The cost of diabetes and its complications: a review

Diabetes mellitus is a disease with major long-term implications, not only for the health and well-being of affected individuals, but also for costs to the National Health Service. Treatment of the disease and its complications takes up to 4-5% of total health care expenditure in the UK. These costs are dominated by in-patient care for the complications arising from diabetes. This paper presents a review of studies which have been carried out on the costs of diabetes and its complications. For such a chronic and potentially disabling disease with numerous complications it is surprising that costs have not been more extensively researched. A large amount of data are available about the implications of diabetes in terms of incidence and prevalence, but few costs have been collected, particularly indirect and marginal costs. Moreover, researchers have frequently failed to distinguish between insulin dependent (IDDM) and non-insulin dependent (NIDDM) diabetes, which have different aetiologies and, therefore, different costs, and few studies have included diabetes as a secondary diagnosis. The studies which are available have tended to focus on direct costs, for example, the costs of hospital care, consultations and drugs, because they are the easiest to measure. Fewer studies have included indirect costs, such as the effect of time lost from work, early retirement and premature death, because of the difficulties in assigning monetary values to these factors. The most important contributors to the costs of diabetes are those of treating complications such as eye and limb disease, heart disease, neuropathy and nephropathy. Individual studies have assessed methods of treating complications such as end stage renal disease and lower limb problems. The effect of the disease on patient quality of life has not been assessed, nor have there been cost-effectiveness studies of diabetes. New advances in treatment, such as new monitoring methods for home glucose measurements, and laser treatment for neuropathy all have the potential to improve patient quality of life, but have yet to be evaluated. Primary interventions, for example dietary advice, and education, are inexpensive but are frequently less successful than secondary intervention which is aimed at preventing the development of diabetic complications.diabetes mellitus

Is there too much laboratory testing?

There is evidence that the numbers of diagnostic tests performed in hospital laboratories could be reduced without affecting outcomes to patients, and with significant concommitant reduction in costs. The concentration of testing in centralised laboratories located in larger hospitals, and the use of automated techniques, together with an increase in the types of tests available, have contributed to the large increase in test requests. This trend has been apparent for many years. There has been little, if any, control of test requests. Moreover, the patterns of requests for laboratory tests differ between physicians, which suggests that some tests are unnecessary. The methods which have been used to modify clinical behaviour fall into six categories: education, feedback, participation, peer review, financial incentives and administrative changes. It is concluded that no single method is effective and a combination of methods may be necessary depending on the situation. Whatever methods are adopted, they must be sustained for introducing test request reductions in hospitals. It is shown that increasing use of desk top analysers in general practice and hospital wards will only have a small impact on the numbers of tests requested. The NHS Review, which incorporates costing procedures for diagnostic tests, may cause a reduction in hospital test requests once their costs are known. Determining costs will itself be an expensive and time consuming process, but an inevitable product of information technology investments (e.g. The Resource Management Initiative).diagnotic tests, screening

Changing medical practice: a study of Reflotron use in general practice

This paper presents the results of a study of the use by two general practices of the Reflotron dry chemistry analyser. The Reflotron is a desk top system which can perform diagnostic tests using a drop of blood, for components such as haemoglobin, glucose and cholesterol, and produces results within minutes. The doctors and nurses who used the Reflotron gave generally favourable responses, and had found the equipment useful but not essential to practice organisation. They felt that patients would benefit most if the practices were able to purchase a Reflotron. The Reflotron was not used to a great extent during the study weeks. Blood samples requiring multiple tests, of which only some were available on the Reflotron, were likely to be sent to the hospital laboratory for all tests. The nurses had found the Reflotron particularly useful in antenatal and diabetic clinics and had continued to use it after the study had ended. The most useful tests were for haemoglobin, glucose and cholesterol, with electrolytes considered to be the most useful additional test. The 10% variation in comparative figures for some tests was viewed with concern, and it was felt that training of staff with emphasis on quality control was essential. Practices which as a result of the NHS Review, choose to control their own budgets could find the Reflotron a useful addition to their practice, but this would depend on the charging policy adopted by the laboratory for diagnostic tests, with GPs choosing the cheapest option.Reflotron

Medical technology in general practice in the UK: will fundholding make a difference?

This paper will concentrate on the use of technology in general practice rather than in primary care as a whole. The following items are discussed in turn: basic medical equipment, minor surgery, diagnostic technology and information technology. The results of a study of the use of fundholding surpluses to purchase equipment are described and, finally, in a discussion section, the major issues for the future are outlined.general practice, fundholding, technology

A stitch in time? Minor surgery in general practice

This paper describes a study of local evidence from 6 socioeconomically different areas of England about the development of minor surgery in general practice since the 1990 contract. The results are discussed in relation to a review of the literature on minor surgery in general practice. Evidence suggests that general practitioners in the study areas have taken up the minor surgery option with enthusiasm, indicated by the increased activity. Activity does, however, vary by area, with greater service provision being evident in the more affluent areas. Issues of concern remain, especially lack of appropriate skills and expertise, and research into the most effective teaching methods is urgently needed. Issues of quality and effectiveness have still to be addressed. Local audit is necessary to ensure that increased activity leads to improved patient care.minor surgery

Randomised cluster trial to support informed parental decision-making for the MMR vaccine

Background In the UK public concern about the safety of the combined measles, mumps and rubella [MMR] vaccine continues to impact on MMR coverage. Whilst the sharp decline in uptake has begun to level out, first and second dose uptake rates remain short of that required for population immunity. Furthermore, international research consistently shows that some parents lack confidence in making a decision about MMR vaccination for their children. Together, this work suggests that effective interventions are required to support parents to make informed decisions about MMR. This trial assessed the impact of a parent-centred, multi-component intervention (balanced information, group discussion, coaching exercise) on informed parental decision-making for MMR. Methods This was a two arm, cluster randomised trial. One hundred and forty two UK parents of children eligible for MMR vaccination were recruited from six primary healthcare centres and six childcare organisations. The intervention arm received an MMR information leaflet and participated in the intervention (parent meeting). The control arm received the leaflet only. The primary outcome was decisional conflict. Secondary outcomes were actual and intended MMR choice, knowledge, attitude, concern and necessity beliefs about MMR and anxiety. Results Decisional conflict decreased for both arms to a level where an 'effective' MMR decision could be made one-week (effect estimate = -0.54, p < 0.001) and three-months (effect estimate = -0.60, p < 0.001) post-intervention. There was no significant difference between arms (effect estimate = 0.07, p = 0.215). Heightened decisional conflict was evident for parents making the MMR decision for their first child (effect estimate = -0.25, p = 0.003), who were concerned (effect estimate = 0.07, p < 0.001), had less positive attitudes (effect estimate = -0.20, p < 0.001) yet stronger intentions (effect estimate = 0.09, p = 0.006). Significantly more parents in the intervention arm reported vaccinating their child (93% versus 73%, p = 0.04). Conclusions Whilst both the leaflet and the parent meeting reduced parents' decisional conflict, the parent meeting appeared to enable parents to act upon their decision leading to vaccination uptake

The costs of diabetes and its complications

Diabetes mellitus is a disease with major long-term implications, not only for the health and well-being of affected individuals, but also for costs to the National Health Service. Treatment of the disease and its complications takes up 4-5% of total health care expenditure in the U.K. These costs are dominated by in-patient care for the complications arising from diabetes. This paper presents a review of studies which have been carried out on the costs of diabetes and its complications. For such a chronic and potentially disabling disease with numerous complications it is surprising that costs have not been more extensively researched. A large amount of data are available about the implications of diabetes in terms of incidence and prevalence, but few costs have been collected, particularly indirect and marginal costs. Both insulin dependent (IDDM) and non-insulin dependent (NIDDM) diabetic patients exhibit similar complications so that the cost of treatment may be comparable, but further studies are needed to establish this. In addition, few studies have included diabetes as a secondary diagnosis. The studies which are available have tended to focus on direct costs, for example, the costs of hospital care, consultations and drugs, because they are the easiest to measure. Fewer studies have included indirect costs, such as the effect of time lost from work, early retirement and premature death, because of the difficulties in assigning monetary values to these factors. The most important contributors to the costs of diabetes are those of treating complications such as eye and limb disease, heart disease, neuropathy and nephropathy. Individual studies have assessed methods of treating complications such as end stage renal disease and lower limb problems. New advances in treatment, such as new monitoring methods for home glucose measurements, and laser treatment for neuropathy all have the potential to improve patient quality of life, but have yet to be evaluated. Primary interventions, for example dietary advice, and education, are inexpensive but are frequently less successful than secondary intervention which is aimed at preventing the development of diabetic complications.diabetes costs complications treatment