Incidence and costs of severe hypoglycaemia requiring attendance by the emergency medical services in South Central England

Incidence and costs of hypoglycemia in insulin-treated diabetes in Switzerland: A health-economic analysis

AIMS

We assess the incidence and economic burden of severe and non-severe hypoglycemia in insulin-treated diabetes type 1 and 2 patients in Switzerland.

METHODS

We developed a health economic model to assess the incidence of hypoglycemia, the subsequent medical costs, and the production losses in insulin-treated diabetes patients. The model distinguishes between severity of hypoglycemia, type of diabetes, and type of medical care. We used survey data, health statistics, and health care utilization data extracted from primary studies.

RESULTS

The number of hypoglycemic events in 2017 was estimated at 1.3 million in type 1 diabetes patients and at 0.7 million in insulin-treated type 2 diabetes patients. The subsequent medical costs amount to 38 million Swiss Francs (CHF), 61 % of which occur in type 2 diabetes. Outpatient visits dominate costs in both types of diabetes. Total production losses due to hypoglycemia amount to CHF 11 million. Almost 80 % of medical costs and 39 % of production losses are due to non-severe hypoglycemia.

CONCLUSIONS

Hypoglycemia leads to substantial socio-economic burden in Switzerland. Greater attention to non-severe hypoglycemic events and to severe hypoglycemia in type 2 diabetes could have a major impact on reducing this burden.

Randomised controlled trial of an innovative hypoglycaemia pathway for self-care at home and admission avoidance: a partnership approach with a regional ambulance trust

Background

Hypoglycaemia is a common and potentially life-threatening condition in people with diabetes, commonly caused by medications such as insulin. Hypoglycaemic events often require in-patient treatment and/or follow-up with a diabetes specialist nurse (DSN) or GP to make adjustments to medication. This referral pathway commonly relies on patient self-referral to primary care, and as a result many patients are not actively followed up and go on to experience repeat hypoglycaemic events.

Methods

Randomised controlled trial in partnership with East Midlands Ambulance Service NHS Trust. People with diabetes calling out an ambulance for a severe hypoglycaemic episode and meeting the eligibility criteria were randomised to either a novel DSN-led pathway or to their general practice for routine follow-up. Primary outcome was proportion of participants with a documented consultation with a healthcare professional to discuss the management of their diabetes within 28 days of call-out.

Results

162 people were randomised to one of the pathways (73 DSN arm, 89 GP arm) with 81 (50%, 35 DSN, 46 GP) providing full consent to be followed up. Due to lower than anticipated randomisation and consent rates, the recruitment target was not met. In the 81 participants who provided full consent, there were higher rates of consultation following the call-out when referred to a DSN compared to primary care (90% vs. 65%). Of the 81 participants, 26 (32%) had a second call-out within 12 months.

Conclusions

Consultation rates following the call-out were high in the DSN-led arm, but there was insufficient power to complete the planned comparative analysis. The study highlighted the difficulty in recruitment and delivery of research in pre-hospital emergency care. Further work is needed to provide more feasible study designs and consent procedures balancing demands on ambulance staff time with the need for robust well-designed evaluation of referral pathways.

Cross-sectional analysis of emergency hypoglycaemia and outcome predictors among people with diabetes in an urban population

AIMS/HYPOTHESIS

Out-of-hospital hypoglycaemia is a common complication for individuals with diabetes mellitus and represents a significant burden to emergency medical services (EMS). We aim to identify the factors associated with receiving parenteral treatment and hospital conveyance.

METHODS

We retrospectively analysed a 6-month data set of all London EMS hypoglycaemia. Individuals with a known diabetes diagnosis were included in our analysis and stratified as either having type 1 diabetes or type 2 diabetes.

RESULTS

A total of 2862 incidents occurred within the area served by London Ambulance Service between January and June 2018. Fifty percent of incidents required parenteral treatment (intravenous glucose or intramuscular glucagon) and were conveyed to hospital. A higher arrival of blood glucose, intact consciousness and receiving oral glucose treatment were all negative predictors for requiring parenteral therapy. Forty-three percent of incidents were labelled as 'hypoglycaemia' by the EMS call handler, and greater odds of hospitalisation were observed among incidents that received parenteral treatment (OR 2.52 [95% CI 1.46, 4.33] p < 0.01) and individuals with type 2 diabetes (OR 2.67 [95% CI 1.52, 4.71] p < 0.01). Repeated callouts from 2% (n = 50) of individuals accounted for 10% (286) of all incidents attended, and 56.4% of individuals attended by EMS on more than one occasion had type 1 diabetes.

CONCLUSIONS/INTERPRETATION

Severe hypoglycaemia requiring emergency service attendance remains common, as does the requirement for parenteral therapy and conveyance to hospital. Early intervention, education and improved accessibility to risk prevention strategies may reduce the necessity for emergency parenteral treatment and hospitalisation, especially among individuals suffering from recurrent hypoglycaemia and high-risk individuals with type 2 diabetes.

Hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

People with diabetes mellitus commonly experience hypoglycemia, but they may not necessarily present to hospital after severe hypoglycemia requiring paramedic assistance. We sought to describe the incidence and characteristics of calls for hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada, and to determine predictors of hospital transport.

METHODS

This population-based retrospective cohort study used data extracted from ambulance call reports (ACRs) of 8 paramedic services of the Southwest Ontario Regional Base Hospital Program from January 2008 to June 2014. We described calls in which treatment for hypoglycemia was administered, summarized the incidence of hypoglycemia calls and performed logistic regression to determine predictors of hospital transport.

RESULTS

Out of 470 467 ACRs during the study period, 9185 paramedic calls occurred in which hypoglycemia treatment was administered to an adult (mean age 60.2 yr, 56.8% male, 81.1% with documented diabetes). Refusal of hospital transport occurred in 2243 (24.4%) of calls. Documented diabetes diagnosis (adjusted odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69-0.96), higher capillary blood glucose (adjusted OR 0.31, 95% CI 0.22-0.44) and overnight calls (adjusted OR 0.80, 95% CI 0.72-0.91) were associated with lower odds of hospital transport. Higher-acuity calls (adjusted OR 2.05, 95% CI 1.58-2.66) were associated with higher odds of transport. The estimated annual incidence rate of hypoglycemia requiring paramedic assistance was 108 per 10 000 people with diabetes per year.

INTERPRETATION

Hypoglycemia requiring paramedic assistance in southwestern Ontario is common, and close to 25% of calls do not result in hospital transport. Physicians managing diabetes care may be unaware of patients' hypoglycemia requiring paramedic care, suggesting a potential gap in follow-up care; we suggest that paramedics play an important role in identifying those at high recurrence risk and communicating with their care providers.

Patient and paramedic experiences with a direct electronic referral programme for focused hypoglycaemia education following paramedic service assist-requiring hypoglycaemia in London and Middlesex County, Ontario, Canada

AIMS

Hypoglycaemia is a common treatment consequence in diabetes mellitus. Prior studies have shown that a large proportion of people with paramedic assist-requiring hypoglycaemia prefer not to be transported to hospital. Thus, these episodes are "invisible" to their usual diabetes care providers. A direct electronic referral programme where paramedics sent referrals focused hypoglycaemia education at the time of paramedic assessment was implemented in our region for 18 months; however, referral programme uptake was low. In this study, we examined patient and paramedic experiences with a direct electronic referral programme for hypoglycaemia education postparamedic assist-requiring hypoglycaemia, including barriers to programme referral and education attendance.

METHODS

We surveyed paramedics and conducted semistructured telephone interviews of patients with paramedic-assisted hypoglycaemia who consented to the referral programme and were scheduled for an education session in London and Middlesex County, Canada.

RESULTS

Paramedics and patient participants felt that the direct referral programme was beneficial. A third of paramedics who responded to our survey used the referral programme for each encounter where they treated patients for hypoglycaemia. Patients felt very positive about the referral programme and their paramedic encounter; however, they described embarrassment, guilt and prior negative experience as key barriers to attending education.

CONCLUSIONS

Paramedics and patients felt that direct referral for focused hypoglycaemia education postparamedic assist-requiring hypoglycaemia was an excellent strategy. Despite this, referral programme participation was low and thus there remain ongoing barriers to implementation and attendance. Future iterations should consider how best to meet patient needs through innovative delivery methods.

Factors influencing hospital conveyance following ambulance attendance for people with diabetes: A retrospective observational study

AIM

To assess variables contributing to hospital conveyance for people with diabetes and the interactions between them. A secondary aim was to generate hypotheses for further research into interventions that might reduce avoidable hospital admissions.

METHODS

A national retrospective data set including 30 999 diabetes-related callouts from the Scottish Ambulance Service was utilized covering a 5-year period between 2013 and 2017. The relationship between diabetes-related hospital conveyance and seven potential risk factors was analysed. Independent variables included: age, gender, deprivation, paramedic attendance, treatment at the scene, first blood glucose measurement and day of the week.

RESULTS

In Scotland, hyperglycaemia was associated with a higher number of people being conveyed to hospital than hypoglycaemia (49.8% with high blood glucose vs. 39.3% with low glucose, P ≤ 0.0001). Treatment provided in pre-hospital care was associated with reduced conveyance rates (47.3% vs. 58.2% where treatment was not administered, P ≤ 0.0001). Paramedic attendance was also associated with reduced conveyance to hospital (51.4% vs. 59.5% where paramedic was not present, P ≤ 0.0001). Paramedic attendance in hyperglycaemic cases was associated with significantly reduced odds of conveyance (odds ratio 0.52, P ≤ 0.001).

CONCLUSIONS

A higher rate of conveyance associated with hyperglycaemic cases indicates a need for more resources, education and training in this area. Higher conveyance rates were also associated with no paramedic being present and no treatment being administered. This suggests that paramedic attendance may be crucial in reducing avoidable admissions. Developing and validating protocols for pre-hospital services and treatment may help to reduce hospital conveyance rates.

Examination of the clinical factors associated with attendance at emergency departments for chronic pain management and the cost of treatment relative to that of other significant medical conditions

ABSTRACT

Little is known about risk factors for emergency department (ED) attendance for chronic pain (CP) management and the relative service burden. We examined ED utilisation in patients with CP, identified risk factors associated with attendance for chronic musculoskeletal pain (CMP), and estimated the comparative cost of treatment. The study cohort comprised a random sample of 3700 adults from the general population in Tayside, Scotland. Linked regional extracts, spanning a 12-month period, were obtained from national registers, providing information on ED attendances, community-dispensed prescribing, and outpatient clinic attendances. The National Health Service Scotland Cost Book was used to ascertain the current average cost of an ED attendance (£130; ∼$167). All-cause ED attendance was higher in those with CP (68.5%; n = 252) than without (29.3%; n = 967). In the entire cohort, more patients attended the ED for the treatment of CMP than for any other medical condition (n = 119; 32.3% of those with CP). Risk factors for ED attendance for CMP were: recent analgesic dose decreases (OR = 4.55); and transitioning from opioid to nonopioid analgesics (OR = 5.08). Characteristics protective of ED attendance for CMP were: being in receipt of strong opioids (OR = 0.21); transitioning from nonopioid to opioid analgesics (OR = 0.25); recent analgesic dose increases (OR = 0.24); and being prescribed tricyclic antidepressants (OR = 0.10), benzodiazepines (OR = 0.46), or hypnotics (OR = 0.45). Chronic musculoskeletal pain was one of the most expensive conditions to treat (£17,680 [∼$22,668] per annum), conferring a substantial burden on ED services. Improved understanding of the risk/protective factors could inform healthcare redesign to reduce avoidable ED attendances for CMP management.

Hypoglycaemia in older home-dwelling people with diabetes- a scoping review

BACKGROUND

Hypoglycaemia is associated with cognitive and functional decline in older people with diabetes. Identification of individuals at risk and prevention of hypoglycaemia is therefore an important task in the management of diabetes in older home-dwelling individuals. The purpose of this scoping review was to map the literature on hypoglycaemia in home-dwelling older people with diabetes.

METHODS

This scoping review included original research articles on hypoglycaemia in older (≥ 65 years) individuals with diabetes from developed countries. A broad search of the databases Cinahl, Embase and Medline was performed in July 2018. The report of the scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews.

RESULTS

Our database search identified 577 articles of which 23 were eligible for inclusion. The identified literature was within four areas: 1) incidence of hypoglycaemia in older home-dwelling people with diabetes (11/23 articles), 2) risk factors of hypoglycaemia (9/23), 3) diabetes knowledge and self-management (6/23) and 4) consequences of hypoglycaemia for health care use (6/23). The majority of the literature focused on severe hypoglycaemia and the emergency situation. The literature on diabetes knowledge and management related to preventing adverse events relevant to older home-dwellers, was limited. We found no literature on long-term consequences of hypoglycaemia for the use of home health care services and the older persons' ability to remain home-dwelling.

CONCLUSIONS

We identified a lack of studies on prevention and management of hypoglycaemia in the older individuals' homes. Such knowledge is of utmost importance in the current situation where most western countries' governmental policies aim to treat and manage complex health conditions in the patient's home. Future studies addressing hypoglycaemia in older individuals with diabetes are needed in order to tailor interventions aiming to enable them to remain home-dwelling as long as possible.

Continuous glucose monitoring in older people with diabetes receiving home care-a feasibility study

Background

Hypoglycemic incidents in older people can cause severe health problems, enhance general age-related disabilities, and cause frailty. Little is known about incidences of hypoglycemia in older home-dwelling people with diabetes. Thus, the aim of this study was to examine the feasibility of capturing hypoglycemia and issues associated with increased risk of hypoglycemia by use of continuous glucose monitoring (CGM) and standardized questionnaires among older home-dwelling individuals with diabetes type 2 receiving home care.

Methods

CGM with the Ipro2-blinded monitoring system were performed for 5 days in six home-dwelling individuals ≥ 75 years diagnosed with diabetes and receiving home care. Demographic (age, gender, living arrangements) and clinical data (diabetes diagnoses and duration, diabetes medication, documented treatment goal, available glycosylated hemoglobin (HbA1c)) were collected from electronic patient records in home care services. Feasibility (ease of use, quality of data, time spent) of standardized questionnaires to identify the risk of hypoglycemia (the McKellar Risk Assessment Tool), risk of malnutrition (the Mini Nutritional Assessment (MNA)), functional status (the Individual-based Statistics for Nursing and Care Services (IPLOS)), and cognitive status (the Mini Mental Status Exam (MMSE)) was also assessed. Questionnaire data was collected by a study nurse in the individuals’ home.

Results

The practical use of CGM was satisfactory, with no major remarks about discomfort or technical errors, except for one participant with skin reaction (redness). Collecting data with the McKellar Risk Assessment Tool, MNA and IPLOS worked well according to quality of data, time spent, and ease of use. The MMSE survey required extensive training of personnel to be conducted.

Conclusion

The feasibility study informs an upcoming study on the incidence and risk factors of hypoglycemia in home-dwelling older individuals. We will ascertain that personnel who will use the MMSE questionnaire to collect cognitive status and skills are familiar with the tool and adequately educated and trained before study start. The use of blinded CGM in this population was well tolerated and can be used “as is” for future studies.

Incidence and prevalence of hypoglycaemia in type 1 and type 2 diabetes individuals: A systematic review and meta-analysis

BACKGROUND

Previous meta-analysis investigating the incidence and prevalence of hypoglycaemia in both types of diabetes is limited. The purpose of this review is to conduct a systematic review and meta-analysis of the existing literature which investigates the incidence and prevalence of hypoglycaemia in individuals with diabetes.

METHODS

PubMed, Embase and Cochrane library databases were searched up to October 2018. Observational studies including individuals with diabetes of all ages and reporting incidence and/or prevalence of hypoglycaemia were included. Two reviewers independently screened articles, extracted data and assessed the quality of included studies. Meta-analysis was performed using a random effects model with 95% confidence interval (CI) to estimate the pooled incidence and prevalence of hypoglycaemia in individuals with diabetes.

RESULTS

Our search strategy generated 35,007 articles, of which 72 studies matched the inclusion criteria and were included in the meta-analysis. The prevalence of hypoglycaemia ranged from 0.074% to 73.0%, comprising a total of 2,462,810 individuals with diabetes. The incidence rate of hypoglycaemia ranged from 0.072 to 42,890 episodes per 1,000 person-years: stratified by type of diabetes, it ranged from 14.5 to 42,890 episodes per 1,000 person-years and from 0.072 to 16,360 episodes per 1,000-person years in type 1 and type 2 diabetes, respectively.

CONCLUSION

Hypoglycaemia is very common among individuals with diabetes. Further studies are needed to investigate hypoglycaemia-associated risk factors.

Rationale and protocol for the Assessment of Impact of Real-time Continuous Glucose Monitoring on people presenting with severe Hypoglycaemia (AIR-CGM) study

BACKGROUND

Severe hypoglycaemia carries a significant risk of morbidity and mortality for people with type 1 diabetes. Economic costs are also high, estimated at approximately £13 million annually in England, UK. Continuous glucose monitoring (CGM) has been shown to reduce hypoglycaemia and associated fear, improve overall glycaemia and quality of life, and is cost-effective. Despite effective pathways in place with high levels of resource utilization, it has been reported there are low levels of follow-up, therapy change and specialist intervention after severe hypoglycaemia. This study is designed to assess the impact of providing real-time CGM to people with type 1 diabetes, who have had a recent episode of severe hypoglycaemia (within 72 h), compared to standard care.

METHODS/DESIGN

Fifty-five participants with type 1 diabetes and a recent episode of severe hypoglycaemia, who are CGM naïve, will be recruited to the study. Participants will be randomised to CGM or standard care. The primary outcome is percentage time spent in hypoglycaemia (< 3.0 mmol/L, 55 mg/dL). Secondary outcomes include other measures of hypoglycaemia, time in euglycaemia, overall glucose status and patient reported qualitative measures.

DISCUSSION

This study assesses the impact of providing continuous glucose monitoring at the outset in individuals at highest risk of hypoglycaemia. Changing demand means that novel approaches need to be taken to healthcare provision. This study has the potential to shape future national standards.

TRIAL REGISTRATION

NCT03748433 , November 2018 (UK).

Deintensification in older patients with type 2 diabetes: A systematic review of approaches, rates and outcomes

AIM

To assess deintensification approaches and rates and evaluate the harm and benefits of deintensification with antidiabetic medication and other therapies among older people (≥ 65 years) with type 2 diabetes with or without cardiometabolic conditions.

METHODS

We identified relevant studies in a literature search of MEDLINE, Embase, Web of Science and Cochrane databases to 30 October 2018. Data were extracted on baseline characteristics, details on deintensification and outcomes, and was synthesized using a narrative approach.

RESULTS

Ten studies (observational cohorts and interventional studies) with data on 26 558 patients with comorbidities were eligible. Deintensification approaches included complete withdrawal, discontinuation, reducing dosage, conversion, or substitution of at least one medication, but the majority of studies were based on complete withdrawal or discontinuation of antihyperglycaemic medication. Rates of deintensification approaches ranged from 13.4%-75%. The majority of studies reported no deterioration in HbA1c levels, hypoglycaemic episodes, falls or hospitalizations on deintensification. On adverse events and mortality, no significant differences were observed among the comparison groups in the majority of studies.

CONCLUSION

Available but limited evidence suggests that the benefits of deintensification outweigh the harm in older people with type 2 diabetes with or without comorbidities. Given the heterogeneity of patients with diabetes, further research is warranted on which deintensification approaches are appropriate and beneficial for each specific patient population.

Time trends in prescribing of type 2 diabetes drugs, glycaemic response and risk factors: A retrospective analysis of primary care data, 2010-2017

AIM

To describe population-level time trends in prescribing patterns of type 2 diabetes therapy, and in short-term clinical outcomes (glycated haemoglobin [HbA1c], weight, blood pressure, hypoglycaemia and treatment discontinuation) after initiating new therapy.

MATERIALS AND METHODS

We studied 81 532 people with type 2 diabetes initiating a first- to fourth-line drug in primary care between 2010 and 2017 inclusive in United Kingdom electronic health records (Clinical Practice Research Datalink). Trends in new prescriptions and subsequent 6- and 12-month adjusted changes in glycaemic response (reduction in HbA1c), weight, blood pressure and rates of hypoglycaemia and treatment discontinuation were examined.

RESULTS

Use of dipeptidyl peptidase-4 inhibitors as second-line therapy near doubled (41% of new prescriptions in 2017 vs. 22% in 2010), replacing sulphonylureas as the most common second-line drug (29% in 2017 vs. 53% in 2010). Sodium-glucose co-transporter-2 inhibitors, introduced in 2013, comprised 17% of new first- to fourth-line prescriptions by 2017. First-line use of metformin remained stable (91% of new prescriptions in 2017 vs. 91% in 2010). Over the study period there was little change in average glycaemic response and in the proportion of people discontinuing treatment. There was a modest reduction in weight after initiating second- and third-line therapy (improvement in weight change 2017 vs. 2010 for second-line therapy: -1.5 kg, 95% confidence interval [CI] -1.9, -1.1; P < 0.001), and a slight reduction in systolic blood pressure after initiating first-, second- and third-line therapy (improvement in systolic blood pressure change 2017 vs. 2010 range: -1.7 to -2.1 mmHg; all P < 0.001). Hypoglycaemia rates decreased over time with second-line therapy (incidence rate ratio 0.94 per year, 95% CI 0.88, 1.00; P = 0.04), mirroring the decline in use of sulphonylureas.

CONCLUSIONS

Recent changes in prescribing of therapy for people with type 2 diabetes have not led to a change in glycaemic response and have resulted in modest improvements in other population-level short-term clinical outcomes.

Direct medical costs in the preceding, event and subsequent years of a first severe hypoglycaemia episode requiring hospitalization: A population-based cohort study

AIMS

We aimed to estimate the use of healthcare services and the direct medical costs accrued by patients with diabetes mellitus (DM) during the year of the first severe hypoglycaemia (SH) event, as well as during the years before and after the event year.

MATERIALS AND METHODS

We analysed a population-based, retrospective cohort including all adults with DM managed in the primary care setting from the Hong Kong Hospital Authority between 2006 and 2013. DM patients for whom SH was first recorded during the designated period were identified and matched to a control group of patients who had not experienced an SH event using the propensity score method. Direct medical costs in the years before, during and after the first SH event were determined by totalling the costs of health services utilized within respective years.

RESULTS

After matching, a total of 22 694 DM patients were divided into the first recorded-SH group (n = 11 347) and the non-SH control group (n = 11 347). Patients for whom SH was first recorded, on average, made 7.85 outpatient clinic visits, made 1.89 emergency visits and spent 17.75 nights hospitalized during the event year. Mean direct medical costs during the event year were 11 751 US$, more than 2-fold that during the preceding year (4846 US$; P < 0.001) and subsequent years (4198-4700 US$; P < 0.001) and was 4.5 times that 2 years before the event (2481 US$; P < 0.001). Incremental costs of SH patients vs matched controls during the event year and the preceding year were 10 873 US$ (P < 0.001) and 3974 US$ (P < 0.001), respectively.

CONCLUSIONS

SH is associated with excessive hospital admission rates and direct medical costs during the event year and, in particular, during the year before as compared to patients who had not experienced an SH event.

National rates of emergency department visits associated with diabetes in Saudi Arabia, 2011-2015

BACKGROUND

Despite the fact that diabetes is an important component of the burden of disease on the individual and on the national healthcare systems in Saudi Arabia, knowledge of the volume of emergency department (ED) visits for diabetes is unclear.

OBJECTIVE

Examine changes in ED visit rates associated with diabetes.

DESIGN

Retrospective.

SETTINGS

Governmental hospitals.

METHODS

Publicly available records of health statistics published by the Saudi Ministry of Health from 2011 through 2015 were used to extract data on ED visits related to diabetes. ED visits associated with diabetes were compared over time and by gender. We calculated diabetes-specific rates per 10000 persons for each sex category by dividing the total number of diabetes-associated ED visits in that category by the sex-specific population. We calculated the rate difference (RD) with 95% CI between 2011 and 2015.

MAIN OUTCOME MEASURES

Diabetes-specific rates per 10000 persons for each sex category.

RESULTS

Total annual visits to the ED for management of diabetes increased from 617683 cases in 2011 to 748605 in 2015. The annual number of ED visits associated with diabetes increased by 21% over the study period (20% for males and 23% for females). Compared to males, females had a larger increase in visit rates from 240.5 to 249.8 visits per 10000 women over the study years (RD, 9.6 per 10000 persons, 95% CI -16.4 to 26.6 versus 5.7 per 10 000 persons, 95% CI-13.6 to 18.3 ; P=.01).

CONCLUSION

Although diabetes-associated ED visit rates dramatically increased in 2012, they remained relatively stable after 2012 to the end of the study period. More effective preventive diabetes programs that prevent the use of ED visits and other expensive healthcare resources among people with diabetes are needed.

LIMITATIONS

We had no information on the specific indications for the reported ED visits. These estimates may represent a lower bound on ED visits associated with diabetes since the private sector was not included.

CONFLICT OF INTEREST

None.

Cost-Effectiveness of Insulin Degludec vs. Insulin Glargine U100 in Type 1 and Type 2 Diabetes Mellitus in a UK Setting

BACKGROUND

Understanding which therapeutic innovations in diabetes represent the best value requires rigorous economic evaluation. Data from randomised controlled trials and observational studies indicate that insulin degludec has a hypoglycemia advantage versus insulin glargine 100 units/mL (glargine U100), the most widely prescribed basal insulin analogue in the UK. This analysis was done to more rigorously assess cost-effectiveness in a UK setting.

METHODS

Data from two double-blinded, randomised, two-period crossover trials in type 1 (SWITCH 1) and type 2 (SWITCH 2) diabetes mellitus were used to assess the cost-effectiveness of degludec vs. glargine U100 with an economic model. Cost-effectiveness was analysed over a 1-year time horizon based on the different rates of hypoglycaemia and actual doses of insulin used, rather than glycaemic control due to the treat-to-target trial design.

RESULTS

In type 1 diabetes mellitus, degludec was highly cost-effective compared with glargine U100, with an incremental cost-effectiveness ratio of £984 (increased costs of only £23/year and improvement in participant health of 0.0232 quality-adjusted life-years (QALYs)). In type 2 diabetes mellitus, it was estimated that quality of life was improved (0.0065 QALYs gain) with degludec compared with glargine U100 at an increased annual cost of £117 (incremental cost-effectiveness ratio, £17,939). One-way sensitivity analyses showed that the results were robust to changes in parameters in both type 1 and type 2 diabetes mellitus.

CONCLUSIONS

The rigorous design of the SWITCH trials, coupled with a representative patient population and a definition of hypoglycaemia that is relevant for real-world patients, makes the results of these trials highly generalisable. The within-trial analysis has the added value of being able to include doses and event rates directly from the trials. This short-term economic analysis estimated that IDeg would be cost-effective relative to IGlar U100 in both type 1 and type 2 diabetes mellitus in the UK.

TRIAL REGISTRATION

SWITCH 1 (NCT02034513); SWITCH 2 (NCT02030600).

FUNDING

Novo Nordisk, Søborg, Denmark.

A retrospective observational study of people with Type 1 diabetes with self-reported severe hypoglycaemia reveals high level of ambulance attendance but low levels of therapy change and specialist intervention

AIM

To evaluate the impact of severe hypoglycaemia on NHS resources and overall glycaemic control in adults with Type 1 diabetes.

METHODS

An observational, retrospective study of adults (aged ≥ 18 years) with Type 1 diabetes reporting one or more episodes of severe hypoglycaemia during the preceding 24 months in 10 NHS hospital diabetes centres in England and Wales. The primary outcome was healthcare resource utilization associated with severe hypoglycaemia. Secondary outcomes included demographic and clinical characteristics, diabetes control and pathway of care.

RESULTS

Some 140 episodes of severe hypoglycaemia were reported by 85 people during the 2-year observation period. Ambulances were called in 99 of 140 (71%) episodes and Accident and Emergency attendance occurred in 26 of 140 (19%) episodes, whereas 29 of 140 (21%) episode required no immediate help from healthcare providers. Participants attended a median of 5 (range 0-58) diabetes clinic consultations during the observation period; 13% (70 of 552) of all consultations were severe hypoglycaemia-related. Of the HbA1c measurements recorded closest prior to severe hypoglycaemia (n = 119), only 7 of 119 measurements were < 48 mmol/mol (< 6.5%) and mean HbA1c was 70 (sd 19) mmol/mol (8.5%, sd 1.7%). Some 119 changes to diabetes treatment were recorded during the observation period (median/person 0;, range 0-11), of which 52 of 119 changes (44%) followed severe hypoglycaemic events.

CONCLUSIONS

We observed a high level of ambulance service intervention but surprisingly low levels of hypoglycaemia follow-up, therapy change and specialist intervention in people self-reporting severe hypoglycaemia. These results suggest there may be important gaps in care pathways for people with Type 1 diabetes self-reporting severe hypoglycaemia.

Role and prevalence of impaired awareness of hypoglycaemia in ambulance service attendances to people who have had a severe hypoglycaemic emergency: a mixed-methods study

OBJECTIVES

(1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event.

DESIGN

A sequential mixed-methods study.

SETTING

A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures.

RESULTS

Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively.

CONCLUSIONS

The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs.

Estimating the risk of severe hypoglycemic event related to glucose-lowering treatment among Italian patients with diabetes: the HYPOTHESIS database

The primary objective of this study was to estimate 1) the annual risk of undergoing a severe hypoglycemic event in Italian patients with diabetes and 2) the risk of hospitalization following such event. From the HYPOTHESIS database, powered by 46 emergency departments covering a 12-million-odd population, data were extracted of 1,922 hypoglycemic events occurring in patients with diabetes in 2011. The mean age was 71.5 (standard deviation 16.8) years, 50.1% were men, and blood glucose at the time of the event was 44.2 (26.5) mg/dL. Patients were being treated with insulin alone (55%) or in combination with oral hypoglycemic agents (OHA, 15%), or with OHA alone, either in monotherapy (14%) or in multiple therapy (16%). Comorbidities were recorded in 71.8% of the patients. Based on the rates of glucose-lowering drug use in Italian patients with diabetes, the annual risk of undergoing a serious hypoglycemic event was estimated at 1.27% for subjects treated with insulin alone, the highest (p<0.00001) as compared with insulin + OHA (0.41%) or OHA alone, either in monotherapy or in multiple therapy (0.1% and 0.17%, respectively). The risk of being hospitalized following the hypoglycemic event was the least (27.6%) for subjects treated with insulin alone (p<0.0083). Subjects treated with insulin + OHA showed a lower risk (34.2%) as compared with that for subjects treated with OHA (p<0.02). Death occurs in 7% of hospitalized patients. Older age (p<0.0001) and comorbidities (p<0.0001) were risk factors for hypoglycemia-related hospitalization. Treatments with insulin alone (p<0.005) or in combination (p<0.049) were negatively associated with hospital admission. Severe hypoglycemic events associated with the use of oral glucose-lowering agents carry the highest risk of hospital treatment. As such, they are also likely to generate higher tangible and intangible costs.

A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: The Eastern Academic Health Science Network (EAHSN) model

AIMS

We developed a new clinical integrated pathway linking a regional Ambulance Trust with a severe hypoglycaemia (SH) prevention team. We present clinical data from the first 2000 emergency calls taken through this new clinical pathway in the East of England.

METHODS

SH patients attended by Ambulance crew receive written information on SH avoidance, and are contacted for further education through a new regional SH prevention team. All patients are contacted unless they actively decline.

RESULTS

Median age (IQR) was 67 (50-80) years, 23.6% of calls were for patients over 80years old, and patients more than 90years old were more common than 20-25year olds in this population. Most calls were for patients (84.9%) who were insulin treated, even those over 80years (75%). One - third of patients attended after a call were unconscious on attendance. 5.6% of patients in this call population had 3 or more ambulance call outs, and they generated 17.6% of all calls. In total, 728 episodes (36.4%) were repeat calls. Insulin related events were clinically more severe than oral hypoglycaemic related events. Patients conveyed to hospitals (13.8%) were significantly older, with poorer recovery in biochemical hypoglycaemia after ambulance crew attendance. Only 19 (1%) opted out of further contact. Patients were contacted by the SH prevention team after a median 3 (0-6) days. The most common patient self - reported cause for their SH episode was related to perceived errors in insulin management (31.4%).

CONCLUSIONS

This new clinical service is simple, acceptable to patients, and a translatable model for prevention of recurrent SH in this largely elderly insulin treated SH population.

Older people with Type 2 diabetes, including those with chronic kidney disease or dementia, are commonly overtreated with sulfonylurea or insulin therapies

AIM

To evaluate potential overtreatment with sulfonylurea and insulin therapies amongst older people with Type 2 diabetes, including those with chronic kidney disease or dementia.

METHODS

Using the ECLIPSE Live software tool, we developed a search to examine data on older people (age ≥ 70 years) with Type 2 diabetes, who were prescribed sulfonylurea or insulin therapies over the previous 90 days. Sixteen Norfolk general practices participated, representing a population of 24 661 older people, including 3862 (15.7%) with Type 2 diabetes. Of these, 1379 (35.7%) people were prescribed sulfonylurea or insulin therapies. Data extracted included age, sex, last recorded HbA_1c value, renal function and dementia codes.

RESULTS

The median age of the study cohort was 78 years. A total of 644 people (47.8%) had chronic kidney disease (estimated GFR < 60 mL/min/1.73m² ) and 60 people (4.35%) had dementia. The median (interquartile range) HbA_1c concentration for the entire cohort was 58 (51-69) mmol/mol [7.5 (6.8-8.5)%], with no difference in median HbA_1c between those with or without either chronic kidney disease or dementia. In total, 400 older people (29.9%) had an HbA_1c concentration < 53 mmol/mol (7%), of whom 162 (12.1%) had HbA_1c < 48 mmol/mol (6.5%). Stratified by prescription for sulfonylurea, insulin or combined insulin and sulfonylurea therapies, 282 (35.2%), 93 (24.2%) and 25 people (16.3%), respectively, had HbA_1c < 53 mmol/mol (7.0%). Treatment to an HbA_1c target of < 53 mmol/mol (7.0%) was as prevalent in those with chronic kidney disease or dementia as in those without.

CONCLUSION

In the present cohort of older people with Type 2 diabetes prescribed sulfonylurea or insulin therapies, overtreatment was common, even in the presence of comorbidities known to increase hypoglycaemia risk.

Emergency treatment of hypoglycaemia: a guideline and evidence review

AIM

To examine the current treatment guidelines for the emergency management of hypoglycaemia and the evidence underpinning recommendations.

METHODS

International diabetes agencies were searched for hypoglycaemia treatment guidelines. Guidelines were assessed using the Appraisal of Guidelines Research and Evaluation II (AGREE II) instrument. An electronic database search was conducted for evidence regarding emergency treatment of hypoglycaemia in adults, and relevant articles were critically appraised.

RESULTS

Of the international diabetes agencies, six sets of guidelines were deemed relevant and of sufficient detail for appraisal by AGREE II. The evidence search returned 2649 articles, of which 17 pertaining to the emergency management of hypoglycaemia were included. High-quality evidence for the management of hypoglycaemia was lacking, limiting treatment recommendations. In general, guidelines and studies were somewhat concordant and recommended 15-20 g of oral glucose or sucrose, repeated after 10-15 min for treatment of the responsive adult, and 10% intravenous dextrose or 1 mg intramuscular glucagon for treatment of the unresponsive adult. No evidence was found for other treatment approaches.

CONCLUSION

Evidence for the emergency treatment of hypoglycaemia in adults is limited, is often low grade and mostly pre-dates contemporary management of diabetes. Guideline recommendations are limited by the lack of randomized trials. Further high-quality studies are required to inform the optimum management of this frequently occurring emergency condition.

Temporal changes in frequency of severe hypoglycemia treated by emergency medical services in types 1 and 2 diabetes: a population-based data-linkage cohort study

Background

Almost 20 years ago, the frequencies of severe hypoglycemia requiring emergency medical treatment were reported in people with types 1 and 2 diabetes in the Tayside region of Scotland. With subsequent improvements in the treatment of diabetes, concurrent with changes in the provision of emergency medical care, a decline in the frequency of severe hypoglycemia could be anticipated. The present population-based data-linkage cohort study aimed to ascertain whether a temporal change has occurred in the incidence rates of hypoglycemia requiring emergency medical services in people with types 1 and 2 diabetes.

Methods

The study population comprised all people with diabetes in Tayside, Scotland over the period 1 January 2011 to 31 December 2012. Patients’ data from different healthcare sources were linked anonymously to measure the incidence rates of hypoglycemia requiring emergency medical services that include treatment by ambulance staff and in hospital emergency departments, and necessitated hospital admission. These were compared with data recorded in 1997–1998 in the same region.

Results

In January 2011 to December 2012, 2029 people in Tayside had type 1 diabetes and 21,734 had type 2 diabetes, compared to 977 and 7678, respectively, in June 1997 to May 1998. In people with type 2 diabetes, the proportion treated with sulfonylureas had declined from 36.8 to 22.4% (p < 0.001), while insulin-treatment had increased from 11.7 to 18.7% (p < 0.001). The incidence rate of hypoglycemia requiring emergency medical treatment had significantly fallen from 0.115 (95% CI: 0.094–0.136) to 0.082 (0.073–0.092) events per person per year in type 1 diabetes (p < 0.001), and from 0.118 (0.095–0.141) to 0.037 (0.003–0.041) in insulin-treated type 2 diabetes (p = 0.008). However, the absolute annual number of hypoglycemia events requiring emergency treatment was 1.4-fold higher.

Conclusions

Although from 1998 to 2012 the incidences of hypoglycemia requiring emergency medical services appeared to have declined by a third in type 1 diabetes and by two thirds in insulin-treated type 2 diabetes, because the prevalence of diabetes was higher (2.7 fold), the number of severe hypoglycemia events requiring emergency medical treatment was greater.

Hypoglycaemia and brief interventions in the emergency department - A systematic review

OBJECTIVE

For people with diabetes, severe hypoglycaemia is the most common reason for emergency service usage and emergency department (ED) presentations. Brief interventions (BI) are a recognised intervention strategy in the ED for other conditions but to date, they have not been applied to those with hypoglycemia. This review aims to identify components and outcomes of BI for people with diabetes mellitus to inform the development of BI in the ED.

METHOD

A systematic review of randomized controlled trials was undertaken in MEDLINE, CINAHL, PsychINFO and EMBASE. Studies that examined brief interventions for people with diabetes were considered. Eligible studies were critically appraised and included in a narrative synthesis.

RESULTS

A total of 2475 citations were identified, 171 full papers were reviewed and four articles were included for review. The components 'advice' and 'assistance' from the five A Framework were the most frequently used BI components. Statistically significant improvements were achieved in psychological, functional, and satisfaction outcomes. However, clinical outcomes were not improved and economic outcomes like costs of BI were not evaluated.

CONCLUSIONS

The literature review demonstrated a lack of evidence related to BI in diabetes within the emergency setting despite the ED being an ideal environment. Future research needs to be conducted to investigate the effectiveness of BI for patients with diabetes.

Diabetes education of patients and their entourage: out-of-hospital national study (EDUCATED 2)

AIMS

To determine the contributing factors in the successful diabetes education of patients and their entourage.

METHODS

Prospective observational study conducted in a pre-hospital setting by 17 emergency services across France (September 2009-January 2011) included all insulin-treated patients (≥18 years) provided that at least one family member was present on scene. Data were collected from patients and their entourage: (1) personal details including language proficiency and educational attainment, (2) treatments, (3) diabetes-related data (log sheets, glucose meter, glucagon, glycated hemoglobin, prior hypoglycemic episodes); (4) care by diabetologist, general practitioner and/or visiting nurse. The main end points were ability to measure capillary blood sugar (patient) and awareness of hypoglycemia symptoms and ability to administer glucagon (entourage).

RESULTS

Overall, 561 patients and 736 family members were included; 343 patients (61%) were experiencing a hypoglycemic episode (<2.5 mmol/L). A total of 141 (75%) patients and 343 (50%) family members could measure capillary blood sugar. They could name a median of 2 [0-3‰] hypoglycemia symptoms although 217 (39%) patients and 262 (39%) family members could name no symptom. Few patients (33%) had glucagon available. In multivariate analyses, the main factor associated with better patient education was care by a diabetologist. Lack of an educational qualification and visits by a nurse were associated with poor patient education, and French mother tongue and care by a diabetologist with better education of the entourage.

CONCLUSIONS

In France, diabetic patients and their entourage are inadequately educated. Their education benefits most from care by a diabetologist.

Cost-effectiveness of switching to insulin degludec from other basal insulins: evidence from Swedish real-world data

OBJECTIVES

Health economic analysis from a healthcare and societal point of view was conducted to assess the cost-effectiveness of insulin degludec (IDeg) after switching from other basal insulins in people with type 1 diabetes.

MATERIAL AND METHODS

This was a prospective, open-label, single arm, observational follow-up from August 2013 to October 2015 of 476 consecutive patients at Danderyd Hospital (Stockholm, Sweden) who switched to IDeg from other basal insulins (99% basal insulin analogs). The IMS CORE Diabetes Model (CDM) was used to predict the cost-effectiveness of life-long treatment with IDeg vs. other basal insulins, based on a Swedish setting.

RESULTS

Mean (SD) duration of follow-up was 21.7 (6.0) weeks. Mean HbA_1c decreased by 2.7 mmol/mol, mean basal insulin dose decreased by 13.1% (p < .0001), and mean bolus insulin dose decreased by 7.5% (p < .0001) after switching. Frequencies of non-severe daytime hypoglycemia and non-severe nocturnal hypoglycemia decreased by 12% (p = .0127) and 53% (p < .0001) respectively and severe hypoglycemia was reduced by 62% (p = .0225). The CDM predicted a gain in life expectancy of 0.33 years, a discounted gain in quality-adjusted life-years (QALYs) of 0.54, and lower estimated direct lifetime healthcare costs of SEK 22,757 for patients switching to IDeg. The incremental cost-effectiveness ratio (ICER) showed IDeg as dominant (i.e. higher effectiveness with a lower cost). Sensitivity analyses confirmed the results.

CONCLUSION

Based on this prospective, real-world, follow-up and using the CDM, it was estimated that switching to IDeg from other basal insulins translated into QALY gains including improved life expectancy and health-related quality of life, as well as dominant ICER, meaning cost-savings for the healthcare system. However, the study is limited by its observational design. Extrapolation into the future is only estimated since the actual treatment effect cannot be projected with certainty.

Preventing Unnecessary Costs of Drug-Induced Hypoglycemia in Older Adults with Type 2 Diabetes in the United States and Canada

BACKGROUND

The costs of drug-induced hypoglycemia are a critical but often neglected component of value-based arguments to reduce tight glycemic control in older adults with type 2 diabetes.

METHODS

An economic (decision-tree) analysis compared rates, costs, quality-adjusted life-years, and incremental costs per quality-adjusted life-year gained associated with mild, moderate and severe hypoglycemic events for 6 glucose-lowering medication classes in type 2 diabetic adults aged 65-79 versus those 80 years and older. The national U.S. (Center for Medicare Services) and Canadian public health payer perspectives were adopted.

FINDINGS

Incidence rates of drug-induced hypoglycemia were the highest for basal insulin and sulfonylureas: 8.64 and 4.32 events per person-year in 65-79 year olds, and 12.06 and 6.03 events per person-year for 80 years and older. In both the U.S. and Canada, metformin dominated sulfonylureas, basal insulin and glucagon-like peptide1 receptor agonists. Relative to sulfonylureas, thiazolidinediones had the lowest incremental cost-effectiveness ratios in the U.S. and dominated sulfonylureas in Canada for adults 80 years and older. Relative to sulfonylureas, dipeptidyl peptidase4 inhibitors were cost-effective for adults 80 years and older in both countries, and for 65-79 year olds in Canada. Annual costs of hypoglycemia for older adults attaining very tight glycemic control with the use of insulin or sulfonylureas were estimated at U.S.$509,214,473 in the U.S. and CAN$65,497,849 in Canada.

CONCLUSIONS

Optimizing drug therapy for older type 2 diabetic adults through the avoidance of drug-induced hypoglycemia will dramatically improve patient health while also generating millions of dollars by saving unnecessary medical costs.

Severe hypoglycemia in patients with known diabetes requiring emergency department care: A report from an Italian multicenter study

•

Patients were frail and had a high prevalence of serious comorbidities.

•

Insulin treatment was the most important cause of severe hypoglycemia.

•

Among oral drugs, glibenclamide and repaglinide were the main used.

•

The rate of all-cause mortality was similar with that reported in other studies.

•

Liver and kidney diseases were the main predictors of hospitalization.

Aims

To describe the characteristics and associated risk factors of patients with established diabetes who required Emergency Department (ED) care for severe hypoglycemia.

Methods

We performed an observational retrospective study to identify all cases of severe hypoglycemia among attendees at the EDs of three Italian University hospitals from January 2010 to December 2014.

Results

Overall, 520 patients with established diabetes were identified. Mean out-of-hospital blood glucose concentrations at the time of the hypoglycemic event were 2.2 ± 1.3 mmol/L. Most of these patients were frail and had multiple comorbidities. They were treated with oral hypoglycemic drugs (43.6%), insulin (42.8%), or both (13.6%). Among the oral hypoglycemic drugs, glibenclamide (54.5%) and repaglinide (25.7%) were the two most frequently used drugs, followed by glimepiride (11.3%) and gliclazide (7.5%). Hospitalization rates and in-hospital deaths occurred in 35.4% and in 2.3% of patients, respectively. Cirrhosis (odds ratio [OR] 6.76, 95% confidence interval [CI] 1.24–36.8, p < 0.05), chronic kidney disease (OR 2.42, 95% CI 1.11–8.69, p < 0.05) and center (Sapienza University OR 3.70, 95% CI 1.57–8.69, p < 0.05) were the strongest predictors of increased rates of hospital admission.

Conclusions

Severe hypoglycemia is a remarkable burden for patients with established diabetes and increases the risk of adverse clinical outcomes (in-hospital death and hospitalization), mainly in elderly and frail patients. This study further reinforces the notion that careful attention should be taken by health care providers when they prescribe drug therapy in elderly patients with serious comorbidities.

Utilisation of emergency medical services for severe hypoglycaemia: An unrecognised health care burden

AIMS

Diabetes is associated with several acute, life-threatening complications yet there are limited data on the utilisation of prehospital services for their management. This study aimed to examine the utilisation of emergency medical services (EMS) for prehospital hypoglycaemia, including patient characteristics and factors related to hospital transportation.

METHODS

An observational study of patients requiring EMS for hypoglycaemia across Victoria, Australia over three years was conducted. Pre-specified data including patient demographics, comorbidities, examination findings and transport outcomes were obtained. Logistic regression was used to assess factors associated with transportation.

RESULTS

During the study period, 12,411 hypoglycaemia events were attended by paramedics for people with diabetes. The majority were individuals with type 1 diabetes (58.8%), followed by type 2 diabetes (35.2%) and unspecified diabetes type (5.9%). Thirty-eight percent of patients were transported to hospital by EMS following hypoglycaemia. Factors associated with transport by EMS included extremes of age (<15 and >75years), female gender, type 2 diabetes, event at a nursing home or hospital/community clinic, presence of comorbidities and time of day.

CONCLUSIONS

Examination of the utilisation of EMS for hypoglycaemia has identified a previously unquantified need for emergency care for people with diabetes as well as factors related to hospital transportation.

Comparative review of dipeptidyl peptidase-4 inhibitors and sulphonylureas

Type 2 diabetes (T2DM) is a progressive disease, and pharmacotherapy with a single agent does not generally provide durable glycaemic control over the long term. Sulphonylurea (SU) drugs have a history stretching back over 60 years, and have traditionally been the mainstay choice as second-line agents to be added to metformin once glycaemic control with metformin monotherapy deteriorates; however, they are associated with undesirable side effects, including increased hypoglycaemia risk and weight gain. Dipeptidyl peptidase (DPP)-4 inhibitors are, by comparison, more recent, with the first compound being launched in 2006, but the class now globally encompasses at least 11 different compounds. DPP-4 inhibitors improve glycaemic control with similar efficacy to SUs, but do not usually provoke hypoglycaemia or weight gain, are relatively free from adverse side effects, and have recently been shown not to increase cardiovascular risk in large prospective safety trials. Because of these factors, DPP-4 inhibitors have become an established therapy for T2DM and are increasingly being positioned earlier in treatment algorithms. The present article reviews these two classes of oral antidiabetic drugs (DPP-4 inhibitors and SUs), highlighting differences and similarities between members of the same class, as well as discussing the potential advantages and disadvantages of the two drug classes. While both classes have their merits, the choice of which to use depends on the characteristics of each individual patient; however, for the majority of patients, DPP-4 inhibitors are now the preferred choice.

Improving self-referral for diabetes care following hypoglycaemic emergencies: a feasibility study with linked patient data analysis

Background

Hypoglycaemia is a common and potentially life threatening consequence of insulin and sulphonylurea treated Diabetes. Some severe hypoglycaemic events result in emergency ambulance attendance. Many of these patients are treated at home and do not require immediate transportation to an Emergency Department. However only 27-37 % of patients then follow up their care with a diabetes specialist. Consequently repeat severe hypoglycaemic events occur.

Methods

The intervention was implemented for 8 months, using a prospective cohort design with a historic control, in one Scottish Health Board in 2012. Data was collected using postal survey questionnaires to patients and ambulance clinicians, telephone survey follow-up questions to patients. Scottish Ambulance Service electronic records were linked with the SCI-Diabetes database of patient records to enable objective measurement of follow-up behaviour.

Results

Ambulance clinicians’ (n = 92) awareness of the intervention was high and both the prompt card and telephone call components of the intervention were delivered to most eligible patients. The intervention was perceived as highly acceptable to patients (n = 37), and very useful by both patients and ambulance clinicians. However, comparison of patient follow-up behaviours using linked-data (n = 205), suggest that the intervention was unsuccessful in improving rates of patients’ following up their care.

Conclusions

This study shows that the intervention is implementable, highly acceptable to patients, and considered very useful by both patients and ambulance clinicians. However, preliminary evidence of effectiveness is not encouraging. The study’s novel use of linking existing clinical data for outcome measurement exposed challenges in the feasibility of using this data for intervention development and evaluation. Future research should examine challenges to the successful testing and effectiveness of the intervention. Revisions are likely to be required, both to study design and the optimisation of the intervention’s content and components.

Electronic supplementary material

The online version of this article (doi:10.1186/s12873-016-0078-1) contains supplementary material, which is available to authorized users.

IDegLira Versus Alternative Intensification Strategies in Patients with Type 2 Diabetes Inadequately Controlled on Basal Insulin Therapy

INTRODUCTION

IDegLira is a once-daily combination of insulin degludec (IDeg) and liraglutide. Trials directly comparing IDegLira with alternative strategies for intensifying basal insulin are ongoing. While awaiting results, this analysis compared indirectly how different strategies affected glycated hemoglobin (HbA_1c) and other outcomes.

METHODS

A pooled analysis of five completed Novo Nordisk randomized clinical trials in patients with type 2 diabetes inadequately controlled on basal insulin was used to compare indirectly IDegLira (N = 199) with: addition of liraglutide to basal insulin (N = 225) [glucagon-like peptide-1 receptor agonist (GLP-1RA) add-on strategy]; basal-bolus (BB) insulin [insulin glargine (IGlar) + insulin aspart] (N = 56); or up-titration of IGlar (N = 329). A supplementary analysis was performed with the BB arm including patients who received IGlar or IDeg as basal insulin in the relevant trial (N = 210). All trials had comparable inclusion/exclusion criteria and baseline characteristics. Individual patient-level data were analyzed using multivariable statistical models with potential baseline heterogeneity accounted for using explanatory variables.

RESULTS

At end of study, differences between IDegLira and BB or up-titrated IGlar, respectively, were as follows: reduction in HbA_1c -0.30%, 95% confidence interval (-0.58; -0.01) and -0.65% (-0.83; -0.47); change in body weight -6.89 kg (-7.92; -5.86) and -4.04 kg (-4.69; -3.40) all in favor of IDegLira. Confirmed hypoglycemia rate was 122.8 (90.7; 166.1), 1060.8 (680.2; 1654.4), and 286.1 (231.1; 354.1) events/100 patient-years for IDegLira, BB, and up-titrated IGlar, respectively. Odds ratios for achieving HbA_1c <7.0%, <7.0% without hypoglycemia, and <7.0% without hypoglycemia and no weight gain were greater with IDegLira versus up-titrated IGlar. The supplementary analysis yielded similar results to the main analysis. Results with IDegLira were similar to those for the 'GLP-1RA add-on' arm.

CONCLUSION

These results suggest that IDegLira may be more effective, with lower hypoglycemia rates and less weight gain, than up-titrated basal insulin or BB in patients uncontrolled on basal insulin.

Incidence and care-related costs of severe hypoglycaemia requiring emergency treatment in Andalusia (Spain): the PAUEPAD project

AIMS

Hypoglycaemia is a serious medical emergency. The need for emergency medical service care and the costs of hypoglycaemic emergencies are not completely known.

METHODS

This was a retrospective observational study using Public Company for Health Emergencies (EPES) data for hypoglycaemia in 2012. The EPES provides emergency medical services to the entire population of Andalusia, Spain (8.5 million people). Data on event type, onsite treatments, emergency room visits or hospitalization were collected. Medical costs were estimated using the public rates for healthcare services.

RESULTS

From a total of 1 137 738 emergency calls that requested medical assistance, 8683 had a primary diagnosis of hypoglycaemia (10.34 per 10 000 person-years). The incidence of severe hypoglycaemic episodes requiring emergency treatment in the estimated population with diabetes was 80 episodes per 10 000 person-years. A total of 7479 episodes (86%) required an emergency team to visit the patient's residence. The majority of cases (64%) were addressed in the residence, although 1784 (21%) cases were transferred to hospital. A total of 5564 events (65%) involved patients aged > 65 years. Overall mortality was 0.32% (28 cases). The total annual cost of attending a hypoglycaemic episode was €6 093 507, leading to an estimated mean direct cost per episode of €702 ± 565. Episodes that required hospital treatment accounted for 49% of the total costs.

CONCLUSIONS

Hypoglycaemia is a common medical emergency that is associated with high emergency medical service utilization, resulting in a significant economic impact on the health system.

GLUCAGON PRESCRIPTION PATTERNS IN PATIENTS WITH EITHER TYPE 1 OR 2 DIABETES WITH NEWLY PRESCRIBED INSULIN

OBJECTIVE

To describe glucagon prescription patterns in patients with type 1 (T1DM) or type 2 diabetes (T2DM) who received an initial insulin prescription.

METHODS

Retrospective analyses were conducted with data from Truven Health MarketScan databases to assess time to glucagon prescriptions: filled within 1.5 months after index date (early) or after 1.5 months postindex (nonearly). The index date was the date of first insulin prescription between January 1, 2009 and December 31, 2011; for T2DM, without an insulin prescription in the previous 6 months; for T1DM, diabetes diagnosis preindex or within 3 months postindex.

RESULTS

Analysis included 8,814 patients with T1DM and 47,051 with T2DM (49.3% and 2.4%, respectively) who had glucagon prescriptions filled. The median times to first glucagon prescription were 196 days (T1DM) and 288 days (T2DM). The rates of filling glucagon were highest in the first 1.5 months. The times to first hypoglycemia-related emergency room (ER) visit for T1DM and T2DM cohorts were initially similar for those with early glucagon versus nonearly glucagon prescriptions. After 10.8 and 2.5 months postindex, respectively, the percentage of hypoglycemia-related ER visits was lower for those with early glucagon prescriptions.

CONCLUSION

Glucagon prescriptions filled for patients with diabetes who are initiating insulin are low. Patients with T1DM who were younger and healthier filled glucagon prescriptions more often; patients with T2DM who were younger and sicker and had a higher percentage of hypoglycemia-related ER visit history filled glucagon prescriptions more often. Glucagon filled early was associated with a lower incidence of hypoglycemia-related ER visits.

Access to emergency room for hypoglycaemia in people with diabetes

BACKGROUND

Hypoglycaemia is a major burden of the pharmacological therapy of diabetes and is associated with increased morbidity, mortality and treatment costs.

METHODS

We screened all admissions to the emergency room of the Pisa University Hospital from 1 January 2009 to 31 December 2013, selecting individuals with a discharge diagnosis of hypoglycaemia. We retrieved 500 admissions involving adult diabetic patients: age 71 ± 16 years; M/F 50.2/49.8%; 70.2% type 2 diabetes (T2DM).

RESULTS

Among T2DM, 42.2% were on insulin, 10.8% on insulin plus oral anti-diabetes drugs and 38.2% on oral anti-diabetes drugs alone (92% sulphonylureas/glinides ± insulin-sensitizers). Glibenclamide was the most frequently used sulphonylurea (69%). Individuals treated with oral anti-diabetes drugs were older than those on insulin (79 ± 11 versus 74 ± 12 years; p < 0.0001). Among patients taking sulphonylurea, 47% had estimated glomerular filtration rate <60 mL/min/1.73 m(2) and 13.5% had <30 mL/min/1.73 m(2) . In-hospital admission occurred in 20% of cases. Hospitalized patients with T2DM were older than those discharged (80 ± 10 versus 76 ± 12 years, p < 0.01) and were on oral antidiabetic drugs in 54.8% of the cases, whereas 35.7% were on insulin (χ(2) , p < 0.0001) and 8.3% on combined therapy. Notably, 93.5% of those on oral anti-diabetic drugs were taking a secretagogue. Insulin-treated subjects were younger than those treated with oral anti-diabetic drugs alone (77 ± 12 versus 82 ± 7 years; p < 0.02). The mean in-hospital annual mortality rate was 85 deaths per 1000 patients-year.

CONCLUSIONS

Our results support the recommendation that the risk associated with insulin and insulin-secretagogues should be carefully assessed, particularly when prescribed in vulnerable patients with T2DM.

Inequality in diabetes-related hospital admissions in England by socioeconomic deprivation and ethnicity: facility-based cross-sectional analysis

Objective

To investigate the effect of social deprivation and ethnicity on inpatient admissions due to diabetes in England.

Design

Facility-based cross-sectional analysis.

Setting

National Health Service (NHS) trusts in England reporting inpatient admissions with better than 80% data reporting quality from 2010–2011 (355 facilities).

Participants

Non-obstetric patients over 16 years old in all NHS facilities in England. The sample size after exclusions was 5,147,859 all-cause admissions.

Main Outcome Measures

The relative risk of inpatient admissions and readmissions due to diabetes adjusted for confounders.

Results

There were 445,504 diabetes-related hospital admissions in England in 2010, giving a directly (age-sex) standardized rate of 1049.0 per 100,000 population (95% confidence interval (CI): 1046.0–1052.1). The relative risk of inpatient admission in the most deprived quintile was 2.08 times higher than that of the least deprived quintile (95% CI: 2.02–2.14), and the effect of deprivation varied across ethnicities. About 30.1% of patients admitted due to diabetes were readmitted at least once due to diabetes. South Asians showed 2.62 times (95% CI: 2.51 – 2.74) higher admission risk. Readmission risk increased with IMD among white British but not other ethnicities. South Asians showed slightly lower risk of readmission than white British (0.86, 95% CI: 0.80 – 0.94).

Conclusions

More deprived areas had higher rates of inpatient admissions and readmissions due to diabetes. South Asian British showed higher admission risk and lower readmission risk than white British. However, there was almost no difference by ethnicity in readmission due to diabetes. Higher rates of admission among deprived people may not necessarily reflect higher prevalence, but higher admission rates in south Asian British may be explained by their higher prevalence because their lower readmission risk suggests no inequality in primary care to prevent readmission. Better interventions in poorer areas, are needed to reduce these inequalities.

Insulin degludec early clinical experience: does the promise from the clinical trials translate into clinical practice--a case-based evaluation

BACKGROUND

Clinical experience of patients is an additional source of information that can inform prescribing decisions for new therapies in practice. In diabetes, for example, patients with recurrent hypoglycemia may be excluded from trials conducted for regulatory purposes. Using insulin degludec (IDeg), a new basal insulin with an ultra-long duration of action as an example, an interim analysis is presented describing whether the decision to prescribe IDeg to patients experiencing treatment-limiting problems on their existing insulin regimes represented good clinical and economic value.

METHODS

Records from the first 51 consecutive patients with diabetes (35 type 1 [T1D] and 16 type 2 [T2D]) switching to insulin degludec from either insulin glargine (IGlar) or insulin detemir (IDet), mostly due to problems with hypoglycemia (39/51, 76.5%), were reviewed at up to 37 weeks. Patients indicated frequency of hypoglycemia and completed a disease-specific questionnaire reporting six measures of confidence and treatment satisfaction. For the largest group of exposed patents, the T1D module of the IMS Core Diabetes Model (CDM) was used to evaluate the cost-effectiveness of the treatment decision.

FINDINGS

HbA1c decreased by 0.5 ± 0.3% points and 0.7 ± 0.3% points for T1D and T2D, respectively. Hypoglycemic events decreased by >90%. Combined mean scores were ≥ 3.7 (1 = much worse, 3 = no change, 5 = much improved) for all six satisfaction and confidence items. In T1D, the treatment decision was highly cost-effective in the CDM lifetime analysis. Even when excluding benefits beyond hypoglycemia reduction, predicted cost per quality-adjusted life-year for IDeg vs IGlar/IDet was £10,754.

INTERPRETATION

These data illustrate the complementary nature of clinical trial and practice data when evaluating the value of therapeutic innovations in diabetes care. There were reductions in patient-reported hypoglycemia, reduced HbA1c, and improved treatment satisfaction in relation to the decision to prescribe IDeg. Initial health economic evaluation suggested that the decision to prescribe IDeg in this phenotypic group of T1D patients represented good value for money.

Patients with diabetes requiring emergency department care for hypoglycaemia: characteristics and long-term outcomes determined from multiple data sources

AIM

To triangulate three data sources and report the characteristics and long-term outcomes of patients with diabetes requiring emergency department (ED) care for hypoglycaemia.

METHOD

Three data sources were used-ambulance electronic records, hospital episode statistics and patient administration system. Hypoglycaemia (capillary blood glucose <4.0 mmol/L)-related attendances to a single hospital's ED between 1 April 2012 and 31 March 2013 were studied.

RESULTS

Using the three sources, there were 165 hypoglycaemia-related attendances in 132 patients with diabetes [type 1-59 episodes in 43 patients, type 2-106 episodes in 89 patients (therapy-54 (51%) insulin, 35 (33%) sulfonylurea, 11 (10%) both, 6 (6%) others)]. At best only 65% of episodes would have been identified were a single data source used. Patients with type 2 vs type 1 diabetes were older (median age 79 vs 61 years, p<0.0001), had more comorbidities (median Charlson comorbidity index (CCI) 4 vs 3, p=0.002) but no difference in HbA1c (median 7.8% vs 8.4%, p=0.065). Compared with insulin-treated type 2 patients with diabetes, sulfonylurea-treated patients (33%) were older (median age 82 vs 76 years, p=0.007), had worse renal function (median estimated glomerular filtration rate 38 vs 56 mL/min/1.73 m(2), p=0.019) and lower HbA1c (median 6.7% vs 8.4%, p<0.0001). At least 17 (10%) hypoglycaemic episodes resulted in additional serious harm. The 30-day, 90-day and 1-year all-cause mortality were 10.6% (14), 16.7% (22) and 28% (37), respectively. Age, CCI and hospitalisation were risk factors for long-term mortality.

CONCLUSIONS

Dependence on a single data source would have at best identified only 65% of episodes. One-third of episodes were sulfonylurea related in patients with type 2 diabetes, and one-fourth of all patients with diabetes who required ED care for hypoglycaemia died the following year.

Healthcare resource implications of hypoglycemia-related hospital admissions and inpatient hypoglycemia: retrospective record-linked cohort studies in England

OBJECTIVE

Using a retrospective cohort study, the mean length of hospital stay (LoS) and total per-patient expenditure for hypoglycemia requiring admission to hospital were estimated. In a separate matched retrospective cohort study, the effect of inpatient hypoglycemia on LoS, expenditure, and risk of all-cause mortality while admitted was investigated.

METHODS

The cohorts consisted of patients aged ≥18 years with a diagnosis of type 1 or 2 diabetes between January 1, 2002 and October 30, 2012 in the Clinical Practice Research Datalink database, who had initiated insulin treatment and had a recording of hypoglycemia in the same period. In the matched retrospective cohort study, exposed patients (who experienced hypoglycemia in hospital) were case-matched with patients who did not experience hypoglycemia during admission (unexposed). Generalized linear regression was used to estimate LoS. Risk of all-cause mortality was evaluated via logistic regression.

RESULTS

In the retrospective cohort study (1131 patients), mean LoS was 5.46 (95% CI 4.62 to 6.45) days for type 1 diabetes, and 5.04 (95% CI 4.46 to 5.71) days for type 2 diabetes. Mean cost per admission was £1034 (95% CI £855 to £1253). In the matched retrospective cohort study (1079 pairs of patients), exposed patients had a mean LoS of 11.91 days (95% CI 10.96 to 12.94 days) versus 4.80 (95% CI 4.41 to 5.23) for unexposed patients, p<0.0001. Exposed patients had a higher mortality risk compared with unexposed patients (OR 1.439 (95% CI 1.060to 1.952), p=0.0195). Total average per-patient cost for exposed patients was GBP (£)2235, 40% (p<0.0001) higher than total average admission cost in unexposed patients.

CONCLUSIONS

Hypoglycemia has a significant negative impact on patient outcomes, healthcare resource use, and expenditure.

The management of severe hypoglycemia by the emergency system: the HYPOTHESIS study

BACKGROUND AND AIMS

Severe hypoglycemia is not rare in diabetes and markedly impacts on health resource use. We aimed to describe the characteristics of patients attending emergency departments (EDs) following a severe episode of hypoglycemia, the factors associated with the management of events and the final outcome.

METHODS AND RESULTS

We carried out a retrospective analysis of cases attending 46 Italian EDs for hypoglycemia from January 2011 to June 2012. A total of 3753 records were retrieved from the databases of the participating centers, part of a network repeatedly involved in collaborative studies; 3516 episodes occurred in subjects with diabetes (median age, 76 years; range, 1-102). Comorbidities were recorded in 2320 (65.9%) diabetes cases; association with trauma or road accidents in 287 (8.2%) and 47 (1.3%), respectively. Patients were treated with insulin (49.8%), oral agents (31.4%), or combination treatment (15.1%). The event required assistance by the out-of-hospital Emergency services in 1821 cases (51.8%). Following the ED visit, admission to hospital departments was deemed necessary in 1161 cases (33.1%). Diabetes treatment (oral agents: OR, 1.63; 95% confidence interval (CI), 1.37-1.94), increasing age (OR, 1.39; 95% CI, 1.31-1.48) and the number of comorbidities (OR, 1.51; 95% CI, 1.38-1.66) were the main drivers of admission. The in-hospital death rate was 10%, associated with the number of comorbidities (OR, 1.28; 95%CI, 1.01-1.63).

CONCLUSION

Severe hypoglycemia requiring referral to EDs is associated with a significant work-up of the Emergency services and a remarkable in-hospital death rate in frail individuals with diabetes.

Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with Type 1 diabetes

AIMS

To determine the impact of structured education promoting flexible intensive insulin therapy on rates of diabetic ketoacidosis, and the costs associated with emergency treatment for severe hypoglycaemia and ketoacidosis in adults with Type 1 diabetes.

METHODS

Using the Dose Adjustment For Normal Eating research database we compared the rates of ketoacidosis and severe hypoglycaemia during the 12 months preceding Dose Adjustment For Normal Eating training with the rates during the 12-month follow-up after this training. Emergency treatment costs were calculated for associated paramedic assistance, Accident and Emergency department attendance and hospital admissions.

RESULTS

Complete baseline and 1-year data were available for 939/1651 participants (57%). The risk of ketoacidosis in the 12 months after Dose Adjustment For Normal Eating training, compared with that before training, was 0.39 (95% CI: 0.23 to 0.65, P < 0.001), reduced from 0.07 to 0.03 episodes/patient/year. For every 1 mmol/mol unit increase in HbA1c concentration, the risk of a ketoacidosis episode increased by 6% (95% CI: 5 to 7%; 88% for a 1% increase), and for each 5-year increase in diabetes duration, the relative risk reduced by 20% (95% CI: 19 to 22%). The number of emergency treatments decreased for ketoacidosis (P < 0.001), and also for severe hypoglycaemia, including paramedic assistance (P < 0.001), Accident and Emergency department attendance (P = 0.029) and hospital admission (P = 0.001). In the study cohort, the combined cost of emergency treatment for ketoacidosis and severe hypoglycaemia fell by 64%, from £119,470 to £42,948.

CONCLUSIONS

Structured training in flexible intensive insulin therapy is associated with a 61% reduction in the risk of ketoacidosis and with 64% lower emergency treatment costs for ketoacidosis and severe hypoglycaemia.

National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations

IMPORTANCE

Detailed, nationally representative data describing high-risk populations and circumstances involved in insulin-related hypoglycemia and errors (IHEs) can inform approaches to individualizing glycemic targets.

OBJECTIVE

To describe the US burden, rates, and characteristics of emergency department (ED) visits and emergency hospitalizations for IHEs.

DESIGN, SETTING, AND PARTICIPANTS

Nationally representative public health surveillance of adverse drug events among insulin-treated patients seeking ED care (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project) and a national household survey of insulin use (the National Health Interview Survey) were used to obtain data from January 1, 2007, through December 31, 2011.

MAIN OUTCOMES AND MEASURES

Estimated annual numbers and estimated annual rates of ED visits and hospitalizations for IHEs among insulin-treated patients with diabetes mellitus.

RESULTS

Based on 8100 National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance cases, an estimated 97,648 (95% CI, 64,410-130,887) ED visits for IHEs occurred annually; almost one-third (29.3%; 95% CI, 21.8%-36.8%) resulted in hospitalization. Severe neurologic sequelae were documented in an estimated 60.6% (95% CI, 51.3%-69.9%) of ED visits for IHEs, and blood glucose levels of 50 mg/dL (to convert to millimoles per liter, multiply by 0.0555) or less were recorded in more than half of cases (53.4%). Insulin-treated patients 80 years or older were more than twice as likely to visit the ED (rate ratio, 2.5; 95% CI, 1.5-4.3) and nearly 5 times as likely to be subsequently hospitalized (rate ratio, 4.9; 95% CI, 2.6-9.1) for IHEs than those 45 to 64 years. The most commonly identified IHE precipitants were reduced food intake and administration of the wrong insulin product.

CONCLUSIONS AND RELEVANCE

Rates of ED visits and subsequent hospitalizations for IHEs were highest in patients 80 years or older; the risks of hypoglycemic sequelae in this age group should be considered in decisions to prescribe and intensify insulin. Meal-planning misadventures and insulin product mix-ups are important targets for hypoglycemia prevention efforts.

Increasing awareness of hypoglycaemia in patients with type 2 diabetes treated with oral agents

Hypoglycaemia is the most common acute complication of type 2 diabetes and can limit therapeutic efforts to improve glycaemic control in order to protect against long-term complications. It is a potential side effect of the drugs used to treat diabetes, specifically exogenous insulin or insulin secretagogues. As many people are prescribed these agents, hypoglycaemia is frequent in clinical practice, although patients commonly do not inform their healthcare professional of the problems spontaneously. The impact of hypoglycaemia on the patient and to the healthcare system is significant through reduced treatment satisfaction and adherence, reduced quality of life and serious health consequences. This has financial implications and costs for the patient, the public and the economy at large. The single most important risk factor for hypoglycaemia is previous hypoglycaemia. Prevention depends on appropriate education regarding diabetes management and selfcare, self-monitoring of blood glucose, awareness of factors that may precipitate hypoglycaemia, and an individualized approach to therapy and glycaemic control targets. The purpose of this review is to increase understanding of the impact and consequences of hypoglycaemia, in particular that associated with sulphonylurea therapy, and to highlight areas requiring more attention in order to improve the overall management of people with type 2 diabetes.

Higher accuracy of self-monitoring of blood glucose in insulin-treated patients in Germany: clinical and economical aspects

BACKGROUND

Accuracy standards of blood glucose (BG) meters are currently under review. Revised standards are expected to tighten accuracy requirements. Regarding clinical and financial impact of BG meter accuracy, very little data are available. The aim of this study was to analyze potential cost savings related to higher accuracy of glucose meters in Germany.

METHODS

As a model for calculation, a reduction of meter error from 20% to 5% was applied. The health economic analysis was based on four main pillars: (1) number of insulin-treated patients; (2) costs for glucose monitoring in Germany; (3) data of a modeling analysis on the impact on hypoglycemic episodes, glycosylated hemoglobin (HbA1c), and, subsequently, myocardial infarctions; and (4) costs of diabetes-related complications in Germany. A reduction of meter error from 20% to 5% was identified to be associated with a 10% reduction in severe hypoglycemic episodes and a 0.39% reduction in HbA1c, which translates into a 0.5% reduction of myocardial infarctions.

RESULTS

According to the health economic analysis, the reduction in severe hypoglycemic episodes and myocardial infarctions led to cost savings of €24.14 per patient per year. Considering 390,000 type 1 diabetes patients or 2.3 million insulin-treated patients in Germany, these savings could be equal to a reduction in health care expenditures of more than €9.4 million and €55.5 million, respectively.

CONCLUSIONS

Potential cost savings and clinical effects due to higher accuracy of BG meters should provide an impetus to implementation of tighter accuracy standards and development of glucose meters that provide highest possible accuracy.

Severe hypoglycaemia requiring emergency medical assistance by ambulance services in the East Midlands: a retrospective study

AIMS

To report the characteristics and treatment of individuals requiring emergency ambulance services for severe hypoglycaemia and estimate associated provider costs.

METHODS

Retrospective analysis of routinely collected data collected by the East Midlands Ambulance Trust, UK, of episodes of severe hypoglycaemia attended by emergency ambulance services during a four-month period. Standard clinical measures, response time, on-site treatment and transportation were recorded and ambulance services costs calculated.

RESULTS

90,435 emergency calls were recorded, 523 (0.6%) for severe hypoglycaemia, equating to an incidence of to 2.76 per 100 patient years; 74% of individuals were insulin-treated, 28% of events occurred nocturnally (00:00-07:59), and 32% were transported to hospital. Higher respiratory rate was a positive predictor (p=0.03), whereas higher post treatment blood glucose (p=0.05) and insulin treatment (p<0.01) were negative predictors of transport to hospital. Median treatment costs for individuals transported and not transported to hospital were £92 and £176 respectively.

CONCLUSIONS

Most cases of severe hypoglycaemia requiring assistance from emergency ambulance services are successfully treated at the scene. Individuals not responding to treatment or were non insulin-treated were more likely to be transported to hospital. Further studies are needed to evaluate the effect of prehospital ambulance care by treatment and diabetes type on subsequent outcomes.

Evaluation of insulin use and value for money in type 2 diabetes in the United kingdom

INTRODUCTION

It is unclear as to whether human or long-acting analog insulins represent the most efficient use of health and non-healthcare resources in the management of type 2 diabetes mellitus (T2DM). The aim of this study was to evaluate the value for money relationship associated with the use of these insulins in the UK setting.

METHODS

A literature search was performed for studies reporting expenditure associated with the use of human and analog insulins. Data from this review informed a budget impact assessment model. Costs were converted to a common currency and results are reported in 2011 British pounds sterling (GBP) values.

RESULTS

Annual diabetes-related medication expenditure and patients total expenditure associated with the management of T2DM were estimated to be £397 million and £3,901 million, respectively. Substitution of human insulin for analog insulins was associated with a drug acquisition cost saving of between £5 million and £23 million each year. Overall, though, total expenditure increased significantly with increased use of human insulin by £34 million to £136 million each year depending on the degree of substitution.

CONCLUSIONS

On the face of it, analog insulins are more expensive, prompting questions about potential cost savings to health services in the UK from direct substitution to the less expensive human preparation. The current analysis illustrates that the increased use of human insulin and decreased use of analog insulin would, however, increase the overall net societal cost of managing insulin-treated patients with T2DM. Governments and decision makers should consider that total healthcare expenditure would not necessarily fall when decisions are based solely on the use of cheaper products.

Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs

AIMS

To estimate the current and future economic burdens of Type 1 and Type 2 diabetes in the UK.

METHODS

A top-down approach was used to estimate costs for 2010/2011 from aggregated data sets and literature. Prevalence and population data were used to project costs for 2035/2036. Direct health costs were estimated from data on diagnosis, lifestyle interventions, ongoing treatment and management, and complications. Indirect costs were estimated from data on mortality, sickness, presenteeism (potential loss of productivity among people who remain in work) and informal care.

RESULTS

Diabetes cost approximately £ 23.7bn in the UK in 2010/2011: £ 9.8bn in direct costs (£1bn for Type 1 diabetes and £ 8.8bn for Type 2 diabetes) and £ 13.9bn in indirect costs (£ 0.9bn and £ 13bn). In real terms, the 2035/2036 cost is estimated at £ 39.8bn: £ 16.9bn in direct costs (£ 1.8bn for Type 1 diabetes and £ 15.1bn for Type 2 diabetes) and £ 22.9bn in indirect costs (£ 2.4bn and £ 20.5bn). Sensitivity analysis applied to the direct costs produced a range of costs: between £ 7.9bn and £ 11.7bn in 2010/2011 and between £ 13.8bn and £20bn in 2035/2036. Diabetes currently accounts for approximately 10% of the total health resource expenditure and is projected to account for around 17% in 2035/2036.

CONCLUSIONS

Type 1 and Type 2 diabetes are prominent diseases in the UK and are a significant economic burden. Data differentiating between the costs of Type 1 and Type 2 diabetes are sparse. Complications related to the diseases account for a substantial proportion of the direct health costs. As prevalence increases, the cost of treating complications will grow if current care regimes are maintained.