The Journal of Healthcare Contracting

Diabetes Management
A small price to pay for patient health

Hospitals today are facing an increased incidence of diabetes, a problem costing millions of dollars, according to Rod Cotton, VP and general manager, point of care diagnosis for Roche Diagnostics in Indianapolis, Ind. About 13 million Americans have been diagnosed with diabetes, while another estimated 5.2 million people are unaware they have the disease. Indeed, the financial burden on the nation as a whole is great. Diabetics incur medical costs of $13,000 or $14,000 annually, compared to $2,500 for non-diabetics.

Largely due to a higher rate of obesity in the United States today, the number of patients admitted to hospitals who are diagnosed with diabetes has almost doubled in recent years, with estimates as high as 40 percent. "If hospitals can control the glycemic index (for these patients) within a normal range (glucose range of 80-110 mg/dl), especially following surgical procedures, they can improve outcomes, reduce mortality rates and reduce hospital stays," says Cotton. "This could save tens of millions of dollars."

Because diabetes is a vascular disease, it can lead to other health disorders, including circulatory disease, amputation, blindness, heart disease or end-stage renal failure. "There are 300,000 dialysis patients in the United States, and 33 percent of them are diabetics," he says.

Hospitals today can be credited with doing more to address diabetes. Glycemic control protocols have encouraged facilities to screen more patients for hyperglycemia, particularly when they are admitted with obesity, high cholesterol, high blood pressure, high triglycerides and other symptoms that place them at high risk. In fact, Cotton says while 80 percent of glucose testing continues to take place in the consumer setting, hospitals now shoulder up to 15 percent of the market.

Screen first, then manage
While experts generally agree that hospitals must screen for diabetes, they warn that emergency rooms are not necessarily the best environment for doing so. Individuals must fast prior to a blood glucose screening, notes Jim Ramsey, M.D., VP of product development for Instant Technologies Inc. in Norfolk, Va. That's not to say that patients passing through the ER should not be screened, particularly if they present high risk factors or have family histories. When a patient comes to the ER with suspect symptoms of diabetes or even is feeling faint, he can have an initial blood test, followed by a more in-depth blood screening later on.

"Everyone 45 years and older should be screened," says Ramsey. "And family history is important. There is a gene for this disease." When diabetes runs in a family, family members should be screened as early as age 20. For this reason, primary care physicians must continue to play a major role in screening patients, as must hospital physicians overseeing admitted patients.

Screening is the first step toward healthy blood sugar management, but its effectiveness is limited unless doctors can integrate this information into the patient's medical record. "The data management piece is critical," says Cotton. "Our success depends on our connectivity ability and our ability to integrate (the patient's) information," he says, referring to Roche Diagnostic's ACCU-CHEK Inform system, which is Palm Pilot based.

Roche Diagnostics relies on RALS-Plus (Medical Automation Systems in Charlotte, Va.) as its point-of-care software IT connectivity solution. RALS enables all information entered into the ACCU-CHEK Inform meter to be uploaded to a hospital information system (HIS) or a hospital laboratory information system, according to Cotton. The caretaker can enter other relevant information as well, such as fecal occult blood test results, to provide hospitals with multiple data to actively manage the patient's health.

As hospitals improve glycemic screening and management processes, patients can be moved more expediently to an outpatient setting. And, if the patient is pleased with quick positive results from the hospital, he will probably continue working closely with the facility's wellness center or outpatient center. Essentially, hospitals can drive revenues by quickly diagnosing and managing patients' diabetes, and then transferring them to outpatient or wellness centers, according to experts.

Insurance companies purchasing devices
Hospitals are not the only institutions taking a proactive role in diabetes management in an effort to reduce costs associated with the disease. Insurance companies have discovered they come out ahead if they purchase monitors in bulk from a manufacturer or distributor, and then hand them out directly to patients. "This is good both for cost reduction and patient compliance," says Scott Taillie, director of national accounts at Instant Technologies Inc. "Medicare reimburses for up to 100 glucose strips in a month, the equivalent of three tests a day, but this is not always enough." And, worse, non-insulin dependent users are reimbursed only for 100 strips every three months. Depending on the severity of their diseases, diabetics must monitor their blood between three and 10 or more times daily.

Taillie says insurance companies can purchase bulk amounts of strips and meters directly from vendors at reasonable rates. "Whereas Medicare may reimburse a diabetic patient $66 for a monitor and $35 for 50 glucose strips, an insurance company can usually purchase a meter for about $20 and pay $14 for 50 strips directly from the vendor," he says.

"It's not only the insurance companies that are providing patients with free meters and strips," adds Cotton. "Some hospitals are teaming up with insurers or even doing this on their own." He points out that providing patients with the right tools to manage their blood glucose levels gives hospitals an opportunity to transfer these patients to an outpatient setting.

Unless glucose-monitoring devices are easy to use, however, it will take more than handouts to convince patients to manage their glycemic levels. "It's all about ease of use for diabetics," says Taillie. In spite of some newer technologies that have appeared on the market in recent years (i.e., devices using infrared light, low-level electrical currents or devices that measure glucose levels in saline), the traditional finger prick test continues to be the gold standard.

Today, monitoring devices are smaller, require less blood and produce results in as little as three to five seconds (compared to 30 seconds for older devices). In fact, diabetics soon will be able to use their cell phones to call in their own results. Together with San Diego-based LG Electronics, Instant Technologies plans to market a cell phone into which the user can slide a glucose test strip.

"Results are stored online," says Taillie. "Each time the user tests, the phone automatically sends a text message to a central office database." He adds that only if a device is user friendly will people actually use it.

Beyond screening
Taillie and Ramsey agree with Cotton that screening patients to determine who is hyperglycemic or diabetic is an important first step, but that caregivers and patients must know how to use this information. "Screening goes hand-in-hand with education, and hospitals and wellness centers can play a greater role in educating the general public," says Taillie.

Ramsey adds that it's a matter of screening for the disease and then educating individuals on managing their disease. And, while IDN contract initiatives and hospital efforts can only go so far in terms of screening people for diabetes, once equipped with the right patient data, much more can be done to help diabetics manage this disease.

The facts about diabetes
In 2000, diabetes was the sixth-leading cause of death listed on U.S. death certificates according to the National Institutes of Health (NIH). As of 2002, over 6 percent of the American population was diagnosed with diabetes. This included about 206,000 people under age 20 and another 18 million people aged 20 years and older. The annual cost to the United States has been over $132 billion. Patients who control their glucose levels, blood pressure and blood lipids have been found to reduce their risks for eye, kidney and nerve disease. Blood pressure control can also reduce the risk of heart disease and stroke.

When diabetes is not well managed, the following complications may arise:
Heart disease and stroke. These are responsible for about 65 percent of deaths among diabetics.
High blood pressure. About 73 percent of adult diabetics have blood pressure greater than or equal to 130/80 mm Hg, or they must use prescription medications for hypertension.
Blindness. Diabetes is the leading cause of new cases of blindness among adults between 20 and 74 years of age.
Kidney disease. Diabetes is the leading cause of end-stage renal disease, accounting for 44 percent of new cases.
Nervous system disease. About 60 percent to 70 percent of diabetics have mild to severe forms of nervous system damage.
Amputations. Over 60 percent of non-traumatic lower-limb amputations occur among diabetics.
Dental disease. About one-third of diabetics have severe periodontal diseases.
Complications in pregnancy. Poorly controlled diabetes before conception and in the first trimester of pregnancy can cause major birth defects in 5 percent to 10 percent of pregnancies, and spontaneous abortions in 15 percent to 20 percent of pregnancies.

Diabetes also often leads to biochemical imbalances that can cause life-threatening cases of diabetic ketoacidosis and hyperosmolar coma, according to the NIH. Diabetics also are more likely to die from pneumonia or influenza than non-diabetics.