Increased cardiovascular disease, resource use, and costs before the clinical diagnosis of diabetes in veterans in the southeastern U.S

J Gen Intern Med. 2015 Jun;30(6):749-57. doi: 10.1007/s11606-014-3075-7. Epub 2015 Jan 22.


Importance: Screening for diabetes might be more widespread if adverse associations with cardiovascular disease (CVD), resource use, and costs were known to occur earlier than conventional clinical diagnosis.

Objective: The purpose of this study was to determine whether adverse effects associated with diabetes begin prior to clinical diagnosis.

Design: Veterans with diabetes were matched 1:2 with controls by follow-up, age, race/ethnicity, gender, and VA facility. CVD was obtained from ICD-9 codes, and resource use and costs from VA datasets.

Setting: VA facilities in SC, GA, and AL.

Participants: Patients with and without diagnosed diabetes.

Main outcome measures: Diagnosed CVD, resource use, and costs.

Results: In this study, the 2,062 diabetic patients and 4,124 controls were 63 years old on average, 99 % male, and 29 % black; BMI was 30.8 in diabetic patients vs. 27.8 in controls (p<0.001). CVD prevalence was higher and there were more outpatient visits in Year -4 before diagnosis through Year +4 after diagnosis among diabetic vs. control patients (all p<0.01); in Year -2, CVD prevalence was 31 % vs. 24 %, and outpatient visits were 22 vs. 19 per year, respectively. Total VA costs/year/veteran were higher in diabetic than control patients from Year -4 ($4,083 vs. $2,754) through Year +5 ($8,347 vs. $5,700) (p<0.003) for each, reflecting underlying increases in outpatient, inpatient, and pharmacy costs (p<0.05 for each). Regression analysis showed that diabetes contributed an average of $1,748/year to costs, independent of CVD (p<0.001).

Conclusions and relevance: VA costs per veteran are higher--over $1,000/year before and $2,000/year after diagnosis of diabetes--due to underlying increases in outpatient, inpatient, and pharmacy costs, greater number of outpatient visits, and increased CVD. Moreover, adverse associations with veterans' health and the VA healthcare system occur early in the natural history of the disease, several years before diabetes is diagnosed. Since adverse associations begin before diabetes is recognized, greater consideration should be given to systematic screening in order to permit earlier detection and initiation of preventive management. Keeping frequency of CVD and marginal costs in line with those of patients before diabetes is currently diagnosed has the potential to save up to $2 billion a year.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Cardiovascular Diseases / diagnosis
  • Cardiovascular Diseases / epidemiology*
  • Case-Control Studies
  • Diabetes Mellitus / diagnosis
  • Diabetes Mellitus / economics*
  • Female
  • Health Care Costs*
  • Health Resources / statistics & numerical data*
  • Health Services Research
  • Humans
  • Male
  • Middle Aged
  • Prevalence
  • Southeastern United States / epidemiology
  • Veterans*