Economic issues in diabetes care are garnering great attention throughout the world today. Cost issues in diabetes self-management training are of interest because of three current and significant influences:
In this light, cost-effectiveness analyses are often used to evaluate the economic arguments surrounding diabetes treatments and interventions. A cost-effectiveness analysis generally summarizes the impact of an intervention by characterizing the cost of the intervention relative to the health outcomes obtained. These studies are used to advocate for the adoption of a healthcare intervention. Typically, the policy decision is whether a new intervention is better able to meet a healthcare goal than the existing standard of care at a reasonable cost.
Economic arguments for the adoption of self-management training can be a powerful tool for advocates and others seeking to improve the health of the diabetes population. Does the implementation of diabetes education represent value for money? The answer is not clearly understood at this time. Both the multi-faceted nature of diabetes self-management and the dynamic way in which it is used in diabetes care make it difficult to decipher the economic benefit related to diabetes education alone.
Three independent reviews note that the economic costs and benefits of diabetes education have not been fully addressed1Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care 2000; 23(3):390-404. 2Norris SL, Engelgau MM, Narayan KMV. Effectiveness of self-management training in type 2 diabetes; a systematic review of randomized controlled trials. Diabetes Care 2001; 24:561-587. 3Kaplan RM, Davis WK. Evaluating the costs and benefits of outpatient diabetes education and nutrition counseling. Diabetes Care 1986; 9(1):81-86.. Several studies provide either a poor accounting of costs (such as neglecting to account for the programme costs inherent in providing education), or an inadequate comparison group to assess the impact on diabetes-related outcomes.
Despite the recognized limitations in economic methodology, self-management training in diabetes is thought to be cost-effective. This judgment is based on a large number of studies that suggest an economic benefit to self-management training programmes1Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care 2000; 23(3):390-404.. For example, reduced future hospitalizations associated with self-management interventions have been noted in several1Klonoff DC, Schwartz DM. An economic analysis of interventions for diabetes. Diabetes Care 2000; 23(3):390-404., though, not all reports4Rettig BA, Shrauger DG, Recker RR, Gallagher TF, Wiltse H. A randomized study of the effects of a home diabetes education program. Diabetes Care 1986; 9(2):173-78. 5de Weerdt I, Visser AP, Kok GJ, de Weerdt O, Van der Veen EA. Randomized controlled multicentre evaluation of an education programme for insulin-treated diabetic patients: effects on metabolic control, quality of life, and costs of therapy. Diabet Med 1991; 8:338-345..
Hospital costs represent the largest expenditure for diabetes care in several countries and reducing hospital costs thereby generally saves money. A multi-centre intervention in 10 countries in Latin America has also demonstrated that an educational programme can reduce the cost of drugs by 62%6White F, Vega J, Aedo C, Jadue L, Robles S, Salazar R, Delgado I. Proyecto de demostración en educación en diabetes. Informe Final. Organización Pan Americana de la Salud - Eli Lilly, 1998.. Another programme in Argentina found a reduction in diabetes-related costs of 38%7Gagliardino JJ, Etchegoyen G. A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Diabetes Care 2001; 24(6):1001-1007..
Diabetes education is also an integral part of several interventions that have been shown to save money. These include interventions that address diabetes and pregnancy8Scheffler RM, Feuchtbaum LB, Phibbs CS. Prevention: the cost-effectiveness of the California diabetes and pregnancy program. Am J Public Health 1992; 82:168-175. 9Elixhauser A, Weschler JM, Kitzmiller JL, Marks JS, Bennert Jr, HW, Coustan DR, Gabbe SG, Herman WH, Kaufmann RC, Ogata ES, Sepe SJ. Cost-benefit analysis of preconception care for women with established diabetes mellitus. Diabetes Care 1993; 16(8):1146-1157. and those that shift the initiation of insulin therapy from inpatient to outpatient settings10Simell T, Moren R, Keltikangas-Jarvinen L, Hakalax J, Simell O. Short-term and long-term initial stay in hospital of children with insulin-dependent diabetes: adjustment of families after two years. Acta Paediatr 1995; 84:41-50. 11Penfornis A, Millot L. Initiating insulin treatment in insulin-requiring type 2 diabetic patients: comparative efficiency and cost of outpatient and inpatient management. INNOV Study Group. Diabetes Metab 1998; 24(2):137-142. 12Mengistu M, Lungi Y, Mamo F. Inpatient or outpatient initiation of insulin therapy. Experience and cost effective analysis in a suboptimal clinical setting. Trop Geogr Med 1991; 43(1-2):180-183. 13Dougherty G, Schiffrin A, White D, Soderstrom L, Sufrategui M. Home-based management can achieve intensification cost-effectively in Type 1 diabetes. Pediatrics 1999;103(1):122-128..
More recently, self-management and diabetes education have been a vital component in landmark intensive treatment and lifestyle modification clinical trials. Intensive treatment, as practised in the Diabetes Control and Complications Trial (DCCT) and United Kingdom Prospective Diabetes Study (UKPDS), is now generally regarded as being cost effective, where health benefits can be obtained at a reasonable additional cost14The DCCT Research Group. Lifetime benefits and costs of intensive therapy as practiced in the DCCT. JAMA 1996; 276:1409-1415. 15Gray A, Raikou M, McGuire A, Fenn P, Stevens R, Cull C, et al. Cost effectiveness of an intensive blood glucose control policy in patients with type 2 diabetes: Economic analysis alongside randomised controlled trial (UKPDS 41). BMJ 2000; 320:1373-1378.. Emerging work from the Diabetes Prevention Program in the US gives promise to the economic benefit of preventing diabetes through lifestyle changes.
In the current healthcare environment, questions arise over the cost of self-care and diabetes education programmes and who will pay for it. While most evidence is encouraging regarding the economic benefits of diabetes education, the multi-faceted nature of self-management training and the team approach to diabetes care limits our ability to conclusively demonstrate its economic effect. As economic data provide effect to advocacy arguments, future evaluations of education interventions should seek to fully describe the associated economic costs and benefits.