Current Trends Impact of Diabetes Outpatient Education Program -- Maine

Diabetes mellitus is an important cause of morbidity and mortality in the United States, affecting 2.4% (almost 6 million people) of the total population and resulting in a direct and indirect outlay of approximately 9.7 billion dollars/year(1). Maine has an estimated 27,000 diabetics, and in 1980 diabetes was the sole or a contributing cause for 788 deaths--7.3% of all deaths in the state that year. It is believed that the suffering and economic burden of this disease can be reduced by training persons with diabetes extensively in proper self-care and that diabetes will eventually become a model for other chronic diseases in demonstrating the cost-effectiveness of preventive intervention.

An audit of the charts of 898 diabetic patients hospitalized in 1979 at 34 hospitals was conducted to determine the number of hospitalizations for diabetes control that could have been prevented if the patient had been better educated in self management of diabetes and to determine the number of patients whose hospital stay was extended solely for education concerning diabetes. A total of 16.5% of the admissions were found to have been caused by lack of knowledge of self-management skills, and 10.3% had their length of stay extended only for diabetes education. An additional 19.9% were readmissions within the year for the same or similar problems.

The Maine Diabetes Control Project (DCP) established educational sites throughout the state in 1980 to provide improved opportunities for diabetes education and to document the effect of intensive education on diabetes-related morbidity and its resultant costs. Diabetics were referred to the program by physicians to receive training in self monitoring, insulin regulation, nutrition education, foot care, and other pertinent topics. Each diabetic referred to the classes participated in a preassessment interview. Self-reported information collected from 533 diabetics at 26 of the education sites in 1980 revealed the following:

1. 59% of the participants were female, average age 57 years

2. The males averaged 53 years of age

3. 78% of all participants were greater than or equal to 45 years of age

4. 53% had a high school education or better

5. The average duration of diabetes was 6.5 years

6. 45% were managed with insulin

7. 58% were greater than or equal to 20% over ideal body weight (2)

8. 43% had not had an eye examination in the past year

1. 50% had "hypertension" j) Of the 97 participants hospitalized for diabetes in the past

   year, 19% had been hospitalized at least once for diabetic ketoacidosis/coma Although a controlled population was not available for comparison,

a 12-month follow-up of the health status and hospitalization patterns was available for 461 diabetics who had completed the course. A total of 96 (33%) fewer hospitalizations occurred in the year following education than in the year preceding the training program (287 hospitalizations before training versus 191 after training). Using average-length-of-stay data from Maine's 100% hospital discharge data base and average cost data, cost savings were estimated to be $203,791 for 941 fewer hospital days among diabetics participating in the education program. The cost of educating the 461 diabetics was approximately $69,150. Thus, the estimated net savings was $134,641 or $292 per participant.

For a 3-year experimental period, Blue Cross and Blue Shield of Maine and Medicare and Medicaid have agreed to reimburse the hospitals and rural health centers that provide the education program. This training costs the third-party payers an average of $150/patient, less than the cost of 1 hospital day.

The Maine DCP has also established a surveillance system using the 100% hospital discharge file to identify morbidity caused by diabetes and Maine vital statistics to identify mortality caused by diabetes. This system will provide baseline data dating back to 1975 and will allow the impact of the education program to be monitored. Reported by W Nersesian, MD, M Zaremba and a Diabetes Public Health Advisor, Dept of Human Svcs, Augusta, Maine; B Willhoite, MA, Medical Care Development, Inc., Augusta, Maine; Technical Services Section, Diabetes Control Activity, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Maine is one of 20 states under cooperative agreement with CDC to conduct diabetes-control demonstration activities. Because self-reported questionnaires administered at specific intervals after educational interventions are commonly used to collect data for evaluation, it is important that individual health-status and health-care-utilization data be verified for reliability and validity. Maine and CDC are working together to corroborate the original information from patient interviews with hospital insurance claims information. The Maine program appears to be reaching a high-risk population, because the pre-program hospitalization rate of participants was 6,225/10,000 diabetics/year compared with the estimated rate for all diabetics in Maine of 3,356/10,000 diabetics in 1980.

These preliminary results, if verified, strengthen reports from earlier studies (3-5) that substantial reductions in health-care utilization and costs can be achieved through more organized and intensive diabetes education activities. They also support the continuing role for public health in organizing these activities.

References

1. Report of the National Diabetes Advisory Board. US Dept. of Health & Human Services, HIH Publication No. 82-2143, May 1982.

2. A guide for professionals: the effective application of "Exchange Lists for Meal Planning," New York and Chicago. American Diabetes Association and American Dietetic Association, 1977.

3. Runyan JW. The Memphis chronic disease program. JAMA 1975;231:264-7.

4. Davidson JK, Alogna M, Goldsmith M, Borden J. Assessment of program effectiveness at Grady Memorial Hospital, In: Steiner G, Lawrence PA, eds. Educating diabetic patients. New York: Springer Publishing Co., 1981;329-48.

5. Miller LV, Goldstein J. More efficient care of diabetic patients in a county-hospital setting. N Engl J Med 1972;286:1388-91.

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