HEALTH CARE AND HUMAN SERVICES POLICY, RESEARCH, AND CONSULTING - WITH REAL-WORLD PERSPECTIVE.
Presented by: Yaozhu (Juliette) Chen, MPA
June 28, 2009

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 Co-authors
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Tim Dall, MS
Grace Yang, MPA
William Quick, MD, FACP
Yiduo Zhang, PhD
Alan Baldwin, MS
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Jane Moran, MD
Victoria Moore, BS
 Navita Sahai, BA
Funded by National Changing Diabetes Program (NCDP)
Citation
 Chen Y, Quick WW, Yang W, et al. Cost of Gestational Diabetes
Mellitus in the U.S. in 2007. Population Health Management. June
2009, 12(3): 165-174. www.lewin.com
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 Cost of Gestational Diabetes Mellitus (GDM) model
 Research design
 Data sources
 Analytical specifics
 Findings
 Strengths and limitations
 Policy implications www.lewin.com
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www.lewin.com
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 Prevalence-based approach
 Focus on medical costs
 Target pregnancies that result in delivery
 Populations to analyze the health care use
 Mothers: 9 months preceding the delivery through 12 months following the delivery
 Newborns: first 12 months of life
 Service delivery setting
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Hospital inpatient and outpatient
Emergency department
Physician office
Attribute risk fractions of GDM www.lewin.com
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Prevalence
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National Hospital Discharge Survey (NHDS) 2003-2005
Case identification: ICD-9-CM code 648.8 at delivery
Health care services
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Hospital inpatient days: Nationwide Inpatient Sample (NIS) 2005
Physician office visits: National Ambulatory Medical Care Survey
(NAMCS) 2000-2005
Emergency and outpatient department visits: National Hospital
Ambulatory Medical Care Survey (NHAMCS) 2000-2005
Pharmaceuticals: NAMCS and NHAMCS 2000-2005
Unit cost per medical event
 NIS 2005 and Medical Expenditure Panel Survey (MEPS) 2003-2005
GDM induced increase in health care use
 Ingenix Research Data Mart (RDM ), extracted 26,911 deliveries in
2005 and mothers were continuously enrolled in 2004-2006 www.lewin.com
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 Direct treatment of GDM
 Maternal outcomes (8 groups)
 Cesarean delivery, polyhydramnios, urinary tract infection, amniotic cavity infection, preeclampsia and eclampsia, other hypertension complicating pregnancy, other pregnancy-related events, and all other maternal care events
 Neonatal outcomes (10 groups)
 Intrauterine hypoxia and birth asphyxia, macrosomia, endocrine and metabolic disturbances specific to the fetus and newborn, birth trauma due to long gestation and high birth weight, fetus or newborn affected by other complications of labor and delivery, respiratory distress syndrome, jaundice, congenital anomalies, other neonatal events, and all other neonatal care events www.lewin.com
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 Etiological fraction method
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Calculate difference in health care use for people with GDM compared to what their health care use would be in absence of GDM
Provide demographic-complication-setting specific estimates of the proportion of national health care use attributed to GDM
 Apply fractions to generate the cost of GDM
 Multiply fractions by estimates of national maternal and neonatal health care use and costs in 2007
 Extrapolation and adjustments
 U.S. population in 2007 using the Census Bureau population estimates
 Cost estimates adjusted to 2007 dollars using medical component of consumer price index www.lewin.com
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P ( RR d
P ( RR d
1)
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ε: etiological fractions
P: GDM prevalence rates
RR: health care use rate ratios
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 c: complication groups of mothers and newborns d: demographic - mother’s age
(for maternal analysis) and newborn’s sex (for newborn analysis) o: outcome measures - hospital inpatient days, emergency visits, other ambulatory visits
(hospital outpatient visits and physician office visits), and pharmaceuticals www.lewin.com
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 Use a generalized linear model (GLM) to estimate a series of demographic-complication-setting specific rate ratios
 With a Poisson distribution and a log link
 Controlling for other determinants of health care use
 Dichotomous control variables, indicating
 Presence of GDM
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Maternal age groups (for maternal analysis only)
 <21,21-25,26-30,31-35, >35
Gender (for newborn analysis only)
 Male and Female
Census region (Northeast, South, West, and Midwest)
Presence of maternal or perinatal complications www.lewin.com
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10%
8%
6%
4%
2%
0%
16%
14%
12%
Age < 21 Age 21-25
NH White
Age 26-30
NH Black
Note: “NH” stands for Non-Hispanic.
Age 31-35
NH Other
Age > 35
Hispanic www.lewin.com
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U.S. Total Pregnant
Women and Their
Offspring
Incurred by Pregnant
Women with GDM and
Their Offspring
Health Resource Use
Mother
Unit (thousands)
Unit
(thousands)
Hospital Inpatient Days 17,423 838
Emergency Visits 3,808 170
Ambulatory Visits 41,438 1,958
Prescriptions 38,435 2,085
Newborn
Hospital Inpatient Days 18,969 873
Emergency Visits 169 8
Ambulatory Visits 5,372 248
Prescriptions 4,928 227
% U.S.
Total
Attributable to GDM
Unit
(thousands)
4.81% 269
4.47% 36
4.73% 651
5.43% 735
4.60% 28
4.63% 1
4.62% 30
4.61% 27
% U.S.
Total
1.54%
0.95%
1.57%
1.91%
0.15%
0.62%
0.56%
0.55% www.lewin.com
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U.S. Total
Pregnant Women and Their
Offspring
Incurred by Pregnant
Women with GDM and
Their Offspring
Medical Cost Dollars (millions)
Dollars
(millions) % U.S. Total
Mother
Hospital Inpatient $ 25,452 $ 1,260
Emergency Department $ 2,125 $ 92
Ambulatory Services $ 8,699 $ 418
Prescriptions $ 3,146 $ 171
Subtotal $ 39,423 $ 1,940
Newborn
Hospital Inpatient $ 24,287 $ 1,092
Emergency Department $ 100 $ 4
Ambulatory Services $ 1,566 $ 70
Prescriptions $ 416 $ 19
Subtotal $ 26,368 $ 1,185
Attributable to GDM
Dollars
(millions)
4.95% $ 386
4.31% $ 20
4.81% $ 130
5.43% $ 60
4.92% $ 596
4.50% $ 28
4.50% $ 1
4.48% $ 9
4.47% $ 2
4.50% $ 40
% U.S.
Total
1.52%
0.93%
1.49%
1.91%
1.51%
0.12%
0.70%
0.55%
0.53%
0.15%
Total (Mother and Newborn) $ 65,791 $ 3,125 4.75% $ 635 0.97%
Note: numbers may not add to totals because of rounding.
www.lewin.com
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 180,000 pregnancies are complicated by GDM every year
 GDM induced per capita costs
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$3,305 per pregnancy for mother
$209 per newborn in the first year of life
 Who paid for the costs imposed by GDM?
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Government programs (primarily Medicaid): 36%
Commercial payers: 56%
Self pay and charity care: 8% www.lewin.com
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 A comprehensive list of pregnancy and newborn complications that the literature suggests may be associated with GDM
 Use of multiple, nationally representative data sources
 A large (n≈27,000) sample of women (and their newborns) with multiple years of medical claims data to analyze the impact of GDM on per capita care use
 A standardized method that was recently used to calculate the national cost associated with pre-diabetes, undiagnosed diabetes, type 1 and type 2 diagnosed diabetes www.lewin.com
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 Use of proprietary data source Ingenix RDM may over represent privately insured
 Claims data tend to be less accurate than clinical data in condition identification
 Estimates do not include
 Intangible costs such as pain, suffering, and reduced quality of life
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Indirect costs such as care provided by non-paid caregivers, increased time off from school, and reduced offspring’s performance in school
Long-term sequelae, e.g., higher risk of developing chronic diseases for both GDM mothers and their offspring www.lewin.com
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 National economic burden of GDM potentially can be reduced by
 Behavior change to prevent GDM
 Early detection of GDM
 Improved management among women diagnosed with GDM
 Timely and appropriate treatment
 Cost estimates of GDM help inform the business case for promoting women and children’s health
 Impact of preventing and treating GDM
 An opportunity of lifetime
 Generational succession of obesity and type 2 diabetes www.lewin.com
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