Methods: Adult patients with diabetes were surveyed in 2 Chicago-area medical centers to elicit their preferences for diabetes treatments using time-trade-off techniques and actual treatment choices. Expected QALYs of actual and potential diabetic treatments were simulated using patients’ preferences using a diabetic progression model developed by the CDC. To assess the effect of education level on the actual benefits (i.e., the difference between the actual and worst treatment), the actual benefits were regressed on the ideal benefits (i.e., the difference between the ideal and worst treatment), education level, the interaction of ideal benefits with education level, and age, gender, race, income and insurance status, using generalized linear models (GLMs).
Results: 630 adult patients with diabetes had mean age of 62.2 (s.d. 13.5) years. 265 (42%) were females, 261 (41%) African American, 154 (24%) Hispanic. 183 (29%) patients did not graduate from high school. 124 (20%) had annual income less than $10,000, and 289 (46%) enrolled in Medicare. The expected QALYs if best treatment was adopted was 8.0 (s.d. 4.5), and the expected QALYs for actual treatment was 7.8 (s.d. 4.5). The average maximum potential benefits were 0.9 QALYs (s.d. 1.9), and actual benefits was 0.7 QALYs (s.d. 1.9). In GLMs, patients on average had 75.7% of their potential benefits of treatments realized given their preferences (p<0.001). However, the benefits realized varied with patient educational attainment: the interaction of less than a high school education with maximum benefits reduced average benefits by 5.2% (p=0.024), controlling age, gender, race, and other socioeconomic variables. In contrast, the direct effect of low educational attainment on average benefits only reduced average benefits 2.6% and was not statistically significant (p=0.655).
Conclusion: Lower educational attainment is associated with reduced benefits of diabetes treatment, with most or all of this effect related to reduced individualization of care. Efforts to better individualize care that target vulnerable patients may be especially valuable.