Chicago, IL—A “team of 4” approach to achieve the “ABC goals”—hemoglobin (Hb) A1c <7%, blood pressure <130/80 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL—and to reduce cardiovascular disease (CVD) risk provides significant cost-savings in managed care, according to an outcomes evaluation presented by Swarna S. Varma, MD, of Pittsburgh Endocrine and Diabetes Associates, Bridgeville, PA, at the 2013 American Diabetes Association annual meeting. The team care approach entails the involvement and accountability of the physician, staff, patient, and family.
The incremental cost per patient was $180 to achieve the ABC goals and $480 to reduce CVD risk compared with standard of care, based on National Health and Nutrition Examination Survey population statistics for patients with diabetes. All costs are in 2012 US dollars.
Over a 10-year period (2000-2009), this led to a cost avoidance of $9,044,500 for the ABC goal attainment and $24,043,500 for CVD risk reduction in a 50,000-person managed care system. At the practice level, the cost avoidances were $71,451 and $189,943, respectively, for 395 patients.
A total of 22% of patients in the team care approach in the community-based practice attained the ABC goals compared with only 7% of patients receiving standard of care, whereas CVD was projected in only 18% of the patients under the team care and in 24% of the patients receiving standard of care.
Specialized Diabetes Team Reduces Hospital Costs
Hospital care accounts for 43% of the $176 billion spent annually on diabetes care in the United States, driving the need for improved in-hospital resource utilization.
A double-blind, retrospective study conducted at a tertiary academic medical center showed that care provided by a specialized diabetes team reduced overall costs compared with a usual primary service team in noncritical care units in patients with diabetes. The specialized team was comprised an of endocrinologist and a diabetes educator.
Vivek Bansal, MD, MPH, Hospitalist, Beth Israel Deaconess Medical Center, Boston, MA, said that the reduction in 30-day hospital readmissions translated to a postulated cost-savings of $3,570,480 for 15,094 admissions in 2011 and $2,975,400 for 12,514 admissions in 2012, using national average costs. The rates of 30-day readmissions were 1.3 for the primary service team versus 1.1 for the specialized team (P = .107).
The total hospital costs for these patients were $60,878,250 with the primary service team and $57,307,770 with the diabetes team in 2011, and $50,480,010 and $47,504,610, respectively, in 2012.
“Early comprehensive diabetes education, early endocrine consultation, appropriate transition of care, and compliance can lead to the costs that you really want,” said Dr Bansal.
Strikingly, Dr Bansal said, the specialist team took care of more complex patients (ie, more type 1 diabetes, higher baseline HbA1c, more insulin therapy), which led to cost-savings. The greatest cost-savings was in the medical patients, because of longer hospitalization and a higher rate of readmission for surgical patients.
Informal Counseling by Endocrinologists Improves Reaching Goals
One-on-one informal counseling by an endocrinologist improved diabetes care provided by clinicians in affiliated Joslin Diabetes Centers. Using the newly devised Joslin Clinical Analytical Tool as a quality measure for achieving goals that have been adjusted based on disease severity, clinicians were provided their metrics and national benchmarks.
The providers who also received the counseling had significantly higher rates (13%) of achieving the HbA1c targets set for 5 medication groups compared with 4% without counseling. Group 0 received no medications, Group 1 received 1 medication, Group 2 received 2 medications; Group 3 received 3 oral medications or basal insulin or a glucagon-like peptide-1 agonist, and Group 4 included pumps or basal/bolus combinations.
In Group 4, the most complex patients, fewer patients with type 2 diabetes achieved an HbA1c <8.5% than patients with type 1 diabetes. It was “a surprise that the patients with type 2 DM [diabetes mellitus] do not do as well with their A1c. Most of the improvement came through the T2DM [type 2 diabetes mellitus] patients, through whatever means this was assessed,” said Richard A. Jackson, MD, Director, Hood Center for Prevention of Childhood Diabetes, Joslin Medical Center, Boston. This was also the group that had the greatest improvements in reaching targets, from 46% before counseling to 69% after counseling.