Editor's Note: Commentary based on Feldman DI, Valero-Elizondo J, Salami JA, et al. Favorable cardiovascular risk factor profile is associated with lower healthcare expenditure and resource utilization among adults with diabetes mellitus free of established cardiovascular disease: 2012 Medical Expenditure Panel Survey (MEPS). Atherosclerosis 2017;258:79-83.

Introduction

According to the Centers for Disease Control and Prevention (CDC), the national healthcare expenditure in 2014 was $3 trillion, which was 17.5% of the gross domestic product (GDP) of the United States.¹ Moreover, healthcare expenditure has increased considerably over the last decade.² Of this exorbitant spending on healthcare, a significant portion is spent on diabetes and cardiovascular disease management. More than 23% of the healthcare expenditure is incurred by patients with diabetes and 17% of the national expenditure is attributable to cardiovascular disease management.^3,4

Diabetes and cardiovascular disease are not two separate categories from a financial perspective. More than 7.6 million patients with diabetes in the United States have a history of heart disease or stroke, and the healthcare expenditure is exceptionally high in these patients.⁵ One study demonstrated that 26% of hospital inpatient costs and 14% of outpatient visit costs are attributable to cardiovascular disease in diabetes patients.³

What about patients with diabetes and a high cardiovascular disease risk? It seems intuitive that patients with diabetes and a poor cardiovascular risk factor (CRF) profile would use more healthcare resources and have high healthcare costs. Surprisingly, there has been a paucity of research investigating the financial aspect and resource utilization in this group of patients.

Study Highlights

In this study, Feldman et al. elaborate on this unanswered question in medical research. They performed a multivariable analysis on healthcare expenditures and resource utilization based on diabetes and CRF profile. This study evaluated 25,317 patients free of cardiovascular disease from the 2012 Medical Expenditure Panel Survey (MEPS) database. They found that among patients with diabetes, 16% had optimal, 57% had average, and 27.1% had poor CRF profiles. Conversely, among patients without diabetes, 59.1% had optimal, 36.3% had average, and only 4.6% had poor CRF profiles. Overall, a favorable CRF profile was closely associated with lower healthcare costs and resource utilization across the spectrum of diabetes. Individuals with diabetes and an optimal CRF profile had a lower rate of resource utilization compared to those with diabetes and a poor CRF profile, with 50% fewer prescription medications purchased/refilled and 58% fewer outpatient visits. On the other hand, individuals with diabetes and a poor CRF profile had the highest expenditures ($9,006). However, diabetes itself contributed to the burden, as patients with diabetes and optimal CRF profiles had higher overall healthcare expenditures and resource utilization compared to those without diabetes and high CRF profiles ($6,461 vs. $4,984).

Commentary/Perspective

This study proved a simple but crucial concept in the management of patients with high cardiovascular disease risk, such as those with diabetes and high CRF profiles, from a healthcare expenditures and resource utilization perspective. First, this finding reiterates the impact of diabetes in cardiovascular disease, and the importance of diabetes management in cardiovascular disease prevention. Diabetes is a powerful predictor of high healthcare expenditures and resource utilization. Studies have shown that proactive management of risk factors to prevent diabetes is very cost-effective and can save costs.⁶ Preventing diabetes will not only have a substantial impact on public health, but also decrease the financial burden of managing diabetes and cardiovascular complications.

Second, this study implies that significant efforts have to be made on early intervention to prevent cardiovascular disease in those who do not have optimal CRF profiles, regardless of diabetes status. The authors defined cardiovascular disease risk factors as hypertension, dyslipidemia, lack of physical exercise, smoking, and/or obesity, all of which are modifiable with aggressive lifestyle improvement and appropriate medical therapy. Physicians often forget that preventive measures such as lifestyle modification or exercise are effective and inexpensive. Studies have demonstrated that regular physical activity and exercise can prevent type 2 diabetes, lower cholesterol levels, improve hypertension, and decrease cardiovascular events and mortality.⁷ Furthermore, aggressive medical therapy with statins is safe and efficacious in preventing cardiovascular disease in those with diabetes and cardiovascular risk factors.⁸ It is imperative to mention that early intensive intervention can be most cost-effective and cost saving when implemented in subjects with high risk yet to develop cardiovascular disease.⁹

The financial aspect of medicine is often forgotten in day-to-day medical practice, as well as in medical research. This could be due to multiple reasons, including limitations in generalizability of the results to other countries and difficulties in obtaining funding for health policy research. However, understanding the structure of healthcare expenditure and resource utilization is essential in promoting public health. Further research is warranted to prioritize limited healthcare resources to the most cost-effective target in cardiovascular disease prevention and cardiovascular outcome improvement. At the same time, implementation of robust nationwide healthcare policies is needed to further emphasize early interventions of risk factor management in patients at early or preclinical stages of disease.

References

1. Centers for Disease Control and Prevention/National Center for Health Statistics. Available at: https://www.cdc.gov/nchs/fastats/health-expenditures.htm. Accessed May 5, 2017.
2. Catlin AC, Cowan CA. History of health spending in the United States, 1960–2013. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/HistoricalNHEPaper.pdf Accessed May 5, 2017.
3. American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care 2013;36:1033-46.
4. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation 2017;135:e146-603.
5. Centers for Disease Control and Prevention/National Center for Health Statistics, Division of Health Interview Statistics. Data from the National Health Interview Survey. Available at: https://www.cdc.gov/nchs/nhis/. Accessed May 5, 2017.
6. Li R, Zhang P, Barker LE, Chowdhury FM, Zhang X. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a systematic review. Diabetes Care 2010;33:1872-94.
7. Colberg SR, Sigal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care 2010;33:e147-67.
8. Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004;364:685-96.
9. Espeland MA, Glick HA, Bertoni A, et al. Impact of an intensive lifestyle intervention on use and cost of medical services among overweight and obese adults with type 2 diabetes: the action for health in diabetes. Diabetes Care 2014;37:2548-56.

Keywords: Biomedical Research, Cardiovascular Diseases, Cholesterol, Diabetes Mellitus, Type 2, Dyslipidemias, Health Care Costs, Health Expenditures, Health Policy, Heart Diseases, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hypertension, Life Style, Obesity, Risk Factors, Smoking, Stroke

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