Stratifying healthcare costs using the Diabetes Complication Severity Index

Type 2 diabetes severity in the workforce: An occupational sector analysis using German claims data

BACKGROUND

Individuals of working age spend a significant amount of time at the workplace making it an important context for disease prevention and management. The temporal development and prevalence of T2D have been shown to differ in the working population based on gender, age group and occupational sector regardless of socioeconomic status. Given potential differences in risk factors associated with different work environments, this study aims to define vulnerable occupational groups by examining T2D severity and its trends in working men and women with T2D of two age groups and among nine occupational sectors.

METHODS

The study is based on claims data of the statutory health insurance provider AOKN. The study population consisted of all insured working individuals with T2D. T2D severity was measured using the adapted diabetes complications severity index-complication count (DCSI-CC). Mean DCSI-CC scores were calculated over four time periods between 2012 and 2019 for men and women of the age groups 18-45 and 46+ years and among nine occupational sectors. Trends of DCSI-CC were investigated using ordinal logistic regression analyses to examine the effect of time-period on the odds of having higher DCSI scores.

RESULTS

Overall, there was a significant rise in T2D severity over time in working men and women of the older age group. Moreover, the study displayed occupational sector differences in T2D severity and its trends. Over all, working men of all sectors had higher DCSI-CC scores compared to working women. Individuals working in the sector "Transport, logistics, protection and security" and "Construction, architecture, measuring and building technology" had higher T2D severity, while those working in the "Health sector, social work, teaching & education" had relatively lower T2D severity. There was a gender-specific significant increase over time in T2D severity in the above-mentioned occupational sectors.

CONCLUSION

The study displayed gender, age group and occupational sector differences in T2D severity and its trends. Working individuals could thus benefit from personalized prevention interventions that consider occupational contexts. As a next step, examining T2D trends and severity in specific occupations within the vulnerable occupational sectors is needed.

Medical Costs Associated With Diabetes Complications in Medicare Beneficiaries Aged 65 Years or Older With Type 2 Diabetes

OBJECTIVE

To estimate medical costs associated with 17 major diabetes-related complications and treatment procedures among Medicare beneficiaries aged ≥65 years with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Claims data from 100% of Medicare beneficiaries enrolled in fee-for-service plans from 2006 to 2017 were analyzed. Records with type 2 diabetes and complications were identified using ICD-9, ICD-10, and diagnosis-related group codes. The index year was the year when a person was first identified as having diabetes with an inpatient claim or an outpatient claim plus another inpatient/outpatient claim in the 2 years following the first claim in Medicare. Included individuals were followed from index years until death, discontinuation of plan coverage, or 31 December 2017. Fixed-effects regression was used to estimate the cost in years when the complication event occurred and in subsequent years. The total cost for each complication was calculated for 2017 by multiplying the complication prevalence by the cost estimate. All costs were standardized to 2017 U.S. dollars.

RESULTS

Our study included 10,982,900 beneficiaries with type 2 diabetes. Follow-up ranged from 3 to 10 years. The three costliest complications were kidney failure treated by transplant (occurring year $79,045, subsequent years $17,303), kidney failure treated by dialysis ($54,394, $38,670), and lower-extremity amputation ($38,982, $8,084). Congestive heart failure accounted for the largest share (18%) of total complication costs.

CONCLUSIONS

Costs associated with diabetes complications were substantial. Our cost estimates provide essential information needed for conducting economic evaluation of treatment and programs to prevent and delay diabetes complications in Medicare beneficiaries.

Medical Costs Associated with Severity of Chronic Kidney Disease in Type 2 Diabetes Mellitus in Singapore

Introduction: This was a retrospective cross-sectional study to assess the impact of chronic kidney disease (CKD) and its severity in Type 2 diabetes mellitus (T2DM) on direct medical costs, and the effects of economic burden on CKD related complications in T2DM in Singapore. Methods: A total of 1,275 T2DM patients were recruited by the diabetes centre at Khoo Teck Puat Hospital from 2011–2014. CKD stages were classified based on improving global outcome (KDIGO) categories, namely the estimated glomerular filtration rate (eGFR) and albuminuria kidney disease. Medical costs were extracted from the hospital administrative database. Results: CKD occurred in 57.3% of patients. The total mean cost ratio for CKD relative to non-CKD was 2.2 (P<0.001). Mean (median) baseline annual unadjusted costs were significantly higher with increasing CKD severity—S$1,523 (S$949), S$2,065 (S$1,198), S$3,502 (S$1,613), and S$5,328 (S$2,556) for low, moderate, high, and very high risk respectively (P<0.001). CKD (P<0.001), age at study entry (P=0.001), Malay ethnicity (P=0.035), duration of diabetes mellitus (DM; P<0.001), use of statins/fibrates (P=0.021), and modified Diabetes Complications Severity Index (DCSI) (P<0.001) were positively associated with mean annual direct medical costs in the univariate analysis. In the fully adjusted model, association with mean annual total costs persisted for CKD, CKD severity and modified DCSI. Conclusion: The presence and increased severity of CKD is significantly associated with higher direct medical costs in T2DM patients. Actively preventing the occurrence and progression in DM-induced CKD may significantly reduce healthcare resource consumption and healthcare costs. Keywords: Chronic kidney disease, costs, endocrinology, nephrology

Trends in Obesity and Medical Expenditure among Women with Diabetes, 2008-2016: Differences by Race/Ethnicity

Objectives

Diabetes results in $327 billion in medical expenditures annually, while obesity, a risk factor for type 2 diabetes, leads to more than $147 billion in expenditure annually. The aims of this study were: 1) to evaluate racial/ethnic trends in obesity and medical expenditures; and 2) to assess incremental medical expenditures among a nationally representative sample of women with diabetes.

Methods

Nine years of data (2008-2016) from the Medical Expenditure Panel Survey Full Year Consolidated File (unweighted = 11,755; weighted = 10,685,090) were used. The outcome variable was medical expenditure. The primary independent variable was race/ethnicity defined as non-Hispanic Black (NHB), Hispanic, or non-Hispanic White (NHW). Covariates included age, education, marital status, income, insurance, employment, region, comorbidity, and year. Cochran-Armitage tests determined statistical significance of trends in obesity and mean expenditure. Two-part modeling using Probit and gamma distribution was used to assess incremental medical expenditure. Data were clustered to 2008-2010, 2011-2013, 2014-2016.

Results

Trends in medical expenditures differed significantly between NHB and NHW women between 2008-2016 (P<.001). Hispanic women paid $1,291 less compared with NHW women, after adjusting for relevant covariates. There were no significant differences in obesity trends from 2008-2016 between NHB (P=.989) or Hispanic women with diabetes (P=.938) compared with NHW women with diabetes.

Conclusions

These findings suggest the need to further understand the factors associated with differences in trends for medical expenditures between NHB and NHW women with diabetes and incremental medical expenditures in Hispanic women with diabetes compared with NHW women with diabetes.

Incidence and Prevalence of Microvascular and Macrovascular Diseases and All-cause Mortality in Type 2 Diabetes Mellitus: A 10-year Study in a US Commercially Insured and Medicare Advantage Population

PURPOSE

The relationship between type 2 diabetes mellitus (T2DM) and increased microvascular and macrovascular disease and mortality is well established; however, data for the broad US T2DM population, especially by age, are limited. To help address this issue, we conducted a cohort study in a large national US commercially insured/Medicare Advantage population that incorporated a broad range of different age groups, including a large subset of younger individuals, during a 10-year study period.

METHODS

This longitudinal study combined health plan claims and mortality data to identify incident T2DM patients and 1:1 directly matched non-DM controls. T2DM individuals (n = 13,883) were identified by a medical claim with a T2DM diagnosis or T2DM medication pharmacy claim in 2007; non-DM controls had no DM medical or pharmacy claims over the entire study period (January 1, 2006 to December 31, 2015). The outcomes assessed were incidence, prevalence, time to vascular disease and all-cause mortality, as well as age-stratified incidence and mortality based on Centers of Disease Control and Prevention-defined age strata.

FINDINGS

Individuals with T2DM developed vascular disease at twice the rate as non-DM controls, 197 versus 98 per 1000 person-years, respectively. Vascular disease (composite) rates increased by age in T2DM/non-DM groups, 107.1/28.2 (18-44 years), 166.3/70.3 (45-64 years), and 391.0/199.7 (≥65 years) per 1000 person-years. The largest rate ratio was observed in younger individuals. All-cause mortality over follow-up was higher in T2DM individuals (27.5%) than in non-DM controls (19.6%). The largest increases in vascular disease prevalence and mortality among T2DM individuals were observed in the first year of follow-up.

IMPLICATIONS

T2DM has a substantial effect on microvascular and macrovascular disease and all-cause mortality rates in all age groups. These outcomes appear to occur early after T2DM diagnosis, and have more pronounced, nearly fourfold, relative impact on younger individuals with T2DM compared to matched non-DM controls.

Diabetes Disease Severity Was Not Associated with Risk of Deep Infection or Revision After Shoulder Arthroplasty

BACKGROUND

Prior studies have identified diabetes and disease severity (defined using hemoglobin A1c [HbA1c]) as potential risk factors for complications after shoulder arthroplasty. Evaluations of diabetes status and risk of adverse outcomes beyond the 30-day window either are limited or have not accounted for disease severity. Further, measures of diabetes severity other than HbA1c have yet to be investigated in a shoulder arthroplasty population.

QUESTIONS/PURPOSES

(1) Are diabetes status and glycemic control associated with adverse events, including deep infection, all-cause revision, and 90-day readmission after shoulder arthroplasty? (2) Is postoperative HbA1c associated with revision risk? (3) Is there a threshold of preoperative HbA1c that best identifies patients with diabetes who are at higher risk of 3-year deep infection, 1-year all-cause revision, or 90-day readmission? (4) Can the Adapted Diabetes Complications Severity index (aDCSI) be used as an alternative measure of diabetes severity in evaluating the risk of deep infection, all-cause revision, and 90-day readmission and identification of patients with diabetes at higher risk for these events? (5) Is there a difference between elective and traumatic shoulder arthroplasty patients?

METHODS

We conducted a retrospective registry-based cohort study using Kaiser Permanente's Shoulder Arthroplasty Registry (2005-2015). Primary shoulder arthroplasties were classified as patients with and without diabetes. Patients with diabetes were further evaluated using two disease severity measures (1) HbA1c, with good glycemic control classified as preoperative HbA1c < 7.0% and poor control defined as HbA1c ≥ 7.0%; and (2) aDCSI, classified as mild (score of 0-2) or severe (score ≥ 3) diabetes. Cox regression was used to evaluate the risk of deep infection and revision according to diabetes status and disease severity; conditional logistic regression was used for 90-day readmission. Time-dependent 1-year postoperative HbA1c was used to evaluate revision risk in Cox regression. All models were adjusted for covariates and stratified by elective versus trauma shoulder arthroplasty. Receiver operating characteristic curves were generated for HbA1c and aDCSI to determine whether a threshold exists to identify patients at higher risk of deep infection, all-cause revision, or 90-day readmission. The study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes.

RESULTS

Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0-2.1; p = 0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk. Receiver operating characteristic curve analysis suggested preoperative HbA1c performed poorly at differentiating adverse events. When using aDCSI, patients with severe diabetes who underwent both elective and traumatic shoulder arthroplasty had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.6; 95% CI, 1.2-2.2; p = 0.001 and OR, 1.8; 95% CI, 1.2-2.7; p = 0.005, respectively). Similar to HbA1c, the aDCSI was a poor classifier in differentiating adverse events.

CONCLUSIONS

Of the longer-term outcomes evaluated, more-severe diabetes was only found to be associated with an increase in 90-day readmissions after shoulder arthroplasty; a stronger association was found when using the aDCSI in identifying diabetes severity. Arbitrary cutoffs in HbA1c may not be the best method for determining risk of postoperative outcomes. Future work investigating perioperative diabetes management should work to identify and validate measures, such as the aDCSI, that better identify patients at higher risk for postoperative outcomes and, more importantly, whether outcomes can be improved by modifying these measures with targeted interventions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Trends in comorbidity burden and treatment patterns in type 2 diabetes: Longitudinal data from a US cohort from 2006 to 2014

AIMS

To gather real-world data on treatment characteristics and comorbidity progression in patients with newly-diagnosed type 2 diabetes (T2D) and evaluate differences by patient age.

METHODS

Retrospective analysis of a US administrative claims database including 16,950 subjects with newly-diagnosed T2D in 2006 and a baseline Diabetes Complications Severity Index (DCSI) score of 0. Patients were categorized by DCSI score at year 8 (0, 1-2, or ≥3) and comparatively analyzed based on demographic variables, drug usage, and diabetes-related comorbidities.

RESULTS

Year 8 DCSI score distribution was 0 (29.9%), 1-2 (36.2%), and ≥3 (33.9%). The highest DCSI score subgroup (≥3) was characterized by a significantly greater percentage of males, older age at T2D diagnosis, and higher Medicare enrollment. DCSI progressed most rapidly in the oldest age group (≥65). Among all subjects at year 8, insulin use was significantly highest among subjects with DCSI ≥3 compared with those having a lower DCSI. However, for subjects with DCSI ≥3, insulin use was lower among those in the oldest age group (≥65) relative to younger age groups.

CONCLUSIONS

These real-world data suggest a relationship between age at T2D diagnosis and disease progression based on comorbidity burden and lower usage of injectable therapies in older patients.

Metformin is associated with a lower risk of active tuberculosis in patients with type 2 diabetes

BACKGROUND AND OBJECTIVE

Metformin is an oral anti-diabetic therapy (ADT) to manage type 2 diabetes mellitus (T2DM), and has been reported to have potential anti-tuberculosis (TB) effects. This study investigates the risk of active TB among persons with T2DM who were treated with various ADT and insulin therapies.

METHODS

We conducted a nationwide population-based cohort study using the Taiwan Longitudinal Health Insurance Database, including 49 028 T2DM patients who were metformin users (n = 44 002) or non-users (n = 5026). A total of 5026 propensity score-matched pairs of metformin users and non-users with T2DM were evaluated from 1998 to 2010. The data were analysed using Cox proportional hazard models.

RESULTS

Patients with T2DM had a significantly higher rate of incident TB than did the control subjects (adjusted hazard ratio: 2.01; 95% confidence interval (95% CI): 1.80-2.25). After adjusting for comorbidities, diabetes complications, ADT type and statin use, metformin use was an independent factor for predicting a reduced risk of active TB (adjusted relative risk (aRR): 0.24; 95% CI: 0.18-0.32). The association between metformin use and active TB risk was also consistent in most subgroup analyses, except for patients with metabolic disorders (aRR: 0.46; 95% CI: 0.11-1.87). This protective effect of metformin was dose-dependent but diminished gradually in the elderly population.

CONCLUSION

Among all types of ADT and insulin therapies, metformin is the only agent with a decreased risk of active TB in the T2DM population. However, this effect was diminished in the elderly population and was not observed in patients with metabolic disorders.

Risk factors and direct medical cost of early versus late unplanned readmissions among diabetes patients at a tertiary hospital in Singapore

OBJECTIVE

To examine the risk factors and direct medical costs associated with early (≤30 days) versus late (31-180 days) unplanned readmissions among patients with type 2 diabetes in Singapore.

METHODS

Risk factors and associated costs among diabetes patients were investigated using electronic medical records from a local tertiary care hospital from 2010 to 2012. Multivariable logistic regression was used to identify risk factors associated with early and late unplanned readmissions while a generalized linear model was used to estimate the direct medical cost. Sensitivity analysis was also performed.

RESULTS

A total of 1729 diabetes patients had unplanned readmissions within 180 days of an index discharge. Length of index stay (a marker of acute illness burden) was one of the risk factors associated with early unplanned readmission while patient behavior-related factors, like diabetes-related medication adherence, were associated with late unplanned readmission. Adjusted mean cost of index admission was higher among patients with unplanned readmission. Sensitivity analysis yielded similar results.

CONCLUSIONS

Existing routinely captured data can be used to develop prediction models that flag high risk patients during their index admission, potentially helping to support clinical decisions and prevent such readmissions.

Paediatric palliative care improves patient outcomes and reduces healthcare costs: evaluation of a home-based program

Background

Around the world, different models of paediatric palliative care have responded to the unique needs of children with life shortening conditions. However, research confirming their utility and impact is still lacking. This study compared patient-related outcomes and healthcare expenditures between those who received home-based paediatric palliative care and standard care. The quality of life and caregiver burden for patients receiving home-based paediatric palliative care were also tracked over the first year of enrolment to evaluate the service’s longitudinal impact.

Method

A structured impact and cost evaluation of Singapore-based HCA Hospice Care’s Star PALS (Paediatric Advance Life Support) programme was conducted over a three-year period, employing both retrospective and prospective designs with two patient groups.

Results

Compared to the control group (n = 67), patients receiving home-based paediatric palliative care (n = 71) spent more time at home than in hospital in the last year of life by 52 days (OR = 52.30, 95% CI: 25.44–79.17) with at least two fewer hospital admissions (OR = 2.46, 95% CI: 0.43–4.48); and were five times more likely to have an advance care plan formulated (OR = 5.51, 95% CI: 1.55–19.67). Medical costs incurred by this group were also considerably lower (by up to 87%). Moreover, both patients’ quality of life (in terms of pain and emotion), and caregiver burden showed improvement within the first year of enrolment into the programme.

Discussion

Our findings suggest that home-based paediatric palliative care brings improved resource utilization and cost-savings for both patients and healthcare providers. More importantly, the lives of patients and their caregivers have improved, with terminally ill children and their caregivers being able to spend more quality time at home at the final stretch of the disease.

Conclusions

The benefits of a community paediatric palliative care programme have been validated. Study findings can become key drivers when engaging service commissioners or even policy makers in appropriate settings.

The Risk of TB in Patients With Type 2 Diabetes Initiating Metformin vs Sulfonylurea Treatment

BACKGROUND

Metformin and the sulfonylureas are common initial antidiabetic agents; the former has demonstrated anti-TB action in in vitro and animal studies. The comparative effect of metformin vs the sulfonylureas on TB risk in patients with type 2 diabetes mellitus (T2DM) remains unclear.

METHODS

In this retrospective cohort study, patients without chronic kidney disease who received a T2DM diagnosis during 2003 to 2013 were identified from the Taiwan National Health Insurance Research Database. Participants with ≥ 2 years of follow-up were reviewed and observed for TB until December 2013. Patients receiving metformin ≥ 60 cumulative defined daily dose (cDDD) and sulfonylureas < 15 cDDD in the initial 2 years were defined as metformin majors; it was the inverse for sulfonylurea majors. The two groups were matched 1:1 by propensity score and compared for TB risk by multivariate Cox regression analysis.

RESULTS

Among 40,179 patients with T2DM, 263 acquired TB (0.65%) over a mean follow-up of 6.1 years. In multivariate analysis, the initial 2-year dosage of metformin, but not that of the sulfonylureas, was an independent predictor of TB (60-cDDD increase (adjusted hazard ratio [HR], 0.931; 95% CI, 0.877-0.990) after adjustment by cofactors, including adapted diabetes complication severity index. Metformin majors had a significantly lower TB risk than that of sulfonylurea majors before and after matching (HR, 0.477; 95% CI, 0.268-0.850 and HR, 0.337; 95% CI, 0.169-0.673; matched pairs, n = 3,161). Compared with the reference group (initial 2-year metformin < 60 cDDD), metformin treatment showed a dose-dependent association with TB risk (60-219 cDDD; HR, 0.860; 95% CI, 0.637-1.161; 220-479 cDDD, HR, 0.706; 95% CI, 0.485-1.028; ≥ 480 cDDD, HR, 0.319; 95% CI, 0.118-0.863).

CONCLUSIONS

Metformin use in the initial 2 years was associated with a decreased risk of TB, and metformin users had a reduced risk compared with their sulfonylurea comparators.

Stratification strategy for evaluating the influence of diabetes complication severity index on the risk of hospitalization: a record linkage data in Western Australia

OBJECTIVE

This study aimed to develop a risk stratification strategy for evaluating the relationship between complications of diabetes and the risk of diabetic-related hospitalization to accurately classify diabetes severity.

METHODS

The study used administrative health records for 40,624 individuals with diabetes aged ≥18years in Western Australian. The adapted Diabetes Complication Severity Index (DCSI), socio-demographic and clinical characteristics were used in random effects negative binomial and threshold effect models to determine the optimal stratification strategy for diabetes severity based on the homogeneity of the risk of hospitalization in response to variation of the DCSI.

RESULTS

The optimal stratification of people with diabetes was specified by four sub-populations. The first sub-population was no complications with an inverse association with the risk of hospitalizations (coefficient-0.247, SE 0.03). Further three sub-populations with DCSI at one (coefficient 0.289, SE 0.01), two (coefficient 0.339, SE 0.01) and three or more (coefficient 0.381, SE 0.01) were used to accurately describe the impact of DCSI on the risk of hospitalization.

CONCLUSION

A stratification into four subpopulations based on the homogeneous impact of diabetes DCSI on the risk of hospitalization may be more suitable for evaluating health care interventions and planning health care provision.

For Diabetes Shared Savings Programs, 1 Year of Data Is Not Enough

Fee-for-service payment models are moving toward pay-for-performance designs, many of which rely on shared savings for financial sustainability. Shared savings programs divide the cost savings between health care purchaser and provider based on provider performance. Often, these programs measure provider performance as the delivery of agreed-upon clinical practice guidelines that usually are represented as evidence-based medicine (EBM). Multiyear studies show a negative relationship between total cost and EBM, indicating that long-term shared savings can be substantial. This study explores expectations for the rewards in the first year of a shared savings program. It also indicates the effectiveness of using 1 year of claims to assess cost savings from evidence-based care, especially in a patient population with high turnover. This study analyzed 1956 adults with diabetes insured through Medicaid. Results of linear regression showed that the relationship between total cost of care and each element of evidence-based medical care during a 1-year period was positive (higher cost) or insignificant. The results indicate that diabetes EBM programs cannot expect to see significant cost savings if the evaluation lasts only 1 year or less. The study concludes that improvements in EBM incentive programs could come from investigating the length of time needed to realize cost savings from each element of diabetes EBM. Investigating other factors that could affect the expected amount of cost savings also would benefit these programs, especially factors derived from sources external to insurance program information such as the medical record and care management data.

Direct medical cost of stroke in Singapore

BACKGROUND

Globally, stroke is recognized as one of the main causes of long-term disability, accounting for approximately 5·7 million deaths each year. It is a debilitating and costly chronic condition that consumes about 2-4% of total healthcare expenditure.

AIMS

To estimate the direct medical cost associated with stroke in Singapore in 2012 and to determine associated predictors.

METHODS

The National Healthcare Group Chronic Disease Management System database was used to identify patients with stroke between the years 2006 and 2012. Estimated stroke-related costs included hospitalizations, accident and emergency room visits, outpatient physician visits, laboratory tests, and medications.

RESULTS

A total of 700 patients were randomly selected for the analyses. The mean annual direct medical cost was found to be S$12 473·7, of which 93·6% were accounted for by inpatient services, 4·9% by outpatient services, and 1·5% by A&E services. Independent determinants of greater total costs were stroke types, such as ischemic stroke (P = 0·005), subarachnoid hemorrhage (P < 0·001) and intracerebral haemorrhage (P < 0·001), shorter poststroke period, more than one complications (P = 0·045), and a greater number of comorbidities (P = 0·001).

CONCLUSION

There is a considerable economic burden associated with stroke in Singapore. The type of stroke, length of poststroke period, and stroke complications and comorbidities are found to be associated with the total costs. Efforts to reduce inpatient costs and to allocate health resources to focus on the primary prevention of stroke should become a priority.

Changes in prevalence of diabetic complications and associated healthcare costs during a 10-year follow-up period among a nationwide diabetic cohort

OBJECTIVE

Long-term health and economic consequences of diabetes mellitus are of significant importance to health policy makers to identify the most efficient interventions for disease managements. However, existing data are mainly from simulation models instead of "real-world" data. The objective of this study was to longitudinally evaluate the changes of prevalence of diabetic complications and associated healthcare costs in a nationally-representative diabetic cohort.

METHODS

We used the 2000-2011 Taiwan's Longitudinal Health Insurance Database (LHID) to conduct a population-based cohort study of 136,372 patients with type 2 diabetes. Diabetic complications of each patient were calculated annually after the cohort entry by the adapted Diabetes Complications Severity Index (aDCSI) score (sum of diabetic complication with severity levels, range 0-13) using diagnostic codes recorded in the LHID. Study subjects were further categorized into six subgroups according to their aDCSI score (0, 1, 2, 3, 4, 5+) at cohort entry. Healthcare utilizations (including outpatient and inpatient visits) as well as direct medical costs for the six subgroups were estimated annually using patient-level data from the LHID.

RESULTS

We found the severity of diabetic complications increased over time, especially for patients with aDCSI score of 2 and above at cohort entry (at 10years of follow-up: aDCSI=0 (cohort entry), 2.37; aDCSI=1, 3.59; aDCSI=2, 4.60; aDCSI=3, 5.14; aDCSI=4, 5.96). There were significant differences in healthcare utilizations and associated medical costs among patients stratified by aDCSI score (e.g. at 1year after cohort entry, mean counts of inpatient visits: 0.14 vs. 1.81 for aDCSI=0 vs.5+). Relatively high healthcare utilizations and associated medical costs in the first year of cohort entry were observed for patients with aDCSI score of 4 and above at cohort entry.

CONCLUSIONS

We provided the important empirical data for patient-level longitudinal changes in diabetic complications and associated healthcare utilization and medical costs among patients with diabetes.

Direct medical cost of type 2 diabetes in singapore

Due to the chronic nature of diabetes along with their complications, they have been recognised as a major health issue, which results in significant economic burden. This study aims to estimate the direct medical cost associated with type 2 diabetes mellitus (T2DM) in Singapore in 2010 and to examine both the relationship between demographic and clinical state variables with the total estimated expenditure. The National Healthcare Group (NHG) Chronic Disease Management System (CDMS) database was used to identify patients with T2DM in the year 2010. DM-attributable costs estimated included hospitalisations, accident and emergency (A&E) room visits, outpatient physician visits, medications, laboratory tests and allied health services. All charges and unit costs were provided by the NHG. A total of 500 patients with DM were identified for the analyses. The mean annual direct medical cost was found to be $2,034, of which 61% was accounted for by inpatient services, 35% by outpatient services, and 4% by A&E services. Independent determinants of total costs were DM treatments such as the use of insulin only (p<0.001) and the combination of both oral medications and insulin (p=0.047) as well as having complications such as cerebrovascular disease (p<0.001), cardiovascular disease (p=0.002), peripheral vascular disease (p=0.001), and nephropathy (p=0.041). In this study, the cost of DM treatments and DM-related complications were found to be strong determinants of costs. This finding suggests an imperative need to address the economic burden associated with diabetes with urgency and to reorganise resources required to improve healthcare costs.

Risk of hospitalization and healthcare cost associated with Diabetes Complication Severity Index in Taiwan's National Health Insurance Research Database

OBJECTIVE

The aim of this study is to test the validity of adapted Diabetes Complication Severity Index (aDCSI) in predicting the risk of hospitalization and healthcare cost in type 2 diabetic patients using a nationally-representative claims database.

STUDY DESIGN

Retrospective cohort study used 4years of claims data from Taiwan's National Health Insurance Research Database (NHIRD).

METHODS

Type 2 diabetic patients who had 4-years of enrollment were identified as study subjects (N=136,372). The aDCSI score (sum of diabetic complication with severity levels, range 0-13) and complication count (sum of diabetic complications, range 0-7) were generated using diagnostic codes for each patient. Poisson model and linear regression model were conducted to predict risk of hospitalization and healthcare costs associated with aDCSI score and count of diabetic complications.

RESULTS

The aDCSI score (risk ratio 1.51 to 10.32 categorically, and 1.41 linearly) and count of diabetic complications (risk ratio 1.56 to 12.20 categorically, and 1.66 linearly) were significantly positively associated with risk of hospitalization. A one-point increase in the aDCSI score was positively associated with increased healthcare costs.

CONCLUSIONS

The performance of aDCSI in predicting risk of hospitalization and healthcare cost in the nationally-representative claims database is similar to those reported in the original study. It may serve as an efficient tool for stratifying type 2 diabetic patients for disease management programs and population-based studies.

Factors predicting the hospital episode costs of emergency medical admissions

BACKGROUND

Important outcome predictor variables for emergency medical admissions are the Manchester Triage Category, Acute Illness Severity, Chronic Disabling Disease and Sepsis Status. We have examined whether these are also predictors of hospital episode costs.

METHODS

All patients admitted as medical emergencies between January 2008 and December 2012 were studied. Costs per case were adjusted by reference to the relative cost weight of each diagnosis related group (DRG) but included all pay costs, non-pay costs and infra-structural costs. We used a multi-variate logistic regression with generalized estimating equations (GEE), adjusted for correlated observations, to model the prediction of outcome (30-day in-hospital mortality) and hospital costs above or below the median. We used quantile regression to model total episode cost prediction over the predictor distribution (quantiles 0.25, 0.5 and 0.75).

RESULTS

The multivariate model, using the above predictor variables, was highly predictive of an in-hospital death-AUROC of 0.91 (95% CI: 0.90, 0.92). Variables predicting outcome similarly predicted hospital episode cost; however predicting costs above or below the median yielded a lower AUROC of 0.73 (95% CI: 0.73, 0.74). Quantile regression analysis showed that hospital episode costs increased disproportionately over the predictor distribution; ordinary regression estimates of hospital episode costs over estimated the costs for low risk and under estimated those for high-risk patients.

CONCLUSION

Predictors of outcome also predict costs for emergency medical admissions; however, due to costing data heteroskedasticity and the non-linear relationship between dependant and predictor variables, the hospital episode costs are not as easy to predict based on presentation status.

Increasing comorbidity with diabetes in the community: diabetes research challenges

BACKGROUND

The purpose of this paper is to discuss the ongoing definitional, measurement and analytic challenges imposed on community-based diabetes researchers examining the experiences and outcomes of home-dwelling adults surviving longer with diabetes and additional comorbid health conditions. When selecting from the still limited number of standard hospital-oriented comorbidity methods, researchers across the world will need to consider a frequently complex series of methodological decisions from their enrolling such adults with increased comorbidity into study samples.

CONCLUSIONS

Three categories of methodological implications from increasing forms of comorbid diabetes are discussed for diabetes researchers. Six sequenced research design strategies with specific examples are offered regarding how to most rigorously incorporate elements of comorbidity into prospective diabetes study designs.