Small Change Brings Big Improvement in Diabetes Care

CHICAGO, May 18 -- A annual investment in diabetes care could save as much as ,000 per patient per year over a lifetime, according to investigators here.

Modest efforts to ensure that patients in federally qualified community health centers are screened for diabetes and that those who are diagnosed with the condition are followed to prevent complications can reduce the lifetime incidence of diabetic retinopathy, renal disease, and coronary artery disease, said Elbert Huang, M.D., M.P.H., of the University of Chicago, and colleagues.

Over five years, a federal quality-improvement initiative, called the Health Disparities Collaborative, produced significant improvements in a number of diabetes quality-of-care parameters, including glycosylated hemoglobin (HbA1c) levels and preventive cardiovascular care, the authors reported online in Health Services Research.

"In this setting, we found that the economic value of improving the delivery of existing diabetes care was roughly equal to the benefits of developing a new treatment, " said Dr. Huang. "A small investment in upgrading the delivery of health care brought about a substantial improvement in health that justified the costs of the program."

He and his colleagues looked at data from a serial cross-sectional follow-up study of the effects of the quality-improvement program in 17 midwestern community health centers in 1998, 2000, and 2002.

They also created a simulation model to project the health consequences and costs of the improvements if they were carried out over a lifetime, using data from the most recent clinical trials and epidemiologic studies.

The researchers extracted information on diabetes care processes and risk factor levels from the medical charts of randomly selected patients. Their mean age in 1998 was 55; 63% were nonwhite, and 67% were women.

They found that multiple indicators of quality of care improved from 1998 to 2002. For example, in 1998, only 71% of patients received HbA1c testing, whereas 91% of patients received it in 2002. Similarly, prescriptions for ACE inhibitors, a measure of the quality of cardiovascular care, improved from 33% of patients in 1998 to 55% of patients in 2002.

Other improvements included an increase in the percentage of patients tested for serum lipids, from 15% to 44% and an increase in those getting eye exams from 25% to 44%.

In addition, HbA1c levels showed a significant decline -- by a mean of -0.45 (95% confidence interval -0.72 to -0.17) -- from a mean of 8.53% in 1998.

The incremental costs for the quality improvement program were about per patient the first year, the second year, the third year, and in the fourth year and every year thereafter.

The authors projected the benefits of these improvements out to a patient's death or to age 95, and estimated that they would reduce the lifetime probability of blindness from 17% (prior to implementation of the quality-improvement program) to 15%, end-stage renal disease from 18% to 15%, peripheral neuropathy from 61% to 58%, and coronary heart disease from 28% to 24%.

The intervention would not, however, reduce the risk for stroke, amputation, or macular edema, the authors estimated.

They calculated that the average improvement in quality-adjusted life year (QALY) was 0.35 and the incremental cost-effectiveness ratio was ,386/QALY. In general, expenditures below ,000/QALY are considered to be cost effective.

"If these improvements are maintained or enhanced over the lifetime of patients, the Health Disparities Collaborative program will be cost-effective for society based on traditionally accepted thresholds," the authors concluded.

They noted that their study was limited by the fact that they measured the effect of the quality improvement program by looking at changes over time, which might also be attributable to long-term changes in diabetes care in general. In addition, their findings may not be applicable to all health care settings or to health centers in different geographic regions.