The GIMeC (Government Industrial Medical Coalition) ignorance fairy has been busy lately, flying around waving her crooked wand at the unsuspecting public. The claim this time is that efforts to prevent diabetes save money. Two articles making this claim were published at nearly the same time.
The first was an article in the Wall Street Journal called Wider Testing to Head Off Diabetes Before It Hits by one of their reporters, Laura Landro. She quotes the American Diabetes Association that 79 million Americans are prediabetic, and that there should be more screening programs to detect these patients early – another know-your-number campaign. In her article, she uses the usual techniques to scare her readers. She states that the GPs of America are too stupid to know what to do:
Many primary-care doctors around the country “fail to recognize the mild aberrations which identify people as being prediabetic or diabetic,” says James Lederer, Novant’s vice president for clinical improvement. Even when they perform blood sugar tests, physicians may dismiss elevated results as “a touch of the sugar,” too borderline to be taken seriously, Dr. Lederer says.
Then she states that when the subject patient of her article goes to the expert, all is good:
Ms. Roundtree, who works with teens in a school program, says she has lost several pounds, exercises regularly and follows a careful diet plan since getting her diagnosis. She also sees her doctor every three months. In July, another A1C test showed Ms. Roundtree’s blood-sugar reading just below the prediabetic range.
Says Dr. Evans: “We caught it very early and intervened, and hopefully she is going to be one of the ones who with lifestyle changes are not going to suffer any of the negative complications of diabetes.”
The waste of a doctor asking Ms. Roundtree to be seen every three months to draw blood from her into eternity doesn’t even cross the reporter’s mind.
Next, we have an editorial in the New England Journal of Medicine pushing for more pre-diabetes testing and treatment. It criticizes CMS for not covering lifestyle intervention because the US Preventive Services Task Force (USPSTF) “has not issued a recommendation on diabetes-prevention services.” It also quotes one cost-effectiveness study as claiming that lifestyle intervention “led to substantial health benefits and health care cost savings.”
Now let’s get our facts straight.
A comprehensive review of diabetes interventions published in 2010 (in the Diabetes Association journal, by the way) found that diabetes preventive efforts are “very cost-effective,” but do not save money.
The USPSTF in fact has reviewed the evidence for lifestyle interventions in pre-diabetes and found several studies showing a modest decrease in diabetes-related outcomes in high-risk people willing to undergo intensive lifestyle interventions. The USPSTF also noted the wide discrepancy in cost-effectiveness estimates on this topic in the literature.
An article on the cost-effectiveness of diabetes prevention by one of the founders of the science of health care cost-effectiveness, David Eddy, MD, using a model he developed to estimate the long-term effects of diabetes and its co-morbid conditions – the Archimedes model – found the cost-effectiveness ratio of lifestyle interventions to be very high (meaning the bang for the buck was very expensive). He wrote, “The program used in the DPP study may be too expensive for health plans or a national program to implement. Less expensive methods are needed to achieve the degree of weight loss seen in the DPP.”
And what about the British? Their National Institute for Health and Clinical Excellence (NICE) supports early lifestyle intervention only for high-risk patients, not the general population. This conclusion means they feel the intervention is cost-effective, but does not mean the intervention saves money in the long run.
Therefore, the totality of evidence is that intensive lifestyle interventions delay some cases of diabetes by 7 or so years in high-risk people — for example, obese 50-year-olds with high blood pressure. This delay results in slightly fewer bad outcomes. But the costs of the interventions on the front end are not made up by savings later on. According to the Eddy article: “Compared with no prevention program, the DPP lifestyle program would reduce a high-risk person’s 30-year chances of getting diabetes from about 72% to 61%, the chances of a serious complication from about 38% to 30%, and the chances of dying of a complication of diabetes from about 13.5% to 11.2%.” The intensive lifestyle intervention helps, but not very much.
The pre-diabetes screening noise is part of the larger red herring movement of wellness and prevention in corporate insurance plans. The prevention-pushers claim the usual something-for-nothing outcomes, and GIMeC once again diverts us from the more difficult conversations we must have to lower healthcare costs in this country.