Increased Cardiovascular Disease, Resource Use, and Costs Before the Clinical Diagnosis of Diabetes in Veterans in the Southeastern U.S.

Abstract

IMPORTANCE:Screening for diabetes might be more widespread if adverse associations with cardiovascular disease (CVD), resource use, and costs were known to occur earlier than conventional clinical diagnosis. OBJECTIVE: The purpose of this study was to determine whether adverse effects associated with diabetes begin prior to clinical diagnosis. DESIGN: Veterans with diabetes were matched 1:2 with controls by follow-up, age, race/ethnicity, gender, and VA facility. CVD was obtained from ICD-9 codes, and resource use and costs from VA datasets. SETTING: VA facilities in SC, GA, and AL. PARTICIPANTS: Patients with and without diagnosed diabetes. MAIN OUTCOME MEASURES: Diagnosed CVD, resource use, and costs. RESULTS: In this study, the 2,062 diabetic patients and 4,124 controls were 63 years old on average, 99 % male, and 29 % black; BMI was 30.8 in diabetic patients vs. 27.8 in controls (p<0.001). CVD prevalence was higher and there were more outpatient visits in Year −4 before diagnosis through Year +4 after diagnosis among diabetic vs. control patients (all p<0.01); in Year −2, CVD prevalence was 31 % vs. 24 %, and outpatient visits were 22 vs. 19 per year, respectively. Total VA costs/year/veteran were higher in diabetic than control patients from Year −4 ($4,083 vs. $2,754) through Year +5 ($8,347 vs. $5,700) (p<0.003) for each, reflecting underlying increases in outpatient, inpatient, and pharmacy costs KEY WORDS: diabetes; health care cost; cardiovascular disease; prediabetes. ABBREVIATIONS A1cHemoglobin A1c 749(p<0.05 for each). Regression analysis showed that diabetes contributed an average of $1,748/year to costs, independent of CVD (p<0.001). CONCLUSIONS AND RELEVANCE: VA costs per veteran are higher-over $1,000/year before and $2,000/year after diagnosis of diabetes-due to underlying increases in outpatient, inpatient, and pharmacy costs, greater number of outpatient visits, and increased CVD. Moreover, adverse associations with veterans' health and the VA healthcare system occur early in the natural history of the disease, several years before diabetes is diagnosed. Since adverse associations begin before diabetes is recognized, greater consideration should be given to systematic screening in order to permit earlier detection and initiation of preventive management. Keeping frequency of CVD and marginal costs in line with those of patients before diabetes is currently diagnosed has the potential to save up to $2 billion a year.

Glucose challenge test screening for prediabetes and early diabetes

“…Consequently, glucose intolerance progresses unchecked, and many individuals already have early diabetes complications and increased cardiovascular disease risk when finally recognized [2,3]. Cardiovascular disease events, health resource use and costs all rise in the period before diabetes is diagnosed [4]. Detection of diabetes early in the natural history of the disease is critical for preventive management with lifestyle change or medication, and the US Preventive Services Task Force has created recommendations for systematic screening [5].…”

Weight Trends in Veterans With and Without Diabetes, 2000 to 2014

“…Consistent with prior Atlanta VA research , subclassification of diabetes by type was not performed. However, the limits placed on ICD‐9 codes and age range make it more likely that most individuals diagnosed according to criteria A and B have type 2 diabetes than type 1 diabetes.…”

“…Concordant with the methods used in previous Atlanta VA Medical Center research , patients were classified as having diabetes if they had a least one use of the International Classification of Diseases, Ninth Revision (ICD‐9) code 250.xx in conjunction with an outpatient visit with a primary care provider (criterion A), if they had any two uses of the 250.xx ICD‐9 codes (criterion B), or if they had been prescribed an antihyperglycemic medication at any time during the study period (criterion C). Individuals who satisfied the diagnostic criteria at any time during the study period were considered to have diabetes for the entire study period.…”

“…The CDW is a comprehensive source of medical records data, including patient demographics, diagnoses, procedures, medications, and laboratory data. 8 The data used for this study comprised essentially all patients in the United States who were seen in an outpatient primary care visit for any reason within the VA healthcare system during 2000-2014. Using a unique patient identifier, demographic, primary care, and laboratory data were extracted with SQL (Oracle Corporation, Redwood Shores, CA) and SAS 9.4 (SAS Corporation, Cary, NC).…”

Healthcare system encounters before COPD diagnosis: a registry-based longitudinal cohort study

“…Increased awareness of the risk of COPD among patients with cardiovascular disease in particular might lead to earlier detection. However, the presence of frequent healthcare encounters is not in itself sufficient to warrant suspicion of COPD, as the pattern of increased healthcare services use leading up to diagnosis is common to other disease areas 23 24. Case detection methods such as risk assessment questionnaires25 26 or screening spirometry27 should be implemented at these types of routine visits in order to identify patients at high risk of having COPD.…”