OBJECTIVE -Cost-utility analyses use information on health utilities to compare medical treatments that have different clinical outcomes and impacts on survival. The purpose of this study was to describe the health utilities associated with diabetes and its treatments, complications, and comorbidities.RESEARCH DESIGN AND METHODS -We studied 2,048 subjects with type 1 and type 2 diabetes recruited from specialty clinics at a university medical center. We administered a questionnaire to each individual to assess demographic characteristics, type and duration of diabetes, treatments, complications, and comorbidities, and we used the Self-Administered Quality of Well Being index (QWB-SA) to calculate a health utility score. We then created regression models to fit the QWB-SA-derived health utility scores to indicator variables for type 1 and type 2 diabetes and each demographic variable, treatment, and complication. The coefficients were arranged in clinically meaningful ways to develop models to describe penalties from the health utility scores for nonobese diabetic men without additional treatments, complications, or comorbidities.RESULTS -The utility scores for nonobese diet-controlled men and women with type 2 diabetes and no microvascular, neuropathic, or cardiovascular complications were 0.69 and 0.65, respectively. The utility scores for men and women with type 1 diabetes and no complications were slightly lower (0.67 and 0.64, respectively). Blindness, dialysis, symptomatic neuropathy, foot ulcers, amputation, debilitating stroke, and congestive heart failure were associated with lower utility scores.CONCLUSIONS -Major diabetes complications are associated with worse health-related quality of life. The health utility scores provided should facilitate studies of the health burden of diabetes and the cost-utility of alternative strategies for the prevention and treatment of diabetes.

OBJECTIVE -To compare the efficacy and safety of continuous subcutaneous insulin infusion (CSII) and multiple daily injection (MDI) in older adults with insulin-treated type 2 diabetes and to assess treatment satisfaction and quality of life.RESEARCH DESIGN AND METHODS -Adults (n ϭ 107) Ն60 years of age (mean age 66 years) with insulin-treated type 2 diabetes (mean duration 16 years, BMI 32 kg/m 2 , and HbA 1C [A1C] 8.2%) were randomized to CSII (using insulin lispro) or MDI (using insulin lispro and insulin glargine) in a two-center, 12-month, prospective, randomized, controlled clinical trial. Efficacy was assessed with A1C, safety by frequency of hypoglycemia, and treatment satisfaction and quality of life with the Diabetes Quality of Life Clinical Trial Questionnaire and the 36-item short-form health survey, version 2.RESULTS -Forty-eight CSII subjects (91%) and 50 MDI subjects (93%) completed the study. Mean A1C fell by 1.7 Ϯ 1.0% in the CSII group to 6.6% and by 1.6 Ϯ 1.2% in the MDI group to 6.4%. The difference in A1C between treatment groups was not statistically significant (P ϭ 0.20). Eighty-one percent of CSII subjects and 90% of MDI subjects experienced at least one episode of minor (self-treated) hypoglycemia (P ϭ 0.17), and three CSII and six MDI subjects experienced severe hypoglycemia (P ϭ 0.49). Rates of severe hypoglycemia were similarly low in the two groups (CSII 0.08 and MDI 0.23 events per person-year, P ϭ 0.61). Weight gain did not differ between groups (P ϭ 0.70). Treatment satisfaction improved significantly with both CSII and MDI (P Ͻ 0.0001), and the difference between groups was not statistically significant (P ϭ 0.58).CONCLUSIONS -In older subjects with insulin-treated type 2 diabetes, both CSII and MDI achieved excellent glycemic control with good safety and patient satisfaction. Diabetes Care 28:1568 -1573, 2005I n the U.S., Ͼ20% of adults Ͼ65 years of age have diabetes (1). The risk of micro-and macrovascular complications increases in elderly patients with diabetes and is associated with higher hemoglobin HbA 1C (A1C) and longer duration of diabetes (2). In middle-aged adults with type 2 diabetes, intensive glycemic management can delay or prevent the development of microvascular and neuropathic complications (3,4). While the benefits of glycemic management are less clearly established in older adults, both the American Diabetes Association and the American Geriatrics Society recommend that older adults with good functional status maintain A1C levels Ͻ7% (5,6). Despite these recommendations, surveys have shown that only onethird of diabetic patients 65-74 years of age had A1C levels Ͻ7%. Of those using insulin, only 27% had A1C levels Ͻ7%, whereas nearly half had A1Cs Ͼ8% (7).While lifestyle changes and oral antidiabetes medications can improve glycemic control early in the course of type 2 diabetes, insulin is often required to reach A1C goals later in the course of disease. Intensive insulin therapy regimens employ either continuous subcutaneous insulin infusion (CSII) or mul...

OBJECTIVE -To describe the direct medical costs associated with type 2 diabetes, as well as its treatments, complications, and comorbidities.RESEARCH DESIGN AND METHODS -We studied a random sample of 1,364 subjects with type 2 diabetes who were members of a Michigan health maintenance organization. Demographic characteristics, duration of diabetes, diabetes treatments, glycemic control, complications, and comorbidities were assessed by surveys and medical chart reviews. Annual resource utilization and costs were assessed using health insurance claims. The log-transformed annual direct medical costs were fitted by multiple linear regression to indicator variables for demographics, treatments, glycemic control, complications, and comorbidities.RESULTS -The median annual direct medical costs for subjects with diet-controlled type 2 diabetes, BMI 30 kg/m 2 , and no microvascular, neuropathic, or cardiovascular complications were $1,700 for white men and $2,100 for white women. A 10-kg/m 2 increase in BMI, treatment with oral antidiabetic or antihypertensive agents, diabetic kidney disease, cerebrovascular disease, and peripheral vascular disease were each associated with 10 -30% increases in cost. Insulin treatment, angina, and MI were each associated with 60 -90% increases in cost. Dialysis was associated with an 11-fold increase in cost. T he worldwide prevalence of diabetes is increasing (1), as is the demand for and cost of medical care (2). Many studies have described the economic impact diabetes has on the health system and society (3-6) and have compared the health care utilization of patients with and without diabetes (7-10). Only a few studies have assessed the relationship between patient characteristics, complications, and costs using patientlevel data (11-16) and most have examined the relationship for aggregated end points (12,13,15,16). The purpose of this study was to describe the relationship between direct medical costs and individual demographic characteristics, treatments, glycemic control, complications, cardiovascular risk factors, and comorbidities in patients with type 2 diabetes. CONCLUSIONSPrevious models have assigned costs to specific diabetes-related health states (17)(18)(19)(20). This approach is most appropriate for acute health states where interactions with other conditions are absent or clearly identifiable and of limited duration (21). A complex chronic disease like diabetes impacts many other apparently unrelated health problems and the resources used in their treatment. Therefore, it is important to extend the scope of a cost model beyond the direct complications of diabetes to include total direct medical costs. Only in this way can the true economic burden of diabetes be assessed. RESEARCH DESIGN AND METHODS -The study was reviewed and approved by the University of Michigan Institutional Review Board. All subjects were enrolled in commercial, Medicare, or Medicaid managed care programs offered by a large Michigan health maintenance organization (HMO). Subjects thus represented ...

OBJECTIVE -Since 1997, the American Diabetes Association has recommended that nondiabetic individuals Ն45 years of age be screened for diabetes at least every 3 years. We sought to characterize the frequency, methods, and results of diabetes screening in routine clinical practice.RESEARCH DESIGN AND METHODS -We studied opportunistic screening in nondiabetic members of a health maintenance organization Ն45 years of age who were assigned to a large, integrated, academic health care delivery system. Screening was defined as the first glucose, HbA 1c , or oral glucose tolerance test (OGTT) performed between 1 January 1998 and 31 December 2000. Chart review was performed to determine the prevalence of diabetes risk factors and to describe follow-up.RESULTS -Of 8,286 nondiabetic patients Ն45 years of age, 69% (n ϭ 5,752) were screened. The frequency of screening was greater in patients with one or more primary care visits and increased with age. Women were more likely to be screened than men, and patients with at least one diabetes risk factor were more likely to be screened than those without risk factors. Random plasma glucose was the most common screening test (95%). Four percent (n ϭ 202) of those screened had abnormal results. Only 38% (n ϭ 77) of those with abnormal results received appropriate follow-up, and 17% (n ϭ 35) were diagnosed with diabetes within 6 months of screening. The yield of screening was very low (0.6%, 35 of 5,752).CONCLUSIONS -Despite frequent screening and appropriate targeting of high-risk patients, follow-up of patients with abnormal results is uncommon and the yield of screening is low. Interventions are needed to help physicians recognize and provide appropriate follow-up for patients with potentially abnormal random glucose levels. Diabetes Care 27:9 -12, 2004I n 2001, 16.7 million Americans were diagnosed with diabetes (1). Unfortunately, ϳ5.4 million Americans with diabetes remained undiagnosed (2). In 1997, the American Diabetes Association (ADA) Expert Committee on the Diagnosis and Classification of Diabetes Mellitus recommended that all nondiabetic individuals Ն45 years of age be screened for diabetes at 3-year intervals as a part of their routine medical care (opportunistic screening). The ADA recommended that screening be performed with either fasting plasma glucose levels or oral glucose tolerance tests (OGTTs) (3). Currently, under the direction of Secretary of Health and Human Services Tommy Thompson, a consortium of federal agencies is exploring the feasibility of a major new "detection initiative" to find the 5.4 million Americans with undiagnosed diabetes.Support for diabetes screening is not based on randomized, controlled clinical trials but on observational data. Analyses of mass screening programs in the former East Germany found that people diagnosed with diabetes as a result of screening had better outcomes than those presenting spontaneously with diabetes (4). More recently, support for screening has come from the U.K. Prospective Diabetes Study, which demonstrated...

These findings suggest that most women with gestational diabetes mellitus are not screened for type 2 DM after delivery. Opportunities for DM prevention and early treatment are being missed.

ObjectivesMost Americans see dentists at least once a year. Chair‐side screening and referral may improve diagnosis of prediabetes and diabetes. In this study, we developed a multivariate model to screen for dysglycemia (prediabetes and diabetes defined as HbA1c ≥5.7 percent) using information readily available to dentists and assessed the prevalence of dysglycemia in general dental practices.MethodsWe recruited 1,033 adults ≥30 years of age without histories of diabetes from 13 general dental practices. A sample of 181 participants selected on the basis of random capillary glucose levels and periodontal status underwent definitive diagnostic testing with hemoglobin A1c. Logistic models were fit to identify risk factors for dysglycemia, and sample weights were applied to estimate the prevalence of dysglycemia in the population ≥30 years of age.ResultsIndividuals at high risk for dysglycemia could be identified using a questionnaire that assessed sex, history of hypertension, history of dyslipidemia, history of lost teeth, and either self‐reported body mass index ≥35 kg/m2 (severe obesity) or random capillary glucose ≥110 mg/dl. We estimate that 30 percent of patients ≥30 years of age seen in these general dental practices had dysglycemia.ConclusionsThere is a substantial burden of dysglycemia in patients seen in general dental practices. Simple chair‐side screening for dysglycemia that includes or does not include fingerstick random capillary glucose testing can be used to rapidly identify high‐risk patients.Practical implicationsFurther studies are needed to demonstrate the acceptability, feasibility, effectiveness, and cost‐effectiveness of chair‐side screening.

OBJECTIVE -To evaluate the impact of systematic patient evaluation and patient and provider feedback on the processes and intermediate outcomes of diabetes care in Independent Practice Association model internal medicine practices.RESEARCH DESIGN AND METHODS -Nine practices providing care to managed care patients were randomly assigned as intervention or comparison sites. Intervention-site subjects had Annual Diabetes Assessment Program (ADAP) assessments (HbA 1c , blood pressure, lipids, smoking, retinal photos, urine microalbumin, and foot examination) at years 1 and 2. Comparison-site subjects had ADAP assessments at year 2. At Intervention sites, year 1 ADAP results were reviewed with subjects, mailed to providers, and incorporated into electronic medical records with guideline-generated suggestions for treatment and follow-up. Medical records were evaluated for both groups for the year before both the year 1 and year 2 ADAP assessments. Processes and intermediate outcomes were compared using linear and logistic mixed hierarchical models.RESULTS -Of 284 eligible subjects, 103 of 173 (60%) at the Intervention sites and 71 of 111 (64%) at the comparison sites participated; 83 of 103 (81%) of the intervention-site subjects returned for follow-up at year 2. Performance of the six recommended assessments improved in intervention-site subjects at year 2 compared with year 1 (5.8 vs. 4.3, P ϭ 0.0001) and compared with comparison-site subjects at year 2 (4.2, P ϭ 0.014). No significant changes were noted in intermediate outcomes. Shortcomings in self-management support, clinical information systems, and decision support contribute to suboptimal diabetes care in primary care (23). The Annual Diabetes Assessment Program (ADAP) was designed as a population-based program of evaluation and feedback to support diabetes clinical practice guidelines (24,25). During a 1-h focused encounter with nonphysician providers within the primary care setting, key diabetes and cardiovascular health parameters were measured and discussed with the patient by a certified diabetes educator. A tailored report with guidelinedriven recommendations for care (25) was then sent to the patient's primary care provider (PCP) and incorporated into the electronic medical record. We hypothesized that implementing the ADAP would improve processes and intermediate outcomes of diabetes care. CONCLUSIONSTo rigorously assess whether the ADAP would improve measures of diabetes care, we conducted a randomized, controlled clinical trial. RESEARCH DESIGN AND METHODS Clinical settingNine university-affiliated primary care internal medicine (IM) practices affiliated with a managed care organization (MCO) were paired by size and type and then randomly assigned as intervention or comparison sites. One unpaired practice was assigned as an intervention site. Most of the PCPs in the practices were working full-time and there were no residents in the practices. ParticipantsDiabetic members of the MCO who were aged Ն18 years and had been members for at least 1 year wer...

Summary Background Research on self-care for chronic disease has not examined time requirements. TRIAD, a multi-site study of managed care patients with diabetes, is among the first to assess self-care time. Objective To examine associations between socioeconomic position and extra time patients spend on foot care, shopping/cooking, and exercise due to diabetes. Data 11,927 patient surveys from 2000–01. Methods Bayesian two-part models were used to estimate associations of self-reported extra time spent on self-care with race/ethnicity, education, and income, controlling for demographic and clinical characteristics. Results Proportions of patients spending no extra time on foot care, shopping/cooking and exercise were respectively 37%, 52% and 31%. Extra time spent on foot care and shopping/cooking was greater among racial/ethnic minorities, less-educated and lower-income patients. For example, African-Americans were about 10 percentage points more likely to report spending extra time on foot care than whites and extra time spent was about three more minutes/day. Discussion Extra time spent on self-care was greater for socioeconomically disadvantaged patients than for advantaged patients, perhaps because their perceived opportunity cost of time is lower or they cannot afford substitutes. Our findings suggest that poorly controlled diabetes risk factors among disadvantaged populations may not be attributable to self-care practices.