Individualized Diabetes Care Reduces Costs, and Improves Quality of LIfe

Taking a patient-centered approach to glycemic goals rather than intensive HbA1C targets promises substantially reduced costs and improve quality of life over the lifetime.

With Neda Laiteerapoing, MD, FACP

Results of an economic analysis indicated a possible savings of $13,546 for every person with diabetes whose treatment is adjusted to individual needs over their lifetime in comparison to uniform aggressive treatment,1 was published in the Annals of General Medicine.

“The cost savings are achieved when treatment is tailored to glycemic goals over their lifetime, allowing them to experience fewer hypoglycemic events, require less medications, and report a higher quality of life with a slightly shortened life expectancy,” said lead author, Neda Laiteerapoing, MD, FACP. an assistant professor in general internal medicine and associate director of the Center for Chronic Disease Research and Policy at the University of Chicago, Illinois.

“I hope our findings will bring consideration of individualized treatment to the front of discussion, especially at in institutions who have adopted a standardized quality measure of HbA1c of > 7% for patients with diabetes,” Dr. Laiteerapoing told EndocrineWeb.

Adjusting glycemic control for the patient will diabetes is better than intensive standard care.

A Closer Look at the Study Protocol

Given the burden of diabetes costs on the US healthcare system, with an estimated at $245 billion dollars spent on care annually,2  the authors wanted to understand the costs behind the current standard of treatment.

The current standard of care for diabetes is intensive control of glycemic goal based on a hemoglobin A1c (Hb A1c) level of less than 7%, however, the guidelines recommend individualizing goals to account for age, comorbidity, duration of diabetes, and additional medical complications.3,4

Study data were pooled from the latest available National Health and Nutrition Examination Survey (2011-2012) of 17.3 million for adults over 30 years old who indicated a diagnosis of diabetes.5

The economic analysis was conducted using a patient-level Monte Carlo-based Markov model,6 which involves a simulated, decision-making approach to repeated events that occur over time, and is believe to more accurately reflect the clinical setting. 

The researchers sought to estimate the cost-effectiveness of following a care plan that individualized diabetes treatment with regard to hemoglobin A1C levels as compared to a consistent, intensive diabetes approach aiming for a HbA1C of less than 7% for all patients.1

“Looking to identify the leading driver of costs, it became evident that medications explained the higher costs over doctor visits or hospitalizations,” Dr. Laiteerapoing said.

In arriving at the simulated annual cost saving per patient for individualized versus uniform intensive glycemic control, the difference in care was $105,307 and $118,853, respectively.1 The authors found the difference in care costs were due primarily to a reduction in medication ($34,521 vs. $48,763).

In addition, there was a slight decrease in life expectancy for patients receiving individualized care (20.63 vs. 20.73 years) stemming from an increase in complications, with a tradeoff in extended quality of life years (16.68 vs. 16.58) given fewer hypoglycemic events and less medications prescribed.1

Explaining the Study Findings 

"We simulated the current diabetes population-based data (as of 2011), projected out to the rest of the patients’ lives,” Dr. Laiteerapoing said, “An individualized treatment goal, based on a fluid hemoglobin A1c goal, adjusting over the lifetime proved much less costly and offered a higher quality of life, than a person is being treated to achieve a HbA1c of less than 7%.”1

“The premise of this study was as follows: a patient who is young and healthy has a year of life deemed a full healthy year. But another person who has had a heart attack and is suffering will not experience the same quality of life over the year so their quality of life year would be slightly less. We were measuring for quality of life (QoL) years in evaluating for economic differences in care,” said Dr. Laiteerapoing.

Quality of life was used to quantify life-adjusted years based on how a person feels with a condition.1 Multiplier of years (ie, 5 years with a heart attack, less function, and taking unwanted but necessary medications) was then converted to a quality of life measure that was lower than a comparable patient with no heart attack or a similar illness, such as a patient with diabetes.

“Given the apparent cost effectiveness of a personalized approach to care, our findings may offer another argument for patient-centered care and different options for settling on a treatment goal for patent and clinician,” she said.

An Examination of Study Limitations

Our economic cost model did not account for initiation of glycemic control either earlier or later. Findings from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial indicated that patients deemed at high risk for cardiovascular disease had an increased mortality risk with very intensive glycemic treatment based on achieving HbA1c of 6.4% in comparison to 7.5%.6

“We might achieve a more accurate analysis by refining the economic model to account for all possible effects on diabetes,” she said, “but it is important to keep in mind that these models are meant to take a big picture view of policy questions, not to drive changes in care for specific patients," said Dr. Laiteerapoing,

"However, if a clinician had a patient with a HbA1c less than 7, clinical evidence su.gests that a patient at an advanced age, with multiple complications, and possibly other chronic diseases, who says ‘I hate taking so many meds,’ then the clinician might agree to be less aggressive in setting a goal for Hb A1c control, thereby reducing the amount of medications prescribed, In turn, this which would lessen the patient’s healthcare bills, and probably improve the patient’s quality of life, and lead to fewer hyperglycemic episodes,” she said.

Looking Ahead in Diabetes Care

Last week, the American Diabetes Association issued their 2018 Standards of Medical Care in Diabetes, which offered new recommendations to treat people with diabetes and cardiovascular disease.3

Use of newer cardiovascular medications are more expensive, but the more recently available drugs were not used in our model but were we to include all the medications indicated according to the updated ADA guidelines, our findings would likely reflect even higher costs,3 said Dr.  Laiteerapoing.

Interestingly, the guidelines encourage clinicians to practice with an awareness of and to screen for social influencers of health, including financial ability to pay for medications, access to healthy food, and community support.

Primary Funding for this study came from the National Institute of Diabetes and Digestive and Kidney Diseases. None of the authors have any potential conflicts of interest.

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