Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Background: Education is well known to influence the efficiency of production both in the workplace and at home. Because of the importance of variation in individual preferences with respect to health, the effects of education on the efficient production of health may be especially important. We use unique data on patient preferences and treatment choices for diabetes care to test whether the effectiveness and cost-effectiveness of diabetes care vary by patients' level of education.

Methods: We interviewed 543 adults with type 2 diabetes to determine their utility values for health states relating to common diabetic complications and treatments and their choice of therapy. We then used a simulation model developed previously by the CDC to assess the cost-effectiveness of intensive therapy for the population as a whole and for the set of patients who chose intensive therapy and then tested whether these patterns differed for patients with less than a high school education compared to those with a high school education or more.

Results: The mean age of subjects was 62 years. 58% were women. 43% were African-American, 30% White, and 27% Latino. 188 had some high school, 143 were high school graduates, 179 had some college and 126 had at least a college education. 31% of patients reported using intensive therapy. The mean utility for intensive glucose control was 0.67 (SD 0.33) and the mean value for conventional control was 0.75 (0.30).

Utilities for complications were similar to prior estimates, and were similar between patients on intensive and conventional therapies. However, patients on intensive therapy had higher utilities for intensive therapy than did patients on conventional therapy. When patient utilities were used in the cost-effectiveness model, intensive therapy for diabetes was harmful on average for the full population of patients with diabetes (mean Dcosts $8007, mean ∆QALYs -0.35) but beneficial and cost-effective for the patients who select it (mean ∆costs $7777, mean ∆QALYs 0.18, ICER $43K/QALY). When these results were stratified by education level, utilities were not statistically different between across education groups, with intensive therapy harmful in all educational groups. However, once self-selection was accounted for, intensive therapy was beneficial and cost-effective in every educational group except among those persons with less than a high school education, where there was no evidence of a health benefit.

Conclusions: Cost-effectiveness results for diabetes care are dramatically altered by accounting for preference heterogeneity and patient selection of treatment choice among patients with a high school education or more. Interventions to help less educated patients better individualize their care may be highly valuable.