Economic evaluation in diabetes

Evaluative Studies of Diabetes-Related Issues in the Literature

A recent and rising practice in diabetes economics has been the use of evaluative studies to examine the economic efficiency of diabetes treatments and programs.

Evaluative studies, such as cost-effectiveness, cost-utility, and cost-benefit studies, attempt to consider the costs of a treatment or intervention relative to the health outcomes produced. Most often, the costs and outcomes of a new treatment are compared to those of an existing treatment to determine if an efficient use of resources might be gained from adopting the new approach.

The table below outlines the economic evaluation studies reported in the literature. The evaluations examine screening or treatment programs for diabetes complications (retinopathy, renal disease, foot ulcers) and adverse outcomes of diabetic pregnancies.

Overall the findings suggest that screening for and treating diabetes retinopathy is extremely cost-effective. There is, however, some debate over the level of efficiency with screening in different settings and among different populations.

A similar message exists with regards to screening and treatment for microalbuminuria. General indications are that screening for microalbuminuria and treatment with angiotensin converting enzyme inhibitors or anti-hypertensives would be beneficial and cost efficient. The cost-effectiveness of screening for microalbuminuria, though, may vary by screening costs, drug compliance, and the cost of end-stage renal disease.

The cost-effectiveness of treatments for diabetic foot ulcers remains muddled, whereas the economic benefits of preconception care appear to be substantial. Two reports have examined the issue of intensive insulin treatment among persons with IDDM (Stern, DCCT Research Group). Both found that the cost of intensive treatment was greater than the cost of standard forms of treatment. Improvements in health, though, were sufficiently large enough that the DCCT group concludes intensive insulin therapy represents a good monetary value.

Issue Examined
Deckert, 1978 Cost-benefit analysis of outpatient care in a diabetes clinic Outpatient care in a Danish diabetes clinic involved little cost ($10,000) and saved $100,000 over 40 years
England, 1981 Cost-effectiveness of a vaccine to prevent IDDM Vaccinating all children at age 3 is preferable vaccinating only those at high risk. A 50% effective vaccine would save $30 million yearly in direct costs.
Weiner, 1986 Screening strategies for gestational diabetes The number of oral glucose tolerance tests required and the cost of identifying gestational diabetes is reduced with 2 hour screening test compared to a 1 hour test.
Kaplan, 1987 Cost-utility of diet and exercise intervention in NIDDM patients The cost-utility of the program was $10,870 per well-year gained; a figure comparable to other advocated health care programs
Javitt, 1989 Cost-effectiveness of treatment and control of diabetic retinopathy in IDDM patients Costs of screening and panretinal photocoagulation per person-year of sight saved = $966
Allan, 1990 Costs and effects of glucose self-monitoring in NIDDM patients Blood glucose monitoring was no more effective than urine testing, but 8-12 times more expensive
Javitt, 1990 Efficiency of screening strategies for detecting diabetic retinopathy in IDDM patients Screening for and treating patients with retinopathy realizes a cost savings under many different types of screening programs, ranging from $62-109 million and saving 71,000-85,000 sight years
Dasbach, 1991 Screening and treatment strategies for diabetic retinopathy Costs for screening are recovered by the avoided costs of blindness in insulin-taking persons, but not in non-insulin-taking persons
Javitt, 1991 Efficiency of current screening conditions and those at higher levels of compliance At current levels of screening, $101 million and 47,000 sight years are saved in an incidence cohort. Added savings of $9500 occur with each new person screened.
Sculpher, 1991 Screening strategies for referring cases of diabetic retinopathy The efficiency of screening varies by the person doing the screening and the site where it is performed
de Weerdt, 1991 Costs and effects of a diabetes education programme for insulin-treated patients No significant effect of education on metabolic control, use of health services, drug costs, or indirect costs was observed between an experimental and control group.
Fendrick, 1992 Cost-effectiveness of screening and treatment of diabetic retinopathy among IDDM patients in Sweden relative to no screening Screening for and treating patients with retinopathy may realize a cost savings of 22-37 million SEK and 2300-3200 sight years saved depending upon patient compliance to screening recommendations
Lairson, 1992 Screening strategies for referring cases of diabetic retinopathy In a government health care setting, screening with retinal photographs (with dilated pupils) is more cost-effective than ophthalmoscopy
Scheffler, 1992 Cost-effectiveness of a diabetes pregnancy intervention program Over $5 in hospital charges was saved for every $1 spent in this preconception and early pregnancy program.
Sculpher, 1992 Additional screening strategies for referring true cases of diabetic retinopathy Tradeoffs exist such that to increase sensitivity, you have to adopt tests with lower specificities and/or higher costs per case detected
Siegel, 1992 Screening strategies for early renal disease and treatment with ACE inhibitors in IDDM patients Screening for and treatment of microalbuminuria with ACE inhibitors appears to be cost-effective. This result, though, depends upon the drug effectiveness, screening costs, and the cost of end-stage renal disease.
Bentkover, 1993 Cost-effectiveness of treating non-healing foot ulcers with platelet releasate in a wound care clinic Clinic and platelet releasate treatment was more cost-effective ($22,500 per healed person) than clinic and saline solution treatment ($36,000 per healed person)
Borch-Johnsen, 1993 Cost-benefit of screening and treatment for microalbuminuria in IDDM patients Screening for microalbuminuria and treatment with antihypertensive drugs would pay for itself if the rate of increase in albuminuria was reduced by 8-10% a year.
Elixhauser, 1993 Preconception care for diabetic women relative to usual prenatal care Intensive medical care before conception appears to result in costs savings from averted complications compared with prenatal care only.
Griffith, 1993 Screening for retinopathy in a primary care setting Screening by ophthalmoscope and fundal photography both had high sensitivities for referring patients. Direct ophthalmoscopy was less expensive than retinal photos.
Levy-Marchal, 1993 Examination of screening strategies to identify early cases of IDDM in the population Cost-benefit ratios (the cost of screening relative to the ability to accurately identify subjects) vary by the population groups examined and the screening test.
Simell, 1993 The costs and effects of shorter hospital stays among children diagnosed with IDDM Direct and indirect costs were reduced among patients with shorter lengths of stay (9 days) compared to those with longer stays (23 days). No difference in metabolic control was observed between the groups up to 2 years.
Haardt, 1994 Cost-benefit analysis of implantable insulin pumps compared to multiple injections The implantable insulin pump was more effective in metabolic control over 6 months than multiple injection therapy, but direct costs were 3 times higher.
Javitt, 1994 Savings to the federal budget from screening and treatment for eye disease in NIDDM patients Screening and treatment for diabetic eye disease saves $248 million to the federal budget. If all patients are screened, could save up to $472 million.
Le Floch, 1994 Cost-effectiveness of screening for microalbuminuria The cost-effectiveness ratio of screening with dipsticks and lab assay for identified positives relative to screening with lab assays alone was 6600 per QALY
Starostina, 1994 Costs and effects of glucose self-monitoring strategies (urine, blood, none) in Russia Glucose control was improved and DKA events reduced among subjects in urine or blood monitoring relative to no monitoring. Both methods were equally effective, but the cost of urine testing strips was markedly lower.
Woolridge, 1994 Cost to a government insurer of paying for therapeutic shoes for patients with foot problems No difference in future payments for health services up to 1 year was observed between patients with shoes paid for by insurance and patients who bought their shoes.
Collins, 1995 Savings in prescription costs from a weight reduction program in NIDDM patients Weight reduction was maintained over a one year period after intervention. Prescription drug costs were reduced by $442 per person over this time.
Eckman, 1995 Cost-effectiveness of treatments in patients with foot infection and suspected osteomyelitis Several strategies were examined for NIDDM patients. In general, those involving long courses of antibiotic therapy were preferable to those involving amputation.
Franz, 1995 Cost-effectiveness of practice guidelines nutrition care in NIDDM patients Nutrition interventions that follow practice guidelines can improve metabolic control at a reasonable cost.
Kiberd, 1995 Cost-utility of screening and treatment for diabetic renal disease in IDDM patients Screening for microalbuminuria and treatment with ACE inhibitors is cost-effective relative to screening and treatment for hypertension and macro-proteinuria if certain conditions are satisfied, including screening costs and accuracy, d rug costs, and renal disease costs.
Steindel, 1995 Cost and effects of insulin pump treatment in poorly controlled adolescents Insulin pump treatment did not change metabolic control over one year, but did reduce hospital stays and direct costs compared with treatment in the year before
DCCT Research Group, 1996Cost-effectiveness of intensive insulin treatment relative to standard treatments Intensive insulin therapy represents a good monetary value. The incremental cost per year of life gained with intensive treatment was $30,400.
Javitt, 1996 Cost-effectiveness of screening and treatment for diabetic eye disease relative to existing disease The cost of detecting and treating diabetic eye disease is $3190 per QALY saved; $1996 for those with IDDM, and $3530 for patients with NIDDM.
Joannou, 1996 Screening for retinopathy in a diabetes clinic Screening with 60 degree retinal photography was more effective than with 45 degree photos. Cost was $6 per patient screened, $37 for each patient referred.
Stern, 1996 Direct costs of intensive insulin treatment relative to standard treatments in IDDM patients Over 35 years, the cost of intensive treatment is about $19,000 higher than the cost of standard treatment. No indirect costs of premature mortality are included.

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This page was last modified on 11 September 1996.

For further information about these studies, see the specific references or contact:

Thomas Songer, PhD
Dept. of Epidemiology, University of Pittsburgh Pittsburgh, PA 15261 USA