CHILDHOOD DIABETES WHAT IS THE WAY FORWARD? - July 21, 2013 Keystone, Colorado Robert H. Slover MD

CHILDHOOD DIABETES
WHAT IS THE WAY FORWARD?

         July 21, 2013
      Keystone, Colorado

     Robert H. Slover MD

Challenges
1. Type 1 diabetes is increasing in the population
2. Type 2 diabetes is increasing also, and notably amongst
    teens
3. Diabetes care is education intense, requires an array of
   specialists, and is expensive
4. Diabetes care, however, is inadequately funded, with
   large blocks of necessary care completely unfunded
5. Emerging technology offers opportunities for improved
   outcomes, but adds to the expense and complexity of
   care
6. There is a paucity of trained clinical diabetes specialists
7. Diabetes has a large and growing economic impact on
   society

Type 1 Diabetes is increasing
in incidence worldwide, and
the age of onset may be moving
toward younger aged children

“…Type 1 diabetes is an autoimmune disease the
  accounts for approximately 5% of US diabetes cases.
  Ominously, the greatest increase (in onset of Type 1
  diabetes) occurred in the youngest children, with
  new cases projected to double in European children
  younger than five years and increase by 70% in those
  younger than 15 between 2005 and 2020.”

Judith Fradkin, MD
Director of the Division of Diabetes, Endocrinology, and Metabolic Diseases, NIDDK
Confronting the Urgent Challenge of Diabetes: An Overview

Health Affairs 31 (2012):12‐19

Type 2 Diabetes in increasing in the population,
  and notably is increasing in adolescents.

  – >8% of the US population is currently affected
    with T2D
  – It is estimated that >20% will be affected by 2050.
  – T2D has a disproportionate impact on the poor
    and minorities
  – This represents a significant public health crisis

Economic Impact of Diabetes in 2012
           in the USA
Total Cost                            $245 billion
Direct Cost                           $176 billion
Reduced Productivity                   $69 billion

Direct Costs:
       Inpatient care                       43%
       Drugs to treat complications         18%
       Antidiabetic drugs/supplies          12%
       Office Visits                         9%
       Residential Care                      8%

The Cost of Diabetes
• 2007‐Total estimated costs $174 billion
  – $116 billion in medical expenditure
  – $58 billion in lost productivity
  – 59% of medical expenditures was inpatient
    hospitalization and physician visits
  – $1 in $5 spent on Diabetes in the United States is
    spent on taking care of someone with diabetes
  – About 157,000 (0.2% of US population

The Cost of Diabetes
• 2012 –Total estimated costs $254 billion (41%
  increase)
  – $176 billion in medical expenditure
  – $69 billion in lost productivity
  – 52% of medical expenditure was inpatient
    hospitalization and physician visits
  – $1 in $5 spent on diabetes in United States is
    spent on taking care of someone with diabetes
  – 189,000 children ages 0‐20 with diabetes, 168,000
    with type 1 diabetes

“People with diagnosed diabetes, on average,
  have medical expenditures approximately 2.3
  times higher than what expenditures would
  be in the absence of diabetes.”

American Diabetes Association Statement
Diabetes Care 36 (April 2013): 36: 1033‐46

How much does Type 1 Diabetes
              cost?
Three phases:

  1. First – Onset; Higher costs
  2. Second – Early years without complications; Lower costs
  3. Third – Later years with complications; Much higher costs

  In the pediatric population we bear the costs of onset
  and education, as well as the costs of therapy and
  prevention or treatment of early complications, but
  only rarely the high costs of complications.

Direct Costs in T1D Texas study of 784 patients

‐ 7% of costs are from diabetes related
   complications (excludes new onset admissions
   and education)
‐ Direct cost per person year           $4730

     Supplies                        38%
     Medication                      33%

Texas Study (continued)
‐ Factors associated with higher costs in T1D
      Older age
      HbA1C >8.5%
      Technology (pumps, sensors)
      Female
      Living in a single‐parent household

‐ Factors associated with hospitalization in T1D
      HbA1C >8.5%
      Female

 Conclusion: Improved metabolic control and stable two‐parent
          households lower direct medical costs in T1D.

   Ying AK et al.,Predictors of direct costs of diabetes care in pediatric patients with type 1 diabetes.
   Pediatric Diabetes 2011, 12: 177‐182

Cost of Type 1 Diabetes in the USA
• Use of a propensity score matching system to estimate
  annual and lifetime direct and indirect costs for T1D
• T1D costs $14.4 billion annually in direct and indirect
  costs
• T1D patients incur a disproportionate share of T1D +
  T2D costs
• If T1D were eliminated, lifetime cost savings would be
  $422.9 billion for existing patients and another $10.6
  billion for new cohort each year.

  Tao B, Petropaolo M, Atkinson M, Schatz D, Taylor D. Estimating the Cost of type 1
  Diabetes in the US: A Propensity Score Matching Method. PloS One (July 2010):
  Vol 5 Issue 7, e11501

Table 11. Summary of estimated costs attributable to T1D (2005 dollars).a

Tao B, Pietropaolo M, Atkinson M, Schatz D, et al. (2010) Estimating the Cost of Type 1 Diabetes in the U.S.: A Propensity Score Matching
Method. PLoS ONE 5(7): e11501. doi:10.1371/journal.pone.0011501
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0011501

Glycemic Control: effect on short‐
              terms costs
• A 1% increase in HbA1C leads to:
     6% increase in cost for Type 1 Diabetes
     4.4% increase in cost for Type 2 Diabetes

  Aargen M and Wenli L. Association between glycemic control and short‐term
  healthcare costs among commercially insured diabetes patients in the United Statds.
  Journal of Medical Economics 2011: Vol 14 No 1, 109‐114

So where are we?
• Diabetes in childhood and adolescence is increasing.
• Both Type 1 and Type 2 Diabetes have a have a large
  and growing impact on our economy and health care
  system. Even now, up to 1 in every 5 health care
  dollars in the USA is spent on diabetes care.
• Improved metabolic control can reduce short term and
  long term costs, but –
• Who will deliver the care?
• Who will pay for time‐consuming education, social and
  psychological support, and technology that at present
  holds the promise of allowing tight metabolic control?

Is diabetes education cost effective?
2009 meta‐analysis reviewed 23 studies of this question from a
literature review of 609 articles
 – 18 showed cost effectiveness
 – 4 were cost neutral
 – 1 showed cost ineffectiveness

None was specifically based on the AADE’s 7 self‐care education
requirements: healthy eating, being active, monitoring, taking
medication, problem solving, healthy coping, and reducing risks.

Only one study specifically addressed adolescents, and none
addressed younger children.

Boren S, et al. Costs and Benefits Associated with Diabetes Education: A Review of the
Literature. 2009: The Diabetes Educator 35: 72‐96.

Should new onset education be done
         in the hospital?
 ‐ One year randomized trial of 84 non‐urgent new onset patients at
 Baystate Children’s Hospital
 ‐ No significant difference in metabolic outcomes at one year
 ‐ Cost for first year of patients educated in hospital $12,332
 ‐ Cost for first year of patients educated as outpatients
   $5,053
 ‐ Physician costs were not significantly different

 Conclusion: In non critically‐ill children there is no
 metabolic advantage to be gained by more expensive
 inpatient education.

 Jasinski CF et al. Heathcare cost of type 1 diabetes mellitus in new‐onset children in a hospital compared
 to an outpatient setting. 2013: BMC Pediatrics 13:55‐65.

BUT…

Will insurers reimburse outpatient
education as well as they reimburse
hospitalization with education?

Will hospitals be as willing to support
outpatient education programs, given the
loss of inpatient revenue?

Who Pays?
1. National Health Care programs
2. Government funded programs (Federal and
   state)
3. Private insurance with member premiums and
   co‐pays
4. Public institutions – federal and state related
   hospitals and clinics, medical schools and
   universities
5. Private foundations
6. Philanthropy
7. Individual families

Patients seen in Pediatrics at the Barbara Davis Center
                    June 2011 – June 2013

 T1D                  3285      New Onset Patients
 T2D                   73
 MODY                  15      2011               375
 Neonatal               3
 CFRD                   50     2012               391
 Secondary              33
 Other (incl R/O)      158     2013 (projected)   415

At the Pediatric Clinic at the Barbara Davis Center
for Diabetes 65% of the cost of providing clinical
care comes from clinical income.

The remaining 35% is funded by physician
research funds (the majority of our faculty
support much of their own salary through
research grants), philanthropy (Children’s
Diabetes Foundation, CU Foundation, Children’s
Hospital Foundation, and private donations), and
Children’s Hospital support.

Telehealth
Short‐term studies from Denmark and the
Barbara Davis Center after initiation of telehealth
agree in showing:
– No deterioration in A1C, and in individual cases,
  improvement
– Extremely high patient satisfaction
– Significant reduction in lost work and school time and
  reduction in travel costs (addressing the indirect
  costs of diabetes)
– Reimbursement is not significantly different from in‐
  person clinic visits

RECOMMENDATIONS
1.    Improve metabolic control to improve outcome and
     reduce stage 3 costs.

2. Provide outpatient new onset education for non‐critically
   ill patients.

3. Lobby for improved funding for diabetes education,
   psycho‐social support, use of advanced technology,
   including reimbursement for the large amount of time
   spent in providing support by telephone and email.

4. Reduce stage 1 costs by vigorous professional and
   community educational programs to reduce DKA by early
   recognition of the signs and symptoms of diabetes.

RECOMMENDATIONS
5. Tie the judicious use of technology to patient compliance.

6. Telehealth and other outreach means of increasing the
   impact of trained diabetes providers in larger geographic
   areas

7. Create new ways to see patients to increase effectiveness
   of education and care (Example – shared appointment
   visits)

8. Focus the skills of diabetologists and other trained
   diabetes professionals on creating educational programs
   to teach the physicians, nurses, and dieticians that
   actually see most of the children with diabetes:
   workshops, seminars, educational conferences

Thank you
Questions?