Diabetes linked to obesity driving up hospital costs

People with diabetes make up less than 8 percent of the population, but they represented nearly 20 percent of U.S. hospitalizations in 2008, according to a new report by the federal Agency for Healthcare Research and Quality.

While the bulk of hospitalizations involving diabetics occurred for other conditions, the report noted that because diabetes increases the amount of time patients spend in the hospital, it increases the costs whether the patient is there because of diabetes or another condition.

The report says that the cost of caring for diabetics accounted for 23 percent of the money hospitals spent treating all conditions that year.

“The numbers, I think, tell the story,” said Dr. Emmanuel Javier, medical director of the Diabetes Care Center at St. Francis Hospital and Medical Center in Hartford. “The problem is diabetes is just increasing in incidence here, and obviously we’re going to spend a lot more money on diabetes as a society.”

Dr. Emmanuel Javier

Dr. Emmanuel Javier with a patient (St. Francis Hospital and Medical Center)

An estimated 90 to 95 percent of diabetes cases are type 2 diabetes, a condition linked to obesity that can, in many cases, be delayed or prevented. It used to be known as adult-onset diabetes, but increasingly has been found in children and teenagers.

Diabetes can lead to severe complications – including heart disease, nerve, kidney and eye damage, and amputations. But tight control over the condition can reduce many of the complications, particularly those involving the kidneys, eyes and nerves.

How well patients manage to do that will make a significant difference in the nation’s health, and its health care spending.

In a report released in April, the actuarial firm Milliman Inc., projected that with no prevention or treatment breakthroughs, the number of Americans with type 2 diabetes would rise by 46 percent from 2011 to 2031, more than twice the rate of population growth. For people with the disease, health care expenditures – including costs not related to diabetes – would more than quadruple, from $340 billion to $1.6 trillion, the report projected.

But better managing the disease in patients who already have it could make a significant dent in complications, deaths and health care costs, the report said. A 10 percent drop in the number of diabetic patients failing to meet goals in three key indicators – blood pressure, HDL cholesterol and hemoglobin A1C – could lead to 48,000 fewer diabetes-related complications, 9,700 fewer deaths, and more than $39 billion in savings in 2031.

A 50 percent drop in uncontrolled diabetes, meanwhile, could produce 239,000 fewer complications, 48,700 fewer deaths, and save $196.5 billion.

The Cost of Care

Nationwide, hospitals spent $82.8 billion caring for people with diabetes in 2008, according to the federal report. On average, people with diabetes stayed longer – 5.3 days, compared to 4.4 days for people without diabetes – and had higher costs – $10,937, compared to $8,746.

Circulatory disorders were among the top reasons diabetics were admitted to the hospital, including congestive heart failure, hardening of the arteries, heart attacks and nonspecific chest pain. And patients with diabetes represented 42 percent of hospital stays for congestive heart failure, 38 percent for hardening of the arteries, and 34 percent of hospital stays for heart attacks.

Dr. Latha Dulipsingh

Dr. Latha Dulipsingh (The Hospital of Central Connecticut)

In Connecticut, the number of hospital stays for people with diabetes as a principal diagnosis rose over the past decade. So did the costs.

From 2001 to 2008, Connecticut hospital discharges for patients with diabetes as the principal diagnosis rose from 4,290 to 5,035. The median charge for those hospital stays rose from $8,916 to $14,751, and the total charges increased from $66,025,945 to $127,784,226.

An estimated 6.9 percent of Connecticut adults have been diagnosed with diabetes, according to the most recent figures the state Department of Public Health has, based on a survey conducted from 2006 to 2008. That’s 184,874 people.

And there are likely even more who have the disease but don’t know it. An estimated 5.7 million people had undiagnosed diabetes in 2007, according to the federal Centers for Disease Control and Prevention. In Connecticut, the figure was estimated at 70,000 in data from 2003 to 2005.

That can contribute to the problem. Diagnosing diabetes early and managing it through medication, diet and exercise can go a long way toward avoiding complications, doctors said.

Control and Prevention

At St. Francis, Javier said he sees many patients with misconceptions about diabetes. Some people think there is little that can be done about it and put off getting treatment. So a major part of the treatment is aimed at educating patients.

“By educating them, we can empower them,” he said.

Some hospitalizations occur because people with diabetes have other health problems that may not be caused by diabetes but could be associated with obesity.

“Diabetes may be the tip of the iceberg,” said Dr. Latha Dulipsingh, medical director of the Joslin Diabetes Center Affiliate at The Hospital of Central Connecticut in New Britain.

Still, Dulipsingh said, controlling diabetes can make a significant difference.

“That will lead to less hospitalization, less complications, and less health care costs,” she said.

At the Joslin center, patients are closely monitored for indicators of diabetes control. They’re also checked for high blood pressure, high cholesterol and urine indicators that suggest kidney problems, a way to identify potential complications and treat them early.

Dr. Silvio Inzucchi (Yale-New Haven Hospital)

Dr. Silvio Inzucchi (Yale-New Haven Hospital)

In response to higher rates of diabetes, particularly among patients in the hospital, Yale-New Haven Hospital began focusing on glucose control, a key part of managing diabetes, for inpatients with diabetes. For critically ill patients, they developed an algorithm for administering insulin to control glucose. Since the hospital began using it in 2003, mortality rates for diabetic patients have plummeted, said Dr. Silvio Inzucchi, director of the Yale Diabetes Center and a professor of medicine at Yale University.

For diabetic patients outside intensive care, the hospital created a team to consult on complicated cases. Managing diabetes has become more complicated in the past 10 to 15 years, Inzucchi said, with more medications and types of insulin. That makes it particularly useful to have experts work with patients who have diabetes, he said.

Javier said he expects diabetes to continue rising exponentially, unless other health issues, particularly obesity, are brought under control.

“It’s a major national health problem, and the big thing about it is that we can do something about it,” he said. “Especially type 2 diabetes, it’s something that we can treat aggressively at this point, it’s something that we can change the course of the disease, hopefully prevent the disease in the future.”