EAL

MNT: Cost Effectiveness, Cost-benefit, or Economic Savings of MNT (2009)

Citation:

Sheils JF, Rubin R, Stapleton DC. The estimated costs and savings of medical nutrition therapy: the Medicare population. J Am Diet Assoc. 1999; 99: 428-435.

PubMed ID: 10207394

Study Design:

Cost-effectiveness analysis

Class:

M - Click here for explanation of classification scheme.

Quality Rating:

NEUTRAL: See Quality Criteria Checklist below.

Research Purpose:

This study was designed to estimate the savings over a six-year period in utilization of hospital and physician's care resulting from the use of MNT services for diabetes, cardiovascular disease and renal disease.

Inclusion Criteria:

Public and private databases were reviewed and data were selected on persons covered under the Group Health Cooperative (GHC) of Puget Sound
Patients age 55 and older with one of the three diseases were selected to be included in analysis. Persons aged 55 to 64 were selected because most of the disabled persons covered under Medicare are in this age group. Patients with diabetes were identified as having a prescription for insulin, metformin or oral agents; persons with out-of-range hemoglobin A1c results; persons who had been hospitalized with a diagnosis of diabetes (by ICD-9 code).
Persons with cardiovascular disease were identified as having a hospital stay with a diagnosis-related group (DRG) code of 106 to 129, 132, 133, 140, 143. Nitrate prescriptions or prescriptions for drugs related to hyperlipidemia, hypercholesterolemia, hypertension and other cardiovascular conditions.
Persons with renal disease were identified as patients who had a hospital stay with a DRG code of 316 to 333 or selected ICD-9 codes; a blood urea nitrogen measure greater than 45; serum creatinine measure greater than 1.5mg or a proteinuria measure greater than one gram per day.

Exclusion Criteria:

None specified.

Description of Study Protocol:

Recruitment: Data selected for longitudinal review
Design: Cost-effectiveness analysis
Intervention: Use of MNT analyzed
Statistical Analysis: Multivariate regression models of changes in utilization for persons after they receive MNT services.

Data Collection Summary:

Timing of Measurements

Review of over six years.

Dependent Variables

Change in utilization measure from the past quarter to the current quarter. Differences in utilization were estimated for hospital discharges per calendar quarter, physician visits per quarter and other outpatient visits per quarter.

Independent Variables

Use of MNT.

Description of Actual Data Sample:

Initial N

Diabetes: 12,308
Cardiovascular disease: 10,895
Renal disease: 3,328.

Attrition (Final N)

As above.

Age

Age 55 and older.

Ethnicity

Not specified.

Other Relevant Demographics

Percentage of female subjects:

Diabetes: 50.6%
Cardiovascular disease (CVD): 47.0%
Renal: 44.0%.

Anthropometrics

Considered to be representative of Medicare population.

Location

Puget Sound, Washington.

Summary of Results:

	Diabetes Regression Hospital Admission	Diabetes Regression Physician Office Visit	Diabetes Regression Hospital Outpatient Visits	CVD Regression Hospital Admission	CVD Regression Physician Office Visit	CVD Regression Hospital Outpatient Visits	Renal Regression Hospital Admission	Renal Regression Physician Office Visit	Renal Regression Hospital Outpatient Visits
Intercept Regression Result	1.039	-0.264	-0.001	-0.025	-0.232	-0.003	-.030	-0.174	-0.020
Intercept T Statistic	143.032	-3.683	-0.231	1.618	3.354	-0.479	-0.436	-0.757	-0.709
Age x 1,000 Regression Result	-0.278	1.509	0.002	0.108	0.781	0.014	0.010	-0.259	0.117
Age x 1,000 T Statistic	-28.088	1.548	0.032	0.522	0.855	0.192	0.012	-0.090	0.493
Diabetes Med Regression Result	0.014	1.007	0.010	NA	NA	NA	NA	NA	NA
Diabetes Med T Statistic	5.221	37.148	5.110	NA	NA	NA	NA	NA	NA
Intmed Regression Result	3.692	27.869	0.094	2.887	27.267	0.146	3.888	25.843	0.789
Int med T Statistic	7.875	6.030	0.267	2.646	5.679	0.380	0.891	1.783	0.436
Family pr Regression Result	3.106	24.248	0.037	2.083	26.927	0.105	3.434	29.683	0.622
Family pr T Statistic	13.729	10.873	0.219	4.059	11.923	0.577	2.171	5.645	0.947
Hosp Admits Regression Result	-6.022	0.801	0.006	-0.258	0.601	0.010	-0.138	0.054	0.029
Hosp Admits T Statistic	-75.018	1.013	0.098	-1.744	0.923	0.189	-0.359	0.042	0.180
Hosp Outpatient Regression Result	-0.259	-1.819	-0.612	-0.067	-0.534	-0.178	0.121	0.709	-0.776
Hosp Outpatient T Statistic	-1.320	0.941	-4.164	-0.152	-0.275	-1.143	0.137	0.240	-2.105
Phys Visits Regression Result	-0.362	1.243	0.000	0.109	0.757	-0.002	0.114	0.441	0.004
Phys Visits T Statistic	-17.441	6.076	0.018	2.249	3.538	-0.140	0.801	0.932	0.071
Qtr Since Regression Result	-0.056	-6.436	-0.099	-0.910	-5.280	-0.022	-1.513	6.169	0.090
Qtr Since T Statistic	-0.296	-3.438	-0.696	-1.688	-2.225	-0.115	-0.625	-0.767	0.090
Dietsev Regression Result	-1.764	-64.607	0.764	-2.020	-51.091	0.017	-5.430	25.057	0.788
Diet Serv T Statistic	-2.542	-9.441	1.468	-1.021	-5.867	0.025	-0.538	0.747	0.188
Combined Effect of Dietserv and Qtr Since x 100 Regression Result	-1.989	-90.349	0.368	-5.661	-72.211	-0.069	-11.400	3.800	1.149
Combined Effect of Dietserv and Qtr Since x 100 T Statistic	-2.224	-10.247	0.548	-2.225	-6.451	-0.078	-0.936	0.009	0.226
R2	0.0483	0.0084	0.0002	0.0002	0.0010	0.0000	0.0002	0.0012	0.0002
No. (in Quarters)	204,315	204,315	204,315	202.998	202.998	202,998	30,034	30,034	30,034

These regressions estimate changes in service utilization depending on various explanatory variables, including patient age, physician specialty, proxy measures for health status and two measures of MNT service utilization
In interpreting the coefficients it is important to remember that the dependent variable is change in utilization, whereas some independent variables are fixed for the entire observation period and others change.

Other Findings

The analysis indicates that MNT leads to reduced physician and hospital utilization for persons with diabetes (9.5% hospital services, 23.5% physician services) and cardiovascular disease (8.6% hospital services, 16.9% physician services)
The MNT variables in the renal disease equation were not statistically significant, which may be because the sample size was too small
MNT benefits costs will exceed savings for the first three years of the program, but will show modest net savings in 2001 and thereafter.

Author Conclusion:

After an initial period of implementation, coverage for MNT can result in a net reduction in health services utilization and costs for at least some populations. In the case of persons aged 55 years and older, the savings in utilization of hospital and other services will actually exceed the cost of providing the MNT benefit. These results suggest Medicare coverage of MNT has the potential to pay for itself with savings in utilization for other services.

Funding Source:

Not-for-profit

Foundation associated with industry:

Reviewer Comments:

Authors note that even after adjusting for age and health status variations between the Medicare population and GHC beneficiaries, GHC beneficiaries are likely to be healthier than traditional Medicare enrollees, making it difficult to extrapolate results to the general Medicare population.

Quality Criteria Checklist: Review Articles
Relevance Questions
	1.	Will the answer if true, have a direct bearing on the health of patients?	Yes
	1.	Will the answer if true, have a direct bearing on the health of patients?	Yes
	2.	Is the outcome or topic something that patients/clients/population groups would care about?	Yes
	2.	Is the outcome or topic something that patients/clients/population groups would care about?	Yes
	3.	Is the problem addressed in the review one that is relevant to dietetics practice?	Yes
	3.	Is the problem addressed in the review one that is relevant to dietetics practice?	Yes
	4.	Will the information, if true, require a change in practice?	Yes
	4.	Will the information, if true, require a change in practice?	Yes

Validity Questions
	1.	Was the question for the review clearly focused and appropriate?	Yes
	1.	Was the question for the review clearly focused and appropriate?	Yes
	2.	Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described?	Yes
	2.	Was the search strategy used to locate relevant studies comprehensive? Were the databases searched and the search termsused described?	Yes
	3.	Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased?	???
	3.	Were explicit methods used to select studies to include in the review? Were inclusion/exclusion criteria specified andappropriate? Wereselectionmethods unbiased?	???
	4.	Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible?	N/A
	4.	Was there an appraisal of the quality and validity of studies included in the review? Were appraisal methodsspecified,appropriate, andreproducible?	N/A
	5.	Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined?	???
	5.	Were specific treatments/interventions/exposures described? Were treatments similar enough to be combined?	???
	6.	Was the outcome of interest clearly indicated? Were other potential harms and benefits considered?	Yes
	6.	Was the outcome of interest clearly indicated? Were other potential harms and benefits considered?	Yes
	7.	Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described?	Yes
	7.	Were processes for data abstraction, synthesis, and analysis described? Were they applied consistently acrossstudies and groups? Was thereappropriate use of qualitative and/or quantitative synthesis? Was variation in findings among studies analyzed? Were heterogeneity issued considered? If data from studies were aggregated for meta-analysis, was the procedure described?	Yes
	8.	Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included?	Yes
	8.	Are the results clearly presented in narrative and/or quantitative terms? If summary statistics are used, are levels ofsignificance and/or confidence intervals included?	Yes
	9.	Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed?	Yes
	9.	Are conclusions supported by results with biases and limitations taken into consideration? Are limitations ofthe review identified anddiscussed?	Yes
	10.	Was bias due to the review's funding or sponsorship unlikely?	Yes
	10.	Was bias due to the review's funding or sponsorship unlikely?	Yes