Type 2 diabetes can be reversed and managed effectively
The cost-savings could be huge
It is now well-established that remission occurs for type 2 diabetes. But just how prevalent is diabetic remission? Researchers in the UK used cross-sectional data from 117,048 adults over age 30 the Scottish Care Information-Diabetes registry to document the prevalence of type 2 diabetes remission in Scotland in calendar year 2019. Remission was defined as both HbA1c less than 6.5 percent (48 mmol/mol) and the absence of glucose-lowering therapy for at least 365 consecutive days. According to these criteria, 4.8 percent of type 2 diabetic patients were in remission in 2019. Key characteristics of patients in remission included older age, greater weight loss between diabetes diagnosis and 2019, lower likelihood of receiving glucose-lowering therapy, and bariatric surgery. The highest prevalence of remission occurred in patients aged 75 years or older and who had lost at least 15 kg of body weight from diabetes diagnosis to 2019. The prevalence of remission increased in a more or less step-wise manner as the amount of weight loss increased. Detecting type 2 remission and following up with appropriate medical care and support to maintain weight loss could have important health consequences.
The American Diabetes Association updated its 2012 report on the cost of diabetes care. The prevalence of diabetes and its direct costs continued to rise from those documented in 2007. From 2012 to 2017, the prevalence of diabetes increased by 11 percent. Direct costs increased from $116 billion in 2007 to $237 billion in 2017. Diabetes accounted for one in four US medical care dollars or an average of $16,752 per year for a diabetic patient. This figure did not include substantial indirect costs of complications (kidney disease, amputations, cardiovascular events) and reduced productivity at work. Low awareness of pre-diabetes (when lifestyle interventions might be especially effective) and low uptake of preventive interventions contribute to rising prevalence and costs of type 2 diabetes.
Some studies suggest that a comprehensive, coordinated, multidisciplinary approach to managing type 2 diabetes can produce better health outcomes than usual care. A group of researchers investigated the five-year effectiveness of the multidisciplinary Risk Assessment and Management Programme–Diabetes Mellitus (RAMP-DM) on diabetes-related complications and health service uses in Hong Kong. A total of 26,718 diabetic patients were matched with an equal number of non-diabetic patients using a propensity matching system.
After an average follow-up of 4.5 years, participants in the RAMP-DM program had about half the number of cumulative events (diabetes complications, all-cause mortality) compared to the usual care group (23.2 vs. 43.6 percent). RAMP-DM program participants also had much lower rates of cardiovascular disease, coronary heart disease, heart failure, stroke, and microvascular complications (retinopathy, neuropathy, kidney disease, hospitalization, accident and emergency, and specialized outpatient clinic care). These impressive results occurred in spite of only modest improvement in HbA1c levels, which researchers often use to diagnose type 2 diabetes. Several factors might explain the dramatic improvement over usual care. The program used a tiered approach to treating diabetic patients by focusing more effort on those with greatest risk of diabetic complications, resulting in fewer complications. Diabetes and diabetic complications were diagnosed earlier when treatments were likely more effective and less costly. Coordination among clinicians helped patients get the care they needed in a timely manner. Hopefully, this type of program is now being tested in the US.
Hong Kong researchers also investigated the five-year cost-effectiveness of the RAMP-DM on diabetes-related complications and health service uses in Hong Kong. Patients diagnosed with type 2 diabetes who enrolled in the RAMP-DM program (N=8,570) were propensity-score matched with 8,570 diabetic patients who received usual care. Program costs included the one-time set-up, ongoing operations, and central administration. Patients in the RAMP-DM program had significantly lower cumulative incidences of diabetes complications (15.3 vs. 28.6 percent) and death (8.0 vs. 21.4 percent) over 5 years compared to the usual care patients.
The per-person cost of the RAMP-DM program over 5 years totaled a mere $157. Over 5 years, the average per-person total costs incurred by patients in the RAMP-DM program was $7,451 less than that for the usual care patients. The large cost-savings arose from fewer diabetes-related complications and lower costs for those complications in the RAMP-DM program. Looked at another way, eliminating one diabetes complication and reducing the number of deaths by one cost $1,304 and $1,464, respectively, over 5 years. The success of the RAMP-DM program may reflect more education regarding healthy living, improved patient consciousness and motivation for healthy living, and increased doctor awareness of the need for timely treatment. Similar programs could be integrated into diabetes care in the US.