|
 |
|
|||||||
|
|||||||||
© 2003 by the American Diabetes Association, Inc.
Epidemiology/Health Services/Psychosocial Research |
The Direct Medical Cost of Type 2 Diabetes
1 Division of Endocrinology & Metabolism, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
2 Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
3 Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
4 Michigan Diabetes Research and Training Center, University of Michigan, Ann Arbor, Michigan
Address correspondence and reprint requests to William H. Herman, University of Michigan Health System, Division of Endocrinology and Metabolism, 1500 East Medical Center Dr., 3920 Taubman Center, Ann Arbor, MI 48109-0354. E-mail: wherman{at}umich.edu
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONRESEARCH DESIGN AND METHODSRESULTSCONCLUSIONSReferences |
|---|
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/m2, and no microvascular, neuropathic, or cardiovascular complications were $1,700 for white men and $2,100 for white women. A 10-kg/m2 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.
CONCLUSIONS—Insulin treatment and diabetes complications have a substantial impact on the direct medical costs of type 2 diabetes. The estimates presented in this model may be used to analyze the cost-effectiveness of interventions for type 2 diabetes.
Abbreviations: CPT, current procedural terminology • DRG, diagnosis-related group • ESRD, end-stage renal disease • HMO, health maintenance organization • IQR, interquartile range • MI, myocardial infarction
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONRESEARCH DESIGN AND METHODSRESULTSCONCLUSIONSReferences |
|---|
The 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 patient-level 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.
Previous models have assigned costs to specific diabetes-related health states (17–20). 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 |
|---|
|
TOPABSTRACTINTRODUCTIONRESEARCH DESIGN AND METHODSRESULTSCONCLUSIONSReferences |
|---|
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 the employed, elderly, poor, and disabled population of southeastern Michigan. Eligible subjects had diabetes and were
18 years of age, nonpregnant, community-dwelling, continuously enrolled in the health plan for at least 18 months, had at least one claim for health services, and were able to give informed consent and to respond to a survey in English or Spanish. Type 2 diabetes was defined as diabetes with onset before 30 years of age without current insulin treatment or onset after 30 years of age with or without current insulin treatment. A patient survey, administered either by computer-assisted telephone interview or in writing, and medical record abstraction were used to assess demographic characteristics, diabetes treatments, glycemic control, complications, and comorbidities (22). Demographic variables included age, sex, race, age at onset of diabetes, duration of diabetes, BMI, household income, and education. Disease state variables included diabetes treatment, HbA1c, retinopathy, nephropathy, neuropathy, cerebrovascular disease, cardiovascular disease, peripheral vascular disease, hypertension, hypercholesterolemia, and cigarette smoking. Subjects were surveyed from April 2000 through February 2001. The survey response rate was 67%, and chart review data were available for 89% of respondents. Medians and 25th and 75th interquartile ranges (IQRs) were reported for continuous variables, and frequencies and proportions were reported for categorical variables.
Medical encounter and/or claims data were obtained from the HMO to describe total direct medical costs including inpatient, outpatient, laboratory, and pharmacy utilization for each subject over the year immediately preceding the subjects’ interview. Costs reflect the HMO’s (or in the case of end-stage renal disease [ESRD], Medicare’s) contracted payment or reimbursement rates and represent total direct medical costs from the perspective of a large health system. Patient copayments and deductibles were not included in the total direct medical costs. We estimate that these accounted for 
5% of total direct medical costs. Since costs were not normally distributed, they were transformed to log10 costs. Costs were expressed in year 2000 U.S. dollars.
The transformed annual direct medical costs were fitted by a multiple linear regression model to demographic and disease state variables. Since the group treated with oral antidiabetic medications was the largest diabetes treatment group (n = 830), we used it as the reference group in the model fitting process. After the best model was determined, we reran the final model so that the group treated with diet or exercise only was the reference group. This did not affect the estimated costs produced by the model. Variables with multiple categories were represented by indicator variables. In the fitting process, all variables were initially entered into the regression model and all possible two-way interactions were examined. The estimates of the variables were computed and correlation among variables, different levels of variables, and interactions were noted. The model-fitting process was repeated using a backward stepwise deletion with a constraint that the ordering of all variable coefficients increased in severity within a disease status category such as nephropathy (e.g., the ordering of coefficients for nephropathy increased in severity from microalbuminuria to proteinuria to ESRD with dialysis). When coefficients did not increase with severity, the levels that had inconsistent orderings were collapsed into one level. Because our primary interest was to model annual direct medical costs as a function of a wide range of demographic characteristics, treatments, and complications, all variables ordered in increasing severity were kept in the model regardless of P value. The coefficients were then transformed back to the original scale in the form of multipliers. Therefore, to calculate cost in dollars for any subject, the annual direct medical cost for diet-controlled white male subjects with BMI of 30 kg/m2, and without microvascular, neuropathic, or cardiovascular complications, is multiplied by the multiplicative factors for each of the characteristics, treatments, and complications for that subject. The multiplicative coefficients of the indicator variables represent the cost factor associated with each variable.
Annual direct medical costs associated with incident stroke, myocardial infarction (MI), and amputation were assessed by studying medical encounter and claims data for all members with diabetes who experienced such events from 1 January 1997 to 31 January 2001. Subjects with acute events were identified by diagnosis-related group (DRG) or current procedural terminology (CPT) codes. Direct medical costs were assessed for 1 year after the onset of the acute event.
All statistical analyses were performed using SAS software version 8.0 (SAS Institute, Cary, NC).
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONRESEARCH DESIGN AND METHODSRESULTSCONCLUSIONSReferences |
|---|
The characteristics of the 1,364 subjects with type 2 diabetes are presented in Table 1. The median age was 66 years and the median duration of diabetes was 8 years. More than 50% of the subjects were obese (BMI
30 kg/m2). Five percent of subjects were treated with diet and/or exercise alone, >60% with oral antidiabetic medications, and about a third with insulin.
|
The costs associated with each demographic characteristic and complication are presented in Table 2. The baseline cost of $1,684 can be interpreted as the median annual direct medical cost for a white man with diet-controlled type 2 diabetes and BMI of 30 kg/m2 and no microvascular, neuropathic, or cardiovascular risk factors or complications. If a subject has any of the characteristics or complications listed in Table 2, the annual direct medical cost is then estimated by the product of the baseline cost and the multipliers corresponding to each of the subject’s characteristics or complications. In each disease status category, only the multiplier associated with the most severe level of a complication is used in the calculation. The median annual direct medical cost for a white woman with diet-controlled type 2 diabetes and BMI of 30 kg/m2 is 1.25 times that of a white man ($2,105). The median annual direct medical cost for an African-American man with type 2 diabetes is 82% the cost of a white man ($1,380). For a white man with type 2 diabetes and a BMI of 35 kg/m2, the baseline direct medical cost is multiplied by 1.015 or 1.05 ($1,770). Subjects who are treated with oral antidiabetic or antihypertensive agents or experience microalbuminuria, proteinuria, cerebrovascular disease, or peripheral vascular disease have 1.10–1.31 times the median annual direct medical costs for each treatment or complication experienced. Subjects who are treated with insulin or experience angina or MI have 1.59–1.90 times the cost for each treatment or complication experienced. Subjects with ESRD treated with dialysis have 10.53 times the cost. For example, the median annual direct medical cost for a white man with BMI of 38 kg/m2, insulin- treated type 2 diabetes, treated high blood pressure, microalbuminuria, history of MI, and peripheral vascular disease is $10,500 ($1,684 x 1.018 x 1.59 x 1.24 x 1.17 x 1.90 x 1.31).
|
Age, duration of diabetes, HbA1c, education, household income, smoking, hypercholesterolemia, retinopathy, neuropathy, and history of amputation were not associated with significant increases in annual direct medical costs after including the factors in the model and were excluded from the final model. As presented, the final model accounts for about one-fifth of the total variance in cost (R2 = 0.205).
Table 3 shows the annual direct medical costs for incident stroke, MI, and amputation. The median direct medical costs for 1 year after the onset of stroke, acute MI, and amputation were $27,000, $25,000, and $38,000, respectively.
|
|
CONCLUSIONS |
|---|
|
TOPABSTRACTINTRODUCTIONRESEARCH DESIGN AND METHODSRESULTSCONCLUSIONSReferences |
|---|
Our economic model describes the annual direct medical cost of type 2 diabetes by demographic characteristics, treatments, and complications. The annual direct medical costs for white men and women with diet-controlled type 2 diabetes and BMI of 30 kg/m2 and no microvascular, neuropathic, or cardiovascular complications are $1,700 and $2,100, respectively. Although other studies have reported higher annual direct medical costs for subjects with type 2 diabetes and no macrovascular complications ($2,800–$4,600), they did not adjust for subject characteristics, treatments, or microvascular complications (13,14,23). Most subjects in our study were overweight, 95% received medications for diabetes, one-third were treated for high blood pressure, and about one-fifth had diabetic kidney disease (Table 1). The annual direct medical cost for a white woman with a BMI of 34 kg/m2 who is treated with oral antidiabetic and antihypertensive medications and has microalbuminuria is $3,500 ($1,684 x 1.25 x 1.014 x 1.10 x 1.24 x 1.17). Application of these multiplicative factors to the baseline cost results in a total annual direct medical cost similar to that reported by others.
The average annual Medicare payment for ESRD with diabetes as primary cause has been reported to be $63,100 (24). Subjects with ESRD suffer from many diabetic complications and comorbidities. Our model suggests that the annual direct medical cost for a white woman with insulin-treated type 2 diabetes, treated high blood pressure, ESRD treated with dialysis, and peripheral vascular disease is $57,200 ($1,684 x 1.25 x 1.59 x 1.24 x 10.53 x 1.31), similar to the cost reported by Medicare.
Our final model explained 20.5% of the variance in annual direct medical costs of subjects with type 2 diabetes. Most of the previously reported models explained <10% of the variation in costs (15,25). It is likely that our model predicted more of the variation in costs because we assessed exposures more rigorously by assessing demographic characteristics, treatments, and complications by both survey and medical chart review. African Americans with type 2 diabetes incurred lower direct medical costs than white type 2 diabetic subjects, suggesting that African Americans may receive less care. Age, duration of diabetes, and HbA1c did not enter our final model. This may be because of their association with both insulin treatment and diabetes complications, which are associated with higher costs. Since this was a cross-sectional study, we could not assess the effect of improved glycemic control on costs. Others have demonstrated that sustained improvements in glycemic control may be associated with decreased costs (17–19,26). Not unexpectedly, direct medical costs during the first year after the onset of acute MI, stroke, and amputation were high (Table 3).
Only a few studies have provided patient level estimates of the direct medical costs of diabetes (11,14,15). O’Brien et al. (11) developed an economic model to estimate the direct medical costs of 15 diabetes complications. Resource use was estimated from the likely course of treatment for each complication and unit costs were estimated from the peer-reviewed literature, acute care discharge databases, government reports, and fee schedules. The report did not assess variation in cost associated with demographic factors or diabetes treatments. The assessment of direct medical costs was not based on empirical data due to the lack of published data on actual practice (11).
Ramsey et al. (14) assessed the relative costs of six major diabetes-related complications using retrospective data from 8,905 subjects with type 1 or type 2 diabetes and 36,520 age- and sex-matched control subjects. The six diabetes-related complications were hypertension, eye disease, ESRD, foot ulcer, stroke, and MI. The relative costs for each complication were computed as ratios of total annual healthcare expenditure for subjects with diabetes and the complication compared with those with no diabetes and no complications. No distinction was made between type 1 and type 2 diabetes. The study assessed relative costs, not absolute costs. Like the study by O’Brien et al., it did not assess direct medical costs for different demographic characteristics and diabetes treatments and assessed costs from claims data only. In addition, unlike our model, the total direct medical cost for subjects with multiple complications may be overestimated, because some costs might be double counted.
Redekop et al. (15) examined the relationship between costs and demographic and clinical characteristics in 1,371 Dutch patients with type 2 diabetes using multivariate linear stepwise regression analyses. They demonstrated independent associations between age, insulin use, presence of macrovascular complications, presence of microvascular and macrovascular complications, hyperlipidemia, and costs. This study differed from ours in several ways. First, demographic characteristics, treatment, and complications were assessed by questionnaire but not with medical chart review. Second, costs were estimated with additive rather than multiplicative models. Third, they did not assess the association among individual microvascular and macrovascular complications and costs. Fourth, their model explained only 5.3% of the variance in costs, whereas our model explained 20.5% of the variance in costs. Finally, the costs represent the costs of subjects with type 2 diabetes in the Netherlands and are not comparable to the costs of type 2 diabetes in the U.S.
Some limitations of our study deserve mention. First, based on our definition of type 2 diabetes, we may have incorrectly classified a few subjects with type 1 diabetes as having type 2 diabetes and a few subjects with type 2 diabetes as having type 1 diabetes. Second, our study population was relatively small and limited to an HMO in Michigan. It represented the employed, elderly, poor, and disabled population of southeastern Michigan, but did not represent the general diabetic population of the U.S. as other states and regions were not represented and Asian Americans, Native Americans, and Hispanics were underrepresented. Third, the costs in our model reflect only direct medical costs from the perspective of a large health system. The costs do not include patient out-of-pocket costs, direct nonmedical costs, and indirect costs. Finally, not all diabetes complications entered the model. It is possible that these complications do not independently contribute to direct medical costs or that the costs associated with these complications are captured through closely associated complications such as diabetic kidney disease.
In summary, our economic model assessed patient-level direct medical costs of type 2 diabetes according to demographic characteristics, diabetes treatment, and complications. Major diabetes complications and insulin treatment have a substantial impact on total annual direct medical costs of type 2 diabetes. This economic model provides crucial information to describe and compare the direct medical costs of treatments, complications, and comorbidities within a type 2 diabetic population and for future cost-effectiveness analyses of new therapies for type 2 diabetes.
|
Acknowledgments |
|---|
This project was supported by the Centers for Disease Control and Prevention (U48/CCU516410), the Economic Modeling Core of the Michigan Diabetes Research and Training Center (DK-20572), and the Foerderung des Akademischen Nachwuchses of the University of Zurich, Switzerland.
|
Footnotes |
|---|
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
Received for publication March 19, 2003. Accepted for publication May 8, 2003.
|
References |
|---|
|
TOPABSTRACTINTRODUCTIONRESEARCH DESIGN AND METHODSRESULTSCONCLUSIONSReferences |
|---|
- King H, Aubert RE, Herman WH: Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections. Diabetes Care 21:1414–1431, 1998[Abstract]
- Caro JJ, Ward AJ, O’Brien JA: Lifetime costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care 25:476–481, 2002
[Abstract/Free Full Text]
- American Diabetes Association: Direct and Indirect Costs of Diabetes in the United States in 1992. Alexandria, VA, American Diabetes Association, 1993
- Rubin RJ, Altman WM, Mendelson DN: Health care expenditures for people with diabetes mellitus, 1992. J Clin Endocrinol Metab 78:809A–809F, 1994
- Pagano E, Brunetti M, Tediosi F, Garattini L: Costs of diabetes: a methodological analysis of the literature. Pharmacoeconomics 15:583–595, 1999[Medline]
- Huse DM, Oster G, Killen AR, Lacy MJ, Colditz GA: The economic cost of non-insulin dependent diabetes mellitus. JAMA 262:2708–2713, 1989[Abstract]
- Selby JV, Ray GT, Zhang D, Colby CJ: Excess costs of medical care for patients with diabetes in a managed care population. Diabetes Care 20:1396–1402, 1997[Abstract]
- Brown JB, Nichols GA, Glauber HS, Bakst AW: Type 2 diabetes: incremental medical care costs during the first 8 years after diagnosis. Diabetes Care 22:1116–1124, 1999
[Abstract/Free Full Text]
- Donnan PT, Leese GP, Morris AD: Hospitalizations for people with type 1 and type 2 diabetes compared with the nondiabetic population of Tayside, Scotland: a retrospective cohort study of resource use. Diabetes Care 23:1774–1779, 2000
[Abstract/Free Full Text]
- Jonsson PM, Marke LA, Nystrom L, Wall S, Ostman J: Excess costs of medical care 1 and 8 years after diagnosis of diabetes: estimates from young and middle-aged incidence cohorts in Sweden. Diabetes Res Clin Pract 50:35–47, 2000[Medline]
- O’Brien JA, Shomphe LA, Kavanagh PL, Raggio G, Caro JJ: Direct medical costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care 21:1122–1128, 1998[Abstract]
- Glauber HS, Brown JB: Impact of cardiovascular disease on health care utilization in a defined diabetic population. J Clin Epidemiol 47:1133–1142, 1994[Medline]
- Brown JB, Pedula KL, Bakst AW: The progressive cost of complications in type 2 diabetes mellitus. Arch Intern Med 159:1873–1880, 1999
[Abstract/Free Full Text]
- Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Wagner EH: Patient-level estimates of the cost of complications in diabetes in a managed-care population. Pharmacoeconomics 16:285–295, 1999[Medline]
- Redekop WK, Koopmanschap MA, Rutten GE, Wolffenbuttel BH, Stolk RP, Niessen LW: Resource consumption and costs in Dutch patients with type 2 diabetes mellitus: results from 29 general practices. Diabet Med 19:246–253, 2002[Medline]
- Henriksson F, Agardh CD, Berne C, Bolinder J, Lonnqvist F, Stenstrom P, Ostenson CG, Jonsson B: Direct medical costs for patients with type 2 diabetes in Sweden. J Intern Med 248:387–396, 2000[Medline]
- The Diabetes Control and Complications Trial Research Group: Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial. JAMA 276:1409–1415, 1996[Abstract]
- Eastman RC, Javitt JC, Herman WH, Dasbach EJ, Zbrozek AS, Dong F, Manninen D, Garfield SA, Copley-Merriman C, Maier W, Eastman JF, Kotsanos J, Cowie CC, Harris M: Model of complications of NIDDM. I. Model construction and assumptions. Diabetes Care 20:725–734, 1997[Abstract]
- Eastman RC, Javitt JC, Herman WH, Dasbach EJ, Copley-Merriman C, Maier W, Dong F, Manninen D, Zbrozek AS, Kotsanos J, Garfield SA, Harris M: Model of complications of NIDDM. II. Analysis of the health benefits and cost-effectiveness of treating NIDDM with the goal of normoglycemia. Diabetes Care 20:735–744, 1997[Abstract]
- The CDC Diabetes Cost-effectiveness Group: Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA 287:2542–2551, 2002
[Abstract/Free Full Text]
- Bagust A, Hopkinson PK, Maier W, Currie CJ: An economic model of the long-term health care burden of type II diabetes. Diabetologia 44:2140–2155, 2001[Medline]
- The TRIAD Study Group: The Translating Research Into Action for Diabetes (TRIAD) study: a multicenter study of diabetes in managed care (Review Article). Diabetes Care 25:386–389, 2002
[Free Full Text]
- Nichols GA, Brown JB: The impact of cardiovascular disease on medical care costs in subjects with and without type 2 diabetes. Diabetes Care 25:482–486, 2002
[Abstract/Free Full Text]
- Dong FB, Manninen DL, Dasbach EJ, Carides GW, Herman WH, Collins AJ: The longitudinal cost of end-stage renal disease in persons with diabetes in the United States (Abstract). Diabetes 51 (Suppl. 2):A272, 2002
- Krop JS, Saudek CD, Weller WE, Powe NR, Shaffer T, Anderson GF: Predicting expenditures for Medicare beneficiaries with diabetes: a prospective cohort study from 1994 to 1996. Diabetes Care 22:1660–1666, 1999
[Abstract/Free Full Text]
- Wagner EH, Sandhu N, Newton KM, McCulloch DK, Ramsey SD, Grothaus LC: Effect of improved glycemic control on health care costs and utilization. JAMA 285:182–189, 2001
[Abstract/Free Full Text]
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  J. G. Trogdon and T. Hylands Nationally Representative Medical Costs of Diabetes by Time Since Diagnosis Diabetes Care, December 1, 2008; 31(12): 2307 - 2311. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. D Deshpande, M. Harris-Hayes, and M. Schootman Epidemiology of Diabetes and Diabetes-Related Complications Physical Therapy, November 1, 2008; 88(11): 1254 - 1264. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. B. Dixon, P. E. O'Brien, J. Playfair, L. Chapman, L. M. Schachter, S. Skinner, J. Proietto, M. Bailey, and M. Anderson Adjustable Gastric Banding and Conventional Therapy for Type 2 Diabetes: A Randomized Controlled Trial JAMA, January 23, 2008; 299(3): 316 - 323. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Tasali, R. Leproult, D. A. Ehrmann, and E. Van Cauter Slow-wave sleep and the risk of type 2 diabetes in humans PNAS, January 22, 2008; 105(3): 1044 - 1049. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. J. Hoerger, K. A. Hicks, S. W. Sorensen, W. H. Herman, R. E. Ratner, R. T. Ackermann, P. Zhang, and M. M. Engelgau Cost-Effectiveness of Screening for Pre-Diabetes Among Overweight and Obese U.S. Adults Diabetes Care, November 1, 2007; 30(11): 2874 - 2879. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. H. Herman Diabetes Epidemiology: Guiding Clinical and Public Health Practice: The Kelly West Award Lecture, 2006 Diabetes Care, July 1, 2007; 30(7): 1912 - 1919. [Full Text] [PDF]
|
|
|
|
|
|
D. S. West, V. DiLillo, Z. Bursac, S. A. Gore, and P. G. Greene Motivational Interviewing Improves Weight Loss in Women With Type 2 Diabetes Diabetes Care, May 1, 2007; 30(5): 1081 - 1087. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 T. S T Smith, J. Szetu, and R. R A Bourne The prevalence and severity of diabetic retinopathy, associated risk factors and vision loss in patients registered with type 2 diabetes in Luganville, Vanuatu Br. J. Ophthalmol., April 1, 2007; 91(4): 415 - 419. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Ramachandran, S. Ramachandran, C. Snehalatha, C. Augustine, N. Murugesan, V. Viswanathan, A. Kapur, and R. Williams Increasing Expenditure on Health Care Incurred by Diabetic Subjects in a Developing Country: A study from India Diabetes Care, February 1, 2007; 30(2): 252 - 256. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. F. Bullano, M. D. Fisher, W. D. Grochulski, L. Menditto, and V. J. Willey Hypoglycemic events and glycosylated hemoglobin values in patients with type 2 diabetes mellitus newly initiated on insulin glargine or premixed insulin combination products Am. J. Health Syst. Pharm., December 15, 2006; 63(24): 2473 - 2482. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. T. Ackermann, D. G. Marrero, K. A. Hicks, T. J. Hoerger, S. Sorensen, P. Zhang, M. M. Engelgau, R. E. Ratner, and W. H. Herman An Evaluation of Cost Sharing to Finance a Diet and Physical Activity Intervention to Prevent Diabetes. Diabetes Care, June 1, 2006; 29(6): 1237 - 1241. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. Zhou, D. J.M. Isaman, S. Messinger, M. B. Brown, R. Klein, M. Brandle, and W. H. Herman A Computer Simulation Model of Diabetes Progression, Quality of Life, and Cost Diabetes Care, December 1, 2005; 28(12): 2856 - 2863. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Tunceli, C. J. Bradley, D. Nerenz, L. K. Williams, M. Pladevall, and J. Elston Lafata The Impact of Diabetes on Employment and Work Productivity Diabetes Care, November 1, 2005; 28(11): 2662 - 2667. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Russell, E. Valiyeva, S. H. Roman, L. M. Pogach, D.-C. Suh, and M. M. Safford Hospitalizations, Nursing Home Admissions, and Deaths Attributable to Diabetes Diabetes Care, July 1, 2005; 28(7): 1611 - 1617. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. C. Trussell, D. Hinnen, P. Gray, S. A. Drake-Nisly, K. M. Bratcher, H. Ramsey, and J. Early Case Study: Weight Loss Leads to Cost Savings and Improvement in Metabolic Syndrome Diabetes Spectr, April 1, 2005; 18(2): 77 - 79. [Full Text] [PDF]
|
|
|
|
 |
|
 W. H. Herman, T. J. Hoerger, M. Brandle, K. Hicks, S. Sorensen, P. Zhang, R. F. Hamman, R. T. Ackermann, M. M. Engelgau, R. E. Ratner, et al. The Cost-Effectiveness of Lifestyle Modification or Metformin in Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance Ann Intern Med, March 1, 2005; 142(5): 323 - 332. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. B. Dixon, W. J. Pories, P. E. O'Brien, P. R. Schauer, and P. Zimmet Surgery as an Effective Early Intervention for Diabesity: Why the reluctance? Diabetes Care, February 1, 2005; 28(2): 472 - 474. [Full Text] [PDF]
|
|
|
|
|
|
T. P. Gilmer, P. J. O'Connor, W. A. Rush, A. L. Crain, R. R. Whitebird, A. M. Hanson, and L. I. Solberg Predictors of Health Care Costs in Adults With Diabetes Diabetes Care, January 1, 2005; 28(1): 59 - 64. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Olveira-Fuster, P. Olvera-Marquez, F. Carral-Sanlaureano, S. Gonzalez-Romero, M. Aguilar-Diosdado, and F. Soriguer-Escofet Excess Hospitalizations, Hospital Days, and Inpatient Costs Among People With Diabetes in Andalusia, Spain Diabetes Care, August 1, 2004; 27(8): 1904 - 1909. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Morsanutto, P. Berto, S. Lopatriello, D. Voinovich, R. Gelisio, and L. G. Mantovani Major Diabetes Complications Have an Impact on Total Annual Medical Cost of Type 2 Diabetes Diabetes Care, July 1, 2004; 27(7): 1841 - 1842. [Full Text] [PDF]
|
|
|
|
 |
|
 S. B. Leichter Third-Party Reimbursement: Now Comes the Really Difficult Part Clin. Diabetes, October 1, 2003; 21(4): 181 - 182. [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |