Introduction

Approximately 6% of the American population have diabetes. Thus, it should not be a surprise that employees with diabetes are found at all levels of a company, from the mailroom to the boardroom. These hard-working men and women do not want diabetes to prevent them from doing a good job and, with your company's and/or labor union's support for their efforts to manage their disease, they can remain productive and contribute significantly to your organization's success. The purpose of this paper is to provide a rationale for diabetes action by corporate leaders like you.

Why the Worksite? What Can My Company Do?

Because most employees spend more than a third of their waking hours, on average, at the worksite, your company has a unique opportunity to provide them with diabetes education and support. You need not be large; organizations of all sizes can do something to help their employees. Specifically, your company can assist both employees with diabetes and those without diabetes by considering the following steps (which will be discussed in further detail):

• Develop a supportive work environment so that employees with diabetes feel comfortable adopting and performing the behaviors that promote good diabetes control.

• Provide encouragement and opportunities for all employees to adopt healthier lifestyles that reduce risk for chronic diseases.

• Coordinate all corporate diabetes control efforts to make them more efficient as well as accountable within the organization.

• Demand the highest quality medical care for people who are dealing with diabetes.

There are three different types of diabetes:

• Type 1 diabetes (formerly known as insulin-dependent or juvenile-onset diabetes) is usually diagnosed before the age of 30. In this disease, the pancreas produces little or no insulin, which the body needs to control the amount of sugar (glucose) in the blood. People with type 1 diabetes must take insulin to live. They control their disease by taking their insulin, monitoring their blood sugar, eating healthy foods, and engaging in regular physical activity.

• Type 2 diabetes (formerly known as non-insulin-dependent or adult-onset diabetes) is usually diagnosed after the age of 40, but it is becoming increasingly more common among younger people. In type 2 diabetes, the insulin is either produced in insufficient amounts or cannot be used by the body to control blood sugar levels. People with type 2 diabetes control their disease by monitoring their blood sugar levels, eating healthy foods, engaging in regular physical activity, and taking their medications (by mouth or injection), when necessary.

• Gestational diabetes is a condition unique to pregnancy in which the blood sugar becomes elevated because of the mother's insufficient production of insulin or her body's inability to use the insulin properly. Women with gestational diabetes are at increased risk for developing type 2 diabetes later in life.

The goal of any type of diabetes care is to keep blood sugar levels as normal as possible. Complications of diabetes, many of which are more likely if blood sugar is not controlled, include high blood pressure, stroke, eye disease/ blindness, kidney disease, heart disease, foot problems and amputations, complications of pregnancy, and dental disease.

Glycemic Control: A Critical Goal

The key component of any company's diabetes intervention should be the promotion of glycemic (blood sugar) control among its employees. Why is glycemic control critical? Keeping glycemic levels near normal will be a major factor in improving your employees' quality of life and reducing your company's human and economic costs from diabetes and its complications.

Two studies have looked specifically at the effect of glycemic control and diabetes interventions for employees. A 12-week double-blind study (Testa et al., 1998) of 569 individuals who had type 2 diabetes found that those who improved their glycemic (blood sugar) control

• Were more productive on the job (99% versus 87%) and able to remain employed longer (97% versus 85%) than employees who did not control and lower their blood sugar levels.

• Lowered their absenteeism rate by 1% compared with an 8% increase in employees with poor glycemic control. Lost earnings due to absenteeism were estimated at only $24 per worker per month for male employees who improved their glycemic control in comparison with $115 for those with uncontrolled blood sugar.

• Had fewer days of restricted activity and bed rest than those who did not improve their glycemic control. Lost earnings due to restricted activity were $2,660 per 1,000 person-days for male employees with good glycemic control versus $4,275 for those with poor control. For those restricted to bed rest, lost earnings were $1,539 per 1,000 person-days for male employees compared with $1,843 for those with poor glycemic control.

Another study (Burton et al., 1998), performed at the First Chicago NBD Corporation, found that after 3 months of attending a worksite diabetes education program, employees with diabetes had

• Lowered their mean fasting blood sugar from 198 mg/dL to 180 mg/dL.

• Reduced their mean hemoglobin A1c from 9.0% to 8.3%. The hemoglobin A1c test indicates average blood sugar control over a 90-day period and is essential for monitoring blood glucose control.

Although the values in this study were still higher than the ideal blood sugar range, any improvement in glycemic control has been shown to reduce the risk for diabetes-related complications.

A third recent study, conducted by Health Partners, a nonprofit HMO, looked at the inpatient and outpatient cost of its members who had diabetes (Gilmer et al., 1997). The researchers found that those with higher hemoglobin A1c values had higher medical costs over a 3-year period. Expenses were significantly higher for each percentage point increase above a hemoglobin A1c of 7%. For example, the medical costs of a person with a hemoglobin A1c of 9% might average $2,000 more than those for a person with a hemoglobin A1c of 8%. Costs were found to be even higher if the person also had heart disease and high blood pressure.

Please note that the Health Partners study did not demonstrate that lowering glucose levels by the amounts in the study would reduce costs. The program costs to lower glucose levels are also not taken into account. Rather, it showed an association between baseline glycemic control and subsequent health care costs.

Why Is Diabetes Important?

Potentially, any one of your employees could have diabetes now or develop the disease in the future. Diabetes does not discriminate; it can affect anyone, regardless of race, ethnicity, or gender. The statistics on diabetes are staggering:

• In the United States, 15.7 million people have diabetes, but approximately a third do not know it.

• Five to 10% of persons with diabetes have type 1. Although the average age at onset is younger than 30 years, type 1 can occur at any age.

• Ninety to 95% of persons with diabetes have type 2. The average age at onset is 51 years, but an increasing number of younger people are being diagnosed with type 2.

• Diabetes is the seventh leading cause of death in this country and the sixth leading cause by disease.

• In 1997, total expenditures attributed to diabetes and its complications were estimated at over $98 billion per year (with a significant amount attributed to treatment of complications). Approximately 15% of national health care expenditures were for diabetes treatment (American Diabetes Association, 1998).

• Estimated total medical expenditures in 1997 incurred by persons with type 1 or type 2 diabetes were $10,071 per capita per year versus $2,669 for persons without diabetes (American Diabetes Association, 1998).

• Diabetes is the leading cause of adult blindness, kidney failure, and nontraumatic lower-limb amputations.

• Persons with diabetes are 2 to 4 times more likely to have heart disease and stroke than persons without the disease.

• Diabetes is on the rise. Between 1980 and 1994, the number of persons diagnosed with diabetes rose by 2.2 million, an increase of 39%. As with other chronic illnesses, this increase is due to the aging of the U.S. population, the rising rate of obesity, a greater incidence of diabetes found among minority groups, and physical inactivity, especially among women and minority populations.

Thus, no matter how large or small your workforce, your company will be increasingly affected by diabetes. Your employees need your support and assistance to continue to be productive and effective workers.

First Chicago NBD Corporation/Bank One Diabetes Intervention Program

First Chicago NBD Corporation/Bank One offered a worksite diabetes education program to employees in Chicago, Illinois. Employees with either type 1 or type 2 diabetes were identified using the bank's integrated health data warehouse, which includes medical claims, records related to extended absences (the company has a salary continuation benefit that begins after 5 consecutive workdays of absence and may last up to 6 months), and a computer-based medical record. Individuals were then invited to participate. A flier announcing the program was mailed to all employees with diabetes. Components of the program included the following:

• Three questionnaires (filled out by participants) measuring knowledge of diabetes, recent symptoms of diabetes, and a brief medical history form for treatment and history of complications.

• A complete health risk appraisal.

• Blood tests performed at no cost to employees.

• Lunchtime seminars featuring a free box lunch that was consistent with American Diabetes Association (ADA) dietary recommendations.

• A free blood glucose monitor if participants wished to trade in their old one.

• Once-a-month diabetes education by a health educator, including meal planning, nutrition, exercise, medications, strategies for preventing complications, and stress management.

A Commitment Benefiting Everyone

Certainly, diabetes is not the only chronic health problem affecting people in the workplace. However, all employees benefit from strategies for controlling diabetes because these strategies can also reduce the risk for, or help to manage, other chronic diseases, including heart disease, stroke, high blood pressure, obesity, and possibly certain cancers.

Specific actions aimed to control diabetes and prevent its complications will help increase overall employee productivity and company profitability. Diabetes is a complex and serious disease requiring a focused commitment to action by people with the disease, those who support them, and the companies where they work. This commitment, in conjunction with significant advances in the technology available to control the disease, will provide the clinical and therapeutic means to significantly improve outcomes for people with diabetes and reduce the burden associated with the disease and its complications.

Human and Economic
Consequences of Diabetes

The consequences of diabetes and its complications impact your company in two ways: human and economic. The human consequences include a lower quality of life, higher absenteeism, and increased risk of premature death. The economic consequences include lower productivity and greater direct and indirect expenditures for illness and disability.

Human Consequences of Diabetes

Did you know that

• In 1994, more than half of all persons with diabetes (4.1 million at that time) reported that they were limited in activity, and more than 60% attributed their limitation to diabetes (Centers for Disease Control and Prevention, 1997).

• On average, persons with diabetes ages 18 to 64 lost 8.3 days per year from work (American Diabetes Association, 1998).

• In 1997, a total of 74,927 workers were reported to be permanently disabled because of the disease (American Diabetes Association, 1998).

• In 1996, death certificate data listed diabetes as a potential contributing cause of death for more than 193,410 persons. This statistic may be underestimated since diabetes is believed to be underreported on death certificates, both as a condition and as a cause of death (Centers for Disease Control and Prevention, 1998).

Diabetes Activities: What Small Businesses Can Do

A small business could

• Support a walk/run for diabetes.

• Display posters about diabetes on company bulletin boards.

• Have diabetes and other health organizations speak at a brown-bag lunch for employees.

• Distribute diabetes information with employee paychecks (paycheck stuffers).

• Host a Diabetes Day to educate employees about diabetes.

• Send a broadcast e-mail to employees about diabetes.

• Encourage employees to browse Web sites (on their free time) for more information on diabetes. (The employer could recommend Web sites to view.)

Corporate Goals and Actions to Reduce the Human Impact of Diabetes

The statistics on diabetes are not inevitable. Your company can take positive steps to reduce the human impact of diabetes and its complications. Examples of such steps are listed below:

Economic Consequences of Diabetes

Did you know that

• Diabetes-related hospitalizations accounted for 13.9 million hospital days in 1997. The mean length of stay was 5.4 days (American Diabetes Association, 1998).

• In 1997, there were 30.3 million physician office visits to treat people with diabetes (American Diabetes Association, 1998).

Of the $98 billion in total medical expenditures attributed to diabetes in 1997, indirect costs were estimated at $54 billion, with $16.9 billion for premature mortality and $37.1 billion for disability (American Diabetes Association, 1998).

Total direct costs were estimated at $44.1 billion, which broke down as follows:

• $7.7 billion for diabetes and acute glycemic care (control of blood sugar levels).

• $11.8 billion due to the excess prevalence of related chronic complications, e.g., circulatory, kidney, eye, nerve, and skin disorders.

• $24.6 billion due to the excess prevalence of other medical conditions not related to diabetes (American Diabetes Association, 1998).

What does this mean to the average corporation? Various cost-effective interventions (listed on the next several pages) have been identified to improve the health outcomes of diabetes, ultimately affecting the cost of treatment and potentially insuring cost-effective measures for the self-insured employer. All employers can benefit financially from the improvements in employee productivity that diabetes control can generate.

Corporate Goals and Actions To Reduce the Economic Impact of Diabetes

The following are steps your company could take to reduce the economic impact of diabetes and its complications:

General Motors Corporation (GM) Diabetes Intervention Program

General Motors Corporation (GM), with the support of unions represented at GM, implemented LifeSteps, a comprehensive wellness program available to all employees, retirees, and dependents.

Components of the program include:

• A comprehensive nationwide effort to raise health awareness and improve health education about diabetes and other health-related matters. This effort includes the development of a self-care book and health risk appraisal mailed to GM households, a quarterly newsletter, a toll-free Personal Health Advisor Line, a booklet outlining national guidelines related to diabetes and GM's available benefits and services, and the LifeSteps online Web site.

• Pilot programs implemented in Flint, Michigan, and Anderson, Indiana, that go beyond education and prevention to include screenings for modifiable health risks and various interventions aimed at health risk reductions (e.g., a 1-year counseling program with an assigned health professional).

Controlling Diabetes-Related Complications

With all the various health promotion interventions (e.g., programs for heart disease, liver disease, and cancer) currently being offered, companies have to make some serious choices when they allocate money for their own worksite programs. Currently, many companies may be unaware that controlling diabetes means controlling its long-term complications as well as the disease itself.

Long-Term Studies

Diabetes research and management have become top priorities for health care in the United States. This development is due largely to the disease's enormous impact on health care systems and corporations nationwide as well as its tremendous personal cost in the health and productivity of individual men and women. Several long-term studies, most notably the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), have shown that improved glucose control can delay the onset and progression of diabetes complications.

The DCCT (The Diabetes Control and Complications Trial Research Group, 1993) demonstrated that people with type 1 diabetes who kept their blood sugar levels near normal through intensive treatment reduced their risk of:

• Eye disease by 76%

• Kidney disease by 50%

• Nerve disease by 60%

In addition, the DCCT found that each patient who received intensive treatment stood to gain 5 years of life, 8 years of sight, and 6 years without kidney disease, nerve damage, or amputation.

The UKPDS was the longest (23 years) and largest study of people (5,102 participants) with type 2 diabetes to examine whether any health improvements could be gained by aggressively lowering blood glucose (UK Prospective Diabetes Study Group, 1998). The study reinforces the DCCT results by showing that aggressive control of blood glucose and high blood pressure can reduce the risk of:

• Eye disease by 25%

• Kidney disease by 25%

The UKPDS also showed that intensive treatment can lead to a significant reduction in hemoglobin A1c values. This is important because each percentage point reduction (e.g., going from 10.0% to 9.0%) is associated with a 35% decrease in the likelihood that significant damage could be done to the eyes, kidney, and nerves and a 25% decrease in the risk of diabetes-related deaths (UK Prospective Diabetes Study Group, 1998).

Interventions

Cardiovascular Disease

Adults with diabetes have heart disease death rates about 2 to 4 times higher than those adults without the disease (National Institutes of Health, 1999). In 1994, about 44% of all diabetes-related deaths had cardiovascular disease (CVD) listed as the underlying cause of death (Centers for Disease Control and Prevention, 1997). In addition, about 33% of all diabetes-related discharges had CVD as the primary discharge diagnosis (Centers for Disease Control and Prevention, 1997). Establishing control of blood pressure in a person with diabetes can reduce the risk of stroke and heart failure (UK Prospective Diabetes Study Group, 1998).

Diabetic Eye Disease

Diabetes is the leading cause of new cases of blindness in adults 20 to 74 years old (National Institutes of Health, 1999), and detection and treatment of diabetic eye disease has been shown to save money. In fact, computer modeling has shown that the cost of screening and treating eye disease in people with diabetes is $3,190 (1986 dollars) per quality-adjusted life-year (QALY) saved (QALYs account for the increase in years of life and the quality of life during those additional years) versus $5,100 for coronary artery bypass graft surgery or $7,650 for thyroxine (thyroid) screening (Javitt et al., 1996). Still, despite its high level of efficacy, clinical effectiveness, and cost-effectiveness, screening and treatment for diabetic eye disease remains a highly underused technology.

Kidney Disease

Diabetes is the leading cause of end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or a transplant for survival), accounting for about 40% of new cases (National Institutes of Health, 1999). In 1995, approximately 27,900 people initiated treatment for ESRD caused by diabetes (National Institutes of Health, 1999). The annual cost for treatment of ESRD exceeds $2 billion, excluding reduced productivity and employment costs (Harris et al., 1995). Controlling a person's blood glucose and blood pressure (the latter often with an angiotensin-converting enyzyme [ACE] inhibitor) are recognized means of delaying the progression of kidney disease and failure. A study showed that treatment with captopril (a blood pressure medicine that seems to prevent the progression of kidney disease) resulted in absolute direct savings or benefit of $32,550 per patient with type 1 diabetes over a lifetime and $9,990 per patient with type 2. Absolute savings in indirect costs were $84,390 for type 1 and $45,730 for type 2 (Rodby et al., 1996).

Lower-Extremity Abnormalities and Amputations

Diabetes is the leading cause of nontraumatic lower-limb amputations. National Hospital Discharge Survey data for 1994 indicate that 67,000 people with diabetes underwent one or more lower-extremity amputations. Such amputations are frequently preventable; in one randomized study, patients with diabetes who received medical intervention and education for foot and skin care were less likely than patients not receiving this care to have serious foot lesions and skin problems. They were also more likely to report that they practiced appropriate foot care at home and that their legs and feet had been checked by their doctors for ulcers and other problems (Litzelman et al., 1993).

Preconception Care

A study by Elixhauser and colleagues showed that providing preconception counseling and care (in addition to prenatal care) for women with known diabetes resulted in cost savings of $1,720 per participant. Preconception counseling and care includes informing the women about the demands of pregnancy complicated by diabetes, helping them develop good general health practices, and assisting them in achieving good glycemic control through diet, medication, and glucose monitoring. For every dollar expended in the preconception program, $1.86 was saved in direct medical expenses (Elixhauser et al., 1993).

Polaroid Corporation Diabetes Intervention Program

Polaroid Corporation formed the Polaroid Diabetes Support Group. Run by dedicated Polaroid volunteers, the support group's purpose is to educate employees about diabetes and its complications, address fears and concerns associated with diabetes, and encourage a healthy, productive lifestyle. The volunteers conduct quarterly educational meetings and provide a videotape library of lectures for interested employees. They also disseminate a Polaroid-developed handbook on diabetes for managers and supervisors, a newsletter, and periodic mailings to members.

Selecting Successful Strategies for Diabetes Control

Control of individual blood sugar levels and prevention of diabetes-related complications continue to be the focus for effective management of diabetes within the workforce. Accomplishing these goals requires continuity of medical care and individualized education. For your employees with diabetes, the key is encouraging and supporting them to become actively involved in the management of their diabetes. Your efforts will help increase employee productivity and well-being.

Any company-developed intervention, no matter how large or how small, is an investment in your entire workforce and the community as a whole. Any intervention should be tailored to the company's needs and available resources, but small size or limited resources need not be a barrier to designing and implementing an intervention. Smaller companies should consider the greater returns that might be realized by working with several other companies to develop these worksite programs.

Successful strategies for managing and controlling diabetes include (but are not limited to) community support, individual counseling and education, group education and support classes, regular blood sugar testing and screening for complications, and routine followup.

Summary

The cost of uncontrolled diabetes in the United States is a serious issue for your company and its employees. This disease impacts 15.7 million people in the United States (6% of the population).

Employees involved in their own self-management typically have better control of their disease and have fewer or less severe complications (stroke, heart disease, kidney disease, etc.). They are more productive and better able to work with their physicians to achieve the best possible health outcomes for themselves.

Corporate action to improve diabetes care and education will help workers remain productive, decrease diabetes-related complications, and reduce associated costs over time. A dedicated effort and financial investment at the senior management level are essential to achieving these goals.

Information

To obtain more information about NDEP and materials that can support your company's efforts,

• Call 1-800-438-5383 or visit the program's Web site: ndep.nih.gov or CDC's Web site: www.cdc.gov/diabetes.

New diabetes research and technology can help detect, treat, and control the disease, thus preventing unnecessary illness and premature death. Employees with diabetes can live longer, healthier lives with your support.

References

American Diabetes Association. Clinical practice recommendations, 1999. Diabetes Care 22 (Supplement 1):S1-114, 1999.

American Diabetes Association. Diabetes facts and figures, 1997. Alexandria, Viriginia: American Diabetes Association, 1998. www.diabetes.org/ada/c20f.asp

American Diabetes Association. Economic consequences of diabetes mellitus in the United States in 1997. Diabetes Care 21:296-309, 1998.

Burton WN, Connerty CM. Evaluation of a worksite-based patient education intervention targeted at employees with diabetes mellitus. J Occup Environ Med 40:702-706, 1998.

Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes in the United States. Atlanta, Georgia: U.S. Department of Health and Human Services Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1998. www.cdc.gov/nccdphp/ddt/pubs/facts98.htm

Centers for Disease Control and Prevention. Diabetes Survelliance, 1997. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1997.

The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-986, 1993.

Elixhauser A, Weschler JM, Kitzmiller JL, et al. Cost-benefit analysis of preconception care for women with established diabetes mellitus. Diabetes Care 16:1146-1157, 1993.

Gilmer TP, O'Connor PJ, Manning WG, Rush WA. The cost to health plans of poor glycemic control. Diabetes Care 20:1847-1853, 1997.

Javitt JC, Aiello LP. Cost-effectiveness of detecting and treating diabetic retinopathy. Ann Intern Med 124:(1 Pt 2) 164-169, 1996.

Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus: a randomized, controlled trial. Ann Intern Med 119:36-41, 1993.

National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes statistics, 1999. Bethesda, Maryland: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1999. www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm

Harris MI et al. Diabetes in America, 2nd Edition. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, D.C: U. S. Government Printing Office, 1995.

Rodby RA, Firth LM, Lewis EJ. An economic analysis of captopril in the treatment of diabetic nephropathy. Diabetes Care 19:1051-1061, 1996.

Selby JV, Ray GT, Zhang D, Colby CJ. Excess costs of medical care for patients with diabetes in a managed care population. Diabetes Care 20:1396-1402, 1997.

Testa MA, Simonson DC. Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus: a randomized, controlled, double-blind trial. JAMA 280:1490-1496, 1998.

UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. Br Med J 317:703-713, 1998.

Recommended Reading

Barrett A, Licking E, Rae-Dupree J. New weapons to cut diabetes' toll: breakthrough drugs may help stem the surging epidemic. Business Week 58-60, March 29, 1999.

Centers for Disease Control and Prevention Diabetes Cost-Effectiveness Study Group. The cost-effectiveness of screening for type 2 diabetes. JAMA 280:1757-1763, 1998.

Centers for Disease Control and Prevention. Division of Diabetes Translation Web site. www.cdc.gov/diabetes/

The Diabetes Control and Complications Trial Research Group. Limited benefits and costs of intensive therapy as practiced in the Diabetes Control and Complications Trial. JAMA 276:1409-1415, 1996.

Diabetic Retinopathy Study. Photocoagulation treatment of proliferative diabetic retinopathy: the second report of Diabetes Retinopathy Study findings. Ophthalmology 85:82-106, 1978.

Early Treatment of Diabetic Retinopathy Study Research Group. Early photocoagulation for diabetic retinopathy. ETDRS report number 9. Ophthalmology 98:766-785, 1991.

Harris MI et al. Diabetes in America, 2nd Edition. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, D.C.: U. S. Government Printing Office, 1995.

National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Diseases Web site. www.niddk.nih.gov/

Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 20:537-544, 1997.

Pyorala K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care 20:614-620, 1997.

Siegel JE, Krolweski AS, Warram JH, Weinstein MC. Cost-effectiveness of screening and early treatment of nephropathy in patients with insulin-dependent diabetes mellitus. J Am Soc Nephrol 3(Supplement 4):S111-119, 1992.