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Gutiérrez-Ortiz CC, Concepción-Zavaleta MJ, García-Villasante EJ. Diabetic ketoacidosis treatment during COVID-19 pandemic in a country with scarce health resources. Diabetes Metab Syndr 2020; 14:1847-1848. [PMID: 32971512 PMCID: PMC7485543 DOI: 10.1016/j.dsx.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/05/2020] [Accepted: 09/08/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Claudia C Gutiérrez-Ortiz
- Universidad Nacional Mayor de San Marcos, Division of Endocrinology, Hospital Nacional Daniel Alcides Carrion, Lima, Peru.
| | - Marcio J Concepción-Zavaleta
- Universidad Nacional Mayor de San Marcos, Division of Endocrinology, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Peru
| | - Eilhart J García-Villasante
- Universidad Nacional Mayor de San Marcos, Division of Endocrinology, Hospital Nacional Daniel Alcides Carrion, Lima, Peru
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2
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Saydah SH, Shrestha SS, Zhang P, Zhou X, Imperatore G. Medical Costs Among Youth Younger Than 20 Years of Age With and Without Diabetic Ketoacidosis at the Time of Diabetes Diagnosis. Diabetes Care 2019; 42:2256-2261. [PMID: 31575641 PMCID: PMC10999225 DOI: 10.2337/dc19-1041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 09/10/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE While diabetic ketoacidosis (DKA) is common in youth at the onset of the diabetes, the excess costs associated with DKA are unknown. We aimed to quantify the health care services use and medical care costs related to the presence of DKA at diagnosis of diabetes. RESEARCH DESIGN AND METHODS We analyzed data from the U.S. MarketScan claims database for 4,988 enrollees aged 3-19 years insured in private fee-for-service plans and newly diagnosed with diabetes during 2010-2016. Youth with and without DKA at diabetes diagnosis were compared for mean health care service use (outpatient, office, emergency room, and inpatient visits) and medical costs (outpatient, inpatient, prescription drugs, and total) for 60 days prior to and 60 days after diabetes diagnosis. A two-part model using generalized linear regression and logistic regression was used to estimate medical costs, controlling for age, sex, rurality, health plan, year, presence of hypoglycemia, and chronic pulmonary condition. All costs were adjusted to 2016 dollars. RESULTS At diabetes diagnosis, 42% of youth had DKA. In the 60 days prior to diabetes diagnosis, youth with DKA at diagnosis had less health services usage (e.g., number of outpatient visits: -1.17; P < 0.001) and lower total medical costs (-$635; P < 0.001) compared with youth without DKA at diagnosis. In the 60 days after diagnosis, youth with DKA had significantly greater health care services use and health care costs ($6,522) compared with those without DKA. CONCLUSIONS Among youth with newly diagnosed diabetes, DKA at diagnosis is associated with significantly higher use of health care services and medical costs.
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Affiliation(s)
- Sharon H Saydah
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Hyattsville, MD
| | - Sundar S Shrestha
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Hyattsville, MD
| | - Ping Zhang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Hyattsville, MD
| | - Xilin Zhou
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Hyattsville, MD
| | - Giuseppina Imperatore
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Hyattsville, MD
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Michelson KA, Bachur RG, Mahajan P, Finkelstein JA. Complications of Serious Pediatric Conditions in the Emergency Department: Definitions, Prevalence, and Resource Utilization. J Pediatr 2019; 214:103-112.e3. [PMID: 31383471 DOI: 10.1016/j.jpeds.2019.06.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/03/2019] [Accepted: 06/25/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.
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Affiliation(s)
| | - Richard G Bachur
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Prashant Mahajan
- Department of Emergency Medicine and Pediatrics, University of Michigan Medical School, Ann Arbor, MI
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Dhatariya KK, Parsekar K, Skedgel C, Datta V, Hill P, Fordham R. The cost of treating diabetic ketoacidosis in an adolescent population in the UK: a national survey of hospital resource use. Diabet Med 2019; 36:982-987. [PMID: 30614052 DOI: 10.1111/dme.13893] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2019] [Indexed: 12/13/2022]
Abstract
AIMS Adolescents with Type 1 diabetes commonly experience episodes of ketoacidosis. In 2014, we conducted a nationwide survey on the management of diabetic ketoacidosis in young people. The survey reported how individual adolescents with diabetes were managed. However, the costs of treating diabetic ketoacidosis were not reported. METHODS Using this mixed population sample of adolescents, we took a 'bottom-up' approach to cost analysis aiming to determine the total expense associated with treating diabetic ketoacidosis. The data were derived using the information from the national UK survey of 71 individuals, collected via questionnaires sent to specialist paediatric diabetes services in England and Wales. RESULTS Several assumptions had to be made when analysing the data because the initial survey collection tool was not designed with a health economic model in mind. The mean time to resolution of diabetic ketoacidosis was 15.0 h [95% confidence interval (CI) 13.2, 16.8] and the mean total length of stay was 2.4 days (95% CI 1.9, 3.0). Based on data for individuals and using the British Society of Paediatric Endocrinology and Diabetes (BSPED) guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £1387 (95% CI 1120, 1653). Regression analysis showed a significant cost saving of £762 (95% CI 140, 1574; P = 0.04) among those treated using BSPED guidelines. CONCLUSION We have used a bottom-up approach to calculate the costs of an episode of diabetic ketoacidosis in adolescents. These data suggest that following treatment guidelines can significantly lower the costs for managing episodes of diabetic ketoacidosis.
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Affiliation(s)
- K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - K Parsekar
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Norwich, UK
| | - C Skedgel
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Norwich, UK
| | - V Datta
- Diabetes Department, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - P Hill
- Diabetes Department, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - R Fordham
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Norwich, UK
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5
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Dhatariya KK, Skedgel C, Fordham R. The cost of treating diabetic ketoacidosis in the UK: a national survey of hospital resource use. Diabet Med 2017; 34:1361-1366. [PMID: 28727175 DOI: 10.1111/dme.13427] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2017] [Indexed: 02/06/2023]
Abstract
AIM Diabetic ketoacidosis is a commonly encountered metabolic emergency. In 2014, a national survey was conducted looking at the management of diabetic ketoacidosis in adult patients across the UK. The survey reported the clinical management of individual patients as well as institutional factors that teams felt were important in helping to deliver that care. However, the costs of treating diabetic ketoacidosis were not reported. METHODS We used a 'bottom up' approach to cost analysis to determine the total expense associated with treating diabetic ketoacidosis in a mixed population sample. The data were derived from the source data from the national UK survey of 283 individual patients collected via questionnaires sent to hospitals across the country. RESULTS Because the initial survey collection tool was not designed with a health economic model in mind, several assumptions were made when analysing the data. The mean and median time in hospital was 5.6 and 2.7 days respectively. Based on the individual patient data and using the Joint British Diabetes Societies Inpatient Care Group guidelines, the cost analysis shows that for this cohort, the average cost for an episode of diabetic ketoacidosis was £2064 per patient (95% confidence intervals: 1800, 2563). CONCLUSION Despite relatively short stays in hospital, costs for managing episodes of diabetic ketoacidosis in adults were relatively high. Assumptions made in the calculations did not consider prolonged hospital stay due to comorbidities or costs incurred as a loss of productivity. Therefore, the actual costs to the healthcare system and society in general are likely to be substantially higher.
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Affiliation(s)
- K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust
| | - C Skedgel
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Norwich, UK
| | - R Fordham
- Health Economics Consulting, Norwich Medical School, University of East Anglia, Norwich, UK
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Barranco RJ, Gomez-Peralta F, Abreu C, Delgado-Rodriguez M, Moreno-Carazo A, Romero F, de la Cal MA, Barranco JM, Pasquel FJ, Umpierrez GE. Incidence, recurrence and cost of hyperglycaemic crises requiring emergency treatment in Andalusia, Spain. Diabet Med 2017; 34:966-972. [PMID: 28326628 DOI: 10.1111/dme.13355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 12/27/2022]
Abstract
AIMS Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact. METHODS An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012. RESULTS Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8. CONCLUSIONS Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system.
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Affiliation(s)
- R J Barranco
- Andalusian Healthcare Emergency Public Service, Neurotraumatologic Hospital
- Department Health Sciences, University of Jaén, Jaén
| | - F Gomez-Peralta
- Endocrinology and Nutrition Unit, Segovia General Hospital, Segovia
| | - C Abreu
- Endocrinology and Nutrition Unit, Segovia General Hospital, Segovia
| | - M Delgado-Rodriguez
- Division of Preventive Medicine and Public Health, University of Jaén, Jaén
- Center for Biomedical Research in Epidemiology and Public Health (CIBERESP), Institute of Health Carlos III, Madrid
| | - A Moreno-Carazo
- Endocrinology and Nutrition Unit, City of Jaén Hospital Complex, Jaén
| | - F Romero
- Andalusian Healthcare Emergency Public Service, Neurotraumatologic Hospital
| | - M A de la Cal
- Andalusian Healthcare Emergency Public Service, Los Morales Hospital, Córdoba
| | - J M Barranco
- Department of Business Management, Insulcloud S.L., Madrid, Spain
| | - F J Pasquel
- Department of Medicine, Emory University School of Medicine, Atlanta, USA
| | - G E Umpierrez
- Department of Medicine, Emory University School of Medicine, Atlanta, USA
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McGuire HC, Ji L, Kissimova-Skarbek K, Whiting D, Aguirre F, Zhang P, Lin S, Gong C, Zhao W, Lu J, Guo X, Ji Y, Seuring T, Hong T, Chen L, Weng J, Zhou Z. Type 1 diabetes mellitus care and education in China: The 3C study of coverage, cost, and care in Beijing and Shantou. Diabetes Res Clin Pract 2017; 129:32-42. [PMID: 28500868 DOI: 10.1016/j.diabres.2017.02.027] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/16/2017] [Accepted: 02/22/2017] [Indexed: 02/05/2023]
Abstract
AIMS The paucity of data on Type 1 diabetes in China hinders progress in care and policy-making. This study compares Type 1 diabetes care and clinical outcomes in Beijing and Shantou with current clinical guidelines. METHODS The 3C Study was a cross-sectional study of the clinical practices and outcomes of people with Type 1 diabetes. The study sequentially enrolled 849 participants from hospital records, inpatient wards, and outpatient clinics. Data were collected via face-to-face interviews with patients and health professionals, the Summary of Diabetes Self-Care Activities, medical records, and venous blood samples. Care was audited using ISPAD/IDF indicators. Data underwent descriptive analysis and tests for association. RESULTS The median age was 22years (IQR=13-34years), and 48.4% of the sample had diabetes less than six years. The median HbA1c was 8.5% (69mmol/mol) (IQR 7.2-10.5%), with significant regional variance (p=0.002). Insulin treatment was predominantly two injections/day (45% of patients). The highest incidence of diabetic ketoacidosis was 14.4 events/100 patient years among adolescents. Of the 57.3% of patients with LDL-C>2.6mmol/L, only 11.2% received treatment. Of the 10.6% considered hypertensive, 47.1% received treatment. Rates of documented screening for retinopathy, nephropathy, and peripheral neuropathy were 35.2%, 42.3%, and 25.0%, respectively. The median number of days of self-monitoring/week was 3.0 (IQR=1.0-7.0). There were significant differences in care practices across regions. CONCLUSIONS The study documented an overall deficit in care with significant regional differences noted compared to practice guidelines. Modifications to treatment modalities and the structure of care may improve outcomes.
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Affiliation(s)
- Helen C McGuire
- International Diabetes Federation, Chausée de la Hulpe 166, Watermael Boitsfort, 1170 Brussels, Belgium; PATH, 455 Massachusetts Ave NW, Washington DC, 20001, USA.
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, No. 11, Xizhimen Nan Da Jie, Xicheng District, Beijing 100044, PR China.
| | - Katarzyna Kissimova-Skarbek
- International Diabetes Federation, Chausée de la Hulpe 166, Watermael Boitsfort, 1170 Brussels, Belgium; Jagiellonian University Medical College, Faculty of Health Sciences, Department of Health Economics and Social Security, Poland
| | - David Whiting
- International Diabetes Federation, Chausée de la Hulpe 166, Watermael Boitsfort, 1170 Brussels, Belgium
| | - Florencia Aguirre
- International Diabetes Federation, Chausée de la Hulpe 166, Watermael Boitsfort, 1170 Brussels, Belgium
| | - Puhong Zhang
- The George Institute for Global Health at Peking University Health Science Center, Level 18, Tower B, Horizon Tower, 6, Zhichun Road, Haidian District, Beijing 100088, China
| | - Shaoda Lin
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Shantou University Medical College, No. 57, Changping Road, Shantou 515041, Guangdong Province, China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, No. 56 South Lishi Road, Xicheng District, Beijing, 100045, China
| | - Weigang Zhao
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No.1 Shuaifuyuan Wangfujing Dongcheng District, 100730, Beijing, China
| | - Juming Lu
- Department of Endocrinology, PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100853, China
| | - Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, 7 Xishiku St, Xicheng District, Beijing 100034, China
| | - Ying Ji
- Department of Social Medicine and Health Education, School of Public Health, Peking University, No. 38 Xueyuan Road, Haidian District, Beijing 100191, China
| | - Till Seuring
- International Diabetes Federation, Chausée de la Hulpe 166, Watermael Boitsfort, 1170 Brussels, Belgium
| | - Tianpei Hong
- Department of Endocrinology and Metabolism, Peking University Third Hospital, No.49, Huayuan North Road, Haidian District, Beijing 100191, China
| | - Lishu Chen
- Department of Endocrinology, The Second Affiliated Hospital of Shantou University Medical College, No. 69, Dongxia North Road, Shantou 515000, Guangdong Province, China
| | - Jianping Weng
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, No. 600, Tianhe Road, Tianhe District, Guangzhou 510630, Guangdong Province, China
| | - Zhiguang Zhou
- Institute of Metabolism and Endocrinology, The Second Xiangya Hospital, Key Laboratory of Diabetes Immunology, Ministry of Education, Central South University, National Clinical Research Center for Metabolic Diseases, No. 139, Renmin Middle Road, Furong District, Changsha 410011, Hunan Province, China
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Bruno G, Pagano E, Rossi E, Cataudella S, De Rosa M, Marchesini G, Miccoli R, Vaccaro O, Bonora E. Incidence, prevalence, costs and quality of care of type 1 diabetes in Italy, age 0-29 years: The population-based CINECA-SID ARNO Observatory, 2002-2012. Nutr Metab Cardiovasc Dis 2016; 26:1104-1111. [PMID: 27817991 DOI: 10.1016/j.numecd.2016.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/04/2016] [Accepted: 09/02/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS To assess temporal trend in incidence (2003-12) and prevalence (2002-12) of type 1 diabetes in children and young adults, direct costs and selected indicators of quality of care under the coverage of the universalistic Italian National Health System (NHS). METHODS AND RESULTS The ARNO Observatory, a healthcare monitoring system based on administrative data, identified a population-based multiregional cohort of subjects aged 0-29 years. Type 1 diabetes was defined by at least two prescriptions of insulin over 12 months and continuous insulin-treatment in the following year. Indicators of quality of care and directs costs were assessed in persons with diabetes and in people without diabetes, individually matched for age, gender and health unit (1:4 ratio). We identified 2357 incident cases of type 1 diabetes aged 0-29 years (completeness of ascertainment, 99%). Incidence rates were similar in ages 0-14 (15.8, 95% CI 14.9-16.8) and 15-29 years (16.3, 15.4-17.2), with no significant trend. Prevalence increased from 137 to 166.9/100,000, particularly in the age 15-29 years. Direct costs accounted for € 2117 in persons with diabetes and € 292 in control individuals. A statistically significant decreasing trend in hospitalization for acute complications was evident (p < 0.001), which was almost completely due to ketoacidosis. People with at least one HbA1c measurement over the year were 48.5%. CONCLUSION We showed high incidence and increasing prevalence of type 1 diabetes in young adults in Italy, which impact on direct costs under the universalistic coverage of the NHS.
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Affiliation(s)
- G Bruno
- Dept. of Medical Sciences, University of Torino, Italy.
| | - E Pagano
- Unit of Cancer Epidemiology, "Città della Salute e della Scienza" Hospital-University of Turin and CPO Piemonte, Turin, Italy
| | - E Rossi
- CINECA Interuniversity Consortium, Health Department, Bologna, Italy
| | - S Cataudella
- CINECA Interuniversity Consortium, Health Department, Bologna, Italy
| | - M De Rosa
- CINECA Interuniversity Consortium, Health Department, Bologna, Italy
| | - G Marchesini
- Unit of Metabolic Diseases and Clinical Dietetics, Alma Mater Studiorum University, Bologna, Italy
| | - R Miccoli
- Dept. of Endocrinology and Metabolism, Section of Metabolic Diseases and Diabetes, University of Pisa, Italy
| | - O Vaccaro
- Dept. of Clinical Medicine and Surgery, University of Napoli Federico II, Napoli, Italy
| | - E Bonora
- Endocrinology, Diabetes and Metabolism, Dept. of Medicine, University and University Hospital of Verona, Italy
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Lien ASY, Jiang YD, Mou CH, Sun MF, Gau BS, Yen HR. Integrative traditional Chinese medicine therapy reduces the risk of diabetic ketoacidosis in patients with type 1 diabetes mellitus. J Ethnopharmacol 2016; 191:324-330. [PMID: 27340102 DOI: 10.1016/j.jep.2016.06.051] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 06/12/2016] [Accepted: 06/18/2016] [Indexed: 06/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Life-long insulin is the standard treatment for type 1 diabetes mellitus (T1DM). The role of traditional Chinese medicine (TCM) in T1DM is still not clear. The aim of this study is to explore the prescription pattern of TCM and its impact on the risk of diabetic ketoacidosis (DKA) in patients with T1DM. MATERIALS AND METHODS We retrieved samples from the registry for catastrophic illness patients from the National Health Insurance Research Database (NHIRD). Based on a frequency (1:4) matched case-control design, patients with T1DM in 2000-2011 were designated as cases (TCM users) and controls (non-TCM users). TCM treatment for patients with T1DM was analyzed. The incidence of DKA and the annual costs of emergency visits and hospitalizations were evaluated for all causes. RESULTS Overall, 416 subjects were TCM users, whereas a total of 1608 matched subjects were classified as non-TCM users. The most common Chinese herbal formula and single herb is Liu-wei-di-huang-wan (Six-ingredient pill of Rehmannia) and Huang-qi (Radix Astragali; Astragalus membranaceus (Fisch.) Bunge, Astragalus membranaceus var. mongholicus (Bunge) P.K.Hsiao), respectively. Compared with non-TCM users, we found a 33% reduction in DKA incidence for all TCM users (aHR 0.67, 95% CI 0.56-0.81, p <0.000) and a 40% reduction for users receiving TCM treatment for more than 180 days (aHR 0.58, 95% CI 0.41-0.82, p <0.01). There were no significant differences between TCM users and non-users in the frequency and medical costs of emergency visits and hospitalizations. CONCLUSIONS Integrative TCM use may reduce the risk of DKA in patients with T1DM. Our results suggest that TCM may have a substantial positive impact on the management of TIDM.
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MESH Headings
- Adolescent
- Adult
- Blood Glucose/drug effects
- Blood Glucose/metabolism
- Case-Control Studies
- Delivery of Health Care, Integrated/economics
- Delivery of Health Care, Integrated/trends
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/economics
- Diabetes Mellitus, Type 1/epidemiology
- Diabetic Ketoacidosis/blood
- Diabetic Ketoacidosis/economics
- Diabetic Ketoacidosis/epidemiology
- Diabetic Ketoacidosis/prevention & control
- Drug Costs
- Drug Prescriptions
- Drugs, Chinese Herbal/adverse effects
- Drugs, Chinese Herbal/economics
- Drugs, Chinese Herbal/therapeutic use
- Emergency Service, Hospital/economics
- Female
- Hospital Costs
- Hospitalization/economics
- Humans
- Hypoglycemic Agents/adverse effects
- Hypoglycemic Agents/economics
- Hypoglycemic Agents/therapeutic use
- Incidence
- Male
- Medicine, Chinese Traditional/economics
- Medicine, Chinese Traditional/trends
- Practice Patterns, Physicians'/economics
- Practice Patterns, Physicians'/trends
- Registries
- Taiwan/epidemiology
- Time Factors
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Angela Shin-Yu Lien
- Department of Nursing, College of Medicine, National Taiwan University, Taipei 100, Taiwan; School of Nursing, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yi-Der Jiang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chih-Hsin Mou
- Management Office for Health Data, China Medical University Hospital, Taichung 404, Taiwan
| | - Mao-Feng Sun
- Department of Chinese Medicine, China Medical University Hospital, Taichung 404, Taiwan; Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung 404, Taiwan; School of Chinese Medicine, China Medical University, Taichung 404, Taiwan
| | - Bih-Shya Gau
- Department of Nursing, College of Medicine, National Taiwan University, Taipei 100, Taiwan.
| | - Hung-Rong Yen
- Research Center for Traditional Chinese Medicine, Department of Medical Research, China Medical University Hospital, Taichung 404, Taiwan; Department of Chinese Medicine, China Medical University Hospital, Taichung 404, Taiwan; Research Center for Chinese Medicine & Acupuncture, China Medical University, Taichung 404, Taiwan; School of Chinese Medicine, China Medical University, Taichung 404, Taiwan.
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10
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Simmons D, Hartnell S, Watts J, Ward C, Davenport K, Gunn E, Jenaway A. Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events. Diabet Med 2015; 32:1361-7. [PMID: 25865087 DOI: 10.1111/dme.12779] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2015] [Indexed: 11/30/2022]
Abstract
AIMS To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes. METHODS Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods. RESULTS Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)]. CONCLUSIONS The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach.
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Affiliation(s)
- D Simmons
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - S Hartnell
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Watts
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - C Ward
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Davenport
- Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Gunn
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - A Jenaway
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
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11
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Wolowacz S, Pearson I, Shannon P, Chubb B, Gundgaard J, Davies M, Briggs A. Development and validation of a cost-utility model for Type 1 diabetes mellitus. Diabet Med 2015; 32:1023-35. [PMID: 25484028 DOI: 10.1111/dme.12663] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2014] [Indexed: 11/28/2022]
Abstract
AIMS To develop a health economic model to evaluate the cost-effectiveness of new interventions for Type 1 diabetes mellitus by their effects on long-term complications (measured through mean HbA1c ) while capturing the impact of treatment on hypoglycaemic events. METHODS Through a systematic review, we identified complications associated with Type 1 diabetes mellitus and data describing the long-term incidence of these complications. An individual patient simulation model was developed and included the following complications: cardiovascular disease, peripheral neuropathy, microalbuminuria, end-stage renal disease, proliferative retinopathy, ketoacidosis, cataract, hypoglycemia and adverse birth outcomes. Risk equations were developed from published cumulative incidence data and hazard ratios for the effect of HbA1c , age and duration of diabetes. We validated the model by comparing model predictions with observed outcomes from studies used to build the model (internal validation) and from other published data (external validation). We performed illustrative analyses for typical patient cohorts and a hypothetical intervention. RESULTS Model predictions were within 2% of expected values in the internal validation and within 8% of observed values in the external validation (percentages represent absolute differences in the cumulative incidence). CONCLUSIONS The model utilized high-quality, recent data specific to people with Type 1 diabetes mellitus. In the model validation, results deviated less than 8% from expected values.
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Affiliation(s)
- S Wolowacz
- Health Economics, RTI Health Solutions, Manchester
| | - I Pearson
- Health Economics, RTI Health Solutions, Manchester
| | - P Shannon
- Patient-Reported Outcomes, RTI Health Solutions, Manchester
| | - B Chubb
- European Health Economics & Outcomes Research, Novo Nordisk Ltd, Gatwick, UK
| | - J Gundgaard
- Health Economics and HTA, Novo Nordisk A/S, Bagsvaerd, Denmark
| | - M Davies
- Diabetes Research Centre, University of Leicester, Leicester
| | - A Briggs
- Institute for Health and Wellbeing, University of Glasgow, Glasgow, UK
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12
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Abstract
Diabetic ketoacidosis (DKA) is associated with negative health outcomes and high costs for patients, families, and communities. Interventions developed to effectively reduce DKA and related costs should target the multiple risk factors associated with DKA and adherence difficulties. Certain demographic, psychological, and family factors are associated with increased risk for adherence problems and DKA. Individuals with a combination of risk factors (e.g., mental health problems, low socioeconomic status, high family conflict) may be particularly vulnerable to DKA. Although several different interventions have demonstrated promise in improving adherence and/or decreasing the risk of DKA, the generalizability of treatment results to those individuals most vulnerable to DKA is limited. Approaches which include multiple evidence-based components of care, are flexible in treatment delivery (e.g., home- and community-based, utilize technology), and target the multiple risk factors across relevant systems (e.g., individual, family, school, medical) are warranted to effectively reduce DKA in vulnerable populations.
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Affiliation(s)
- David V Wagner
- Oregon Health & Science University, 707 SW Gaines St., Portland, OR, 97239, USA
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13
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Li J, Yang D, Yan J, Huang B, Zhang Y, Weng J. Secondary diabetic ketoacidosis and severe hypoglycaemia in patients with established type 1 diabetes mellitus in China: a multicentre registration study. Diabetes Metab Res Rev 2014; 30:497-504. [PMID: 24687395 DOI: 10.1002/dmrr.2547] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 03/05/2014] [Accepted: 03/17/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and severe hypoglycaemia are common acute complications of type 1 diabetes mellitus (T1DM). This study aimed to determine the incidence of, and risk factors for, these complications in Chinese patients with established T1DM. METHODS This cross-sectional study recruited patients with established T1DM from 16 centres in Guangdong Province, China. Incidence rates were expressed as episodes/100 patient-years. Regression models identified risk factors for the occurrence and recurrence of secondary DKA and severe hypoglycaemia. RESULTS A total of 611 patients with established T1DM (53.7% women) were recruited. The incidence of secondary DKA and severe hypoglycaemia was 26.4 (22.4, 31.0) and 68.8 (62.2, 76.0)/100 patient-years, respectively. Significant risk factors for secondary DKA were female gender [relative risk (RR) = 2.12], medical reimbursement rate <50% (RR = 1.84), uncontrolled diet (RR = 1.76), smoking (RR = 2.18) and poor glycaemic control [glycated haemoglobin A1c (HbA1c)/1.0% increase; RR = 1.15]. Overweight/obesity was a protective factor (RR = 0.57). Significant risk factors for severe hypoglycaemia included male gender (RR = 1.71), medical reimbursement rate < 50% (RR = 1.36), longer duration of T1DM (per 5-year increase, RR = 1.22), underweight (RR = 1.44), uncontrolled diet ('never controlled' or 'sometimes controlled' vs. 'usually controlled', RR = 2.09 or 2.02, respectively), exercise <150 min/week (RR = 1.66), presence of neuropathy (RR = 1.89), smoking (RR = 1.48) and lower HbA1c values (per 1.0% decrease, RR = 1.46). Overweight/obesity was a protective factor (RR = 0.62). Additionally, 34.4% of secondary DKA and 81.1% of severe hypoglycaemia episodes occurred in 3.8% and 16.2% patients with recurrent events (≥two episodes), respectively. CONCLUSIONS The results indicate that secondary DKA and severe hypoglycaemia occur at high rates in Chinese patients with established T1DM and that recurrence is likely to occur in high-risk patients. Comprehensive management of T1DM should include recommendations to control modifiable risk factors.
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Affiliation(s)
- Jin Li
- Department of Endocrinology and Metabolic Disease of the Third Affiliated Hospital, and Guangdong Provincial Key Laboratory of Diabetology, Sun Yat-Sen University, Guangzhou, China; Guangdong Diabetes Center, Sun Yat-sen University, Guangzhou, China
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14
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Klocker AA, Phelan H, Twigg SM, Craig ME. Blood β-hydroxybutyrate vs. urine acetoacetate testing for the prevention and management of ketoacidosis in Type 1 diabetes: a systematic review. Diabet Med 2013; 30:818-24. [PMID: 23330615 DOI: 10.1111/dme.12136] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 11/02/2012] [Accepted: 01/15/2013] [Indexed: 11/29/2022]
Abstract
AIM Diabetic ketoacidosis is a life-threatening complication of Type 1 diabetes. Blood β-hydroxybutyrate testing is now widely available as an alternative to urine acetoacetate testing for detecting ketosis. The aim of this study was to review the effectiveness of capillary or serum β-hydroxybutyrate compared with urine acetoacetate testing in prevention and management of diabetic ketoacidosis. METHODS MEDLINE, EMBASE, EBM Reviews, The Cochrane Library and CINAHL (until April 2012, no language restrictions, studies in humans) were searched for experimental and observational studies comparing the effectiveness of blood β-hydroxybutyrate and urine acetoacetate testing. Outcomes examined were prevention of diabetic ketoacidosis, time to recovery from diabetic ketoacidosis, healthcare costs and patient or caregiver satisfaction. Additional sources included reference lists, conference proceedings and contact with experts in the field. RESULTS Four studies (two randomized controlled trials and two cohort studies) met eligibility criteria, including 299 participants across 11 centres. Risk of bias was low to moderate. Blood ketone testing compared with urine testing was associated with reduced frequency of hospitalization (one study), reduced time to recovery from diabetic ketoacidosis (three studies), cost benefits (one study) and greater satisfaction (one study, intervention group only). No study assessed prevention of diabetic ketoacidosis. Meta-analysis could not be performed because of heterogeneity in study design and published data. CONCLUSIONS There is evidence suggesting that blood β-hydroxybutyrate testing is more effective than urine acetoacetate testing in reducing emergency department assessment, hospitalization and time to recovery from diabetic ketoacidosis, as well as potentially lowering healthcare expenditure. Further research in both young people and adults is needed.
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Affiliation(s)
- A A Klocker
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
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15
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Abdulrahman GO, Amphlett B, Okosieme OE. Trends in hospital admissions with diabetic ketoacidosis in Wales, 1999-2010. Diabetes Res Clin Pract 2013; 100:e7-10. [PMID: 23380135 DOI: 10.1016/j.diabres.2013.01.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 01/03/2013] [Accepted: 01/07/2013] [Indexed: 11/19/2022]
Abstract
We determined the incidence of diabetic ketoacidosis in Wales using nationwide hospital discharge data. Ketoacidosis admission rate was 24 per 100,000 person years and increased progressively from 1999 to 2010. The highest incidence was seen in 10-29 year olds, highlighting the need for targeted prevention in this age-group.
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Affiliation(s)
- G O Abdulrahman
- Department of Endocrinology and Diabetes, Prince Charles Hospital, Cwm Taf Local Health Board, Merthyr Tydfil, Mid Glamorgan, CF47 9DT, UK
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16
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Centers for Medicare and Medicaid Services (CMS), HHS. Medicaid program; payment adjustment for provider-preventable conditions including health care-acquired conditions. Final rule. Fed Regist 2011; 76:32816-38. [PMID: 21644388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This final rule will implement section 2702 of the Patient Protection and Affordable Care Act which directs the Secretary of Health and Human Services to issue Medicaid regulations effective as of July 1, 2011 prohibiting Federal payments to States under section 1903 of the Social Security Act for any amounts expended for providing medical assistance for health care-acquired conditions specified in the regulation. It will also authorize States to identify other provider-preventable conditions for which Medicaid payment will be prohibited.
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MESH Headings
- Accidental Falls/economics
- Accidental Falls/prevention & control
- Blood Group Incompatibility/economics
- Blood Group Incompatibility/prevention & control
- Catheter-Related Infections/economics
- Catheter-Related Infections/prevention & control
- Diabetic Ketoacidosis/economics
- Diabetic Ketoacidosis/prevention & control
- Economics, Hospital/legislation & jurisprudence
- Embolism, Air/economics
- Embolism, Air/prevention & control
- Foreign Bodies/economics
- Foreign Bodies/prevention & control
- Health Care Reform/economics
- Health Care Reform/legislation & jurisprudence
- Humans
- Insurance, Health, Reimbursement/economics
- Insurance, Health, Reimbursement/legislation & jurisprudence
- Legislation, Hospital/economics
- Medicaid/economics
- Medicaid/legislation & jurisprudence
- Medical Errors/economics
- Medical Errors/prevention & control
- Medicare/economics
- Medicare/legislation & jurisprudence
- Patient Protection and Affordable Care Act/economics
- Pressure Ulcer/economics
- Pressure Ulcer/prevention & control
- Prospective Payment System/economics
- Prospective Payment System/legislation & jurisprudence
- Quality Assurance, Health Care/economics
- Quality Assurance, Health Care/legislation & jurisprudence
- Surgical Wound Infection/economics
- Surgical Wound Infection/prevention & control
- United States
- Venous Thrombosis/economics
- Venous Thrombosis/prevention & control
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17
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Abstract
Health research often gives rise to data that follow lognormal distributions. In two sample situations, researchers are likely to be interested in estimating the difference or ratio of the population means. Several methods have been proposed for providing confidence intervals for these parameters. However, it is not clear which techniques are most appropriate, or how their performance might vary. Additionally, methods for the difference of means have not been adequately explored. We discuss in the present article five methods of analysis. These include two methods based on the log-likelihood ratio statistic and a generalized pivotal approach. Additionally, we provide and discuss the results of a series of computer simulations. Finally, the techniques are applied to a real example.
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Affiliation(s)
- Yea-Hung Chen
- Department of Biostatistics, University of Washington, Seattle WA 98195, USA.
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18
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Smaldone A, Honig J, Stone PW, Arons R, Weinger K. Characteristics of California children with single versus multiple diabetic ketoacidosis hospitalizations (1998-2000). Diabetes Care 2005; 28:2082-4. [PMID: 16043767 DOI: 10.2337/diacare.28.8.2082-a] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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19
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Maniatis AK, Goehrig SH, Gao D, Rewers A, Walravens P, Klingensmith GJ. Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus. Pediatr Diabetes 2005; 6:79-83. [PMID: 15963034 DOI: 10.1111/j.1399-543x.2005.00096.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES (a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM). RESEARCH DESIGN AND METHODS Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained. RESULTS Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old. CONCLUSIONS At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.
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Affiliation(s)
- Aristides K Maniatis
- The Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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20
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Ellis DA, Naar-King S, Frey M, Templin T, Rowland M, Cakan N. Multisystemic treatment of poorly controlled type 1 diabetes: effects on medical resource utilization. J Pediatr Psychol 2005; 30:656-66. [PMID: 16260435 DOI: 10.1093/jpepsy/jsi052] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could decrease rates of hospital utilization and related costs of care among adolescents with poorly controlled type diabetes. METHODS Thirty-one adolescents were randomly assigned to receive either MST or standard care. MST lasted approximately 6 months, and all participants were followed for 9 months. Rates of inpatient admissions and emergency room (ER) visits were calculated for a 9-month prestudy period and during the 9 months of study participation. The relationship between changes in inpatient admissions and changes in metabolic control was also investigated. RESULTS Intervention participants had a decreasing number of inpatient admissions from the baseline period to the end of the study, whereas the number of inpatient admissions increased for controls. Use of the emergency room did not differ. Related medical charges and direct care costs were significantly lower for adolescents receiving MST. Correlational analyses conducted with a subset of participants indicated that decreases in inpatient admissions were associated with improved metabolic control for MST but not control participants. CONCLUSIONS Findings suggest that MST has the potential to decrease inpatient admissions among adolescents with poorly controlled type 1 diabetes.
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Affiliation(s)
- Deborah A Ellis
- Children's Hospital of Michigan, Department of Child Psychitary and Psychology, 3901 Beaubien, Detroit, MI 48201, USA.
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21
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Haas RM, Hoffman AR. Treatment of diabetic ketoacidosis: should mode of insulin administration dictate use of intensive care facilities? Am J Med 2004; 117:357-8. [PMID: 15336586 DOI: 10.1016/j.amjmed.2004.06.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2004] [Indexed: 11/16/2022]
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22
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Umpierrez GE, Latif K, Stoever J, Cuervo R, Park L, Freire AX, E Kitabchi A. Efficacy of subcutaneous insulin lispro versus continuous intravenous regular insulin for the treatment of patients with diabetic ketoacidosis. Am J Med 2004; 117:291-6. [PMID: 15336577 DOI: 10.1016/j.amjmed.2004.05.010] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2003] [Revised: 05/21/2004] [Accepted: 05/21/2004] [Indexed: 12/21/2022]
Abstract
PURPOSE To compare the efficacy and safety of subcutaneous insulin lispro with that of a standard low-dose intravenous infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis. METHODS In this prospective, randomized open trial, 20 patients treated with subcutaneous insulin lispro were managed in regular medicine wards (n=10) or an intermediate care unit (n=10), while 20 patients treated with the intravenous protocol were managed in the intensive care unit. Patients treated with subcutaneous lispro received an initial injection of 0.3 unit/kg followed by 0.1 unit/kg/h until correction of hyperglycemia (blood glucose levels <250 mg/dL), followed by 0.05 to 0.1 unit/kg/h until resolution of diabetic ketoacidosis (pH > or =7.3, bicarbonate > or =18 mEq/L). Patients treated with intravenous regular insulin received an initial bolus of 0.1 unit/kg, followed by an infusion of 0.1 unit/kg/h until correction of hyperglycemia, then 0.05 to 0.1 unit/kg/h until resolution of diabetic ketoacidosis. RESULTS Mean (+/- SD) admission biochemical parameters in patients treated with subcutaneous lispro (glucose: 674 +/- 154 mg/dL; bicarbonate: 9.2 +/- 4 mEq/L; pH: 7.17 +/- 0.10) were similar to values in patients treated with intravenous insulin (glucose: 611 +/- 264 mg/dL; bicarbonate: 10.6 +/- 4 mEq/L; pH: 7.19 +/- 0.08). The duration of treatment until correction of hyperglycemia (7 +/- 3 hours vs. 7 +/- 2 hours) and resolution of ketoacidosis (10 +/- 3 hours vs. 11 +/- 4 hours) in patients treated with subcutaneous lispro was not different than in patients treated with intravenous regular insulin. There were no deaths in either group, and there were no differences in the length of hospital stay, amount of insulin until resolution of diabetic ketoacidosis, or in the rate of hypoglycemia between treatment groups. Treatment of diabetic ketoacidosis in the intensive care unit was associated with 39% higher hospitalization charges than was treatment with subcutaneous lispro in a non-intensive care setting ($14,429 +/- $5243 vs. $8801 +/- $5549, P <0.01). CONCLUSION Treatment of adult patients who have uncomplicated diabetic ketoacidosis with subcutaneous lispro every hour in a non-intensive care setting may be safe and more cost-effective than treatment with intravenous regular insulin in the intensive care unit.
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Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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23
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Balasubramanyam A, Maldonado M. Novel syndromes of ketosis-prone diabetes: implications for management and medical economics. Manag Care 2004; 13:7-10; discussion 19-21. [PMID: 15156714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Affiliation(s)
- Ashok Balasubramanyam
- Endocrine Service, Ben Taub General Hospital, Baylor College of Medicine, Houston, USA
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24
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Beck JK, Logan KJ, Hamm RM, Sproat SM, Musser KM, Everhart PD, McDermott HM, Copeland KC. Reimbursement for pediatric diabetes intensive case management: a model for chronic diseases? Pediatrics 2004; 113:e47-50. [PMID: 14702494 DOI: 10.1542/peds.113.1.e47] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Current reimbursement policies serve as potent disincentives for physicians who provide evaluation and management services exclusively. Such policies threaten nationwide availability of care for personnel-intensive services such as pediatric diabetes. This report describes an approach to improving reimbursement for highly specialized, comprehensive pediatric diabetes management through prospective contracting for services. The objective of this study was to determine whether pediatric diabetes intensive case management services are cost-effective to the payer, the patient, and a pediatric diabetes program. METHODS A contract with a third-party payer was created to reimburse for 3 key pediatric diabetes intensive case management components: specialty education, 24/7 telephone access to an educator (and board-certified pediatric endocrinologist as needed), and quarterly educator assessments of self-management skills. Data were collected and analyzed for 15 months after signing the contract. Within the first 15 months after the contract was signed, 22 hospital admissions for diabetic ketoacidosis (DKA) occurred in 16 different patients. After hospitalizations for DKA, all 16 patients were offered participation in the program. All were followed during the subsequent 1 to 15 months of observation. Ten patients elected to participate, and 6 refused participation. Frequency of rehospitalization, emergency department visits, and costs were compared between the 2 groups. RESULTS Among the 10 participating patients, there was only 1 subsequent DKA admission, whereas among the 6 who refused participation, 5 were rehospitalized for DKA on at least 1 occasion. The 10 patients who participated in the program had greater telephone contact with the team compared with those who did not (16 crisis-management calls vs 0). Costs (education, hospitalization, and emergency department visits) per participating patient were approximately 1350 dollars less than those for nonparticipating patients. Differences between participating and nonparticipating groups included age (participants were of younger age), double-parent households (participants were more likely to be from double parent households), and number of medical visits kept (participants kept more follow-up visits). No differences in duration of diabetes, months followed in the program, sex, or ethnicity were observed. CONCLUSIONS Contracting with third-party payers for pediatric diabetes intensive case management services reduces costs by reducing emergency department and inpatient hospital utilizations, likely a result of intensive education and immediate access to the diabetes health care team for crisis management. Such strategies may prove to be cost saving not only for diabetes management but also for managing other costly and personnel-intensive chronic diseases.
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Affiliation(s)
- Joni K Beck
- University of Oklahoma Health Sciences Center, Oklahoma City 73104, USA.
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25
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Maldonado MR, Chong ER, Oehl MA, Balasubramanyam A. Economic impact of diabetic ketoacidosis in a multiethnic indigent population: analysis of costs based on the precipitating cause. Diabetes Care 2003; 26:1265-9. [PMID: 12663608 DOI: 10.2337/diacare.26.4.1265] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic ketoacidosis (DKA) is a common complication of diabetes. We analyzed the inpatient costs of treating DKA in a multiethnic, indigent population in Houston, Texas. RESEARCH DESIGN AND METHODS We measured the cost of resources utilized for all patients admitted to our hospital with DKA from 1 January to 31 December 1998. We also analyzed their medical records to determine the factors that precipitated the episode of DKA and then grouped them into three categories: acute illnesses, noncompliance with diabetes treatment, and new-onset diabetes. The data were analyzed by one-way ANOVA. The Tukey-Kramer procedure was used for post hoc multiple comparisons. RESULTS There were 167 admissions for DKA. The mean age was 40 +/- 13 years. The ethnic distribution was 49% African American, 32% Hispanic American, and 18% white. The total inhospital cost of treating DKA was $1,816,255. The mean cost per hospitalization was $10, 876 +/- 11,024. The frequency distribution by category of DKA-precipitating factor was 18% acute illness, 59% noncompliance, and 23% new onset. There were differences in mean cost of DKA associated with the three categories: $20,864 +/- 17,910 for acute illness, $11,863 +/- 8,701 for new onset, and $7,470 +/- 6,300 for noncompliance (P < 0.0001). The total cost for each category was $671,375 for acute illness, $694,082 for noncompliance, and $450,798 for new onset. CONCLUSIONS DKA is an expensive complication among indigent, multiethnic diabetic patients. Although the mean cost per admission was lowest for DKA precipitated by noncompliance, this causal category was responsible in sum for the greatest portion of the economic burden.
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Affiliation(s)
- Mario R Maldonado
- Division of Endocrinology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
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Vanelli M, Chiari G, Capuano C. Cost effectiveness of the direct measurement of 3-beta-hydroxybutyrate in the management of diabetic ketoacidosis in children. Diabetes Care 2003; 26:959. [PMID: 12610078 DOI: 10.2337/diacare.26.3.959] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Abstract
OBJECTIVE More than 100,000 people are hospitalized annually in the U.S. with diabetic ketoacidosis (DKA). Outcome differences have not been examined for these patients based on whether their primary care provider is a generalist or a diabetes specialist. The objective of this study was to investigate hospital charges and hospital length of stay (LOS) for patients with DKA according to the specialty of their primary care provider. RESEARCH DESIGN AND METHODS We investigated all patients with a primary diagnosis of DKA during a 3.5-year period (n = 260) in a large urban teaching hospital. Hospital charges and LOS were studied regarding the specialty of the primary care provider. Demographic factors, severity of illness, laboratory data, and readmission rates were compared. RESULTS Patients cared for by generalists and endocrinologists had a similar case mix and severity of DKA. The age-adjusted mean LOS for patients of generalists was 4.9 days (95% CI 4.5-5.4), and the mean LOS for patients of endocrinologists was 3.3 days (2.6-4.2) (P < 0.0043). Mean hospital charges differed (P < 0.0001) with an age- and sex-adjusted mean for patients of endocrinologists of $5,463 ($4,179-7,141) and a mean for patients of generalists of $10,109 ($9,151-11,166). The additional charges incurred by generalists were due in part to patients undergoing more procedures. No differences in diabetes-related complications occurred during admission, but the endocrinologist-treated group had a lower readmission rate for DKA during the study period than the generalist-treated group (2 vs. 6%, respectively) (P = 0.03). CONCLUSIONS Endocrinologists provide more cost-effective care than generalists do when serving as primary care providers for patients hospitalized with DKA.
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Affiliation(s)
- C S Levetan
- MedStar Research Institute, Washington, DC 20003-4393, USA.
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Grimberg A, Cerri RW, Satin-Smith M, Cohen P. The "two bag system" for variable intravenous dextrose and fluid administration: benefits in diabetic ketoacidosis management. J Pediatr 1999; 134:376-8. [PMID: 10064682 DOI: 10.1016/s0022-3476(99)70469-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
1 case-controlled retrospective analysis compared the "two bag system," based on the euglycemic clamp technique, versus the traditional "one bag" method for intravenous diabetic ketoacidosis management. The two bag system can provide more cost-effective intravenous dextrose and fluid delivery and enhance quality of care by improving the efficiency, timeliness, and flexibility of overall control.
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Affiliation(s)
- A Grimberg
- Division of Pediatric Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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Javor KA, Kotsanos JG, McDonald RC, Baron AD, Kesterson JG, Tierney WM. Diabetic ketoacidosis charges relative to medical charges of adult patients with type I diabetes. Diabetes Care 1997; 20:349-54. [PMID: 9051386 DOI: 10.2337/diacare.20.3.349] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the medical charges for treating diabetic ketoacidosis (DKA) episodes relative to direct medical care charges of adult patients with type I diabetes. RESEARCH DESIGN AND METHODS Using data from an electronic medical record system, we identified adult patients with type I diabetes who had received inpatient or outpatient care on at least two occasions between 1 January 1993 and 30 June 1994. Resources and charges for hospitalizations, emergency room visits, outpatient visits, and pharmaceuticals were recorded during this period. One additional year of information was collected to assess the resources and charges associated with multiple DKA episodes. RESULTS A total of 200 patients were identified, of whom 72 (36.0%) experienced a total of 161 DKA episodes. The direct medical care charges associated with DKA episodes represented 28.1% of the direct medical care charges for the cohort of patients with type I diabetes. The average charge per DKA episode was $6,444. The estimated annual medical care charge for each patient was $7,855 ($13,096 per patient experiencing a DKA episode versus $4,907 per patient not experiencing an episode). Multiple DKA episodes were experienced by 24 (12.0%) of the study patients and accounted for 55.6% of the direct medical care charges for these patients. CONCLUSIONS DKA episodes represented more than $1 of every $4 spent on direct medical care for adult patients with type I diabetes and $1 of every $2 in those patients experiencing multiple episodes. Interventions that are capable of even a modest reduction in the number of DKA episodes could produce substantial cost savings in a health care system and could be particularly cost-effective in adult patients with recurrent DKA.
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Affiliation(s)
- K A Javor
- Purdue University School of Pharmacy and Pharmacal Sciences, West Lafayette, Indiana, USA.
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Abstract
Diabetes mellitus accounts for 5.8% of the total health care costs of citizens of the United States. Hospitalization expenses produce 40.5% of these costs. We sought to determine the public expenditure and major precipitators of admissions for uninsured diabetic hyperglycemic emergencies at a large public hospital. Of 247 diabetic emergency admissions over a 30 month period 49% (n = 121) of these patients had no medical insurance. The uninsured patients were younger and had relatively mild disease in comparison to the insured patients. These patients identified a primary physician in only 6% of the cases and had a higher incidence of admissions associated with lack of medications. We conclude that public funds to provide access to primary care and enhancement of employer-sponsored health insurance programs may decrease the numbers and costs of hospitalizations due to hyperglycemic emergencies in uninsured patients with diabetes mellitus.
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Affiliation(s)
- B E Wilson
- University of Nevada School of Medicine, Las Vegas, USA
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Alsever RN. Specialist versus primary care: not an easy question. Physician Exec 1995; 21:39-41. [PMID: 10139604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The central focus in the debate to reform our nation's health care system is on cost, quality, and access. There is general agreement that there are too many specialists in the wrong places, which is said to contribute to the rising cost of health care. Physician profiling has supported the concept that some specialists are more costly than primary care physicians, although the severity of illness in patients treated by specialists may often be greater. Increasing the number of primary care providers may be a solution to reduce costs and will clearly improve access. The study reported in this article was carried out to examine the efficiency of primary care physicians and endocrinologists, a specialty that has been cited as one in which resource utilization is high, in caring for hospital inpatients with diabetic ketoacidosis.
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Affiliation(s)
- R N Alsever
- Sisters of Charity Healthcare Systems, Inc., Colorado Springs, CO
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