THE COST OF QUALITY-OF-CARE IMPROVEMENTS FOR DIABETES

Purpose: A national study demonstrated that U.S. adults receive on average only 55 percent of recommended medical care processes for the leading causes of death and disability. This considerable shortfall in health care quality has prompted renewed calls to improve care delivery. However, addressing the underuse of highly beneficial care has the potential to increase expenditures on physician visits, pharmaceuticals, and laboratory tests, which may temper policymakers’ and purchasers’ enthusiasm for action. Our objective was to estimate the cost of improving the delivery of certain basic care processes required by adults with Type 2 diabetes mellitus (DM), one of the most costly and prevalent medical conditions. Methods: We developed a deterministic decision model of physician visits, hemoglobin A1c tests, and medication adjustments that the American Diabetes Association (ADA) recommends to optimize blood glucose control. We used this model to calculate how expected costs vary with changes in adherence to recommended care across a hypothetical population of patients with new and established DM. Rates of adherence to recommended care were estimated from two consecutive years of medical-record data from the Community Quality Index (CQI) study. Costs of recommended physician visits and laboratory tests were based on the Medicare fee schedule, and medication costs and utilization patterns were based on pharmacy claims from large health plans in Massachusetts. Results: In the CQI study, 56% of adults with newly diagnosed DM received hemoglobin A1c tests and 89% had medications initiated when recommended. Across this population, increasing testing rates to 66% and 76% would increase expected costs by $3.66 and $7.32 per person per year, respectively. Increasing recommended medication initiation rates to 99% would cost $0.73. Among adults with established DM in the CQI study, 35% received hemoglobin A1c tests when recommended, and 67 to 78% had medications initiated or adjusted when recommended. Increasing testing rates to 45% and 55% would increase expected costs by $17.03 and $34.07, respectively. Increasing recommended medication initiation and adjustment rates to 77% to 88% would cost $0.85. Conclusion: Hemoglobin A1c testing should be a priority for quality improvement because rates are low and results influence the need for medication adjustment. Our study finds that per-patient costs involved in meeting ADA recommendations for laboratory testing and medication-related care for diabetic adults are relatively modest.