Cost-Effectiveness of Medical Nutrition Therapy Provided by Dietitians for Persons with Non–Insulin-Dependent Diabetes Mellitus

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Abstract

Objective To conduct a cost analysis and cost-effectiveness study based on a randomized clinical trial of basic nutrition care (BC) and practice guidelines nutrition care (PGC) provided by dietitians in outpatient clinics.

Design Subjects with non–insulin-dependent diabetes mellitus (NIDDM) from three states (Minnesota, Florida, Colorado) were randomly assigned to a group receiving BC or a group receiving PGC for a 6-month clinical trial. Along with data about medical and clinical outcomes, data about cost resources were collected. The cost-effectiveness of PGC compared with BC was calculated using per-patient costs and glycemic outcomes for the 6 months of the study. A net cost-effectiveness ratio comparing BC and PGC, including the cost savings resulting from changes in medical therapy, was also calculated.

Subjects The study reports on a sample of 179 subjects with NIDDM between the ages of 38 and 76 years who completed the clinical trial.

Results Patients in the PGC group experienced a mean 1.1±2.8 mmol/L decrease in fasting plasma glucose level 6 months after entry to the study, for a total per-patient cost of $112. PGC costs included one glycated hemoglobin assay used by the dietitian to evaluate nutrition outcomes. Patients in the BC group experienced a mean 0.4±2.7 mmol/L decrease, for a total per-patient cost of $42. In the PGC group, 17 persons had changes in therapy, which yielded an average 12-month cost savings prorated for all patients of $31.49. In contrast, in the BC group, 9 persons had changes in therapy, for an average 12-month prorated cost savings of $3.13. Each unit of change in fasting plasma glucose level from entry to the 6-month follow-up can be achieved with an investment of $5.75 by implementing BC or of $5.84 by implementing PGC. If net costs are considered (per-patient costs – cost savings due to therapy changes), the cost-effectiveness ratios become $5.32 for BC and $4.20 for PGC, assuming the medical changes in therapy were maintained for 12 months.

Applications These findings suggest that individualized nutrition interventions can be delivered by experienced dietitians with a reasonable investment of resources. Cost-effectiveness is enhanced when dietitians are engaged in active decision making about intervention alternatives based on the patient's needs. J Am Diet Assoc. 1995; 95:1018-1024.

Section snippets

Methods

The economic analysis was defined as a cost-effectiveness analysis from the perspective of the health care organization. Effectiveness focused on indicators of glucose control, which are described herein, and costs were limited to direct health care costs as documented through an accounting approach. Inputs and outcomes were estimated for the short-term period of 6 months. Protocols for documentation and costing were planned in the original study design and were approved by the research review

Results

The analysis is based on 179 adults with NIDDM aged 38 to 78 years who were free of serious diabetes complications or comorbidities contraindicated in the study protocol. Characteristics of the study groups have been reported (11).

The mean time spent with the dietitian for BC subjects was 65±20 minutes, and it varied significantly by site: Florida=83±28 minutes, Minnesota=63±15 minutes, Colorado=55±8 minutes. The mean time with the dietitian for PGC subjects was 151±53 minutes; it also varied

Discussion

A major strength of this study was the random assignment of patients to two nutrition care options in three different areas of the United States. As a result, a wide range of ages, income levels, and ethnic backgrounds were represented, and both genders were included. Implementing the study at different sites reduced the potential influence on costs and outcomes of practice styles, patient attitudes and characteristics, and administrative policies and practices of a single study site.

The study

Applications

Medical professionals, including dietitians, must be skilled riot only in providing high-quality care that leads to desired health outcomes but also in evaluating the costs associated with this care. When a new or modified technology or protocol is introduced into clinical practice, it is important to evaluate its clinical effectiveness and its cost. Such assessments are essential in determining whether to replace an existing treatment with the new protocol. Carefully planned evaluations can

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