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Health Care Costs Associated with Chronic Kidney Disease in Patients with Type II Diabetes

Health Care Costs Associated with Chronic Kidney Disease in Patients with Type II Diabetes. Zita Shiue , MD Internal Medicine, R3 Chief of Medicine Conference October 25, 2011. Outline. Background Methods Results Conclusion Future Directions. Background.

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Health Care Costs Associated with Chronic Kidney Disease in Patients with Type II Diabetes

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  1. Health Care Costs Associated with Chronic Kidney Disease in Patients with Type II Diabetes ZitaShiue, MD Internal Medicine, R3 Chief of Medicine Conference October 25, 2011

  2. Outline • Background • Methods • Results • Conclusion • Future Directions

  3. Background • In 2009, it was estimated that the United States had $2.5 trillion in health care expenditures • These numbers are projected to continue rising over the next several years • Understanding health care costs is an integral part of our job as physicians

  4. Background • Chronic kidney disease (CKD) is a growing epidemic, estimated to affect nearly 12% of the country’s population and projected to rise • CKD is known to be associated with increased mortality and cardiovascular risk, even at early stages of disease

  5. Background

  6. Background • Patients with CKD are known to utilize health care at high rates and incur more costs (Smith) • Up to 1.9 times more outpatient visits • Up to 4.1 times more use of diabetes medications • Up to 4.2 more inpatient stays • Patients with CKD double the costs of age-matched controls

  7. Background • Diabetes is the primary cause of end stage renal disease (ESRD) in the U.S. and is shown to be one of the strongest cost modifiers in patients with CKD • In 2007, the number of people diagnosed with diabetes was at least 17.5 million • Costs associated with diabetes were estimated at $174 billion by the American Diabetes Association • $116 billion in expenditures • $58 billion in lost productivity • Utilized health care 2.3 more times when compared to patients without diabetes

  8. Background • After cardiovascular disease, CKD is the second most costly complication of diabetes • Patients with CKD and diabetes cost 1.7 times as much as either alone • Patients with diabetes are 12 times more likely to progress to ESRD • Once patients are end stage, costs dramatically increase due to dialysis and transplantation

  9. Background • Despite the large economic burden created by both diabetes and CKD, there is very little know about the costs at the earlier stages of CKD in patients with diabetes • National Kidney Foundation (NKF) revealed 5 part staging system in 2002 • Most studies have focused on CKD stage 3 and above • Previous studies show that even patients with mild stages of CKD can have increased CVD risk • Objective: to evaluate and stratify costs of care at all stages of CKD in a primary care population with Type 2 diabetes

  10. Methods

  11. Methods • Participants for the study were recruited as part of the Pathways Epidemiology Study • A prospective population-based cohort sampled from the Group Health diabetes registry • Group Health is a non-profit health maintenance organization in Western Washington State • 9 of the 30 primary care clinics were selected to be a part of this study for their large population with diabetes and increased diversity

  12. Methods • To qualify for the diabetes registry, patients had to fulfill one of the following: • Filled a prescription for insulin or oral hypoglycemic • Two fasting glucose ≥ 126 mg/dl in one year • Two random glucose levels ≥ 200 in one year • Two outpatient diagnoses of diabetes • Any inpatient diagnosis of diabetes

  13. Methods • Surveys were mailed to 9064 patients from the diabetes registry • The survey included questions regarding demographics, characteristics of their diabetes, comorbidities, depression • Exclusion criteria included: type 1 diabetes, lack of laboratory information regarding kidney function

  14. Methods • Primary predictor • Stage of CKD as defined by the National Kidney Foundation • stage 1 = eGFR >90mL/min per 1.73m2 with evidence of proteinuria • stage 2 = eGFR 60-89 mL/min per 1.73m2 with evidence of proteinuria • stage 3 = eGFR 30-59 mL/min per 1.73m2 • stage 4 = eGFR 15-29 mL/min per 1.73m2 • stage 5 = eGFR <15 mL/min per 1.73m2 or on kidney replacement therapy such as dialysis or transplant. • eGFR calculated using MDRD • Covariates • age, gender, sex, hypertension, LDL, diabetic complications, education, smoking, body mass index

  15. Methods • Costs were evaluated at 6 months • GH assigns budge based costs to every unit of health service rendered • Primary Cost Outcomes • Primary and specialty outpatient • Laboratory • Imaging • Emergency • Inpatient • Total Costs • Diabetes related costs - including pharmacy costs (insulin, oral hypoglycemic agents), and laboratory tests (glucose, albumin, hemoglobin A1C (HbA1C)).

  16. Methods • Statistical Methods • Descriptive statistics • T-tests for comparisons • Cuzick non-parametric tests for trends • Proportions of costs calculated using individual proportions rather than aggregate proportions

  17. Results

  18. Results • 4,938 of 9,064 surveys were returned for a 62% response rate • 3,754 people met inclusion criteria • Compared to patients in earlier stages of CKD, patients in later stages: • Were older • Had increased number of complications • Less college education • Greater number of people with hypertension

  19. Results • Absolute mean total costs of care increased with worsening stage of CKD • Costs at each stage of CKD were significantly increased when compared to stage 0 • Increased age was also associated with increased costs • African Americans and females were associated with decreased costs

  20. Total and Component Costs

  21. Outpatient Costs

  22. Proportional Costs • The proportion of outpatient costs decreased with increasing stage • The proportion of inpatient costs increased with increasing stage

  23. Proportional Costs

  24. Inpatient Costs • Inpatient costs were rare and few people contributed to the mean costs • Mean total costs were recalculated using those that actually incurred costs > 0, • Means were not significantly different by stage • However, the number of people contributing did increase with stage

  25. Inpatient Costs

  26. Inpatient Costs

  27. Diabetes Related Care • Absolute costs related to diabetes care increased with stage • However, the proportion of total costs attributed to diabetes care decreased with stage

  28. Diabetes Related Care

  29. Conclusion

  30. Conclusions • Worsening stage of CKD is associated with significantly increased absolute costs across all cost categories in this Type 2 diabetes population • These results are consistent with previous studies demonstrating increased costs and health care utilization in patient with CKD • This study includes earlier stages of disease and reveals significant increases compared to stage 0 • Even “mild” stages of CKD can increase the total cost to the health care system

  31. Conclusions • The proportion of inpatient costs increase with stage while the proportion attributed to outpatient costs decreased • Similar to existing studies demonstrating increased hospitalizations in this group • This is due to the increased number of people contributing to inpatient costs at higher stages • Absolute costs related to diabetes care increased but the proportion decreased with worsening stage of CKD • This may represent increased utilization of health care on non-direct diabetes care including cardiovascular disease, anemia, ESRD

  32. Discussion • In this study, stage 3 CKD was the stage at which the proportions of inpatient, outpatient, and diabetes care changed significantly when compared to stage 0 • We often categorize people as chronic kidney disease once they have reached stage 3 • However, it may be that prevention of progression to this stage is most important

  33. Discussion • As the burden of CKD rises, more research has been devoted to methods of cost control • Angiotensin-converting enzyme inhibitors • Better control of hypertension • Early referral to nephrology • Referral of patients to specialist care group • Early screening • Control of anemia • Most of these studies do not involve patients with eGFR >60

  34. Limitations • Short follow up time of 6 months • eGFR using MDRD at one point in time • Costs are CKD plus comorbidities, not isolated • Stage 5 analysis included those on dialysis, likely skewing data

  35. Future Directions • Would ideally calculate annual costs as well as 5 and 10 years • Re-evaluate data using CKD – EPI equation, a better predictor for earlier stages of CKD • Females, African Americans, younger age • More cost effectiveness studies, cost saving strategies, even at lower stages of disease

  36. Summary • Worsening stage of CKD in patients with diabetes is associated with significantly increased health care costs, even at 6 months • This is true even at the earliest stages of disease • It is a reflection of increasing comorbidities and health care utilization, especially of inpatient services • Efforts should continue to be focused on primary preventive measures to lower late stage costs

  37. References

  38. Thank You • Bessie A. Young, MD • Courtney Rees Lyles, PhD • Group Health Cooperative

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