173. October 1996. 

OBJECTIVE: To review presentations at the 1996 meeting of the American Diabetes 

Association (ADA) about managed care and changes in health care delivery. 

CATEGORY: Policy/position statement. 

CONCLUSION: Various presentations at the meeting are discussed. 

RECOMMENDATION: None. 

ABSTRACT: At the annual meeting of the ADA, the president of the association, Frank 

Vinicor, asserted that the United States does not perceive diabetes to be high risk (i.e., a 
transmissible disorder) or economically important. Edward Wagner, of Group Health of Puget 

Sound, advocated a population-based approach to diabetes care focused on preventing 

complications and reaching all patients. He considered it critical to define the subset of 

patients who need a specialist. Another speaker, Neal Friedman, advocated critical pathways 

for decision making, which lower inter-physician variability, increase cost efficiency, and 

improve outcomes. Dr. Friedman recommended using experts from other industries in the 

quality assurance process, as well as focus groups. He stressed data management and 

emphasized using the database to improve quality. His clinic in New Mexico uses disease 

management for the 30 most expensive diseases, which include diabetes. Also at the meeting, 

the potential adverse impact of managed care practices on diabetes care was addressed. Alan 

Jacobson, of Boston, raised the possibility that diabetes care may become similar to that of 

mental health disorders under managed care, with carve-out for-profit specialty companies 

drastically limiting patient access to specialty care. The subprograms of the Diabetes Control 

Network, a program that was publicized by both the Pfizer drug company and the ADA, were 

detailed. This program includes practice guidelines for primary physicians in managed care 

organizations and a computer program that models future medical costs and potential quality 

control strategies. Other issues addressed at the meeting included the disproportionately high 

use of medical resources by patients with diabetes, inadequate and variable reimbursement for 

preventive and self-management methods, and deficiencies in the current treatment of 

diabetes, particularly in screening for complications. 

228 

TITLE: Medicare Supplement Plan Required to Cover Diabetes. Minnesota Medicine. 78 

(12): 40. December 1995. 

OBJECTIVE: To describe a new law governing Medicare supplemental insurance plans. 

CATEGORY: Policy/position statement. 

CONCLUSION: The law will help the elderly afford preventive testing and management 

supplies they need for diabetes care. 

RECOMMENDATION: Accepted standards of care ought to be covered by insurance 

policies. 

ABSTRACT: Medicare supplemental insurance plans are now required to cover the cost of 

supplies and equipment necessary to treat diabetes. Previous law required only that health 

plans cover "all physician-prescribed, medically appropriate and necessary" equipment and 

supplies used to manage and treat diabetes. The change takes effect for those plans issued or 

renewed on or after January 1, 1996. In Minnesota, 45 percent of persons diagnosed with 

diabetes are aged 65 or over. According to the Minnesota chapter of the American Diabetes 

Association (ADA), the new law will make it easier for the elderly to afford the preventive 

testing and management supplies they need to control their diabetes and reduce the risk of 

complications. According to the chair of the government relations committee of the ADA, the 

new law will greatly improve access to appropriate medical care for the patient with diabetes. 
229 

TITLE: Budget Trends and Issues Affecting Biomedical Research: A Perspective from the 

National Institute of Diabetes and Digestive and Kidney Diseases. Gorden, P.; Cyphers, D.F.; 

Feld, C. Hepatology. 18(3): 677-687. September 1993. 

OBJECTIVE: To review the federal budget process for research from the perspective of the 

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 

CATEGORY: Policy/position statement. 

CONCLUSION: The federal deficit and debt and associated cost containment and cost 

management principles will continue to have a major impact on the National Institutes of 

Health (NIH) budget, limiting the size of research grants. 

RECOMMENDATION: None. 

ABSTRACT: The authors describe the NIH budget process and review historical 

developments. In the late 1980s, NIH funding became more constrained, but average grant 

size continued to rise; the duration of grant awards increased, and the number of applications 

rose. In response to congressional concerns about rising grant costs and approval rates, the 

NIH developed the NIH Financial Management Plan (1991). The plan limits the percentage 

increase in grant size to the rate of inflation, adjusts grant budgets on a case-by-case basis, and 

limits the length of an award to 4 years. From 1987 to 1993, the NIDDK's appropriation in 

constant dollars was virtually flat. The institute has become increasingly committed to 

investigator-initiated research and to the NIH peer review system for making funding 

decisions based on scientific merit. The NIDDK will need to continue to conceptualize and 

justify its research portfolio in terms of major cross-cutting categories of interest to the public, 

the administration, and Congress, such as research in the areas of prevention and women's and 

minority health. To the extent that the NIDDK can compete successfully for trans-NIH funds, 

it will increase its own funding and help its constituencies. With limited funding for grants 

likely to continue, other funding options will be explored: cofunding; smaller, short-term 

awards; a sliding-scale approach to paying grant costs; cost containment incentives; caps on 

salaries and other costs; and reducing indirect costs. 6 figures, 2 tables, 6 references. 

230 

TITLE: CDC Diabetes Control Programs — Overview of Diabetes Patient Education. 

Alogna, M. The Diabetes Educator. 10(4): 32-36, 57. Winter 1985. 

OBJECTIVE: To describe the planning process for the development of diabetes patient 

education programs in state Diabetes Control Programs (DCPs) supported by the Centers for 

Disease Control (CDC). 
CATEGORY: Policy/position statement. 

CONCLUSION: Preliminary results from state Diabetes Control Programs show that 

education interventions have increased knowledge, improved self-management skills, reduced 

hospitalizations, and lowered costs. 

RECOMMENDATION: None. 

ABSTRACT: The CDC established its DCP in 20 states in 1977 on the recommendation of 

the National Commission on Diabetes. The goal of the DCP was to reduce mortality, 

morbidity, and cost burden from preventable complications of diabetes at the community level. 

As part of this effort, CDC collected data from participating states on mortality, morbidity, 

and available resources as well as problems in controlling patients with diabetes and factors 

contributing to those problems. These data showed a lack of outpatient education programs; 

in most states, inpatient education was offered at more than 80 percent of hospitals but 

outpatient education at less than 25 percent. Inspection of Utah programs revealed that 

smaller hospitals there were less likely to have written teaching plans, formal follow-up of 

patients, and support groups. An inquiry into education in Ohio found that simple measures 

such as return demonstration and repetition and preassessments and postassessments were 

used most frequently. The least-used evaluation methods were monitoring the number of 

hospital admissions or emergency room visits. The states formed a working group to develop 

recommendations for quality patient education and process and outcome evaluation. As a 

result, the CDC developed the CDC-State Patient and Professional Education Guidelines to 

be used in evaluating existing programs, developing new programs, promoting reimbursement, 

and providing a guide for program certification. The CDC guide also served as a basis for 

Patient Education Standards later developed by the National Diabetes Advisory Board. 

Numerous other materials, manuals, assessment tools, instruments, and standards of care for 

diabetes care and education have been developed. The author describes diabetes education 

activities undertaken in the individual states with a DCP. 2 tables, 6 references. 

231 

TITLE: Coverage of Diabetes Education Programs. Health Care Financing Administration 

Memorandum dated August 25, 1987. U.S. Department of Health and Human Services, 

Public Health Service, Health Care Financing Administration, Office of Coverage Policy, 

Bureau of Eligibility, Reimbursement & Coverage. 

OBJECTIVE: To detail Medicare coverage of outpatient diabetes education programs. 

CATEGORY: Policy/position statement. 

CONCLUSION: Outpatient hospital diabetes education programs located in a hospital or 

rural health clinic are covered under Part B of the Medicare program. Programs must be 

closely related to the care and treatment of individual patients. 
RECOMMENDATION: Intermediaries for Medicare should be making coverage decisions. 

ABSTRACT: In this memorandum, the author, Robert E. Wren of the Health Care Financing 

Administration, responds to an inquiry from the Regional Administrator in Dallas, Texas, 

about Medicare coverage of outpatient diabetes education programs. The author notes that 

Section 801 of the Coverage Issues Manual provides a useful framework for intermediaries in 

the claims review process. He also states that outpatient hospital education programs may be 

covered by Medicare if services are ordered by a physician, given by the provider's personnel, 

supervised by the medical staff, and rendered to registered patients of that provider. The 

services must be closely related to the care and treatment of the individual patient and must 

provide essential skills and knowledge that will aid in the patient's active participation in 

his/her own treatment. In general, patients likely to be suitable for such education efforts 

would be those newly diagnosed with diabetes, persons with unstable diabetes, and those with 

longterm diabetes who have current management problems. Long-term patients with stable 

diabetes would not likely be candidates. Programs should be relatively brief, with entrance by 

physician referral only. A letter to David C. Warner, Chairman of the Texas Diabetes Council, 

is appended in which Mr. Wren goes over many of the same points. 

232 

TITLE: Diabetes Outpatient Education: The Evidence of Cost Savings. American Diabetes 

Association Task Force on Financing Quality Health Care for Persons with Diabetes. 1986. 4 

pp. 

OBJECTIVE: To document evidence of cost savings resulting from diabetes education; to 

report the existence of standards for assuring quality educational programs. 

CATEGORY: Policy/position statement. 

CONCLUSION: Diabetes education is now recognized as an integral component of 

treatment that results in cost savings and improved quality of life. The quality of an education 

program is assured by the existence of certification exams for educators, national standards 

and criteria for programs, and a recognition process for programs that meet the standards. 

RECOMMENDATION: None. 

ABSTRACT: This report summarizes reported evidence of cost savings achieved through 

diabetes outpatient education. Much of the economic cost of diabetes is due to short- and 

long-term complications. Outpatient education in self-care leads to improved blood glucose 

control, self-care skills, and adherence to treatment regimens and reduces morbidity and 

premature mortality associated with diabetes and its complications. A record audit of 78 

consecutive community hospital admissions for complications due to diabetes found that 27 

percent of these admissions occurred because of a specific educational deficit. Lack of 

reimbursement is the most significant barrier to the development of outpatient education 

programs. The American Diabetes Association, American Hospital Association, National 
Diabetes Advisory Board, American Public Health Association, and the American Association 

of Diabetes Educators have all endorsed the concept of patient education as an integral part of 

diabetes treatment. Many studies on outpatient education show that these programs are 

clinically and cost effective. National standards for diabetes patient education programs have 

been developed, and a recognition process has been established for programs meeting the 

standards. In addition, a certification process for diabetes educators has been implemented. An 

increasing number of insurers are recognizing diabetes outpatient education as a reimbursable 

benefit. 2 tables, 23 references. 

233 

TITLE: Evaluative Approaches to Type II Diabetes. Triomphe, A. PharmacoEconomics. 8 

(Supplement 1): 58-61. 1995. 

OBJECTIVE: To review major methods for evaluating the economic efficiency of diabetes 

therapy and educational programs. 

CATEGORY: Policy/position statement. 

CONCLUSION: The economic evaluation of type 2 diabetes could play an important role in 

making management decisions about the disease. Yet, results of economic analyses should be 

used cautiously. 

RECOMMENDATION: A more consistent application of recent methods of economic 

evaluations could improve understanding of the economic consequences of type 2 diabetes. 

ABSTRACT: The author asserts that there are still very few economic evaluation studies on 

diabetes, especially type 2 diabetes. Cost-of-illness, the simplest form of economic evaluation, 

considers costs but not outcomes of therapy. Cost-effectiveness, cost-utility, and cost-benefit 

analyses are the major methods of evaluating the economic efficacy of diabetes therapy and 

educational programs. All three methods express costs in monetary terms, but they differ in 

the way they assess outcomes. In cost-effectiveness analysis, the efficiencies of interventions, 

treatments, or control programs are compared; and the health outcomes of the interventions 

are measured in physical units. Cost-utility analysis usually summarizes health outcomes in 

quality-adjusted life years saved. Cost-benefit analysis places a monetary value on the health 

outcomes of a program or therapy and can be used to compare the benefits and opportunity 

costs of a program. The quantity of health obtained is usually valued in terms of work 

productivity gained, which is generally measured by average wages. An alternative approach is 

to value life or health with a "willingness to pay" approach. The author notes that prevention 

programs are commonly held to save money over the long term, but she reports that they 

generally cost more than they save. She states the economic issue for discussion is not 

whether prevention saves money but whether it improves health at a reasonable cost. 1 table, 

9 references. 

234 
TITLE: Improving the Financing of Diabetes Care in the 1990s: Recommendations of the 

1989 Conference. Bransome, E.D. Diabetes Care. 15(Supplement 1): 66-72. March 1992. 

OBJECTIVE: To report on the financing problems identified by the 1989 Conference on 

Financing the Care of Diabetes Mellitus in the 1990s and on the recommendations for action 

made at the conference. 

CATEGORY: Policy/position statement. 

CONCLUSION: Major problems evident in the financing of diabetes care include lack of an 

adequate chronic disease model, inadequate communication between the treatment and 

reimbursement communities, and absence of data demonstrating the cost-effectiveness of 

diabetes care. 

RECOMMENDATION: Develop a health care delivery model appropriate for diabetes, 

establish better communication mechanisms between the diabetes and reimbursement 

communities, and expand the database of information pertinent to diabetes care 

reimbursement activity. 

ABSTRACT: The author reviews problems identified by participants in a conference 

workshop on the financing of diabetes care as well as their recommendations to address these 

problems. The prevailing acute disease model is not applicable to diabetes care, which 

involves ongoing, mostly outpatient services. Communication between reimbursers and the 

diabetes community is often ineffective, with health care professionals focusing on quality of 

care and service delivery and insurers on cost containment. A national forum is needed to 

involve both parties in the reimbursement decision-making process and ensure ongoing 

communication. Most patients with diabetes do not receive care that meets the current 

standards established by the American Diabetes Association and the Centers for Disease 

Control (CDC). Standards of care should be reviewed and updated in a timely fashion and 

widely disseminated to health care professionals and reimbursers. The diabetes community 

should work with the Health Care Financing Administration to expand reimbursement for 

patient education to Medicare beneficiaries. It should also support efforts to include 

reimbursement costs for patient education in services provided by nonphysicians. Patients are 

not meaningfully involved in the reimbursement decision-making process. Informed consumers 

should have input along with health care professionals working to implement standards of 

care. Insufficient data are available to document the cost-effectiveness of diabetes care. The 

CDC's database on reimbursement activity should be expanded to include data on program 

costs, outcomes of various delivery systems, cost-effectiveness and cost-benefit studies, and 

health care utilization patterns. 7 references, 2 appendixes. 

235 

TITLE: Medical Technology and Costs of the Medicare Program. Office of Technology 

Assessment, U.S. Congress, Washington, DC. July 1984. 230 pp. 
OBJECTIVE: To review policy mechanisms for limiting or reducing Medicare costs related 

to technology. 

CATEGORY: Policy/position statement. 

CONCLUSION: Medicare policies increase the use of medical technologies, and the use of 

medical technologies significantly affects Medicare costs. 

RECOMMENDATION: The authors make several suggestions for restraining the rise in 

Medicare costs by changing the incentives for adopting and using technology. 

ABSTRACT: The authors define medical technologies as the drugs, devices, and medical and 

surgical procedures used in medical care as well as the organizational and supportive systems 

in which such care is provided. Medical technology has been a primary cause of the rapid 

escalation in U.S. health care costs over the past 15 years. Medicare policies affect the 

adoption and use of medical technologies and, conversely, patterns and levels of use of 

Medicare technologies significantly affect Medicare costs. In this report, the Congressional 

Office of Technology Assessment identifies possible areas for changes in Medicare policies 

that could be used to influence the adoption and use of medical technology and to restrain 

Medicare costs: coverage policy for specific technologies, methods of payment to hospitals, 

methods of payment to physicians, and approaches to changing the incentives for adopting 

and using technology that do not directly involve the Medicare payment system (e.g., 

alternative delivery systems). Efforts to curb the escalation in Medicare costs and control the 

diffusion of medical technology have been largely ineffective to date. There are numerous 

incentives in Medicare's benefit policy to provide too many of some kinds of technologies and 

too few of others. The authors note Medicare's policy of not explicitly considering cost or 

cost-effectiveness in making coverage decisions; Medicare also has refrained from limiting 

coverage of particular technologies to specific institutions or to physicians with specific skills. 

29 tables, 3 figures, 5 appendices, 437 references. 

236 

TITLE: The National Long-Range Plan to Combat Diabetes, 1987. National Diabetes 

Advisory Board, U.S. Department of Health and Human Services, Public Health Service, 

National Institutes of Health. Washington, DC, 1987. 76 pp. 

OBJECTIVE: To set forth a long-range plan to combat diabetes mellitus that includes 

research, national goals, the translation of research findings to patient care, a review of 

accomplishments and future directions, and the role of the private sector. 

CATEGORY: Policy/position statement. 

CONCLUSION: None. 
RECOMMENDATION: Numerous recommendations are set forth in the body of the report. 

ABSTRACT: The National Diabetes Advisory Board, whose members (scientists, physicians, 

other health professionals, members of the general public) are appointed by the Secretary, 

Department of Health and Human Services, set forth recommendations in research, patient 

care, and other areas. In research, the Board recommended the development of eight 

interdisciplinary research programs, a biologic resource bank for studies on diabetes, and an 

information and data system for Diabetes Research. The objective of the interdisciplinary 

programs is to promote the rapid integration of newly developed methodologies of the basic 

sciences into diabetes-related research. Various recommendations are made to continue and 

strengthen current programs: for example, the Board recommended that adequate funds be 

appropriated to institutes of the National Institutes of Health to support at least 50 percent of 

approved diabetes-related, competing, individual research grants at budget levels approved by 

the scientific review committees; it is also recommended that the National Institute of 

Diabetes and Digestive and Kidney Diseases receive adequate funding to complete the 

Diabetes Control and Complications Trial as planned. In the section on diabetes goals for the 

nation, the Board recommended that consensus be reached on treatment guidelines for the 

diabetes patient without complications and that guidelines for the management of patients with 

complications be developed. In diabetes translation, the Board recommended that a Diabetes 

Translation Center be established at the Centers for Disease Control. In the section on the 

private sector, the Board recommended that this sector increase financial and human 

participation in Diabetes Research. 

237 

TITLE: National Standards and Review Criteria for Diabetes Patient Education Programs: 

Quality Assurance for Diabetes Patient Education. National Diabetes Advisory Board. 

Diabetes Educator. 12(3): 286-291. Summer 1986. 

OBJECTIVE: To define the standards and review criteria for a diabetes patient education 

program. 

CATEGORY: Policy/position statement. 

CONCLUSION: None. 

RECOMMENDATION: None. 

ABSTRACT: Ten standards developed under the aegis of the National Diabetes Advisory 

Board and endorsed by the diabetes community are presented. (1) Needs assessment: This 

activity should guide program management and form the basis for program planning. (2) 

Planning: The planning process should describe the program's goals and objectives, target 

audience, setting, referral mechanisms, procedures, and evaluation methods. (3) Program 

management: The ultimate responsibility should lie with the designated program coordinator. 

(4) Communications/coordination: A physician should act as liaison between the medical staff 
and the program coordinator. (5) Patient access to teaching: Both patients and staff should be 

routinely informed about self-care programs. (6) Content/curriculum: The individual needs 

assessment provides the basis for a patient's instructional program. (7) Instructor: Instructors 

should be skilled professionals with recent experience and training in diabetes and educational 

principles. (8) Follow-up: Written communication between program staff and primary 

physicians is essential for identifying the patient's needs. (9) Evaluation: Review should be 

conducted by an advisory committee made up of at least one of each of the following: 

physician, nurse (or qualified diabetes health educator), dietitian, consumer, and the patient 

education program coordinator. (10) Documentation: All information about the patient's 

educational experience should be documented in the patient's permanent medical or 

educational record. 

238 

TITLE: New Approaches to Medical Technology Coverage: Conference Proceedings. Miller, 

J.E. Health Insurance Association of America. 48 pp. April 1991. 

OBJECTIVE: To provide a synopsis of the proceedings of a 1990 conference on medical 

technology coverage sponsored by the Health Insurance Association of America. 

CATEGORY: Policy/position statement. 

CONCLUSION: Insurers must try to balance cost control, resource utilization, and quality of 

care as they make coverage and payment decisions. 

RECOMMENDATION: Insurers must develop the will and ability to adapt to pressures for 

faster and more open coverage processes. 

ABSTRACT: The author synopsizes the proceedings of the 1990 conference "New 

Approaches to Medical Technology Coverage" sponsored by the Health Insurance 

Association of America. Topics included the ethics of technology assessment, insurance 

coverage issues and innovative approaches to coverage decisions, law and policy, evaluating 

the clinical effectiveness of screening tests, designation of qualified centers for specialized 

services, and methodologies and applications of quality assessment. The controversy 

surrounding the development and use of medical practice guidelines was debated, with 

opinions offered by representatives of the medical and insurance communities. The issue of 

coverage policy relative to a technology's cost-effectiveness was also addressed. Cost-benefit 

and cost-analysis data were noted to be inadequate in many areas of health care, and it was 

suggested that such studies be conducted not only by the government but also by companies 

seeking to market new drugs and technologies. 

239 

TITLE: Office Visits for Diabetes Mellitus: United States, 1989. Schappert, S.M. Advance 

Data from Vital and Health Statistics of the National Center for Health Statistics; No. 211. 
12 pp. March 24, 1992. 

OBJECTIVE: To present national estimates of diabetes-related office visits in the United 

States in 1989. 

CATEGORY: Policy/position statement. 

CONCLUSION: During the study period, there were an estimated 13.2 million visits to 

nonfederally-employed, office-based physicians in the United States in which the principal 

diagnosis was diabetes mellitus. 

RECOMMENDATION: None. 

ABSTRACT: The author reports on estimates of diabetes-related office visits in the United 

States for the 12-month period of March 1989 to March 1990. Data were derived from the 

National Ambulatory Medical Care Survey. During the study period, there were an estimated 

13.2 million visits made to nonfederally-employed, office-based physicians at which the 

principal (first-listed) diagnosis was diabetes mellitus. More than half (57.5 percent) of these 

visits were made by females, and 86.3 percent were made by persons aged 45 years and older; 

79.3 percent of visits were made by white persons. Forty-four percent of visits were made to 

general or family practice physicians. Internal medicine specialists received 28.7 percent of 

visits, and ophthalmologists received 6.8 percent. Patients making return visits to the 

physician for care of their condition accounted for 92.2 percent of the 13.2 million office 

visits. During the study period, diabetes mellitus was the second- or third-listed diagnosis for 

an additional 8.7 million office visits. For all office visits in 1989, diabetes mellitus was the 

seventh most frequently reported principal diagnosis but the fourth most frequently reported 

morbidity-related principal diagnosis (essential hypertension, otitis media, and acute upper 

respiratory infections were the first three). Approximately 72 percent of visits with a principal 

diagnosis of diabetes mellitus included a blood pressure check; other frequently performed 

diagnostic services on these visits included "other" blood tests, urinalysis, cholesterol measure, 

and visual acuity examination. Weight reduction was the most frequently reported type of 

counseling/advice ordered or provided. 3 figures, 18 tables, 7 references, 1 technical note with 

3 tables. 

240 

TITLE: Practice Guidelines for Nutrition Care by Dietetics Practitioners for Outpatients with 

Non-Insulin-Dependent Diabetes Mellitus: Consensus Statement. Franz, M.J. Journal of the 

American Dietetic Association. 92(9): 11361139. September 1992. 

OBJECTIVE: To present practice guidelines for nutrition care to dietetic practitioners who 

treat outpatients with type 2 diabetes. 

CATEGORY: Policy/position statement. 

CONCLUSION: Nutrition practice guidelines provide a road map for nutrition care that 
allows for consistency in the individualized care of people with type 2 diabetes. 

RECOMMENDATION: Patients with type 2 diabetes should be referred to a registered 

dietitian within the first month after diagnosis, with a follow-up visit at two to four weeks and 

semiannual or annual visits thereafter. Physicians should supply the registered dietitian with 

information on diagnosis, treatment modalities and response to date, laboratory values, 

medical clearance or limitations for exercise, and, if appropriate, psychological or economic 

data. 

ABSTRACT: The American Dietetic Association contracted with the International Diabetes 

Center (IDC) in Minneapolis, Minnesota, to develop, fieldtest, and evaluate nutrition care 

practice guidelines. This article is the report of an interdisciplinary consensus panel of experts 

chaired by the IDC's M.J. Franz, which met in Minneapolis in October 1991. The panel was 

charged with addressing several critical questions: (1) What are realistic outpatient nutrition 

care practice guidelines for persons with type 2 diabetes? (2) What decisions are the 

responsibility of the physician? Of the registered dietitian? (3) What are the expected 

outcomes related to the nutrition practice guidelines? (4) What is usual nutrition care in the 

United States for persons with type 2 diabetes? The panel concluded that registered dietitians 

should determine an appropriate diet prescription for the patient and select appropriate 

educational materials and interventions. It was determined that two-way communication 

between the physician and the registered dietitian is critical and that medical outcomes should 

be evaluated to determine the effectiveness and cost of treatment. Implementing therapeutic 

advice is important for patients, but how patients view their quality of life may be equally 

important. In evaluating usual nutrition care in the United States for persons with type 2 

diabetes, the panel found that initial nutrition information is provided by the physician, nurse, 

or registered dietitian. Physicians may spend approximately five minutes handing out diet 

sheets, but they solicit little if any information from patients about convenience or their ability 

to follow the meal plan. Another frequent option is for the nurse to spend 10 to 20 minutes 

providing initial nutrition information. In a 1989-1990 physician survey conducted by the 

National Institute of Diabetes and Digestive and Kidney Diseases, a majority of respondents 

said they referred patients with type 2 diabetes to registered dietitians, but it is not known how 

may patients actually see a dietitian. 17 references. 

241 

TITLE: Practice Guidelines for Nutrition Care by Dietetics Practitioners for Outpatients with 

Non-Insulin-Dependent Diabetes Mellitus: Methodologies for Field Testing and Cost 

Effectiveness Analysis. Mazze, R.S.; Franz, M.J.; Monk, A.; Cooper, N.; Barry, B.; Weaver, 

T.; McClain, K.; Upham, P.; Haugen, D.; Bergenstal, R. Journal of the American Dietetic 

Association. 92(9): 11391142. September 1992. 

OBJECTIVE: To describe a clinical study designed to assess the impact of nutrition care on 

persons with type 2 diabetes. 

CATEGORY: Policy/position statement. 
CONCLUSION: The study is expected to yield information that will help physicians and 

dietitians better understand the nature of nutrition care in diabetes management. Designing 

and implementing the nutrition protocols has already yielded important information, such as a 

consensus as to what is meant by basic and intensive nutrition care for people with type 2 

diabetes. 

RECOMMENDATION: This study design may serve as a model for the study of the 

effectiveness and cost-effectiveness of nutrition care for other diseases and conditions. 

ABSTRACT: A 2year clinical study has been designed to test three hypotheses for persons 

with type 2 diabetes treated in an ambulatory setting with either basic nutrition care or care 

based on practice guidelines determined by expert consensus. The hypotheses are that 

nutrition care based on practice guidelines will significantly lower blood glucose levels, will 

significantly improve abnormal lipid profiles, and will significantly control weight in obese 

patients; in each case, the change is to be within three months, with a requirement for 

stabilization or further improvement over the next three months. The study will include 240 

patients diagnosed with type 2 diabetes and free of diabetes complications (e.g., nephropathy), 

who were recruited from ambulatory clinical sites in three states and randomly assigned to 

either basic nutrition care or care based on the guidelines. The patients will be between the 

ages of 40 and 70 years, must be able to attend the clinics as required by the protocol, and be 

willing to follow either the basic or practice guideline care regimen. Patients will be evaluated 

at study enrollment, at three months, and at six months. Data will be collected for biophysical 

measures (e.g., blood glucose, body mass index), behavior/education (e.g., compliance, 

knowledge), and cost. Records will be kept of adverse events (e.g., coma, infections). A cost 

analysis of the two interventions will document the costs for labor, administrative overhead, 

supplies, and medications related to direct service delivery and outpatient treatment. Rigorous 

documentation of effects and careful cost documentation will permit a cost-effectiveness 

analysis to be performed. 1 figure, 35 references. 

242 

TITLE: Preventive Health Services for Medicare Beneficiaries: Policy and Research Issues. 

Washington, DC: Office of Technology Assessment, United States Congress. February 1990. 

37 pp. 

OBJECTIVE: To examine the process that dictates the coverage and delivery of preventive 

services for Medicare beneficiaries. 

CATEGORY: Policy/position statement. 

CONCLUSION: None. 

RECOMMENDATION: Consideration should be given to funding extended follow-up 

periods at some of the sites for federal demonstration projects on the costs and effectiveness 

of providing preventive health services under Medicare. Effectiveness research should be 
targeted to services offering the potential for large impacts on health status or health costs of 

the elderly. 

ABSTRACT: Vaccines for pneumococcal pneumonia and hepatitis B, screening, 

mammography, and Pap smears are the only preventive services covered by Medicare. The 

wisdom of excluding preventive services has been questioned by numerous experts and 

interested groups. The authors point out that some procedures performed for screening 

purposes (e.g., lower GI endoscopy) may be paid by Medicare as diagnostic procedures, and 

tertiary preventive services (e.g., hypertension control) may be reimbursable as therapeutic 

services. In addition, Medicare beneficiaries enrolled in health maintenance organizations or 

other competitive medical plans may receive extra preventive care. The authors note several 

reasons why Medicare coverage of a preventive service may not be enough to bring about 

appropriate use patterns; consumer, physician, and service characteristics may be more 

important than out-of-pocket costs. The current strategy for adding preventive services is ad 

hoc and procedure-specific; formulation of a complete strategy requires choices in the unit of 

payment (individual procedures versus a service package), criteria to govern the coverage 

decision and standards for evidence (possible criteria include effectiveness, cost-effectiveness, 

impact on Medicare outlays, and net economic benefits), and locus of responsibility for 

coverage decisions. The authors discuss several issues relating to the evaluation of evidence 

on the cost-effectiveness of preventive services for the elderly and note that the Health Care 

Financing Administration is supporting six demonstration projects whose goals are to assess 

the costs and effectiveness of providing health services under Medicare. They cite problems 

(e.g., design and funding) in the studies and predict that the evidence they produce will be 

limited. Appendices A-D cover acknowledgments, Office of Technology studies in preventive 

services for the elderly, Medicare preventive services demonstration projects, and 

recommendations for periodic health examinations in the elderly. 6 tables (1 in main text, 5 in 

appendices), 4 appendices, 101 references. 

243 

TITLE: Preventive Services. United States Department of Health and Human Services, 

Public Health Service, Health Care Financing Administration. In: State Medicaid Manual. 

Part 4: Services. Transmittal No. 41. February 1989. 4 pp. 

OBJECTIVE: To provide guidelines on optional coverage of preventive services under 

Medicaid. 

CATEGORY: Policy/position statement. 

CONCLUSION: Increased use of preventive services offers the potential for improving 

individual health and reducing the cost of treating illness and injury. 

RECOMMENDATION: States should consider reviewing their Medicaid programs for ways 

to make a wider range of preventive services available and accessible to their Medicaid 

beneficiaries. 
ABSTRACT: In addition to including preventive care as part of other covered services, each 

state may cover preventive care as a separate benefit under its Medicaid program. For a 

Medicaid service to be covered, it must involve direct patient care and be for the express 

purpose of diagnosing, treating, or preventing (or minimizing the adverse effects of) illness, 

injury, or other impairments to an individual's physical or mental health. Often, a state may 

have a wide range of preventive services available, but the services are fragmented among 

numerous agencies and programs in addition to Medicaid. States interested in initiating or 

expanding a Medicaid preventive care effort can take a two-pronged approach: (1) Medicaid 

funding of medically oriented personal preventive services for which federal financial 

participation is available under Title XIX; and (2) increased coordination between Medicaid 

and other programs that fund or provide preventive care, including referral to social and 

environmental programs and services. In evaluating amendments to state plans for providing 

preventive services, the Health Care Financing Administration requires that the proposed 

services be preventive and fit within the basic Medicaid medical-remedial framework, be 

directed at the patient, not be otherwise available without cost, not duplicate other federally 

funded services, and not entail additional payment for a service that is logically a part of 

otherwise covered services (e.g., a physician providing preventive counseling). Regarding 

coordination with other programs, the Medicaid agency can perform a valuable referral 

function and help to supplement available preventive services by directing beneficiaries to 

appropriate preventive care (e.g., examinations, immunization and treatment services) 

available from other sources. 

244 

TITLE: Public Health Focus: Physical Activity and the Prevention of Coronary Heart 

Disease. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report 

(MMWR). 42(35): 669-672. September 10, 1993. 

OBJECTIVE: To summarize information on the potential efficacy and cost benefit of 

promoting physical activity as a way to prevent coronary heart disease. 

CATEGORY: Policy/position statement. 

CONCLUSION: Educating health professionals and lay persons to implement effective ways 

of reducing risk factors for coronary heart disease could reduce health care costs substantially. 

RECOMMENDATION: Sites that promote physical activity should emphasize participation 

in a variety of self-directed, moderate-level physical activities with a goal of 30 minutes of 

participation a day for 5 days a week. 

ABSTRACT: Coronary heart disease is the leading cause of mortality in the United States; 

each year 1.5 million people are diagnosed with this disorder, whose direct and indirect heath 

care costs are estimated at $47 billion. A 1987 review of 43 epidemiologic studies concluded 

that moderate to vigorous physical activity reduced coronary heart disease. The risk for 

coronary heart disease was almost doubled for persons who were physically inactive. Based 
on 1989 mortality estimates for coronary heart disease, the extrapolated cost of physical 

inactivity was $5.7 billion, with elevated serum cholesterol the only risk factor for coronary 

heart disease having a higher estimated cost. In an analysis using hypothetical cohorts over a 

30-year period, physical activity was associated with 78 fewer coronary heart disease events 

and 1,138 quality-adjusted life-years gained. For each quality-adjusted life-year gained, direct 

cost equals $1,395 and total costs, $11,313. Worksite-based physical activity programs have 

been estimated to cost employers $100 to $400 per employee per year, but they return an 

estimated $513 per employee per year. A Canadian intervention program reduced medical 

claims $6.85 per year for each dollar invested. Annually, in the United States, 20,000 fewer 

people would die if half the persons with no leisure-time physical activity engaged in moderate 

physical activity two to three times per week. Physical activity may prevent coronary heart 

disease by improving weight control, enhancing glucose tolerance and insulin sensitivity, 

reducing blood pressure, improving coronary artery blood flow, and augmenting high-density 

lipoprotein levels. Educating health professionals and lay persons to implement effective ways 

to reduce risk factors for coronary heart disease could result in substantially reduced health 

care costs. In addition to worksite programs, physical activity programs have been promoted 

in the schools, community, physician offices, health clinics, homes, and neighborhoods. 2 

tables, 16references. 

245 

TITLE: Public Health Focus: Prevention of Blind-ness Associated with Retinopathy. Division 

of Diabetes Translation, National Center for Chronic Disease Prevention and Health 

Promotion, Centers for Disease Control and Prevention. Morbidity and Mortality Weekly 

Report (MMWR). 42(10): 191-195. March 19, 1993. 

OBJECTIVE: To summarize information on the efficacy and cost-effectiveness of screening 

for retinopathy. 

CATEGORY: Policy/position statement. 

CONCLUSION: (from editorial note) Screening for retinopathy is effective for preventing 

blindness and is cost effective. 

RECOMMENDATION: (from editorial note) Improvement must be made in the timeliness 

of screening, case-finding, and entry into the health care system of persons with diabetes. All 

persons with diabetes (except those with type 1 diabetes for less than 5 years) should receive 

an annual dilated eye examination by a trained provider with appropriate referral and 

treatment. 

ABSTRACT: Studies of the efficacy and cost-effectiveness of screening for retinopathy are 

reviewed. More than 90 percent of persons with type 1 diabetes have some retinopathy 15 

years after diagnosis; 90 percent of persons with type 2 diabetes who are treated with insulin 

have some retinopathy 25 years after diagnosis. Among type 2 patients not treated with 

insulin, more than 60 percent have some retinopathy after 20 years. Prospective clinical trials 

have shown that laser photocoagulation therapy is effective in reducing the risk of visual 
impairment. Panretinal laser photocoagulation can reduce the risk of severe visual loss by at 

least 60 percent in some patients with diabetes. An annual eye examination can identify 

retinopathy early and permit timely treatment to prevent loss of vision and possible blindness; 

in a retinal study, however, half of diabetes patients had not had a dilated eye examination in 

the preceding year. Economic evaluations indicate that screening for retinopathy costs less 

than the cost of 1 person-year of blindness. A study by Dasbach et al. (1991) showed that 

biannual and annual screening programs for persons with type 1 and type 2 diabetes were cost 

effective. A study by Javitt et al. (1990) evaluated the cost-effectiveness of different screening 

protocols for retinopathy in patients with type 1 diabetes; the various strategies were 

estimated to save $62 million to $109 million and 71,000 to 85,000 sight years annually in the 

United States. 2 figures, 1 table, 14 references. 

246 

TITLE: Rediagnosing Health Care: Providers' Perspectives. Shortridge, C.L. Diabetes Care. 

17(3): 248250. March 1994. 

OBJECTIVE: To provide an overview of the Health Security Act unveiled by President 

Clinton in October 1993 and to discuss the potential health care implications of this plan 

should it be enacted. 

CATEGORY: Policy/position statement. 

CONCLUSION: The American Diabetes Association supports health care reform, but the 

specifics of the Health Security Act give concern to many physicians who treat patients with 

diabetes. 

RECOMMENDATION: As this and other health care plans are circulated through 

Congress, concerns raised by the medical community (e.g., ease of referral to specialists in the 

treatment of diabetes, effective preventive services for people with diabetes) must be 

considered. 

ABSTRACT: If passed, President Clinton's 1993 Health Security Act would create a national 

managed competition system with health alliances, which would be similar to health 

maintenance organizations and preferred provider organizations. Some physicians fear that 

this system will hurt private practice, restrict access to specialists, and impair freedom of 

choice. The Health Security Act establishes a seven member National Health Board that 

would oversee the health care system, which would be composed of regional or corporate 

health alliances or state run, single-payer systems. Regardless of which system a state chooses, 

a comprehensive benefits package will be offered. The American Diabetes Association is 

committed to ensuring that the plan's basic benefits package includes access to appropriate 

diabetes treatment and management. Physicians in a health alliance will be paid by the alliance, 

and those in a single-payer system will be reimbursed by the state. Provider fees will be set by 

the alliance or by the state. Physicians may choose to join the health alliance or single-payer 

system in their state or remain outside the system in private practice. The only way patients 

can access a provider in private practice, however, is to pay for the visit themselves. The plan 
will establish programs to retrain some specialists as primary care physicians. The plan will 

also guarantee that 55 percent of medical students enter residencies in family medicine, 

general internal medicine, general pediatrics, or obstetrics and gynecology. To further deter 

specialization, the plan will determine the number of specialty slots nationwide available for 

enrollment in medical education programs. 

247 

TITLE: Resource Manual to Help Your Program Meet the National Standards. Teza, S.L.; 

DeVito, A.V. II; Hiss, R.G. Diabetes Educator. 13 Supplement: 210-228. May 1987. 

OBJECTIVE: To provide advice on developing or improving diabetes education programs; 

to give specific suggestions on ways to meet the National Standards for Diabetes Patient 

Education Programs. 

CATEGORY: Policy/position statement. 

CONCLUSION: Specific suggestions are provided for establishing, organizing, 

implementing, and evaluating education programs for patients with diabetes. 

RECOMMENDATION: These program suggestions should be considered by diabetes 

educators in developing and evaluating their patient programs. 

ABSTRACT: The authors first discuss needs assessment standards, which involve evaluating 

the need for diabetes education in the area served by a given institution and the educational 

needs of persons with diabetes. The planning phase of a diabetes education program is then 

detailed, including methods of establishing policy, the development and role of an advisory 

committee, and the steps involved in actual program planning. Program management is then 

discussed, including the role of the program coordinator, organizational relationships, and 

budgeting. The fourth section examines communication/coordination, the use of physician 

liaisons, educational teams, and education records and provides sample education records. 

The fifth through tenth sections deal with patient access to teaching, content/curriculum, 

instructors, follow-up, evaluation, and documentation. A glossary of terminology and a 

collection of abstracts relating to diabetes education programs are included. Also included are 

the National Standards for Diabetes Patient Education Programs, which were developed under 

the aegis of the National Diabetes Advisory Board and have been endorsed by the diabetes 

community. 6 figures, 16 tables, 1 glossary. 

248 

TITLE: Screening for Diabetes Mellitus. U.S. Preventive Services Task Force. In: Guide to 

Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. 

Baltimore: Williams & Wilkins. 1989. pp. 95-103. 

OBJECTIVE: To assess the appropriateness of screening for diabetes mellitus in the U.S. 
population. 

CATEGORY: Policy/position statement. 

CONCLUSION: Screening for diabetes mellitus has not been proven sufficiently beneficial in 

nonpregnant, asymptomatic individuals to warrant widespread use. 

RECOMMENDATION: An oral glucose tolerance test is recommended for pregnant 

women between gestational weeks 24 and 28, but routine plasma or urine glucose screening in 

other asymptomatic persons is not recommended except possibly for people at high risk for 

diabetes. 

ABSTRACT: The authors discussed screening for diabetes mellitus in the population at large. 

As there are large intra- and interindividual variations in glucose measurements in healthy 

individuals and those with impaired glucose tolerance or diabetes, complex criteria involving 

multiple measurements are needed for a definitive diagnosis. Fasting blood glucose is an 

accurate test, but fasting is inconvenient, and, in some cases, sensitivity has been poor. 

Postprandial blood glucose is more convenient, but the time limitations for collecting blood 

makes it difficult to use for screening. The oral glucose tolerance test (GTT) is expensive and 

inconvenient because of the requirement for multiple venipunctures over several hours. A halfdose oral GTT for pregnant women has 83 percent of the sensitivity and 87 percent of the 

specificity of the full-dose GTT; for every true positive case of gestational diabetes identified, 

5 false positives are found. Urine glucose testing is considered unreliable with a sensitivity of 

less than 30 percent. Evidence is conflicting about the benefit of early detection and treatment 

impaired glucose tolerance; most people do not develop diabetes even without treatment. 

Data on the effect of early glycemia regulation on the subsequent development and 

progression of complications from diabetes are also conflicting. Studies have shown benefit to 

mother and child of glycemic control during pregnancy, although the influences of good 

prenatal care on outcome could not be assessed. An oral GTT is recommended for pregnant 

women between gestational weeks 24 and 28, but routine plasma or urine glucose screening in 

other asymptomatic persons is not recommended, except possibly for people at high risk for 

diabetes. 79 references. 

249 

TITLE: Source Book of Health Insurance Data 1991. Health Insurance Association of 

America. Washington, DC. 1991. 135 pp. 

OBJECTIVE: To provide a basic reference tool for private health insurance in the United 

States. 

CATEGORY: Policy/position statement. 

CONCLUSION: None. 

RECOMMENDATION: None. 
ABSTRACT: The authors describe the role and function of health insurance (chapter 1) and 

review the private health insurance industry (chapter 2). Succeeding chapters discuss public 

health coverage — expenditures and enrollment; medical care costs; health services, 

resources, and utilization; and disability, morbidity, and mortality. Brief sections cover "health 

and health care acronyms" and "historical facts." An extensive glossary is included. The report 

contains tables on a wide variety of topics, including coverage, premiums, health maintenance 

organization enrollment, Medicare enrollment, national health expenditures, hospital 

utilization, disability days, and many others. Data in the book were obtained from reports of 

insurance companies, government agencies, hospital and medical associations, and other 

health insurance plans. The book has been published annually by the Health Insurance 

Association of America since 1960. 67 tables. 

250 

TITLE: Third Party Coverage for Diabetes Education Program. Schwartz, R.; Zaremba M.; 

Ra, K. Quarterly Review Bulletin. 11(7): 213-217. July 1985. 

OBJECTIVE: To review the Ambulatory Diabetes Education and Follow-up Program in 

Maine and its efforts to acquire third party reimbursement. 

CATEGORY: Policy/position statement. 

CONCLUSION: The Maine Diabetes Control Project has successfully obtained third party 

reimbursement for a diabetes education program, first as a demonstration project, then on the 

basis of a study that revealed its economic benefit. 

RECOMMENDATION: Health education programs seeking reimbursement are encouraged 

to keep up with existing literature and Medicare and Medicaid regulations, ensure 

representation from third party payers, and prepare a cost-benefit analysis. 

ABSTRACT: Under an agreement with the Centers for Disease Control, Maine's Department 

of Human Services developed the Ambulatory Diabetes Education and Follow-up Program by 

working with area physicians to identify individuals with diabetes, interviewing the patients to 

assess their level of knowledge and attitudes about diabetes, and enrolling individuals and 

family/friends into group education classes and individual diet counseling. The curriculum 

(five classes plus a one-to-one dietary counseling session) covered an introduction to diabetes, 

testing and hyperglycemia, meal planning, medications and hypoglycemia, and "general 

factors" such as foot care, smoking, and publications and associations. In 1980, major third 

party payers agreed to reimburse hospitals or rural health centers in the state for this program 

if participants were referred by a physician, had an individualized education plan, had records 

maintained for them, and if the program met state guidelines. A follow-up study for January 

1981 through June 1982 found that the number of hospitalizations and length of stay were 

both reduced 32.2 percent, with a gross savings of $359,835. Participation in the program 

cost $150 per participant and resulted in a net savings of $293 per patient. Blue Cross-Blue 

Shield of Maine, Medicare, and Medicaid have continued to reimburse the program, which the 
parent Diabetes Control Project oversees to ensure its quality and to keep insurers informed of 

institutions that are participating. The authors suggest that those seeking third party coverage 

become familiar with existing literature and with Medicare and Medicaid regulations, solicit 

representation from third party payers at the project's beginning, prepare a cost-benefit 

analysis, form a committee of various entities (e.g., Blue Cross-Blue Shield, the hospital 

association) that might endorse the project's efforts to get reimbursement, and gain and 

maintain physician support. 2 figures. 

251 

TITLE: Third Party Reimbursement for Outpatient Diabetes Education and Counseling. 

American Diabetes Association. Diabetes Care. 13 (Supplement 1): S36. January 1990. 

OBJECTIVE: To articulate the position of the American Diabetes Association on 

reimbursement for outpatient education programs for patients with diabetes. (Note: This 

position statement was superseded by "Third Party Reimbursement for Diabetes Care, SelfManagement Education, and Supplies." Diabetes Care. 19 (Supplement 1): S48. January 

1996.) 

CATEGORY: Policy/position statement. 

CONCLUSION: Not making outpatient education a covered benefit is a major barrier to its 

availability and accessibility. 

RECOMMENDATION: The American Diabetes Association strongly supports and 

encourages adequate reimbursement and payment for those outpatient education services for 

patients with diabetes that meet accepted standards. 

ABSTRACT: Complications for patients with diabetes cost about $20 billion in 1987. Many 

studies have shown that education and self-management programs reduce costs of diabetes. 

Continuing patient education for self-management is integral to diabetes treatment, and all 

people with diabetes should have access to affordable patient education. National standards 

and a quality assurance program are already in place. The major barrier to patient education 

services is the lack of reimbursement by insurers and health care financing plans. 10 

references. 

252 

TITLE: Worksheet to Estimate Program Costs and Savings. Hunt, C. Diabetes Educator. 16 

(4): 282283. July-August 1990. 

OBJECTIVE: To provide a worksheet that clinicians can use to estimate program costs and 

net cost savings for diabetes outpatient education programs. 

CATEGORY: Policy/position statement. 
CONCLUSION: None. 

RECOMMENDATION: None. 

ABSTRACT: A worksheet used by Pennsylvania diabetes outpatient education programs to 

assist them in their dialogue with third party payers is presented. According to Barbara 

Bodnar, diabetes nurse consultant with the Pennsylvania Department of Health, pilot studies 

have documented a one-third reduction in inpatient hospital usage attributable to diabetes 

outpatient education programs. The worksheet has three distinct sections: inpatient costs, 

program costs, and net cost savings (estimated). Users of this worksheet simply input 

numerical data as outlined in the instructions. Upon reaching the end of the worksheet, users 

will have an estimate of the net savings to their hospital/clinic from the diabetes outpatient 

education program. A 30 percent figure is used in the worksheet for the reduction in hospital 

costs from diabetes patient education. 

EXPERT OPINION 

253 

TITLE: Access to Coverage: Health Insurance for People With Diabetes. Bransome Jr., E.D. 

Diabetes Spectrum. 1(1): 5962. March-April 1988. 

OBJECTIVE: To review progress made in health insurance coverage following the 1984 

Conference on Financing Quality Health Care for Persons with Diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: The diabetes community has made some progress in influencing coverage 

decisions by the reimbursement community, but much more still needs to be done. 

RECOMMENDATION: Since many coverage decisions are made locally, data collection 

and advocacy are needed at that level. The involvement of government relations, public 

policy, and advocacy committees of the American Diabetes Association affiliates is needed. 

ABSTRACT: The author provides an update of accomplishments and work still to be done in 

each of the topic areas for the 1984 Conference on Financing Quality Health Care for Persons 

with Diabetes. He notes that the American Diabetes Association (ADA) estimated that 5 to 8 

percent of all persons with diabetes (i.e., 550,000 to 880,000 persons) have no health 

insurance. He discusses legislation under consideration that would encourage states to 

establish health insurance risk pools. The author notes that reimbursement for patient 

education is usually not covered by third parties despite agreement that it is integral to care 

and evidence that it reduces hospitalizations. He reviews efforts by the diabetes community to 

justify coverage for outpatient education and notes that the Health Care Financing 
Administration (HCFA) issued a memorandum to a regional administrator that outpatient 

hospital and rural health education should be reimbursed under Part B of Medicare. The 

author points out that Medicare is still not paying for teaching programs except those based in 

hospitals or rural health clinics. He reports that the American Diabetes Association has begun 

discussions with HCFA about covering free-standing programs that are the sole educational 

programs in a community. The author also notes that preconference surveys found that 

important durable equipment and supplies were frequently not covered. He reports that the 

ADA has begun discussions with HCFA about broadening Medicare coverage to all people 

with diabetes who require insulin. In addition, the Office of Health Technology Assessment is 

reviewing continuous subcutaneous insulin infusion pumps, whose purchase is not covered by 

Medicare. 1 figure, 1 table, 9 references. 

254 

TITLE: Ambulatory Medical Care for Diabetes. Janes, G.R. In: Diabetes in America. 2d ed. 

National Diabetes Data Group, ed. National Institute of Diabetes and Digestive and Kidney 

Diseases. NIH Publication No. 95-1468. 1995: 541-552. 

OBJECTIVE: To review survey data on ambulatory care for persons with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Patients with diabetes account for a disproportionate amount of ambulatory 

care services. 

RECOMMENDATION: None. 

ABSTRACT: The author assessed data from the National Health Interview Survey (NHIS); 

National Ambulatory Medical Care Survey (NAMCS), which samples office-based physicians; 

and the National Medical Expenditure Survey concerning the impact of diabetes on the 

ambulatory medical care system. Per the 1990 NHIS, persons with diabetes accessed 

ambulatory care 96.1 million times, averaging 15.5 visits per person, compared with 5.5 visits 

per person in the general population. Rates were somewhat higher for women than men and 

for whites versus blacks. Per the NAMCS for 1981 and 1985, diabetes ranked second 

(excluding well-baby and pregnancy visits) to hypertension among frequently cited principal 

diagnoses associated with the patient's primary complaint during return office visits (for 1989 

and 1990 it ranked third after these exclusions). Between 1981 and 1990, the number of visits 

by persons with diabetes to an office-based physician increased 44 percent, versus an increase 

of 20 percent in the population at large. According to the 1990 NHIS, 96 percent of patients 

with diabetes indicated that as an inpatient or outpatient they had seen or talked with a 

physician or an assistant within the past year. Patients with type 2 diabetes saw a physician 

more frequently than those with type 1 diabetes; frequency of visits increased with age. Per 

NAMCS, in 1990-1991, only 8 percent of visits by patients with diabetes were made to a 

specialist in diabetes/endocrinology; in the 1989 NHIS, fewer than 50 percent of patients 

recalled seeing an ophthalmologist in the previous year, only 21 percent a dietitian/nutritionist, 

and only 17 percent a podiatrist. Mean length of physician visits (per NAMCS) for diabetes 
increased from 15.3 minutes in 1981 to 17.5 minutes in 1990. The percentage of visits paid for 

by patients decreased from 1985 to 1990, while the percentage paid by Medicare and 

commercial insurance (other than Blue Cross-Blue Shield) increased. 6 figures, 13 tables, 2 

appendices, 12 references. 

255 

TITLE: Ambulatory Nutrition Care: Adults-Diabetes Mellitus. Disbrow, D.D. VIII. Journal 

of the American Dietetic Association. 89(4):S35-S39. April 1989. 

OBJECTIVE: To describe through a literature review the economics, benefits, and costs of 

diabetes education programs. 

CATEGORY: Expert opinion. 

CONCLUSION: Evaluations of structured programs to provide diabetes education in 

outpatient settings have found improved clinical outcomes and cost savings from reduced use 

of health services. 

RECOMMENDATION: The cost of various nutrition services for patients with diabetes is 

very important information to provide to third party payers; dietitians need to report the costs 

of services provided. 

ABSTRACT: The author summarizes economic, benefit, and cost analyses of diabetes 

education programs. Reported costs per patient for outpatient diabetes education programs 

have ranged from $100 to $770. The North Dakota Diabetes Education Program (1982) was 

found by Blue Cross of North Dakota to be cost-saving; in 1985, Medicare and 18 insurance 

companies agreed to cover the service. Programs in Maine and Rhode Island and at Grady 

Memorial Hospital in Atlanta were also found to be cost-saving. A meta-analysis of 47 studies 

found that diabetes education had a moderate effect on all outcomes examined. The research 

suggests that opportunities for frequent contact and reinforcing the education principles over a 

long time have the greatest impact. The author states that there is considerable evidence that 

large savings in health dollars can be achieved by delivering diabetes education programs in 

the outpatient setting rather than during hospitalizations, but she points out that the validity of 

the research results has been questioned. Kaplan and Davis (1986) criticized reports used to 

support the resolution of the American Diabetes Association for third party reimbursement of 

outpatient diabetes education and nutrition counseling, finding fault with the study designs, 

cost analyses, follow-up, and extrapolation of results. 2 tables, 22 references. 

256 

TITLE: Amputation in the Diabetic Population: Incidence, Causes, Cost, Treatment, and 

Prevention. Fylling, C.P.; Knighton, D.R. Journal of Enterostomal Therapy.16(6): 247255. 

November-December 1989. 
OBJECTIVE: To summarize the current medical literature on the criteria for nontraumatic 

amputation and proposed interventions to reduce its incidence. 

CATEGORY: Expert opinion. 

CONCLUSION: Amputation is a complex problem for the patient, the health care system, 

and the country. 

RECOMMENDATION: Every effort should be made to reduce the incidence of amputation; 

this can only be achieved by identifying the causative problems and designing interventions to 

solve those problems. 

ABSTRACT: Patients with diabetes or with peripheral vascular disease are primary 

candidates for amputation. In the United States, there were 118,000 amputations of the lower 

limb in 1983. The authors found that contralateral amputation is common (e.g., 42 percent of 

patients in 1 study required an amputation of the other leg within 1 to 3 years of the first 

amputation). Death frequently occurs soon after an amputation (50 percent died in 3 years in 

1 study). The cost of amputation is high (over 50,000 lower extremity amputations in 1985 

cost a total of about $500 million for direct medical care, not including rehabilitation). 

Diabetes mellitus is by far the most common primary indication for lower extremity 

amputation; ischemia without diabetes ranks second. Amputations should be performed at the 

lowest level consistent with function (with the intent to maintain or restore the best function 

with the least loss of tissue). The most frequently cited criteria for amputation are gangrene, 

infection, and nonhealing ulcers. Modern prevention of amputation in the patient with diabetes 

includes state-of-the-art noninvasive vascular testing, angiography, distal vascular 

reconstruction procedures, infection control, total contact casting as appropriate, growth 

factors to enhance healing, orthopedic shoes, and patient education. 5 tables, 109 references. 

257 

TITLE: Applying Recent Findings to Clinical Care in Type II Diabetes. Williams, R. 

PharmacoEconomics. 8 (Supplement 1): 80-84. 1995. 

OBJECTIVE: To discuss the economics of applying findings from major clinical trials to the 

care of patients with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: The economic arguments for applying the results of major diabetes studies 

from the United States and the United Kingdom are compelling in the long term but require 

considerable short-term investment. This level of investment may be beyond the means of 

many developing countries. 

RECOMMENDATION: None. 
ABSTRACT: The economic consequences of diabetes vary in different parts of the world, 

due to differences in disease burdens (the epidemiologic transition) and differences in who 

bears the burden of the costs of diabetes (the individual, their families, or society). It has often 

been argued that advances in diabetes therapy, particularly advances in preventing 

complications, will reduce the cost of care. The effects of preventive measures on quality of 

life and on indirect costs, however, are likely to be much greater than on direct costs. 

Unfortunately, there are wide disparities in estimates of indirect costs and severe 

methodological difficulties in making these estimates. Application of the Diabetes Control and 

Complications Trial (DCCT) conducted in the United States and the United Kingdom 

Prospective Diabetes Study (UKPDS) (a study of the effectiveness of various oral 

hypoglycemic regimens versus dietary therapy alone in type 2 diabetes) to practice in 

developing countries will have economic consequences that are largely inconceivable, let alone 

sustainable. Analysis of the economic consequences of the DCCT, which confirmed the 

benefit of intensive therapy, found that the benefits of reduced complications outweighed the 

costs of more intensive treatment in the long term. In the UKPDS, glycemic control was 

significantly better in the groups treated with insulin or with oral hypoglycemic agents than in 

those treated with diet alone. Both the DCCT findings and early results of the UKPDS show 

that "higher tech" solutions are more effective. The economic case for implementing available 

interventions is usually less convincing for type 2 diabetes than for type 1, in part because the 

time that persons can remain free of complications is much less with type 2. The capacity for 

developing countries to make short-term investments is severely limited and will be further 

taxed as noncommunicable diseases such as diabetes become more prevalent. 2 tables, 15 

references. 

258 

TITLE: Assessing the Costs and Benefits of Medical Research: The Retinopathy Study. 

Drummond, M.F.; Davies, L.M.; Ferris, F.L. Social Science and Medicine. 34(9): 973-981. 

May 1992. 

OBJECTIVE: To develop and test a methodology for assessing the social costs and benefits 

of medical research. The Retinopathy Study is used as an example. 

CATEGORY: Expert opinion. 

CONCLUSION: It is possible to develop and test a methodology of assessing the costs and 

benefits of medical research that does not have the defects of earlier approaches. Using this 

method, the Retinopathy Study was extremely cost beneficial, with $10.5 million in research 

costs generating a net savings of $2,816 million to society. 

RECOMMENDATION: With some modification, the methodology described can be applied 

prospectively to assess not only how many resources should be invested in a specific clinical 

trial but also to determine the payoff from investing resources in promoting the dissemination 

of results or in changing incentives to encourage the adoption of new, cost-effective clinical 

practices. 
ABSTRACT: The authors retrospectively assessed the costs and benefits of the Retinopathy 

Study, a major clinical trial funded by the National Eye Institute between 1972 and 1981. The 

impact of the study, which was a randomized, controlled clinical trial of photocoagulation for 

severe retinopathy, on clinical practice for both proliferative and nonproliferative retinopathy 

was examined. Decision analysis was used to assess the expected costs and consequences of 

laser photocoagulation for persons with proliferative retinopathy in two alternatives: with and 

without the clinical trial. It was estimated that the trial, which cost $10.5 million, would 

provide a net savings to society of $2,816 million over 22 years' use of photocoagulation 

therapy, most of that figure coming from the avoidance of lost production. The government 

would save $2,249 million; patients, $1,339 million; and third party payers would incur a net 

cost of $772 million because of an increase in the use of photocoagulation. Even excluding the 

costs of lost productivity, there would be a net savings of $231 million to society over the 

same time period. In addition, there would be a net gain to the population of patients with 

retinopathy of 279,000 vision years. Sensitivity analysis showed the results were most affected 

by the assumptions about the likely impact of the trial on clinical practice, the effectiveness of 

the therapy, and the view taken on the relevance of including productivity losses. 2 figures, 4 

tables, 25 references. 

259 

TITLE: Cardiovascular Complications of Diabetes Mellitus: What We Know and What We 

Need to Know about Their Prevention. Savage, P.J. Annals of Internal Medicine. 124 (1 Part 

2): 123-126. January 1, 1996. 

OBJECTIVE: To review the problem of cardiovascular disease in persons with diabetes. To 

discuss the questions related to prevention of cardiovascular complications of diabetes that 

must be addressed by future clinical trials. 

CATEGORY: Expert opinion. 

CONCLUSION: Persons with diabetes are at substantially increased risk for cardiovascular 

complications, particularly those related to atherosclerosis. 

RECOMMENDATION: Until new clinical trials determine whether optimal glucose 

concentration normalizes the risk of cardiovascular disease and whether this approach is the 

most cost-effective intervention, existing guidelines for the control of cardiovascular disease 

risk factors in patients with diabetes should be strictly followed. 

ABSTRACT: The author reviews the existing literature on the etiology of cardiovascular 

disease in persons with diabetes and discusses future research needs relevant to prevention. 

Many studies have demonstrated an association between overt diabetes and cardiovascular 

disease. In developed countries, the risk of cardiovascular disease is increased two- to fourfold among patients with diabetes. Up to 75 percent of deaths among patients with type 2 

diabetes in the United States are attributed to ischemic heart disease or other heart and 

vascular diseases. The cardiovascular complications of diabetes are increasingly important 
because of population trends (rapid growth among the elderly and minorities) and because 

success in reducing microvascular complications will increase the numbers at risk for 

macrovascular complications. The Diabetes Control and Complications Trial did not establish 

that the macrovascular complications of diabetes can be reduced by controlling glucose 

concentrations, and questions about the relationship of hyperglycemia to risk for 

cardiovascular disease remain unanswered. Because of concern about medical care costs, 

consideration must be given to issues of relative efficacy, relative cost, and the patient burden 

from different interventions in developing a cardiovascular disease reduction program 

effective for most patients with diabetes. As the average patient with diabetes sees a physician 

less than one hour annually, without a major expansion in care there will be severe limits in the 

complexity of any program that could be implemented. Key questions to be answered are 

whether optimal glucose control normalizes the risk of cardiovascular disease and whether 

controlling glucose concentration is the most cost-effective intervention to prevent 

cardiovascular complications. 2 tables, 29 references. 

260 

TITLE: Case Management and Quality of Care for Diabetic Patients. Korn, A. Diabetes 

Care. 15(Supplement 1): 59-61. March 1992. 

OBJECTIVE: To describe a clinically sensitive case management process and its impact on 

quality of care. 

CATEGORY: Expert opinion. 

CONCLUSION: All patients may benefit from case management if it is accomplished 

through a peer-driven process. 

RECOMMENDATION: None. 

ABSTRACT: The author describes the elements of a clinically sensitive case management 

process and its potential impact on the quality of care of patients with diabetes. Case 

management, which he also calls managed care, is designed to achieve the best possible 

clinical outcome for each episode of patient care at a cost that represents the best value to the 

patient and benefit plan. The overall process must be ongoing and dynamic; a commitment to 

flexibility is required of payers so that, as feasible, benefits may be matched to clinical need in 

a sensitive, efficient manner. To achieve the best possible clinical outcome, case management 

must focus on the medical necessity of services. Interpretation of medical necessity should 

include a peer review. The value of a given treatment plan must also be evaluated from a 

financial as well as a clinical perspective. To serve the patient's best interests, the treatment 

plan should focus on the long-term outcome. But good case management must look at both 

short- and long-term values; price is only one determinant of cost over time. Clinical criteria 

are an evolving part of the case management process. Applying appropriateness criteria for 

specific therapies results in a risk-benefit analysis for a particular patient. Appropriateness 

criteria are gaining increased acceptance within the provider and payer communities. Case 

management has the potential to affect the quality of care of patients with diabetes, including 
aspects of individual patient treatment plans and laboratory screening procedures, patient 

compliance monitoring, and hospital utilization. 6 references. 

261 

TITLE: Clinical Economics: A Guide to the Economic Analysis of Clinical Practices. 

Eisenberg, J.M. Journal of the American Medical Association (JAMA). 262(20): 28792886. 

November 24, 1989. 

OBJECTIVE: To provide information for clinicians on how economic techniques can be 

applied to their medical practice to improve decision making about ways to use resources in 

the hope of improving health. 

CATEGORY: Expert opinion. 

CONCLUSION: The clinical economic techniques reviewed may help clinicians reach the 

societal goal of achieving the greatest benefit for the most people. 

RECOMMENDATION: None. 

ABSTRACT: The author provides a broad overview of the principles of economic analysis 

and how they can be used to make intelligent choices between alternative uses of resources. 

These decisions must consider both cost and outcome because there are only limited resources 

available; tradeoffs and choices are inevitable. The author describes three dimensions of 

economic analysis applied to medical care: type of analysis (cost identification, costeffectiveness, and cost benefit), point of view (society, patient, payer, and provider), and type 

of costs and benefits (direct medical, direct nonmedical, indirect, and intangible). Cost 

identification simply asks what the cost is; this analysis can guide medical practice only if a 

service has both lower cost and better or equal outcomes than the alternatives. Cost-effective 

analysis measures the net cost of offering a service and the outcomes obtained. It does not, 

however, assess whether outcomes are worth the cost. Cost-benefit analysis forces an explicit 

decision about whether the cost is worth the benefit. In terms of point of view, the author 

notes the bias that generally favors medical care for identifiable victims. He also discusses 

sensitivity analysis, which determines the degree to which uncertainty can influence 

conclusions about the economic impact of clinical decisions. The principles and methods of 

clinical economics equip physicians to be more critical users of information about the costs 

and effects of clinical practice. 4 figures, 2 tables, 44 references. 

262 

TITLE: A Clinician's Guide to Cost-Effective Analysis. Detsky, A.S.; Naglie, I.G. Annals of 

Internal Medicine. 113(2): 147154. July 15, 1990. 

OBJECTIVE: To show how economic analysis can be used to help decision makers set 

priorities for funding health care programs. 
CATEGORY: Expert opinion. 

CONCLUSION: Policymakers will be better able to set priorities for funding if their 

perspective and objectives follow some of the principles of a cost-effectiveness analysis. 

RECOMMENDATION: Clinicians should understand cost-effectiveness analysis, even 

though they do not use it in their clinical practice. 

ABSTRACT: The authors examine fundamental ideas about efficiency analysis in health care, 

which includes cost-effectiveness, cost-benefit, and cost-November/Decemberutility analysis. 

They provide examples to define cost effectiveness analysis and to show how it can be 

employed to allocate scarce health care resources across competing uses. Using this technique 

to set priorities assumes the decision maker has one objective, to maximize net health benefit 

to a target population from a fixed amount of resources, and that the decision maker values 

health benefits accruing to all persons in the target population equally. Cost-effectiveness 

analysis of a health care intervention requires comparing it with alternative methods of dealing 

with the patients in a given health state (e.g., comparison of drugs for patients with 

hypertension). The tension between the extra costs of an intervention and the extra clinical 

benefits brings forth the issue of setting priorities. Ratios of extra costs required to achieve 

one extra unit of clinical outcome are derived; these may be cost-effectiveness, cost-utility, or 

cost-benefit ratios. When units of clinical outcome can be measured in direct clinical terms 

(e.g., premature deaths avoided), cost-effectiveness ratios will be estimated. If clinical 

outcome units also consider utility or quality of life, cost-utility ratios are estimated. 

Incremental (marginal) cost-effectiveness or cost-utility ratios can be used to set priorities. 

The type of economic analysis discussed in this paper has a very limited role for individual 

clinicians caring for individual patients and is more appropriate for decisions affecting 

populations. 4 tables, 17 references. 

263 

TITLE: Cost Concepts for Diabetes Educators: An Introduction. Tobin, C.T. Diabetes 

Educator. 16(6): 456, 459. November-December 1990. 

OBJECTIVE: To introduce diabetes educators to decision analysis tools for business that are 

currently used in the health care setting. 

CATEGORY: Expert opinion. 

CONCLUSION: Understanding economic analysis and incorporating it into diabetes 

management practices enables diabetes educators to use cost terminology and analysis 

correctly, to evaluate the diabetes literature, to develop accurate cost data for individual 

services, and to enhance the credibility of reimbursement proposals to third party payers. 

RECOMMENDATION: It is more practical for health care professionals to learn business 

language than for policymakers or decision makers to learn the language of education and 
diabetes. 

ABSTRACT: Lack of third party reimbursement for outpatient education is a common 

problem for diabetes educators. When developing a proposal to have this service reimbursed, 

educators must understand the concerns of insurers. The author provides an overview of 

economic analysis so that diabetes educators can improve their communication with 

policymakers. She discusses four types of economic analysis: cost identification, costeffectiveness, cost benefit, and cost utility. Cost identification identifies the lowest cost of 

available alternatives. Cost-effectiveness provides the least costly alternative to achieve an 

outcome. Cost benefit determines whether a benefit is worth the cost. Cost utility adjusts 

outcome for quality and measures costs in dollars (e.g., cost of quality-adjusted life-years). 

The more diabetes educators know and understand about reimbursement and cost analysis, the 

more they will be able to activate their policymakers and third party payers and to make more 

informed decisions affecting their patient population. 1 table, 4 references. 

264 

TITLE: Cost of Diabetes Care. In: Clinical Diabetes Mellitus: A Problem-Oriented 

Approach. InZwaag, R.V.; Connor, M.; Dickson, H.D.; Runyan, J.W. (eds.) New York, NY: 

Thieme Medical Publishers. 1991. pp. 717-722. 

OBJECTIVE: To discuss direct and indirect costs for patients with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Medical care costs are increasing and will continue to increase, but attempts 

are being made to change these trends through government regulations, preventive care, and 

new methods of health care delivery. Hospitalization costs related to the treatment of diabetes 

complications are a major component of the total cost of diabetes. 

RECOMMENDATION: None. 

ABSTRACT: The authors define direct costs as those associated with diagnosis and 

treatment of diabetes, and indirect costs as those associated with loss of productivity from 

work, disability, and early mortality. The authors discuss direct costs of diagnostic tests, home 

glucose monitoring (urine and blood tests), and physician visits in 1987. The American 

Diabetes Association (ADA) reported for that year that 63 percent of persons with diabetes 

used home urine tests ($.10 per test) and 16 percent used home glucose tests ($.83 per test); 

of the home-monitoring group, 64 percent tested once a day. National Ambulatory Medical 

Care Survey data published in 1981 found diabetes ranked second to hypertension for diseasecoded physician visits. Diabetes had the highest proportion of return visits (.94), indicating a 

recurring expense for patients with diabetes. The authors analyze hospitalization data from 

two Memphis, Tennessee, providers. At the Baptist Memorial Hospital in 1988, circulatory 

disorders and hyperosmolar coma were the most expensive major complications of diabetes in 

terms of average length of stay and charge per day. Although average charges per day for 

most disorders were less for patients with diabetes, total charges were greater because lengths 
of stay were longer. Much earlier, the Memphis Chronic Disease Program demonstrated that 

hospital days can be reduced with a system of decentralized clinics using specially trained 

nurses as primary care providers. The total charges per patient in that program averaged $611 

per year (1977 dollars), in the range of national per capita expenditures for medical care in 

that period. Blindness, kidney disease, limb amputation, myocardial infarction, and stroke are 

expensive conditions that also should be considered in the direct costs of diabetes. In 1975, 

the direct cost of diabetes was estimated at $2.52 billion, and the indirect costs at $2.82 

billion. A 1987 report estimated direct costs for the disease of $9.6 billion and indirect costs 

of $10.8 billion. The authors note that the greatest benefit from prevention programs may 

derive from educational efforts directed to juvenile patients and pregnant women with 

diabetes. 4 tables, 15 references. 

265 

TITLE: Cost-Effectiveness of Diabetes Education. Assal, J-P. PharmacoEconomics. 8 

(Supplement 1): 68-71. 1995. 

OBJECTIVE: To present an argument for diabetes education. 

CATEGORY: Expert opinion. 

CONCLUSION: Resources spent on patient education lead to substantial savings over the 

longer term. 

RECOMMENDATION: Investment in patient education is needed. 

ABSTRACT: A review by Bartlett (1995) showed average savings of $3 to $4 per $1 

invested in patient health education. Diabetes education is also cost effective, but many 

patients do not have adequate access to such a program. In addition, educational programs on 

diabetes often do not include the poorly motivated or poorly educated, the elderly and 

isolated, and patients in denial. Physicians and allied health professionals have not been 

prepared through their education and training to educate their patients. The methodology 

required to educate patients about diabetes must be based on active learning by health 

professionals. Initially, education specialists need to supervise the educational programs for 

these professionals. Major investment in patient education by health care policymakers and 

administrators appears to be warranted. Without such investment there is little prospect of 

substantial improvement in the delivery of health education to the population with diabetes. 1 

figure, 1 table, 15 references. 

266 

TITLE: The Cost-Effectiveness of Preventive Care for Diabetes Mellitus. Elixhauser, A. 

Diabetes Spectrum. 2(6): 349-353. November/December 1989. 

OBJECTIVE: To summarize the literature on the costs associated with diabetes and to 
evaluate the economic aspect of programs for preventing its complications. 

CATEGORY: Expert opinion. 

CONCLUSION: Most of the programs were found to be effective in reducing morbidity, 

mortality, and costs associated with diabetes, but the strength of these findings is limited by 

study deficiencies. 

RECOMMENDATION: More accurate assessment of the clinical and economic impact that 

interventions have on preventing complications of diabetes is needed. 

ABSTRACT: The author summarizes the literature on the costs of diabetes and interventions 

against the disease. Five types of interventions are examined from an economic point of view: 

primary prevention, screening for gestational diabetes, glucose monitoring, changes in 

structure of medical care services, and educational or behavioral interventions. The main types 

of economic evaluation discussed are cost-of-illness studies, cost-benefit analysis (CBA), costeffectiveness analysis (CEA), and cost-utility analysis (CUA). All of the studies examined in 

this analysis were deficient in some way, limiting valid conclusions. The cost-of-diabetes 

studies examined only the primary diagnosis to avoid counting resource use twice, but this 

approach underestimates costs — diabetes is a secondary diagnosis in 2.5 times as many 

hospital discharges as it is a primary diagnosis and it is reported as a secondary cause of death 

3.5 times more often than as a primary cause. Studies to evaluate the cost-effectiveness of 

interventions are flawed by weak study design, lack of validation for the methodology used, 

failure to outline potentially relevant costs and consequences, use of a restricted range of 

costs, failure to report intervention costs, attributing changes to global measures without 

ruling out alternative explanations, failure to provide justification that the patient group 

examined was representative of the larger group with which it was compared, and failure to 

take into account false-negative screening results. Suggestions for improving the studies 

include allowance for false-negative screening results, adherence to performance standards 

(e.g., assessment of nonmedical direct and indirect costs), and adherence to the same 

research-design criteria governing studies of medical interventions. 3 tables, 49 references. 

267 

TITLE: The Costs of Diabetes and Its Complications. Leese, B. Social Science and 

Medicine. 35(10): 1303-1310. November 1992. 

OBJECTIVE: To review studies of the costs of diabetes and its complications. 

CATEGORY: Expert opinion. 

CONCLUSION: Major gaps exist in the data on the economics of diabetes, particularly on 

the indirect costs of the disease and the marginal benefits and costs of investing (e.g., 

providing funding for prevention and treatment) in diabetes. 

RECOMMENDATION: Cost-effectiveness studies must be performed for diabetes 
interventions to provide a basis for attempts to reduce the costs of the disease and to ensure 

that persons with diabetes are treated with efficacy and equity. 

ABSTRACT: The author reviews several studies of the costs of diabetes and its 

complications in order to locate gaps in the data, particularly for the United Kingdom. Results 

of studies on the economics of diabetes are presented in five categories: direct costs, indirect 

costs, psychological costs, cost of treatment of complications, and cost-effectiveness. 

Numerous direct-cost studies are reviewed; in Britain, people with diabetes consume 4 to 5 

percent of all health care resources. Few studies have included calculations of indirect costs 

because of the difficulty in assigning monetary values for such studies (e.g., to time lost from 

work, early retirement, and premature death). Psychological costs have rarely been considered 

in economic analyses. Complications are the most important contributors to the costs of 

diabetes, but lack a great deal of investigation from an economic perspective. Most studies of 

the economics of diabetes have been conducted in the United States, where health care is 

provided very differently than in the United Kingdom, making comparisons unreliable. Most 

studies also lack suitable retrospective data, and needed long-term prospective studies are 

difficult to set up and expensive to run. The literature lacks evidence on the efficacy and costeffectiveness of interventions to reduce the burdens of diabetes and its complications. 50 

references. 

268 

TITLE: Diabetes Care in Health Maintenance Organizations. Geffner, D. Diabetes Care. 15 

(Supplement 1): S44-S50. March 1992. 

OBJECTIVE: To review the history of health maintenance organizations (HMOs) and to 

describe the organization of the CIGNA Health plans of California; to describe how HMOs 

have dealt with health education, drug prescriptions, cost containment, and other issues. 

CATEGORY: Expert opinion. 

CONCLUSION: HMOs theoretically offer a system of delivering care that is accessible, 

affordable, and of good quality to patients with diabetes. 

RECOMMENDATION: None. 

ABSTRACT: The author reviews the historical development of HMOs and describes 

developments in managed care. Within CIGNA Health plans of California, provisions for 

access to care for patients with diabetes are described and details of cost containment 

practices presented. In both the staff model HMO and at the independent practice association 

(IPA) model, primary care physicians are responsible for the care of patients with diabetes. 

Most HMOs provide health education and nutrition counseling and at CIGNA Health plans of 

California, there is unlimited access (with no copayments) to health education programs. Cost 

containment is an underlying precept of the HMO model. While fee-for-service plans reward 

maximum use of resources, in the HMO setting, financial incentives favor conservation of 

resources. Financial incentives include bonuses to physicians for surpluses and responsibility 
and financial risks for deficits. Other administrative constraints in the outpatient setting for the 

use of services include prior authorization for elective hospitalization and expensive diagnostic 

and therapeutic procedures, concurrent utilization review, mandatory second opinions, and 

drug formularies. Nonfinancial measures to improve cost-effectiveness can also improve 

quality; they include specialized clinics with integrated personnel, easy referral to specialists, 

exposure to patient education opportunities, and peer review. Studies have shown that HMO 

patients are less likely to be hospitalized and undergo fewer outpatient procedures and 

laboratory testing with the same health care outcomes. Whether differences in rates of 

utilization in the outpatient setting represent overutilization in the fee-for-service system or 

underutilization in the HMO setting is not known. 62 references. 

269 

TITLE: Diabetes Guidelines, Outcomes, and Cost-Effectiveness Study: A Protocol, 

Prototype, and Paradigm. Carey, M. Journal of the American Dietetic Association. 95(9): 

976-978. September 1995. 

OBJECTIVE: To review several articles in the September 1995 issue of the Journal of the 

American Dietetic Association that report the findings of the diabetes guidelines, outcomes, 

and cost-effectiveness studies. 

CATEGORY: Expert opinion. 

CONCLUSION: Medical nutrition therapy provided by dietitians to persons with type 2 

diabetes is clinically beneficial and cost effective. 

RECOMMENDATION: Future challenges include long-term management of diseases using 

medical nutrition therapy, quality of life, and segmenting study subjects according to variables 

likely to affect outcomes, such as duration of disease. 

ABSTRACT: The author comments on several articles in the referenced journal issue that 

address practice guidelines for medical nutrition therapy in patients with diabetes. Monk et al. 

(1995) discussed the development of the guidelines. Following a randomized, controlled 

clinical trial, Franz et al. (1995) concluded that medical nutrition therapy provided by 

dietitians significantly improves medical and clinical outcomes and is, therefore, beneficial to 

persons with type 2 diabetes. A second study by Franz et al. (1995) found that medical 

nutrition therapy is cost effective for type 2 diabetes. Using fasting plasma glucose levels as 

the primary indicators and a 6-month time frame, they found that basic nutrition care cost 

$5.32 per unit of outcome and practice guidelines (expanded) nutrition care cost $4.20 per 

unit. 23 references. 

270 

TITLE: Diabetes, Health Insurance, and Health-Care Reform. Herman, W.H.; Dasbach, E.J. 

Diabetes Care. 17(6): 611-613. June 1994. 
OBJECTIVE: To outline the health insurance issues that faced patients with diabetes in 

1994. 

CATEGORY: Expert opinion. 

CONCLUSION: The United States needs a new health insurance system. Many persons with 

diabetes have no health insurance, have inadequate coverage, or receive less than optimum 

care. 

RECOMMENDATION: A new health insurance system should provide coverage that is not 

employment based, disregards preexisting conditions, is rated on community rather than 

individual health care usage, and will provide for health education, supplies, equipment, and 

preventive services. 

ABSTRACT: The authors summarize the underlying issues influencing health care reform in 

1994 by outlining information from several studies. The authors state that in 1988, 17 percent 

of children or adolescents under age 18 had no health insurance. For 1989, they report that 

among persons with diabetes, 13.5 percent of those aged 18 to 64 and 1.2 percent aged 65 

and over were not insured. Among people aged 18 to 64, those with diabetes were more likely 

to have Medicare or Medicaid coverage than those without diabetes. However, fewer than 

one-half of all people with annual incomes below the federally defined poverty level receive 

Medicaid benefits, and approximately one-fourth of practicing physicians do not accept 

Medicaid patients. In 1987, 46 percent of the uninsured population were working adults, 7 

percent were nonworking spouses, and 24 percent were children of working adults; 13 

percent of those under age 65 were underinsured. A survey in the 1980s revealed that many 

primary care providers did not adhere to consensus guidelines for care of diabetes. A 1993 

report found that fewer than half of all patients with diabetes received annual dilated eye 

examinations. These data show that the United States needs a better health insurance system 

that will provide broader and more adequate coverage for patients with diabetes. Coverage 

should provide for preventive care, health education, and management by a multidisciplinary 

team. 21 references. 

271 

TITLE: Diabetes in a Managed Care System. Quickel, K. Annals of Internal Medicine. 124(1 

Part 2): 160-163. January 1, 1996. 

OBJECTIVE: To analyze the effects of managed care strategies on the care of persons with 

diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Managed care programs have the potential to provide excellent care for 

persons with diabetes if clear evidence is presented to them that costs can be cut and quality 

improved. 
RECOMMENDATION: The diabetes community must work with managed care 

organizations to develop diabetes care programs that are cost effective and result in improved 

outcomes. 

ABSTRACT: The author provides a general review of managed care, then examines the care 

of patients with diabetes in that setting. Managed care uses payment incentives, provider 

designation, coverage policies, and traditional insurance mechanisms. Payment incentives 

effectively limit use of some services, particularly inpatient hospitalization. While payment 

incentives have the positive effect of encouraging routine initiation of insulin therapy on an 

outpatient basis, they may also adversely affect the care of some patients with diabetes who 

would benefit from hospitalization. There is evidence of deficient knowledge of diabetes 

among primary care physicians, but no direct studies have compared the quality (by process or 

outcome) of diabetes care provided by primary care physicians with that given by specialists. 

Provider designations will likely adversely affect the care of patients with complex diabetes, 

especially those with type 1 diabetes. However, structured programs provided by managed 

care programs, such as eye care, may improve some aspects of diabetes care. Acute care 

needs and the care of documented complications are generally well covered under managed 

care. Coverage of self-management training and nutrition counseling are inconsistently 

covered, however. As care of patients with diabetes costs three times as much as care of those 

without diabetes, managed care programs tend to exclude patients with diabetes. Preexisting 

condition exclusions by managed care plans may leave persons with diabetes without health 

insurance for necessary services. 1 table, 35 references. 

272 

TITLE: Diabetes Mellitus and the St. Vincent Declaration: The Economic Implications. 

Leese, B. PharmacoEconomics. 7(4): 292-307. April 1995. 

OBJECTIVE: To examine the social and economic factors that affect diabetes mellitus and 

how the St. Vincent Declaration (St. Vincent, Italy, 1989) addresses them. 

CATEGORY: Expert opinion. 

CONCLUSION: The cost of providing more services to people with diabetes is a major 

barrier to implementing the St. Vincent Declaration. 

RECOMMENDATION: None. 

ABSTRACT: The St. Vincent Declaration (1989) set forth two general goals and several 5-

year targets for improving quality of life and life expectancy for people with diabetes mellitus 

and reducing the disease's complications. The authors examine social and economic factors 

affecting diabetes mellitus and how the declaration addresses them. One problem with chronic 

diseases is that money spent on prevention will not achieve savings for 20-30 years and thus 

has little appeal for governments. In Britain, type 2 diabetes often remains undiagnosed, and 

systematic screening in general practice will reveal many undiagnosed cases. A U.S. report 
indicates that increasing age, decreasing income, poor education, poor diet, obesity, race, and 

heredity are risk factors for diabetes. The cost-of-illness approach, including direct, indirect, 

and psychological costs, can be used for diabetes. Indirect costs include losses in productivity 

from short-term illness, early retirement, and death before retirement. In general, about 55 

percent of total costs are direct and 45 percent are indirect (psychological costs are usually 

disregarded). A standardized method of collecting data for economic evaluations of the 

disease does not yet exist. Prevention of diabetes would lead to cost savings and improve 

quality of life for patients. There have been few cost-effectiveness analyses of diabetes 

mellitus. Financial considerations are a major barrier to implementing the St. Vincent 

Declaration. Diagnosing and treating more people with diabetes will add costs, but benefits 

may not be seen for many years. However, prospects are good for reducing costs of 

complications in the long term. The authors discuss primary, secondary, and tertiary 

prevention. With patient compliance, complications would be reduced and costs lowered. The 

St. Vincent Declaration has been an impetus for further research and refinement of databases, 

which are essential to effectively monitor improvements in service provision and outcomes. 1 

table, 1 figure 104 references. 

273 

TITLE: Diabetes Patient Education Programs: Quality and Reimbursement. Wheeler, M.L.; 

Warren-Boulton, E. Diabetes Care. 15(Supplement 1): S36-S40. March 1992. 

OBJECTIVE: To describe a quality assurance process for diabetes education programs and 

to evaluate the impact of recognition by the American Diabetes Association (ADA) on 

reimbursement for these programs. 

CATEGORY: Expert opinion. 

CONCLUSION: Reimbursement for ADA-recognized education programs is inconsistent 

and unpredictable. 

RECOMMENDATION: Professionals in the diabetes community and third party payers 

should work together to clarify coding and coverage issues related to the delivery of 

outpatient education services in all appropriate settings. Programs seeking reimbursement 

should achieve positive review of quality assurance from an external source. Medicare should 

reimburse hospital-based programs and extend coverage to alternative programs such as those 

in the physician's office. 

ABSTRACT: The authors detail the components of a quality assurance mechanism for 

patient education programs in diabetes, including a description of the recognition program of 

the ADA. Results of a 1990 survey evaluating the impact of ADA recognition on 

reimbursement are presented. A survey of 120 recognized programs from 40 states showed 

reimbursement by third party payers to be inconsistent and largely unpredictable. Programs in 

17 states showed disparity in Medicare reimbursement coverage, with recognized programs in 

9 states showing no Medicare activity at all. Medicaid provided very limited coverage for 

diabetes education; no recognized programs were reimbursed in 23 states. Blue Cross/Blue 
Shield provided no reimbursement for recognized programs in 15 states, and 17 states had 

inconsistent coverage by these carriers. Further effort is needed to clarify, for both providers 

and payers, coding and coverage issues related to the delivery of the specific components of 

acceptable, reimbursable education services. Specific recommendations are made, particularly 

with reference to Medicare coverage. Diabetes education is provided most effectively and 

efficiently in the outpatient setting; Medicare should appropriately reimburse hospital-based 

outpatient education programs as well as education programs in alternative sites. 4 tables, 9 

references. 

274 

TITLE: Diabetic Dyslipidemia: A Case for Aggressive Intervention in the Absence of Clinical 

Trial and Cost-effectiveness Data. Lewis, G.F. Canadian Journal of Cardiology. 11 

(Supplement C): 24C-28C. May 1995. 

OBJECTIVE: To provide a rationale for aggressively treating dyslipidemia in patients with 

diabetes in the absence of clinical trials and cost-effectiveness data. 

CATEGORY: Expert opinion. 

CONCLUSION: The evidence is overwhelming that patients with diabetes have a high rate 

of coronary artery disease, that traditional risk factors for coronary artery disease operate in 

diabetes, and that dyslipidemia in people with diabetes is highly prevalent and atherogenic. 

RECOMMENDATION: Compelling clinical trial evidence is needed to support treating 

dyslipidemia in people with diabetes to reduce the incidence of coronary artery disease in the 

population. 

ABSTRACT: People with diabetes have a twofold to fourfold increase in incidence of 

atherosclerotic cardiovascular disease. Atherosclerotic complications account for up to 80 

percent of all deaths for people with diabetes; about 75 percent of these deaths are due to 

coronary artery disease. In 1992, people with diabetes made up 4.5 percent of the United 

States population, but they accounted for 14.6 percent of health care expenditures. People 

with diabetes who do not have complications incur few additional costs versus those without 

diabetes. Once complications occur, however, individual costs are high. The traditional risk 

factors for atherosclerotic cardiovascular disease (age, hypertension, left ventricular 

hypertrophy, hyperlipidemia, and smoking) operate in people with diabetes but do not account 

for the total increase in atherosclerotic cardiovascular disease; diabetes itself confers an 

independent additional risk. The most common lipid abnormalities in type 2 diabetes and 

poorly controlled type 1 diabetes are hypertriglyceridemia and low high-density lipoprotein. 

Treating dyslipidemia with conservative measures (diet, weight loss, aerobic exercise, 

improving glycemic control, etc.) and pharmacological management has been effective in 

correcting lipid levels. The author reports that few trials of lipid-lowering therapy have 

included patients with diabetes or demonstrated the cost-effectiveness of lipid-lowering 

therapy in reducing atherosclerotic cardiovascular disease. 1 table, 35 references. 
275 

TITLE: Economic Costs of Diabetes. Lipsett, L.F. Pediatric and Adolescent Endocrinology. 

11: 143-148. 1983. 

OBJECTIVE: To review estimates of the direct and indirect costs of diabetes in the United 

States. 

CATEGORY: Expert opinion. 

CONCLUSION: The economic burden of diabetes is significant, with the total cost of 

diabetes estimated at $9.7 billion in 1980. 

RECOMMENDATION: Indirect costs of diabetes due to morbidity might be reduced 

through improving the accessibility of health services and creating greater awareness of 

diabetes complications. 

ABSTRACT: The author reviews recent estimates of the direct and indirect costs of diabetes 

in the United States. The human capital approach (Rice 1966), which has been used by most 

economists in estimating the economic burden of disease in this country, includes estimates of 

both direct and indirect costs (time lost from work, losses to the economy from premature 

mortality). Estimates of the cost of diabetes grew from $2.6 billion in 1969 to $9.7 billion in 

1980. In 1969, morbidity accounted for 56 percent of the total economic cost of diabetes and 

mortality accounted for 43 percent. In 1980, morbidity accounted for over 85 percent of costs 

and mortality just 15 percent. Siebert (unpublished data) estimated the annual costs per patient 

for outpatient dialysis, renal transplant, and home dialysis to be $23,088, $19,000, and 

$12,400, respectively, for patients with diabetes and end-stage renal disease. Patients with 

diabetes account for one-fourth of entrants into end-stage renal disease programs. In 1973, 

only 57 percent of adults with diabetes were estimated to have had an eye examination during 

the preceding 2 years, only 52 percent an electrocardiogram, and only 41 percent a glaucoma 

test. 1 figure, 1 table, 17 references. 

276 

TITLE: The Economic Costs of NIDDM. Songer, T.J. Diabetes-Metabolism Reviews. 8(4): 

389-404. December 1992. 

OBJECTIVE: To review basic concepts in health economic research and how they have been 

applied to issues involving type 2 diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Health Economics data provide relevant information for decisions made by 

governments and health agencies about diabetes. 
RECOMMENDATION: Developing a better means of identifying persons with type 2 

diabetes could help a great deal to highlight the epidemiologic and economic components of 

the disease. 

ABSTRACT: The author discusses three broad kinds of health economic approaches: 

descriptive, evaluative, and explanatory. Descriptive approaches include cost-of-illness studies 

and assessments of patients' costs and concerns. Cost-of-illness studies usually include direct 

and indirect costs; intangible or psychosocial costs are normally not included. Although the 

literature on the cost of diabetes is fairly extensive, data specific to type 2 diabetes are 

uncommon. Costs and concerns of patients include direct payments by individuals for health 

care or insurance as well as sacrifices (losses) in time; little has been published in this area 

relative to diabetes. Evaluative approaches include cost-benefit analysis, cost-effectiveness 

analysis, and cost-utility analysis. Cost-benefit analysis considers monetary cost versus 

monetary benefits; there is no measure of health gained. Both cost-effectiveness analysis and 

cost-utility analysis consider monetary cost minus monetary benefit versus health gained 

(measures for cost-effectiveness analysis include years of life, disability prevented, etc.; for 

cost-utility analysis the measure is quality-adjusted life-years). Explanatory approaches include 

examinations of incentives, demand, and supply. Economic incentives might change the price 

of a healthy or an unhealthy activity, or they might change an individual's knowledge about the 

consequences of activities. The author suggests including an economic component in the 

evaluation of intervention programs to prevent type 2 diabetes. He points out that in most 

scenarios, prevention does not save money. Referencing Weinstein (1990), he states that the 

economic issue is not whether prevention saves money, but whether prevention improves 

health at a reasonable cost. 4 figures, 4 tables, 83 references. 

277 

TITLE: Economic Implications of IGT Intervention: The Case of a "Phantom Alternative"? 

Gafni, A. Diabetic Medicine. 13(3 Suppl 2): S25-S28. March 1996. 

OBJECTIVE: To assess whether it is possible to perform an economic evaluation of primary 

strategies for preventing diabetes in patients with impaired glucose tolerance (IGT) or 

whether such strategies represent "phantom alternatives" (illusionary choices that look real but 

are unavailable at the time a decision is made). 

CATEGORY: Expert opinion. 

CONCLUSION: At present, an economic evaluation of primary prevention strategies cannot 

be performed, even for the purpose of determining the strategies' technical efficiency. 

RECOMMENDATION: Effectiveness-type clinical trials should be designed, based on 

existing evidence in favor of possible interventions, to test properly the effectiveness of 

potential primary intervention strategies. 

ABSTRACT: The methodologies of economic evaluations of health care interventions are 
reviewed and the economic questions to be answered are discussed. Key issues are (1) the 

identification of the cluster of technically efficient programs for each disease level and (2) the 

determination of the optimal mix of interventions. The author argues that no comprehensive 

descriptions have yet been put forward about primary prevention strategies for diabetes. 

Satisfactory evidence of the effectiveness of existing preventive strategies, their impact on 

quality of life, or their acceptance by individuals, also is not available. Evidence is also lacking 

on effective methods for identifying high-risk individuals. The author concludes that, because 

of these deficiencies, no economic evaluation of primary prevention strategies can be 

performed. 12 references. 

278 

TITLE: Emotional Side Effects of Diabetes Educational Program (letter; comment). Conget, 

J.I.; Esmatjes, E.; Ferrer, J.; De Pablo, J.; Gomis, R. Diabetes Care. 13(8): 901-902. August 

1990. 

OBJECTIVE: To argue that an intensive diabetes educational program can produce severe 

adverse emotional effects in predisposed patients and to recommend a psychological 

assessment before program participation. 

CATEGORY: Expert opinion. 

CONCLUSION: Following their participation in a health education program, patients with 

chronic diseases and premorbid personalities have exhibited psychological disorders. 

RECOMMENDATION: A psychological assessment should be performed before a diabetes 

education program begins to rule out patients at high risk of developing emotional disorders. 

Select patients would be given special educational techniques. 

ABSTRACT: The authors respond to an article by Rubin et al. (Diabetes Care. 12(10): 673-

679. 1989) on the effects of diabetes education. They agree with Rubin et al. that an intensive 

diabetes education program evaluated by those investigators improved the emotional status of 

participants and that this improvement contributed markedly to improved metabolic control. 

However, the authors argue that intensive diabetes educational programs can also produce 

severe adverse emotional effects in predisposed patients. They illustrate their point with the 

history of a 19-year-old patient who exhibited disturbed behavior following such a program. 

They recommend a preprogram psychological assessment to rule out patients at high risk for 

emotional disturbances. They note that psychological disorders have been described in patients 

with chronic diseases and premorbid personalities after their inclusion in a health education 

program. In a reply, Rubin et al. argue that the disorder of the patients described by Conget et 

al. might not have been caused by the educational program. Rather than preprogram 

assessment, they suggest close monitoring during and after the program. 6 references. 

279 
TITLE: Estimating the Impact of Total Illness Burden on Patient Outcomes among Patients 

with Non-Insulin Dependent Diabetes: A Comparison of Three Co-Morbidity Measures 

(abstract). Greenfield, S.; Sullivan, L.M.; Dukes, K.A.; D'Agostino, R.; Dittus, R.; Wagner, 

E.; Kaplan, S.H. AHSR FHSR Annual Meeting Abstract Book. 12: 85. 1995. 

OBJECTIVE: To compare three different measures used to assess total disease burden in 

patients with type 2 diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: The Total Illness Burden Index provided the most accurate assessment of 

total illness burden. This index may reveal a formerly underestimated disease burden among 

women and minorities and may decrease distortions in assessing quality of care. 

RECOMMENDATION: None. 

ABSTRACT: The investigators compared the accuracy of three comorbidity measures in 

estimating the burden of diabetes in two populations of patients with type 2 diabetes included 

in the Type II Diabetes Patient Outcome Research Team (PORT) study. One group of 

patients (n = 1,738) was from the Group Health Center of Puget Sound (Washington state); 

the other (n = 790), from the Regenstrief Health Center in Indianapolis. The measures were a 

simple count of diagnoses (NDX), the Charlson Index (CI), which is a weighted measure, and 

the Total Illness Burden Index (TIBI), an aggregated patient-reported measure of severity 

scores for each of 15 body systems. The groups differed significantly in terms of race, 

socioeconomic level, and presence of diabetes complications. Compared with the Puget Sound 

group, patients from Regenstrief had lower annual incomes, less education, a longer duration 

of diabetes, more diabetes-related complications, and were more likely to be female and 

African American. In multivariate models, the authors found that TIBI explained a greater 

proportion of the variation in PFI10, office visits, and restricted activity days than did the 

other two measures. Results were not explained by multi-collinearity. Sex was significantly 

related to the TIBI but not to the CI. Race and income were significantly related to each of 

the measures. 

280 

TITLE: Financial Implications of Implementing Standards of Care for Diabetic Eye Disease. 

Rand, L. Diabetes Care. 15(Supplement 1): S32-S35. March 1992. 

OBJECTIVE: To review the practical financial implications of implementing published care 

standards for diabetic eye disease. 

CATEGORY: Expert opinion. 

CONCLUSION: Several economic factors influence the implementation of guidelines for eye 
care for patients with diabetes and will greatly influence how effective these guidelines will be 

in reducing blindness due to retinopathy. 

RECOMMENDATION: Factors affecting the full implementation of eye care standards 

must be addressed, particularly in terms of prepaid health care organization standards and 

regional variations in resource availability. 

ABSTRACT: The author reviews the financial implications of implementing the American 

Diabetes Association (ADA) guidelines for retinopathy screening. Broad financial issues 

related to practice patterns are discussed, and no specific dollar projections on potential cost 

savings are made. ADA guidelines emphasize the role of the primary physician in coordinating 

the total health care of persons with diabetes mellitus. The financial implications of physicians' 

taking this role are enormous, not only because of liability issues, but also because of cost 

escalations resulting from increased testing and referral. Full implementation of each of the 

specific ADA guidelines for retinopathy screening will result in increased costs. 

Implementation of annual ophthalmic exams, for example, is expected to increase the cost of 

care by at least 30 percent, as only one-half of patients with diabetes currently receive annual 

care. However, increased costs of care may be offset by decreases in disability payments: a 

1990 study showed screening for retinopathy resulted in net annual savings of $62 million to 

$109 million to the federal government when disability payments were considered. The 

available guidelines are excellent and their implementation should reduce visual loss from 

retinopathy. The financial impact of implementing these guidelines, however, both in terms of 

manpower and dollars, is wide-ranging and will greatly influence how effective they will be in 

reducing blindness due to retinopathy. Low-cost screening strategies must be developed, 

particularly for low-risk groups. 15 references. 

281 

TITLE: The Health Belief Model and Adolescents with Insulin-Dependent Diabetes Mellitus. 

Bond, G.G.; Aiken, L.S.; Somerville, S.C. Health Psychology. 11(3): 190198. 1992. 

OBJECTIVE: To test the utility of the health belief model for predicting both behavioral 

adherence to the diabetic regimen and glycemic control among adolescents with type 1 

diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Compliance was positively associated with two of three constructs (cues, 

benefits-costs) of a modified health belief model. Compliance was not significantly related to 

metabolic control. 

RECOMMENDATION: None. 

ABSTRACT: Fifty-six adolescents (mean age: 14.2 years) with type 1 diabetes were included 

in this study; 43 percent were male and 91 percent were white. All participants had type 1 

diabetes for at least 1 year (mean: 5.8 years) and were attending school. The study protocol 
had four components: (1) a children's self-administered questionnaire that covered the health 

belief model for diabetes, (2) three telephone interviews on compliance in which the 

adolescent recalled the day's regimen-related events in sequence, (3) three parent telephone 

interviews on compliance in which the parent recalled his or her child's regimen-related events, 

and (4) a glycosylated hemoglobin blood test for each adolescent four to six weeks after 

completion of the last compliance interview. Because of the small sample size, a measurement 

model containing the five constructs of the health belief model (susceptibility, severity, costs, 

benefits, and cues) could not be estimated. Instead, the authors used a benefits-costs 

construct, a perceived threat construct (severity plus susceptibility), and a construct of 

perceived cues to action as their model. Benefits refer to a conviction that the preventive 

regimen is effective, costs are difficulties or barriers in undertaking the regimen, threat is 

perceived susceptibility combined with viewing the disease as severe (severity), and cues 

involve willingness to seek help or medical treatment after symptoms (e.g., cold sweats) are 

experienced. Data obtained from parents about compliance were not used because the parents, 

in 70 percent of the cases, were unaware of the details of their children's daily routines. The 

authors found that as a child's age increased, adherence to the exercise, injection, and 

frequency components of the regimen decreased. Compliance was positively associated with 

cues to action and with perceived benefits-costs. The greatest compliance was achieved with 

high benefits-costs and low threat. Glycosylated hemoglobin did not correlate significantly 

with either age or disease duration. Poor metabolic control was associated with high threat 

and cues. Better metabolic control was associated with lower carbohydrate consumption. 2 

figures, 5 tables, 45 references. 

282 

TITLE: Health-Insurance Coverage for Adults with Diabetes in the U.S. Population. Harris, 

M.I.; Cowie, C.C.; Eastman, R. Diabetes Care. 17(6): 585-591. June 1994. 

OBJECTIVE: To compare health insurance coverage for adults with diabetes with coverage 

for adults without diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Health care coverage in the United States is similar in adult patients with 

and without diabetes, but in the 18 to 64 age group, persons with diabetes are more likely to 

depend on government-funded insurance than those without diabetes. 

RECOMMENDATION: None. 

ABSTRACT: As part of the 1989 National Health Interview Survey, 2,405 adults with 

diagnosed diabetes and 20,131 adults with no known diabetes were asked about their health 

care insurance coverage. Coverage was similar for persons with diabetes and those without 

diabetes (92.0 versus 86.8 percent). About 600,000 persons with diabetes had no insurance 

coverage. Among persons under age 65, 26.4 percent of those with diabetes relied on 

government-funded medical care, compared with 8.3 percent of persons without diabetes; for 

private health insurance, the proportions were 69.3 percent and 78.6 percent, respectively (p 
< .001 for both comparisons). Reasons given by adults with diabetes aged 18 to 64 for not 

having private insurance included cost; having other coverage; being unable to obtain 

insurance because of poor health, illness, or age; and unemployment. Among persons aged 65 

and over, 69.2 percent of those with diabetes and 79.9 percent of those without diabetes had 

private insurance (p < .001). In this age group, more than half of persons with type 2 diabetes 

had no coverage for insulin or prescription drugs; only 13.5 percent of those with diabetes of 

any type had dental coverage. Among younger diabetes patients (aged 18 to 64 years), 23 

percent of type 1 patients, about 26 percent of insulin-using type 2 patients, and 32 percent of 

noninsulin-using type 2 patients had no coverage for prescription medicines. Uninsured 

diabetes patients under age 65 were more likely than those who were insured to be of minority 

ethnicity, have less than a high school education, have annual family incomes less than 

$25,000, report more episodes of hyperglycemia and glycosuria, and have less preventive 

care. Because government-funded insurance programs provide coverage for 57 percent of 

adults with diabetes, changes in government health care policies could have a major impact on 

this patient group. 6 figures, 2 tables, 13 references. 

283 

TITLE: Insurance Coverage for People with Diabetes: Third Party Reimbursement for 

Diabetes Education and Technologies. Sinnock, P.; Bauer, D. Diabetes Dateline. 4(5): 1-2. 

September-October 1983. 

OBJECTIVE: To discuss the status of insurance reimbursement for outpatient education, 

new technologies, services, and equipment for persons with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Medicare is the largest insurer of persons with diabetes. Per the Medicare 

Part A Intermediary Manual, patient education programs appear to be covered, but just five 

states have obtained Medicare reimbursement for patient education programs. 

RECOMMENDATION: More efforts are needed to foster an understanding among third 

party payers of the potential cost benefits of patient education, technologies, and services for 

diabetes care. 

ABSTRACT: Educational activities can improve the ability of people with diabetes to care 

for themselves and to comply with medically prescribed treatment protocols, which in turn can 

lead to a reduction in diabetes morbidity, mortality, and related costs. Medicare is the largest 

insurer of persons with diabetes; in 1978, it covered 41.3 percent of patients with diabetes 

aged 20 or over and 95.9 percent of those aged 65 or over. Five states have obtained 

reimbursement under Medicare for diabetes outpatient education; programs must be 

therapeutic rather than preventive, provided by a Medicare-certified hospital or rural health 

center, and have physician referral and involvement. As of September 1983, 11 Blue 

Cross/Blue Shield plans, 6 commercial insurers, and 1 Medicaid program also reimbursed 

outpatient diabetes education. There is little uniformity nationwide of coverage for diabetesrelated technologies and services among third party payers; of the four major payer groups, 
only Medicare has a national office that can serve as an arbitrator. Third party reimbursement 

of diabetes-related technologies, services, and equipment seems to depend on the type of 

insurance, the state of residence, and the item or procedure to be covered. 

284 

TITLE: Intensive Ambulatory Treatment of Insulin-Dependent Diabetes. Felig, P.; Bergman, 

M. Annals of Internal Medicine. 97(2): 225-230. August 1982. 

OBJECTIVE: To determine whether an intensive management program should be preferred 

over a conventional management program in the treatment of type 1 diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: In many patients, intensive management is superior to conventional 

management in terms of lowering blood glucose concentrations and improving the metabolic 

state. Net savings from intensive management will be substantial if reducing blood glucose is 

effective in preventing or delaying complications or reducing hospitalization for diabetic 

ketoacidosis or hypoglycemia. 

RECOMMENDATION: Additional observations on safety and efficacy are needed before 

insulin pump treatment can be considered routine. Prospective studies are needed that 

compare morbidity and mortality attributable to hypoglycemia during conventional treatment 

with morbidity and mortality during intensive treatment. 

ABSTRACT: The authors reviewed available data on the efficacy of intensive management 

regimens for type 1 diabetes. Intensive management is defined as self-monitoring of blood 

glucose (SMBG) and adjusting insulin doses based on this monitoring. In intensive 

management, insulin is administered in a continuous subcutaneous infusion with portable 

insulin pumps or given as two or more manual injections per day. Conventional management 

involves one or two insulin injections daily, urine glucose monitoring by the patient, and blood 

glucose measurement by the physician during office visits. Opinions on the desired frequency 

of SMBG differ, but the favored approach is four times daily (before main meals and at 

bedtime) plus occasionally during the night. Drawbacks of intensive management include 

possible hypoglycemia, adverse psychological effects due to preoccupation with the care of 

diabetes, and the need for multiple blood tests and frequent contact with health professionals. 

In one study, although 34 percent of patients reported fewer hypoglycemic reactions with 

intensive therapy, 20 percent noted an increase. Additional observations are needed to 

determine the safety and efficacy of the insulin pump. In the hospital setting, the insulin pump 

lowers the blood glucose as well as does manually injected insulin; in the outpatient setting, 

data are less conclusive. Potential adverse effects of the pump include hyperglycemia, 

hypoglycemia, and cutaneous complications at the needle site. No long-term data are available 

to determine the effectiveness of intensive therapy in preventing or delaying long-term 

complications of diabetes. Some studies have shown a progression of eye disease and only a 

transient reduction of proteinuria with improved blood glucose control. 50 references. 
285 

TITLE: Intensive Insulin Therapy: Part I. Basic Principles. Hirsch, I.B.; Herter, C.D. 

American Family Physician. 45(5): 2141-2147. May 1992. 

OBJECTIVE: To review insulin therapy in patients with type 1 or type 2 diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Meticulous glycemic control has beneficial effects on diabetic 

complications, but neither advanced retinopathy nor advanced nephropathy seems affected by 

improved glycemic control. 

RECOMMENDATION: None. 

ABSTRACT: The authors review the basic approach to intensive insulin therapy for both 

type 1 diabetes and type 2 diabetes: Intensive therapy includes a multicomponent insulin 

regimen; balancing of food intake, activity, and insulin dosage; daily home blood glucose 

monitoring; and individualized blood glucose goals but not tight glycemic control. A team 

approach to therapy is beneficial; teams typically include a physician, a nurse, and a 

nutritionist but could also include a social worker or a psychologist, an exercise physiologist, 

a pharmacist, and a physician's assistant or a certified nurse practitioner. The authors provide 

a table comparing time to onset, time to peak concentration, and duration of effect for 

different animal and human insulin preparations. Animal insulin is bioavailable for a longer 

time but is also associated with higher circulating anti-insulin antibodies. Intraindividual 

variation in absorption of insulin is about 25 percent. Absorption is affected by the site of 

injection and exercise; premeal insulin injections should be timed based on blood glucose. The 

incidence and progression of retinopathy and glycosylated hemoglobin are positively 

associated. However, some patients experience a transient increase in retinopathy progression 

with improved glycemic control, which is thought to be a consequence of retinal ischemia. 

Microalbuminuria is reduced with glycemic control, but advanced nephropathy is not affected. 

Nerve function improves with better glycemic control. Individualized glycemic goals are 

required because of the risk of developing hypoglycemia following treatment. The relationship 

between glycemic control and complications from diabetes is under study. 2 tables, 22 

references. 

286 

TITLE: Intensive Insulin Therapy: Part II. Multicomponent Insulin Regimens. Hirsch, I.B.; 

Herter, C.D. American Family Physician. 45(6): 2643-2648. June 1992. 

OBJECTIVE: To review optimum regimens for insulin treatment of type 1 and type 2 

diabetes. 
CATEGORY: Expert opinion. 

CONCLUSION: A variety of approaches may be used to provide insulin therapy in patients 

with diabetes. 

RECOMMENDATION: Additional studies are required to investigate combination therapy 

with insulin and sulfonylureas for patients with type 2 diabetes. 

ABSTRACT: The authors review optimal insulin therapy for diabetes mellitus. Twenty-one 

percent of patients with type 1 diabetes are on once-daily insulin injections, despite their 

proven inefficiency. Many patients administer short- and intermediate-acting insulin prior to 

breakfast and supper, which requires that the mid-day meal be precisely timed and which may 

result in nocturnal hypoglycemia. In these patients, a bedtime snack to eliminate nocturnal 

hypoglycemia is likely to cause fasting hyperglycemia. Another regimen uses only the shortacting insulin for the suppertime dose, with the intermediate-acting insulin given at bedtime. 

For individuals with unpredictable schedules, a regimen of short-acting insulin prior to 

breakfast, lunch, and supper and intermediate-acting insulin with a bedtime snack permits 

more control. A variation of this regimen uses the same three doses of short-acting insulin 

with long-acting insulin administered prior to breakfast and supper. Continuous subcutaneous 

infusion of insulin is also available to maintain basal blood concentrations of insulin. For type 

2 diabetes, diet and exercise are the primary treatments, followed, if adequate blood glucose 

control is not achieved, by sulfonylureas. Up to one-third of patients initially fail to respond 

adequately to sulfonylureas, and 5 to 10 percent of initial responders later stop responding to 

the drug; these patients require insulin therapy. Moderate hyperglycemia (fasting blood 

glucose of 140 to 200 mg/dL) is managed with once-daily injection of intermediate- or longacting insulin. For severe hyperglycemia (fasting blood glucose greater than 200 mg/dL), at 

least twice-daily intermediate-acting insulin is required. Using insulin and sulfonylurea in 

combination remains controversial. 6 figures, 1 table, 13 references. 

287 

TITLE: Is Glycohemoglobin Testing Useful in Diabetes Mellitus? Lessons from the Diabetes 

Control and Complications Trial. Goldstein, D.E.; Little, R.R.; Wiedmeyer, H.M.; England, 

J.D.; Rohlfing, C.L.; Wilke, A.L. Clinical Chemistry. 40(8): 1637-1640. August 1994. 

OBJECTIVE: To evaluate glycohemoglobin testing in the management of patients with 

diabetes mellitus as a model of laboratory testing cost analysis. 

CATEGORY: Expert opinion. 

CONCLUSION: Glycohemoglobin testing in patients with diabetes mellitus provides an 

objective measure of a patient's risk for developing diabetes complications and may prove cost 

effective through savings incurred by the prevention of these complications. 

RECOMMENDATION: Those involved in medical cost containment must weigh short-term 
costs (e.g., laboratory studies) against long-term benefits. 

ABSTRACT: The authors discuss testing for glycohemoglobin in patients with diabetes 

mellitus as a model for determining whether laboratory tests cost or save money. The Diabetes 

Control and Complications Trial provided strong evidence that glycemic control as assessed 

by glycohemoglobin testing predicts risk for developing diabetic complications. The authors 

point out that knowing a patient's glycohemoglobin would help the patient and health provider 

make changes in treatment that would lower the glycohemoglobin and thereby decrease risks 

of complications. Larsen et al. (1990) performed a study in which 240 patients with type 1 

diabetes were randomly assigned to a treatment group in which glycohemoglobin test results 

were made known to patients and health providers or to a control group in which these results 

were not made known. After 12 months, glycohemoglobin values were substantially lower in 

the treatment group. Data from the Diabetes Control and Complications Trial and Larsen et 

al. study argue strongly for the routine use of glycohemoglobin testing, but despite widely 

published recommendations, only about 25 percent of patients with diabetes undergo this 

testing regularly. The authors argue that the costs of increased glycohemoglobin testing and of 

other aspects of intensive therapy should be offset by savings in other areas (e.g., laser 

therapy, kidney dialysis). 24 references. 

288 

TITLE: Managed Care Approaches to Diabetes Mellitus. Fore, W.W. Hospital Practice. 31 

(7): 115-117. July 15, 1996. 

OBJECTIVE: To review approaches by managed care organizations to the management of 

diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: As more managed care organizations implement prevention programs, 

information on optimum methods of care and cost reduction should become available. 

RECOMMENDATION: None. 

ABSTRACT: Most managed care organizations now have insured populations with the same 

prevalence of diabetes as the general population. Managed care information systems have 

confirmed that the costs of caring for enrollees with diabetes are four times those for members 

without diabetes. The author states that 90 percent of managed care patients with diabetes 

have type 2, which has a mortality of approximately 50 percent from coronary artery disease 

and stroke. Ninety percent of managed care patients with diabetes have type 2. 

Implementation of intensive treatment may not realize cost savings for 12 to 16 years, while 

most managed care organizations have annual budgeting and can expect one-third of their 

members to change plans annually. Even so, additional resources are being allotted to the care 

of patients with diabetes. Managed care organizations are initiating various programs to 

improve outcomes and reduce cost of care, including home or workplace visits from nurses 

and dietitians, follow-up telephone calls from nurses and educators, and providing telephone 
access to a computer system than can advise patients on insulin dosage. It appears that many 

managed care organizations are focusing on preventing the complications of diabetes. The 

pharmaceutical industry plans to expand its role in the long-term management of diabetes in 

the managed care setting. 6 references. 

289 

TITLE: Medicare Admission Criteria for Diabetes Mellitus in Florida. O'Malley, B.L. 

Diabetes Care. 15(Supplement 1): S54-S58. March 1992. 

OBJECTIVE: To document the modification of Medicare hospital admission criteria for 

diabetes mellitus in Florida and the physician response to the process. 

CATEGORY: Expert opinion. 

CONCLUSION: Stricter Medicare hospital admission criteria for patients with diabetes 

mellitus in Florida proved to be unacceptable to diabetologists and endocrinologists, who 

forced a change to the proposed admission criteria. Adoption of the less strict criteria had 

little impact on the number of hospital admissions. 

RECOMMENDATION: Diabetologists and endocrinologists must be involved in the 

establishment of acceptable hospital admission criteria. 

ABSTRACT: The author details physician response to modifications proposed by the Florida 

Peer Review Organization in 1986 to the Florida Medicare admission criteria for diabetes 

mellitus. Peer review organizations, which were mandated by the Tax Equity and Fiscal 

Responsibility Act of 1982, try to control health care costs. The proposed criterion required 

the fasting blood glucose to be $ 22.4 mM. Endocrinologists and diabetologists in Florida 

recognized that the revised criteria would have a significant adverse impact on the quality of 

care of patients with diabetes mellitus. Peer Review Organization council physicians, 

responding to these inputs from specialists, developed and approved less strict criteria for 

hospital admission. The introduction of these criteria had no significant impact on the number 

of patients admitted with a primary diagnosis of diabetes mellitus or its complications; such 

Medicare admissions totaled 6,954, 6,686, and 6,687 in 1986, 1987, and 1988, respectively. 

The author also notes that some health care providers erroneously thought that admissions 

criteria are a standard of care. Instead, he contends, they are minimal criteria to be met before 

thinking about the need to hospitalize a patient. This case illustrates the importance of the 

involvement of diabetologists and endocrinologists in establishing acceptable hospital 

admission criteria on a state-by-state basis. 4 tables, 2 references. 

290 

TITLE: Meeting the Needs of the Economically Deprived Diabetic. Hopper, S.V. Nursing 

Clinics of North America. 18(4): 813-825. December 1983. 
OBJECTIVE: To examine the factors that influence treatment of patients from low-income 

groups and suggest a plan of intervention. 

CATEGORY: Expert opinion. 

CONCLUSION: Educating low-income patients with diabetes presents the nurse with special 

challenges. 

RECOMMENDATION: The author's recommended intervention covers teaching strategies, 

economic realities, health attitudes, diet and nutrition, the social network, and adapting the 

teaching setting. 

ABSTRACT: The author reviews the effect of low economic status on the impact and 

management of diabetes, using information about low-income participants with diabetes who 

attended a municipal clinic in St. Louis, Missouri, to illustrate various points. According to a 

1978 survey, 74 percent of the clinic's patients were black; the same percentage were female; 

and most had type 2 diabetes. The author reviews the cost of diabetes, the social network of 

patients with diabetes, and knowledge and beliefs; she outlines an approach to intervention 

and presents a case study. Many poor people believe they cannot afford the diabetic diet; this 

has caused conflict between patient and practitioner. Nurses must acknowledge value 

differences when negotiating self-care priorities with the low-income patient. In setting forth a 

proposed lay model for treating diabetes, the author indicates that 28 percent of the clinic 

patients believed that most of what happened to a person's health was due to chance. A clinic 

study also found that 14 percent of the patients believed that diabetes was not a lifelong 

illness. In addition, knowledge of the signs and symptoms of hypoglycemia and hyperglycemia 

did not guarantee better control. Effective patient education uses communication strategies 

appropriate to the cultural group. 29 references. 

291 

TITLE: Money Matters: Should Ability to Pay Ever Be a Consideration in Gaining Access to 

Transplantation? In: Cost and Outcome Analysis of Kidney Transplantation: The 

Implications of Initial Immunosuppressive Protocol and Diabetes (Final Report: Volume I), 

Chapter 16. Evans, R.W.; Manninen, D.L.; and Thompson, C. Battelle Human Affairs 

Research Centers, Seattle, Washington. 1989. 

OBJECTIVE: To discuss whether ability to pay should be a condition for gaining access to 

transplantation. 

CATEGORY: Expert opinion. 

CONCLUSION: Ability to pay should never be a consideration in gaining access to 

transplantation, but in reality such a capability is currently a consideration and will be one in 

the future. 
RECOMMENDATION: Ultimately, society must ask itself what it is willing to pay to avoid 

making decisions about medical treatment based on ability to pay. 

ABSTRACT: The authors note that when coverage of transplant procedures is a 

consideration, both the uninsured (1987 estimate: 37 million people) and the underinsured 

(estimate: 26 or 27 million) are at near equal risk of not gaining access to selected transplant 

procedures when the criterion is ability to pay. Most transplant programs in the United States 

require assurance of payment, which often takes the form of a direct down payment or prior 

approval by an insurer. In the immediate future, ability to pay will probably become even more 

important, but this criterion is a condition of access that characterizes all of medical care in a 

system such as the one in the United States. The National Task Force on Organ 

Transplantation (1986) rejected the notion that ability to pay should obstruct access. The 

authors note that although they continue to support the Task Force's recommendations, the 

concerns of public and private insurers as well as legislators should be recognized. In deciding 

which new medical and surgical procedures to cover, insurers have historically asked about its 

safety, effectiveness, and acceptance within the medical community. Four more contemporary 

questions that insurers ask are about the procedure's cost; whether it maintains or improves 

health status in the most cost-effective manner; whether it replaces an older, less efficient 

procedure; and whether costs will increase as the procedure becomes more routine. In many 

instances, hospitals lose money on transplants but may benefit indirectly from the visibility that 

transplant programs create. The authors note that patient discrimination in transplantation may 

be based not only on ability to pay but also on the payment methodology of the insurer; in this 

regard, Medicare and Medicaid would be less attractive than private insurance. The public 

strongly objects to use of an economic criterion for transplantation. The National Task Force 

concluded that it would be unfair and even exploitative to ask the public to donate organs and 

the distribute them on the basis of ability to pay. 1 figure, 8 tables. 

292 

TITLE: New Mexicare. Vall-Spinosa, A. Archives of Internal Medicine. 151(8): 1503-1509. 

August 1991. 

OBJECTIVE: To propose a health insurance system for the uninsured in New Mexico that 

would benefit the patient, provider, businessperson, and state. 

CATEGORY: Expert opinion. 

CONCLUSION: New Mexicare offers a low-cost system for providing basic medical 

services to people currently denied health care because they lack health insurance. 

RECOMMENDATION: New Mexicare could be a paradigm for an eventual national 

solution to this country's health care problems. 

ABSTRACT: The author, a member of the Department of Medicine at the University of New 

Mexico School of Medicine, presents a proposal for a public health insurance plan that would 
provide access to primary and preventive outpatient health care on a fee-for-service basis for 

all uninsured citizens of New Mexico. The plan, called New Mexicare, would use annual, 

globally budgeted monies to pay for inpatient care, which is now unreimbursed for those 

without insurance. Funding would come from a Health Care Trust Fund, which would help set 

state health policy, determine New Mexicare benefits, and supervise payments to hospitals, 

laboratories, and physician specialists. All state health care funds, including Medicaidmatching dollars, would support the fund. New Mexicare would function within the state 

Medicaid Department and would use the Medicaid primary care network and system, which 

uses primary care providers as gatekeepers to specialist and hospital services. Premiums for 

unemployed persons would be subsidized, and premiums for employed persons would be 

shared between workers and employers, with higher-paid workers assuming a larger share of 

cost than lower-paid workers. The plan includes provisions for low premiums and nominal 

copayments. All employers and their workers with no private insurance plan would 

automatically be covered. The plan's very low cost should be acceptable to all employers and 

eliminate the need for tax credits or incentives. 12 references. 

293 

TITLE: Nurses' Perceptions: Issues that Arise in Caring for Patients with Diabetes in a 

Managed Care Environment (abstract). McDonald, P.E.; Tilley, B.C.; Havstad, S. AHSR 

FHSR Annual Meeting Abstract Book. 1996;13:191. 

OBJECTIVE: To examine the role of nurses in the care of patients with diabetes within the 

Henry Ford Health System, a managed care environment. 

CATEGORY: Expert opinion. 

CONCLUSION: Constituting the largest segment of health care providers in the country, 

nurses are in a unique position to facilitate the improvement of health and quality-of-life 

outcomes for patients with diabetes. 

RECOMMENDATION: None. 

ABSTRACT: Randomly selected registered nurses from the Henry Ford Health System 

completed surveys on caring for patients with diabetes. Twenty-six percent of the respondents 

reported they did not see diabetes patients, a surprising finding given the prevalence of 

diabetes in the community. Nurses felt they needed more education in caring for patients with 

diabetes, saw practice guidelines as helpful, believed it was appropriate for a nurse to change 

treatment regimens, considered primary patient problems to be lack of knowledge and 

acceptance of diabetes, and believed solutions should focus on educating nurses and 

reinforcing to patients the need for follow-up care. 

294 

TITLE: Optometrist Screening for Retinopathy: Evidence and Environment. Mason, J.; 
Drummond, M.; Woodward, G. Ophthalmic & Physiological Optics. 16(4): 274-285. July 

1996. 

OBJECTIVE: To examine the role of optometrists in screening for retinopathy and to 

challenge inappropriate conclusions in the literature about this issue. To consider how 

screening for retinopathy should be developed in Great Britain. 

CATEGORY: Expert opinion. 

CONCLUSION: How screening for retinopathy should be conducted is still unresolved. 

RECOMMENDATION: Research should be conducted on a variety of issues relative to 

screening. 

ABSTRACT: For the present review, a MEDLINE search was conducted that identified two 

data sets relating to screening by optometrists that the authors considered to bear directly on 

screening in the United Kingdom-the Special Medical Development Project (SMDP) and the 

Frenchay study. In the SMDP, no significant difference in performance of ophthalmoscopy 

was found among screeners (general practitioners, hospital physicians, and optometrists) in 

terms of sensitivity. However, test sensitivity was lower than expected for all methods used 

(Buxton et al. 1991). In another evaluation of SMDP (by Sculpher et al. 1992), screening by 

opticians (optometrists) alone was, in relative terms, found not to be a competitive option. 

The authors of the present study express concern with the SMDP study design and subsequent 

analysis; they find the conclusion that screening strategies based in general practices provide 

considerable cost savings over those obtained with screening by optometrists to be 

questionable. The authors note that results of the Frenchay study, in which optometrists were 

asked to report retinopathy and indicate whether it was sight-threatening, suggest that they 

performed considerably better in this study than did the optometrists in the SMDP. Two 

studies (one on the SMDP, one on the Frenchay study) that addressed referral on the basis of 

need for treatment suggested test sensitivities for optometrist screening of 48 and 87 percent, 

respectively, with specificities of 94 percent in both. The authors note a study (Ryder et al. 

1994) reported in abstract form that found a sensitivity of 100 percent when optometrists 

performed both mydriatic-assisted photography and ophthalmoscopy. General practitioners 

and optometrists, because of their numbers, are the main candidates for community screening 

according to the authors. In their discussion they state that the need to screen for retinopathy 

is uncontroversial, but the mode of screening is unresolved. They note that the only way to 

resolve current controversies may be to undertake a more methodologically rigorous 

comparison of primary screeners. 7 tables, 54 references. 

295 

TITLE: Pancreas Transplantation for Type I Diabetes Mellitus: Do the Benefits Offset the 

Risks and Cost? Larsen, J.L.; Duckworth, W.C.; Stratta, R.J. Postgraduate Medicine. 96(3): 

105-111. September 1, 1994. 

OBJECTIVE: To determine whether the benefits of a pancreas transplant to treat type 1 
diabetes are worth the risks and cost. 

CATEGORY: Expert opinion. 

CONCLUSION: Combined pancreas-kidney transplantation is becoming increasingly 

common and acceptable for treating patients with type 1 diabetes and end-stage renal disease. 

Patient mortality and kidney graft survival are not significantly different from a kidney 

transplant alone, and costs are offset by the added benefits to the patient of improved glycemic 

control without exogenous insulin, better lipid profiles, and improved quality of life. 

RECOMMENDATION: None. 

ABSTRACT: The authors discuss the current status of pancreas transplantation, either alone 

or in combination with a kidney transplant, as a treatment for type 1 diabetes. Between 1987 

and 1991, the overall 1-year patient survival rate in the United States for all types of pancreas 

transplants was 91 percent, and the 1-year pancreas graft survival rate was 72 percent. 

Pancreas transplantation should be considered for all patients with type 1 diabetes and severe 

nephropathy. At the University of Nebraska, patients with significant nephropathy are 

considered for a combined transplant, and patients who have had a kidney transplant or those 

with severe end-organ complications (e.g., proliferative retinopathy) or severely unstable 

glucose control are considered candidates for pancreas transplants. A comprehensive 

multidisciplinary evaluation confirms the diagnosis of type 1 diabetes, the patient's ability to 

undergo major surgery, absence of exclusion criteria, and existence of end-organ 

complications that would benefit from improved metabolic control. The success rates for 

solitary and sequential pancreas transplants are not as high as those for combined pancreaskidney transplants. Improved graft and patient survival rates result from better HLA matching, 

better organ retrieval with shorter preservation times, better operative techniques, improved 

ability to predict rejection by renal parameters, and better immunosuppressive regimens. 

Potential immediate complications include graft rejection, vascular thrombosis, pancreatitis, 

and infection, while later concerns relate to the effects of immunosuppression and 

hyperinsulinemia. At most centers, kidney-graft survival and overall mortality rates for 

combined trans-plants are comparable to those for kidney transplants only. Patients who have 

had transplants must take immunosuppressive drugs for the remainder of their lives, but they 

have fewer dietary and activity restrictions and experience a marked improvement in quality of 

life, with improved glycemic control and potential for rehabilitation. 1 figure, 3 tables, 6 

references. 

296 

TITLE: Patient Education Financing under Medicare. Smith, S.A. Patient Education and 

Counseling. 8(3): 299-309. September 1986. 

OBJECTIVE: To provide the history of Medicare reimbursement for preventive services. 

CATEGORY: Expert opinion. 
CONCLUSION: Medicare payment is currently limited to diagnostic or therapeutic care, 

with a few exceptions. The Prospective Payment System (PPS) may benefit hospitals, patients, 

and health education specialists if educators provide good evidence of their own usefulness in 

decreasing stay and shifting care to the outpatient setting. 

RECOMMENDATION: None. 

ABSTRACT: In this overview, the author notes that since 1965 Medicare reimbursement has 

been generally limited to treatment of illness or injury. Two exceptions have been 

pneumococcal immunization (authorized in 1981) and hepatitis B vaccination (1984), both of 

them primary prevention. A broad range of secondary prevention clinical/educational services 

are reimbursable under Part B of Medicare if an individual physician deems them appropriate 

as part of routine care. The key to assuring Medicare coverage for preventive services lies in 

presenting the claim to Medicare carriers as necessary to the diagnosis or treatment of a 

disease or injury. Before the advent of the Diabetes Control Program of the Centers for 

Disease Control (CDC), Medicare did not pay for outpatient diabetes education. The CDCsponsored project has succeeded in defining what is allowable under Medicare regulations for 

patient education as a separately billable item. By 1988, PPS will have replaced retrospective 

cost reimbursement. Under PPS, certain patient education services could be more attractive to 

hospitals; solid evidence shows that focusing on ambulatory outpatient diabetes education is 

profitable because stays can be reduced. As a result of the Tax Equity and Fiscal 

Responsibility Act of 1982, expanded benefit programs including preventive services are being 

offered by health maintenance organizations. 16 references. 

297 

TITLE: Paying for Preventive Care: Moving the Debate Forward. Davis, K.; Bialek, R.; 

Parkinson, M.; Smith, J.; Vellozzi, C. American Journal of Preventive Medicine. 6(4 

Supplement): S7-S30. 1990. 

OBJECTIVE: To suggest methods of improving the delivery and reimbursement of 

preventive services. 

CATEGORY: Expert opinion. 

CONCLUSION: Several strategies need to be adopted to improve payment for and delivery 

of preventive services, including the modification of health insurance plans to cover preventive 

services specified by the U.S. Preventive Services Task Force. 

RECOMMENDATION: In addition to modification of insurance plans, reimbursement 

codes need to be modified and more research on preventive services needs to be conducted. 

ABSTRACT: The authors discuss primary and secondary preventive care services. They 

review the Guide to Clinical Preventive Services (1989) developed by the U.S. Preventive 

Services Task Force, which contains age-, sex-, and risk-specific recommendations for 
prevention of illness and death. Both public and private insurers base reimbursement for 

services and procedures defined with the American Medical Association's Current Procedural 

Terminology (CPT-4), and CPT-4 codes exist for age-specific preventive services. However, 

a 1986 survey found that only 35 percent of reporting insurance companies offered preventive 

care coverage under group contracts. Furthermore, until 1981, no preventive service was 

covered by Medicare. Use of preventive services is correlated with insurance coverage, and 

such services are used less than is recommended. The authors consider four methods (a-d) of 

paying providers for preventive services. They note that (method a) fee-for-service 

reimbursement is the primary mode of paying for physician services and is most acceptable to 

physicians, but they point out that overuse is a possibility. A periodic preventive health visit 

fee (method b), which would involve a specified package of preventive services, would create 

an incentive to provide appropriate preventive services at appropriate intervals. However, it 

would have extensive administrative requirements as well as other shortcomings. Capitation 

payment (method c) may not be seen by capitated organizations as cost-beneficial; many users 

are transient, and the organization may not believe there will be a long-term benefit from 

providing preventive services. A preventive services account (method d) would allow patients 

to decide which preventive services they wanted, but patients might get caught up in current 

fads; other weaknesses are discussed. The authors make several recommendations: public and 

private health insurance plans need to be modified and fee-for-service payment for preventive 

services merits continued consideration, but a periodic preventive health visit fee might be 

preferable in the longer term. 1 figure, 10 tables, 48 references. 

298 

TITLE: Payment for Diabetes Care Under the Medicare Fee Schedule. Lasker, R.D. Diabetes 

Care. 15(Supplement 1): S62-S65. March 1992. 

OBJECTIVE: To review the problems with payment for diabetes care under the current 

(pre-1992) Medicare system; to describe the anticipated effects of the Medicare fee schedule 

on physician reimbursement and on the quality of care of patients with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: The Medicare fee schedule to be phased in beginning January 1992 should 

more adequately compensate physicians who provide evaluation and management services for 

patients with diabetes and should improve the quality of care of these patients. 

RECOMMENDATION: None. 

ABSTRACT: The author describes problems associated with payment for diabetes care 

under the current (pre-1992) Medicare system and reviews the anticipated impact of the new 

Medicare fee schedule on physician reimbursement and the quality of care of patients with 

diabetes. The care of patients with diabetes primarily involves evaluation and management 

services; the current Medicare payment system, which is based on "customary, prevailing, and 

reasonable" charges, inadequately compensates physicians for such services, and payments do 

not correlate well with service resource costs. Payments also vary for the same service, 
depending on physician specialty and location of practice. Under the Medicare fee schedule to 

be implemented in 1992, a fee will be assigned to each patient care service that is proportional 

to the work and practice costs involved in providing it. Fees for evaluation and management 

services are expected to increase an average of 28 percent over what they would increase with 

the current system; Medicare payments to physicians providing primarily evaluation and 

management services should increase by 17 to 38 percent. Payments for evaluation and 

management will differ by specialty to reflect differences in time and effort. With more 

equitable compensation for lengthy and new patient visits, physicians will be encouraged to 

provide the time-consuming evaluation and management services that patients with diabetes 

require. Physicians will also have greater financial incentive to obtain advanced training in 

diabetes management, and specialties such as endocrinology and internal medicine will be 

more attractive to physicians-in-training. The Medicare fee schedule should improve access to 

care and the quality of care for patients with diabetes who are beneficiaries of the Medicare 

program. Note: A footnote to the article indicates that budget cuts and other factors may 

reduce expected increases in evaluation and management payments. 6 references. 

299 

TITLE: Perceived Effectiveness, Cost, and Availability of Patient Education Methods and 

Materials. Funnell, M.M.; Donnelly, M.B.; Anderson, R.M.; Johnson, P.D.; Oh, M.S. 

Diabetes Educator. 18(2): 139-145. March-April 1992. 

OBJECTIVE: To determine the efficacy and cost-effectiveness of patient education methods 

and media. 

CATEGORY: Expert opinion. 

CONCLUSION: Teaching methods that were used most frequently and given the highest 

marks for effectiveness received relatively low marks for cost-effectiveness. 

RECOMMENDATION: None. 

ABSTRACT: A survey about patient education was sent to 816 members of the American 

Association of Diabetes Educators; there were 325 respondents (40 percent). The educators 

were asked to rate selected educational materials and methods on their educational and costeffectiveness. Among educational materials, videotapes, slides/tapes, and booklets received 

the highest rankings for both measures of effectiveness. Among methods, individual 

approaches (skill sessions, counseling sessions, content sessions) got the highest marks on 

educational effectiveness but received relatively low marks on cost-effectiveness. Booklets, 

videotapes, and books were used by more than four-fifths of respondents; most did not use 

computer-assisted or programmed instruction. Respondents obtained materials from 

manufacturing companies (88 percent), developed their own (84 percent), or purchased them 

from other sources (60 percent). Lack of third party reimbursement and lack of patient 

motivation were identified most often as major barriers to high-quality patient education. 

Psychosocial issues (e.g., adjustment, stress) were found to be the areas of greatest need for 

developing more educational materials, followed by special populations and long-term 
complications. The authors point out that the teaching methods that diabetes educators use 

most frequently and believe to be educationally sound are not considered by this group to be 

cost effective. 8 tables, 8 references. 

300 

TITLE: Potential for Reducing Health Care Costs by Public and Patient Education: Summary 

of Selected Studies. Roccella, E.J. Public Health Reports. 91(3): 223-225. May-June 1976. 

OBJECTIVE: To review selected studies pertaining to the potential impact of patient 

education on health care costs. 

CATEGORY: Expert opinion. 

CONCLUSION: Educational programs that help patients to understand the nature of their 

illness and what they can do to help themselves have the potential to reduce health care costs. 

RECOMMENDATION: Additional, more carefully controlled studies are needed to fully 

document the impact of patient and public education programs on health care costs. 

ABSTRACT: The authors review several studies that document the impact of patient 

education programs on health care costs. A study by Miller and Goldstein (1972) assessed the 

effects of a telephone hot line developed by a California clinic for patients with diabetes . 

Patients could call the hot line for information, medical advice, and prescriptions. An 

education program on use of the service was designed for clinic patients with diabetes. Over a 

2-year period, the incidence of diabetic coma at the clinic was reduced from 300 to 100 cases, 

and the number of emergency room admissions for patients with diabetes decreased by 50 

percent even though the clinic population increased from 4,000 to 6,000. The hot line saved 

an estimated 2,300 clinic visits for medications alone. This and other studies indicate the 

potential positive impact of patient education programs on health care costs. More detailed, 

controlled cost-benefit and cost-effectiveness studies are needed to document the potential 

cost savings associated with patient education programs. 18 references. 

301 

TITLE: Psychosocial Challenges for Children with Insulin-Dependent Diabetes Mellitus. 

Pond, J.S.; Peters, M.L.; Pannell, D.L.; Rogers, C.S. Diabetes Educator. 21(4): 297-299. 

July-August 1995. 

OBJECTIVE: To relate the psychosocial stages of child development delineated by Erik 

Erikson to children with type 1 diabetes; to give suggestions to families and health care 

providers involved with such children. 

CATEGORY: Expert opinion. 
CONCLUSION: Key issues in the psychosocial growth of children include the development 

of trust, autonomy, initiative, and industry. These key issues are particularly important for 

children with type 1 diabetes. 

RECOMMENDATION: Family members and caregivers should try to build trust, 

autonomy, initiative, and industry at every age. 

ABSTRACT: The authors apply the psychosocial stages of childhood delineated by Erik 

Erikson (1950) to children with type 1 diabetes. They emphasize the first four stages, which 

include developing a foundational trust or acquiring a mistrust of the world during infancy; 

developing a sense of autonomy; the conflict of initiative versus guilt (preschool years); and 

"industry versus inferiority" (at school and home). Chronic illness, such as diabetes, affects a 

child's progression through the psychosocial stages. Recommendations are made for families 

and health care providers to help children with their development. During "initiative versus 

guilt," for example, health care providers can help parents understand that it is normal for 

children to consider their illness a punishment. Family members and health care providers 

should try to build trust, autonomy, initiative, and industry at all ages; consistent 

understanding and support can enhance trust at any stage. Autonomy can be increased by 

helping children explore and master the environment with as few limitations as appropriate for 

maintaining health and conforming to social obligations. Initiative can be increased by not 

allowing type 1 diabetes to be the only focus of the child's life. Helping children with type 1 

diabetes to care for themselves and make as many decisions as possible is crucial to 

maintaining adequate metabolic control. Parents should be encouraged to gradually transfer 

responsibilities for diabetes care to their children. Children are usually ready to begin injecting 

insulin at about age 9. 9 references. 

302 

TITLE: Quality Assurance Issues. Homa-Lowry, J. Diabetes Care. 15 (Supplement 1): S51-

S53. March 1992. 

OBJECTIVE: To document changes since 1965 in health care quality assurance systems and 

their impact on health care for patients with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Since enactment of the Prospective Payment System for Medicare in 1983, 

the venue of diabetes care has shifted dramatically from inpatient hospitalization to outpatient 

care, a setting not subject to significant quality assurance review. 

RECOMMENDATION: Standards must be established for patient outcomes and the 

processes needed to attain them to fully assess the impact of quality assurance system changes 

on the quality of diabetes care. 

ABSTRACT: The author documents changes since the 1965 establishment of Medicare and 
Medicaid in health care quality assurance systems and the impact of these changes on the 

financing of diabetes care. The most significant change to the utilization review and quality 

assurance processes resulted from the 1983 enactment of Title IV of the Social Security Act, 

which established the Prospective Payment System for Medicare. With this act, reimbursement 

was shifted from reasonable costs to a predetermined fixed price per discharge. Prior to the 

Prospective Payment System, utilization review programs were not very effective in 

monitoring and limiting resource utilization; the cost reimbursement system rewarded those 

that used the most resources. The impact of the financial changes of the Prospective Payment 

System on quality of care is difficult to assess because data on patient outcomes prior to its 

enactment are not readily available. Hospital admissions for treatment of type 2 or type 1 

diabetes as a primary diagnosis declined dramatically from 1981 to 1988, suggesting a 

significant shift in diabetes care to the outpatient setting. The issue of quality assurance 

systems in the outpatient treatment venue remains to be addressed, as does the potential 

impact of case management on patient quality of care. 2 tables, 1 reference. 

303 

TITLE: Quality-of-Life Evaluation in Diabetes. Eiser, C.; Tooke, J.E. PharmacoEconomics. 

4(2): 85-91. August 1993. 

OBJECTIVE: To review the state of the art in developing quality-of-life scales and to assess 

their potential value in Diabetes Research and clinical practice. 

CATEGORY: Expert opinion. 

CONCLUSION: Measures of quality of life appear to be most important for assessing the 

impact of different treatments and procedures. 

RECOMMENDATION: Quality-of-life assessments should be integral components of 

clinical trials of alternative therapies for patients with diabetes and should be part of everyday 

clinical decisions. 

ABSTRACT: The authors review current methods of measuring quality of life, discuss the 

application of such measures to diabetes, and examine sex differences in self-reports of life 

quality. Managing diabetes, especially its emphasis on self-care, imposes great demands on 

patients and their families, and it potentially compromises the attainment of a good quality of 

life in numerous ways. Two broad approaches are used in quality-of-life assessments: one 

assumes that quality of life is synonymous with health status; it emphasizes the importance of 

an individual's absolute level of functioning relative to the general population. A second 

approach stresses individual differences in how people perceive and appraise situations; in this 

approach, the individual's perceptions of and satisfaction with level of functioning are central. 

Diabetes-specific quality-of-life scales are useful in assessing how a specific treatment for 

diabetes affects individuals and where comparisons across alternative treatments are desired. 

The most widely quoted instrument is the Diabetes Quality of Life measure developed for the 

Diabetes Control and Complications Trial (Jacobson et al. 1988). The authors note that 

quality-of-life measures have most commonly been used to assess the impact of new 
treatments, particularly when patients change from syringe injections to multiple pen 

treatments. They have also been used in assessing the impact of transplants and in studies 

involving the conversion to insulin in type 2 diabetes. In using these measures, differences in 

quality of life as a function of age and sex must be considered, especially in evaluating clinical 

trials. 26 references. 

304 

TITLE: Rationale for the Hypertension Guidelines for Primary Care in South Africa. Opie, L. 

H.; Steyn, K. South African Medical Journal. 85(12 Part 2): 13251328, 13301331, 

13341335. December 1995. 

OBJECTIVE: To provide a rationale for the proposed hypertension guidelines for primary 

care in South Africa. 

CATEGORY: Expert opinion. 

CONCLUSION: Cost-Effective care should be provided to as many persons with 

hypertension as possible. 

RECOMMENDATION: The guidelines need to be reviewed and adapted regularly as new 

knowledge becomes available or if their practical application suggests viable alternatives. 

ABSTRACT: The authors reviewed the hypertension guidelines proposed by the 

Hypertension Society of Southern Africa and rationalize their adoption. Aims are to provide 

practical recommendations that can be followed in the primary care setting and to provide 

Cost-Effective care for as many hypertensive persons as possible. The guidelines recommend 

measuring blood pressure with the patient sitting and taking more than one measurement. Per 

the guidelines, patients with a systolic blood pressure reading of 140 to 169 mm Hg or a 

diastolic reading of 90 to 99 mm Hg should be provided with education on hypertension and 

treatment by lifestyle modifications (e.g., proper diet, exercise). The cutoff point for drug 

treatment is a diastolic blood pressure of 110 to 114 mm Hg or a systolic blood pressure of 

170 to 199 mm Hg. For a patient with a diastolic blood pressure of 115 to 129 mm Hg and/or 

a systolic blood pressure of 200 mm Hg or higher, the blood pressure reading should be 

repeated after 1 hour's rest; if it is still in this range, the primary care provider should start 

drug treatment promptly and refer or investigate the patient within 1 week. All patients with 

diabetes should be referred, and the aim in these patients should be a diastolic pressure of 90 

mm Hg and a systolic blood pressure of 140 mm Hg or less. Drug therapy for hypertension is 

categorized as first-line (e.g., diuretics), second-line (e.g., betablockers, ACE inhibitors), and 

third-line (e.g., hydralazine). Each line of treatment is progressively more expensive. 

Practitioners should begin drug treatment with a low-dose diuretic because of its costeffectiveness and the wide experience with it. 3 tables, 55 references. 

305 
TITLE: Reimbursement for Diabetes Self-Care Training: The North Carolina Experience. 

Fore, W.W. Diabetes Care. 17(6): 608-610. June 1994. 

OBJECTIVE: To determine why diabetes programs in North Carolina were slow to use 

special codes enacted in 1985 for the reimbursement of training in self-care. 

CATEGORY: Expert opinion. 

CONCLUSION: The establishment of specific service codes by Blue Cross/Blue Shield of 

North Carolina did not lead to the use or level of reimbursement anticipated. Other sources of 

revenue are supporting self-care programs. Just six of nine programs were aware of the codes 

eight years after enactment, and only four of these six used them to obtain reimbursement 

from two major North Carolina insurers. 

RECOMMENDATION: The team approach to diabetes self-care needs specific billing 

codes that identify the service as well as reimbursement that will cover the cost of providing it. 

ABSTRACT: Providers of health services encounter barriers in obtaining reimbursement for 

preventive and educational services. In 1985, Blue Cross/Blue Shield (BC/BS) of North 

Carolina published Guidelines for Reimbursement of Diabetes Self-Care, which acknowledged 

the team approach in diabetes care and provided three service codes for billing. The guidelines 

were extended the same year to the State Health Insurance Plan of North Carolina. A 1993 

review of the guidelines' effect found that in 1991, insurance benefits were paid for less than 

250 patients under either BC/BS's regular business plan or the state plan. Patient volumes 

were similar in 1992. This minimal activity contrasted with the growth of diabetes programs in 

North Carolina recognized by the American Diabetes Association from none in the first six 

months of 1988 to nine in 1992. A 1993 survey of the nine programs found only six to be 

aware of the codes and only four of these six to be obtaining reimbursement from the insurers 

noted; the remaining two programs billed under physician or hospital codes in an effort to 

obtain more revenue. Two of the four programs using the new codes mentioned obstacles to 

filing or exclusion of coverage. The author notes that Medicare requires diabetes self-care 

training to be associated with a hospital to be reimbursed under Medicare Part B. He states 

that the restriction of reimbursement to physicians or hospitals for self-care is not preventing 

the use of such programs nor decreasing their cost. The author also notes that current 

payments for self-care training do not cover costs. He calls for adequate compensation of the 

administrative and teaching effort of physicians. In discussing proposed legislation to extend 

Medicare reimbursement for self-care training, the author states that the costs of such training 

are already present in physician and hospital billing and would not be all new funding. 5 

references. 

306 

TITLE: Reimbursement Issues in Diabetes. Sinnock, P.; Bauer, D.W. Diabetes Care. 7(3): 

291296. May-June 1984. 
OBJECTIVE: To review reimbursement issues in outpatient education and in new 

technologies and services for people with diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Outpatient diabetes education is generally a covered service, but the 

mechanism to reimburse providers for the service varies from state to state. For diabetesrelated technologies or services, there is little uniformity among third party payers. 

RECOMMENDATION: The authors make a variety of recommendations to improve 

problems with reimbursement for education. 

ABSTRACT: The authors review coverage under Medicare, Medicaid, Blue Cross/Blue 

Shield, and private insurance for 20 inpatient diabetes education programs; 15 states have 

coverage through 1 or more of these sources. Although third party payers recognize the role 

of patient education, they routinely reimburse only when the education is provided during a 

hospital stay. Third party reimbursement of diabetesrelated technologies/services and 

equipment depends on the type of coverage, the state, and the item or procedure covered. 

Many third party payers do not have stated policies on reimbursement for a particular piece of 

equipment, or they do not have consistent, well-communicated standards for determining 

coverage. Based on their review of attempts to obtain third party reimbursement for diabetes 

outpatient education, the authors assert the following: the language of insurers differs from 

that of providers, the types of services covered under existing policies are explicitly stated, 

patience is a virtue in requesting coverage, third party payers usually request that costeffectiveness be addressed, and requests for reimbursement will be evaluated according to the 

criteria of the third party payer. To help overcome the problem with reimbursement for 

education, the authors state that there is a need for rapid dissemination of Medicare policies 

on outpatient education. They also ask that successes in obtaining coverage be documented 

and published in national journals. In addition, they request that the minimum standard for 

patient education developed by the National Diabetes Advisory Board be disseminated to all 

insurers. They also recommend educating providers about health care finance. 3 tables, 27 

references. 

307 

TITLE: Reins or Fences: A Physician's View of Cost Containment. Grumbach, K.; 

Bodenheimer, T. Health Affairs. 9(4): 120-126. Winter 1990. 

OBJECTIVE: To discuss the impact of expenditure targets and utilization review on cost 

containment and clinical decisions. 

CATEGORY: Expert opinion. 

CONCLUSION: Global budgeting strategies are preferable to utilization review for cost 

containment. 
RECOMMENDATION: When evaluating cost-containment measures, physicians and 

policymakers should consider the impact on clinical autonomy. 

ABSTRACT: The authors compare the impact of utilization review and global budgetary 

controls on the professional autonomy of physicians. They define professional autonomy as 

clinical freedom, which is essentially the ability of the physician to deliver optimum medical 

care to a patient without restraint from groups with other interests. The authors consider peer 

review and negotiations with third party payers to set fees as unrelated to professional 

autonomy. Utilization (not peer) review, however, suffers from uncertainty about what 

constitutes inappropriate care and has turned American physicians into the most "secondguessed and paperwork-laden physicians in western industrialized democracies." Proposals to 

expand current utilization review practices into the ambulatory sector are daunting. The 

utilization review system has promoted a large bureaucracy, which has resulted in 

administrative costs increasing more than twice as fast as overall health costs from 1980 to 

1986. The alternative is expenditure targets, which limit resource usage by particular groups 

but distance day-to-day clinical decisions from the cost-control process. Expenditure limits let 

the community of physicians regulate itself rather than relying on outside review, although 

such limits exert pressure to control the number of physicians relative to the population. 

Global budgetary strategies allow more clinical freedom for physicians than does utilization 

review. 18 references. 

308 

TITLE: Relevance of Postprandial Glycosuria in Survey for Diabetes Mellitus. Tosetti, C.; 

Brunetti, R.; Evangelisti, A.; Napoli, A. Minerva Medica. 87(11): 505-508. November 1996. 

OBJECTIVE: To evaluate the measurement of postprandial glycosuria as an approach to 

selecting adults needing a fuller assessment for possible diabetes. 

CATEGORY: Expert opinion. 

CONCLUSION: Performing urinalysis measured after a meal rich in carbohydrates and 

urinalysis following glucose load could be considered simple, inexpensive approaches in 

people over 50 years old. In those under age 50, fasting glycosuria or clinical criteria, 

particularly relevant family history, are superior approaches to postprandial urinalysis. 

RECOMMENDATION: None. 

ABSTRACT: The authors studied 110 adults; 64 had had postprandial glycosuria on a 

previous screening, and 46 had been referred by general practitioners to the authors' diabetes 

center in Italy because of risk factors (family history with or without overweight, or 

overweight plus dyslipidemia). Urine was tested for glucose with the participant in the fasting 

state, postprandially (after a hyperglycemic meal), and 30, 60, 90, and 120 minutes after 75 g 

of glucose was ingested. Five criteria (family history of diabetes, relevant family history [at 

least one first-degree relative with diabetes], overweight, overweight plus diabetic family 
history, and overweight plus relevant diabetic family history) were also evaluated 

retrospectively. Ten of those evaluated (9 percent) were found to have diabetes and 16 (15 

percent) to have impaired glucose tolerance. All 10 determined to have diabetes had 

postprandial glycosuria as well as glycosuria 60 minutes or more after glucose load; thus these 

tests had 100 percent sensitivity. Only 2 of 10 persons found to have diabetes had fasting 

glycosuria. The specificity of postprandial glycosuria in younger patients (# 50 years old) was 

48 percent; in older patients it was 44 percent. Specificities for glycosuria 60 or more minutes 

after glucose load ranged from 61 to 67 percent in younger patients and from 35 to 48 percent 

in older patients. The sensitivity of fasting glycosuria was 100 percent for younger adults 

(specificity equaled 96 percent) but just 11 percent for older adults (specificity equaled 94 

percent). All five clinical criteria had 100 percent sensitivity in younger patients (specificity 

ranged from 37 to 87 percent), but in older patients the sensitivity was 33 percent or less for 

four of the five criteria. The positive predictive value of postprandial glycosuria was 23 

percent for older patients but only 4 percent for younger patients, which the authors attribute 

to the much higher prevalence of diabetes in the older population. 1 table, 11 references. 

309 

TITLE: Scientific Rigor of Economic Analyses (letter). Lee, J.T.; Sanchez, L.A. Annals of 

Internal Medicine. 117(2): 172. July 15, 1992. 

OBJECTIVE: To supplement the findings of Udvar-helyi et al. that were published in an 

earlier issue of Annals of Internal Medicine with a similar assessment of manuscripts 

appearing in pharmacy journals. 

CATEGORY: Expert opinion. 

CONCLUSION: Economic articles in the pharmacy literature reviewed by the authors were 

often deficient methodologically. 

RECOMMENDATION: A multidisciplinary initiative is warranted to educate researchers, 

practitioners, and third party payers in the essential components of a thorough economic 

analysis. 

ABSTRACT: The authors performed an assessment, using a process similar to that of 

Udvarhelyi et al., of the methodologic soundness of 65 articles that included economic 

analyses in six pharmacy journals from 1985 to 1990. The articles were subjected to 10 

criteria to assess whether appropriate methodologic techniques were used. Only 3 of the 10 

criteria were fulfilled by 50 percent or more of studies evaluated. The authors found 

deficiencies in identifying all relevant costs and consequences, in discounting, and in 

performing sensitivity and incremental analyses. The term "cost effective" was misinterpreted 

in 57 percent of the studies evaluated. The authors found no differences in methodologic 

soundness by journal or year of publication. 4 references. 

310 
TITLE: Screening for Retinopathy. Singer, D.E.; Nathan, D.M.; Fogel, H.A.; Schachat, A.P. 

Annals of Internal Medicine. 116(8): 660671. April 15, 1992. 

OBJECTIVE: To determine appropriate patients, methods, timing, and cost-effectiveness for 

screening for retinopathy. 

CATEGORY: Expert opinion. 

CONCLUSION: Cost-effectiveness analyses indicate that widespread screening for 

retinopathy appears to be good policy. 

RECOMMENDATION: Although the current recommendations for retinopathy screening 

are reasonable, the following changes should be considered to increase efficiency and benefit: 

(1) reduce the frequency of screening in the initial years after the diagnosis of diabetes in 

selected patients with type 2 diabetes, and (2) encourage wider use of stereoscopic fundus 

photography for screening. 

ABSTRACT: The authors review the natural history of retinopathy, identify risk factors for 

its development, review intervention studies defining eye lesions that respond to laser therapy, 

and review cost-effectiveness analyses and evaluate available screening modalities. Relevant 

articles were identified by examining prominent review articles and the authors' own files as 

well as through recommendations from experts at the American Academy of Ophthalmology 

and a MEDLINE search. Articles on the natural history of retinopathy were limited to large 

clinical series and formal epidemiologic studies of defined populations; those on the 

therapeutic effect of photocoagulation and of glycemic control were restricted to randomized 

trials. For important data variables, individual estimates from multiple studies were presented 

in the study rather than a single metaanalytic summary estimate. Analysis revealed that 

photocoagulation therapy can reduce the risk for vision loss due to macular edema or 

proliferative retinopathy by about 50 percent. The evidence also showed that duration of 

diabetes is the main risk factor for retinopathy. (The type of diabetes and the severity of 

baseline retinopathy also influence the onset and progression of retinopathy.) The authors 

found that standard ophthalmoscopic examination has moderate sensitivity (80 percent in 

research settings) and specificity (greater than 90 percent for proliferative retinopathy, lower 

for macular edema), thereby making seven-field stereoscopic photography of the fundus a 

more accurate method. cost-effectiveness analyses indicate that widespread screening for 

retinopathy seems to be good health policy. Among patients with type 1 diabetes, the cost of 

preventing blindness is less than averted disability payments. Screening is far less beneficial for 

patients with type 2 diabetes but still can be expected to provide additional years of sight 

efficiently. Cost savings could safely be realized by having patients with type 2 diabetes who 

do not have retinopathy on initial screening wait 4 years for their next screening, then proceed 

with annual screening. 3 figures, 2 tables, 74 references. 

311 

TITLE: Should Persons with Diabetes Be Licensed to Drive Trucks? Risk Management. 
Lave, L.B.; Songer, T.J.; LaPorte, R.E. Risk Analysis. 13(3): 327-334. June 1993. 

OBJECTIVE: To assess whether persons with diabetes mellitus who use insulin should be 

licensed to drive trucks on interstate highways. 

CATEGORY: Expert opinion. 

CONCLUSION: The additional risks of licensing insulin-using drivers are well within the 

currently accepted range of risks for all drivers. The annual costs per driver from additional 

crashes incurred by insulin-dependent drivers were estimated at $4,800; for such drivers with 

a history of severe hypoglycemia, $17,900. 

RECOMMENDATION: Denying commercial vehicle licenses for persons with a recent 

history of severe hypoglycemic reactions should be considered because of the large costs 

potentially incurred by such persons. 

ABSTRACT: The Federal Highway Administration has denied commercial motor vehicle 

licenses to persons who use insulin but is reconsidering this decision; the authors apply risk 

analysis to this issue. As a group, persons with diabetes who use insulin have almost four 

times the risk of highway crashes as persons without diabetes. Songer et al. (1993) estimated 

that mild hypoglycemia would cause an insulin-dependent driver to have an additional 0.00002 

crashes each year, on average, while an insulin-using, but not insulin-dependent, person would 

have an additional 0.00001 crashes per year. Severe hypoglycemia would lead to 0.04 to 0.24 

additional crashes per driver, depending on insulin-use status. Additional crashes caused by 

insulin-using drivers were estimated to cost society at least $3,600 per driver per year. The 

additional annual costs for insulin-dependent persons were estimated at $4,800; for persons 

with a history of severe hypoglycemia, $17,900. The authors note that the three- to five-fold 

increases in risks of a crash (for persons using insulin) are well within tolerable limits for 

highway risks for type of highway, size of car, and time of day. For example, the safest urban 

highways are 9.2 times safer than the most dangerous rural highways. The authors also note 

that 70 percent of states permit insulin-using persons to drive trucks within their states. They 

contend, however, that the additional social costs due to fatalities, injuries, and property 

damage associated with allowing persons with a history of severe hypoglycemia to drive 

exceed currently acceptable levels. 3 figures, 4 tables, 16 references. 

312 

TITLE: Social and Economic Impact on Youth-Onset Diabetes in Japan. Matsushima, M.; 

Tajima, N.; Agata, T.; Yokoyama, J.; Ikeda, Y.; Isogai, Y. Diabetes Care. 16(5): 824-827. 

May 1993. 

OBJECTIVE: To evaluate whether patients in Japan with type 1 diabetes are socially 

handicapped and to determine the factors associated with their socioeconomic status. 

CATEGORY: Expert opinion. 
CONCLUSION: Patients with type 1 diabetes experienced discrimination in the job market 

and had lower average incomes. 

RECOMMENDATION: Further studies should be performed to precisely document the 

social and economic impact of diabetes. 

ABSTRACT: The authors used a matched-pair, case-control approach to study patients with 

type 1 diabetes (onset before 25 years) who had visited a Tokyo clinic. Case patients (n = 35) 

and controls, all of whom were siblings without diabetes, completed a questionnaire on 

socioeconomic status and employment. The distribution of educational achievement was 

similar between the two groups. There was also no significant difference in current 

employment status, but the controls had higher incomes than patients with diabetes (p < 0.05); 

there was still a difference even when the data from the six patients with work disability from 

diabetic complications and their control siblings were excluded. While none of the controls 

had experienced job refusal, seven patients with diabetes had been refused a job. Six of these 

seven had developed diabetes before obtaining a job and had mentioned their diabetes to job 

interviewers. Multivariate analysis showed that diabetes status was independently associated 

with income level. Absenteeism did not differ between patients with diabetes and controls. 3 

tables, 10 references. 

313 

TITLE: Statistics, CPT, ICD9, CDM, and Level III Codes: What Are They and How Did I 

Get This Job? Bourgeois, P. Diabetes Educator. 17(5): 349, 351352. September-October 

1991. 

OBJECTIVE: To provide diabetes educators with an overview of what they can do to 

reduce the risk of their program being cut financially or eliminated entirely. 

CATEGORY: Expert opinion. 

CONCLUSION: Diabetes educators must be aware of reimbursement issues and terminology 

for their patients' sake as well as for their own, or risk losing the diabetes education program 

entirely. 

RECOMMENDATION: Diabetes educators should prepare a mission statement with goals, 

objectives, and a business plan; meet with administrators to discuss the program; obtain 

admission statistics on patients with diabetes; learn the coding terminology; prepare charge 

descriptions; and meet with Medicare/Medicaid intermediaries and private insurers to discuss 

reimbursement. 

ABSTRACT: Acknowledging that education, particularly diabetes education, is one of the 

first hospital services to be eliminated or cut back, the author encourages diabetes educators 

to justify the importance of their position to administrators. The author recommends 

developing a mission statement and 1-year business plan. Diabetes educators should document 
their time by activity. The American Diabetes Association's (ADA's) publications Diabetes 

Outpatient Education: The Evidence of Cost Savings and Third party Reimbursement for 

Diabetes Outpatient Education: A Manual for Health Care Professionals are recommended. 

Educators should meet with administrators to discuss the education program, including 

preparation of charge descriptions and use of various codes (e.g., ICD-9, CPT). They should 

prepare charge description master codes for procedures using the ADA's manual. They should 

request an audit of patients admitted with a diabetes-related diagnosis and possibly ask for 

statistics about patients admitted with a secondary diagnosis of diabetes. These statistics 

should be available for reimbursement discussions with administration or negotiations with 

insurance companies. The number of patients admitted with diabetes as a secondary diagnosis 

is usually three times the number of those admitted with diabetes as a primary diagnosis. The 

business office should be asked to file insurance claims for patients with diabetes, even briefly, 

to convince that office it is worthwhile. The memorandum on outpatient diabetes education 

reimbursement coverage, Hosp 88-08, should be requested from Medicare. Diabetes 

educators must be aware of reimbursement issues and technology. 5 references. 

314 

TITLE: Summary Document of Nutrition Intervention in Diabetes. Geppert, J.; Splett, P.L. 

Journal of the American Dietetic Association. 91(11):S27-S30. November 1991. 

OBJECTIVE: To describe and assess nutrition interventions in diabetes mellitus. 

CATEGORY: Expert opinion. 

CONCLUSION: Nutrition is important in managing diabetes and in preventing and treating 

its complications. 

RECOMMENDATION: With other members of the diabetes team, dietitians can help 

patients improve glycemic control, promote appropriate weight loss, control hypertension, and 

improve lipid concentrations. 

ABSTRACT: Nutrition affects outcomes for diabetes mellitus directly through control of 

blood glucose and indirectly through therapeutic effects on high blood pressure and obesity. 

The primary goal of nutritional therapy for this disorder is to promote normal blood 

concentrations of glucose and lipids. Thirty-three percent of patients who have had type 1 

diabetes for more than 15 years and 20 percent of those who have had type 2 diabetes that 

long will develop nephropathy; restricting protein intake and controlling hypertension are 

thought to slow progression of renal disease. Blood pressure control, which is important in 

preventing and treating diabetic nephropathy, retinopathy, and cardiovascular disease, includes 

weight control and a low-sodium diet. The success of nutrition intervention in promoting 

normal blood sugar and lipid concentrations is well established. Studies are cited in which 

diabetes education reduced hospital days by 50 percent (a Rhode Island study reported by 

Fishbein, 1985) and by 33 percent (Nersesian et al. 1982). Reported per-patient costs for 

diabetes education programs range from $150 to $250. 1 table, 40 references. 
315 

TITLE: Where Do We Go From Here? Clark, C., Jr. Annals of Internal Medicine. 124 (1 

Part 2): 184-186. January 1996. 

OBJECTIVE: To review research in care for type 2 diabetes and make recommendations for 

the care of patients with this disorder. 

CATEGORY: Expert opinion. 

CONCLUSION: Given the enormous cost of diabetes complications, the benefit of 

comprehensive management should outweigh the cost relatively quickly. 

RECOMMENDATION: Further research is needed to precisely define how comprehensive 

care will be delivered and to determine who will pay for it. 

ABSTRACT: The author assesses care for type 2 diabetes and broadly describes research on 

the care of patients with that disorder. Comprehensive patient education is an essential 

component of care; all patients must be made aware of the risks inherent in a diagnosis of type 

2 diabetes. Thorough assessment of a patient's risk status is needed, including assessment of 

retinopathy, nephropathy, and neuropathy. Initial evaluation must also include assessment of 

cardiovascular disease and risk factors. The applicability of specific glycemic goals to various 

subsets of patients with type 2 diabetes remains controversial, but any decrease in hemoglobin 

A1c levels is beneficial. The limitations of diet, exercise, and available oral hypoglycemic 

therapies are being reduced through the introduction of new therapeutic agents; type 2 

diabetes may eventually be controlled with combined oral agents. Ongoing research is 

evaluating the impact of current therapies on macrovascular and microvascular disease in type 

2 diabetes, current diabetes practices and outcomes, and care in both health maintenance 

organizations and fee-for-service sites. A collaborative model involving the expanded use of 

nurses, dietitians, diabetes educators, and subspecialist physician consultation for specific 

complications is the most likely model for diabetes care, particularly within the managed care 

setting. The question remains, however, of who will pay for comprehensive care. 26 

references. 

316 

TITLE: Where Have All the Pennies Gone? The Work of Manchester Medical Audit 

Advisory Group. Johnson, R. British Medical Journal. 309(6947): 92-102. July 9, 1994. 

OBJECTIVE: To review the work of the Manchester Medical Audit Advisory Group, 

including the group's involvement in the Diabetes 2000 project, a multi-practice audit of 

diabetes. 

CATEGORY: Expert opinion. 
CONCLUSION: Preliminary results from the second year of the Diabetes 2000 project show 

indicators of improved care. 

RECOMMENDATION: Continuing support for medical audit advisory groups, along with 

continued evaluation, is justified. 

ABSTRACT: The author reviews the work of the Manchester Medical Audit Advisory 

Group, including the group's involvement in the Diabetes 2000 project, which involves an 

audit of diabetes care in general practices. The group developed a stepwise audit approach to 

the management of the disease and produced audit packs that permitted practices to enter the 

audit regardless of their current level of diabetes management. The project had a target of 

recruiting 25 practices for the first year; currently, 80 of the 107 Manchester practices are 

actively participating. In the second complete year of the audit, markers of improved care 

have been documented. The recorded prevalence of diabetes has increased, as has the 

recording of monitoring measures such as foot pulse examination and fundoscopy. Project 

fieldworkers report better practice organization and improved confidence in the care of 

patients with diabetes. The Manchester group expects to follow patients with diabetes to 

measure final outcomes, but it is anticipated that many years of follow-up will be required to 

document the benefits of the audit process. The author points out that the Manchester group's 

core funding from the family health services authority is less than the annual amount spent by 

an average general practitioner on drugs. In addition to the core funding, the group has funds 

from the Department of Health (for Diabetes 2000) and the regional health authority. 5 tables, 

16 references.