Diabetes management saves lives, dollars

10-year study paves way for national programs

First, the Diabetes Control and Complications Trial (DCCT) showed clinical outcomes improved for patients who followed intensive regimens to keep blood glucose levels under control.1 Now, a new cost analysis of DCCT data makes the study’s findings even more significant, projecting billions of dollars in cost savings if the intensive regimen is practiced by the nation’s insulin-dependent diabetics.

The DCCT, which was sponsored by the National Institute of Digestive Disorders, Diabetes, and Kidney Disease in Bethesda, MD, indicated that a comprehensive treatment regimen including flexible adjustment of insulin dose and frequent blood glucose monitoring was more effective than less-aggressive, conventional treatment. Blood glucose levels were much lower with the intensive method than with the conventional method of treatment, and patients on intensive therapy had fewer problems such as retinopathy, neuropathy, and end-stage renal disease (ESRD).2 The DCCT took place from 1983 to 1993.

"There have been lots of arguments that diabetes control — that is, diabetes management aimed at achieving normal glucose levels — would decrease complications," says David M. Nathan, MD, director of the Diabetes Research Center and Clinic at Massachusetts General Hospital in Boston and one of the lead investigators of the trial. "But until the DCCT published its results, there had really been no study that had demonstrated with any kind of confidence that this was the case. It demonstrated a 50% to 75% reduction in retinopathy, nephropathy, and neuropathy."

More than 100,000 diabetics eligible

The more recent analysis of the study’s results indicates that the lifetime benefits and costs of intensive therapy not only improve health and save lives, but could save billions of dollars if implemented on a broad scale. If the 120,000 diabetics in the United States who meet the eligibility criteria for intensive therapy received it, there would be a gain of 920,000 years of sight, 691,000 years free from ESRD, 678,000 years free from lower extremity amputation, and 611,000 years of life. The total cost savings would be $4 billion over the lifetime of the population, and the incremental cost per year of life gained would be $28,661.

"The take-home message of this analysis is that the long-term economic impact of intensive therapy of diabetes is such that it represents a pretty reasonable bargain," says Nathan. "This therapy does cost something over the lifetime of the patients, but it’s the same kind of investment we put into many other diseases . . . such as hypertension. But with this, you’re talking about saving people’s feet and vision and kidney function."

Nathan says too many diabetes programs focus on measuring problems as they develop rather than preventing them in the first place. For example, checking urinary albumin levels and other regular monitoring are a necessary part of treating diabetes, he says. But by keeping patients’ blood glucose levels under control, many problems simply are avoided in the first place.

"To the extent that you measure [albumin levels], you can tell the person when they’re getting kidney disease and when they’ll need dialysis. What’s much more important is the lesson from DCCT — that [nephropathy] can be decreased by a minimum of 50%," he explains.

The DCCT involved having patients measure their blood glucose levels at least four times daily, with insulin taken either by injection (three or more daily) or via continuous subcutaneous infusion. (See related article on study comparing the two insulin regimens, p. 7.) Nathan admits that is a more cost-intensive regimen than conventional therapy, which usually requires patients to check their blood glucose levels only two or three times a day and to take two insulin injections.

"Diabetes treatment is not cheap," he notes. "The average cost is somewhere between $1,500 and $1,700 a year per person. If you add this intensive therapy, it increases to $3,500 to $4,000 per year. But you have to look at the overall lifetime cost savings associated with intensive therapy when considering those costs."

Regimen includes frequent monitoring

Sue Crowell, RN, BSN, research nurse coordinator at the Diabetes Research Center, says this is the intensive regimen used at the facility for adult diabetics, based on the DCCT:

• New patients receive a half day of education on blood glucose monitoring, insulin administration, and diet. Patients are allowed to choose between an insulin pump or multiple injections.

• Patients are instructed to check their blood glucose levels at least four times a day: before meals and at bedtime. Postprandial and 3 a.m. monitoring can be added as needed.

"If we’re instituting changes in their regimen — changing their insulin type or adding an injection — I’d have them increase their monitoring to include post-meal blood sugars and a 3 a.m. blood sugar, especially if they’re having lows during the night," Crowell explains. "But generally, I don’t have patients do a 3 a.m. blood sugar if it’s in an acceptable range and they’re not experiencing frequent hypoglycemia during the night."

• Patients with recurrent, severe hypoglycemia and high HbA1c levels may need to have their blood glucose target levels modified by decreasing their insulin doses.

"When someone starts on an intensive regimen, generally the goal is to get the blood sugars within as normal a range as possible — 70 to 120 before meals, less than 180 two hours after a meal, and less than 140 an hour after a meal," Crowell explains. "Some patients have severe hypoglycemia with that [target level]."

• Nutrition counseling is done at the first visit, then a month afterward, and then quarterly, as needed.

"It depends on what the patient wants to do," Crowell explains. "If they really want to do carbohydrate counting, that would require several visits to the nutritionist."

• A team of clinicians works together to treat patients comprised of two nurses, two nutritionists, and two endocrinologists.

"There really needs to be a team approach," she notes. "I think you run into trouble if you set this up as an assembly line. The patient goes to see the nutritionist and then the nurse, and there’s not a whole lot of communication other than what’s written in the record."

References

1. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New Engl J Med 1993; 329:977-986.

2. The Diabetes Control and Complications Trial Research Group. Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial. JAMA 1996; 276:1,409-1,415.