Cost burden of type 2 diabetes in Germany: results from the population-based KORA studies

Incidence trend of type 2 diabetes from 2012 to 2021 in Germany: an analysis of health claims data of 11 million statutorily insured people

AIMS/HYPOTHESIS

The aim of the study is to describe the time trend of type 2 diabetes incidence in the largest state of Germany, Bavaria, from 2012 to 2021, and to compare the incidence rates during the pandemic period (2020-2021) to the pre-pandemic period (2012-2019).

METHODS

This secondary data analysis uses health claims data provided by the Bavarian Association of Statutory Health Insurance Physicians (KVB), covering approximately 11 million insurees, accounting for 85% of the total population of Bavaria, Germany. Newly diagnosed type 2 diabetes cases in adults (≥20 years) coded as E11 (Diabetes mellitus, Type 2) or E14 (Unspecified diabetes mellitus) under ICD-10, German modification (ICD-10-GM) for the study period 2012 to 2021 were included. Annual and quarterly age-standardised incidence rates (ASIR) stratified by sex, age and region were calculated using the European standard population. Sex-specific crude incidence rates (CIR) were calculated using 10-year age groups. Regression analyses adjusted for time trends, seasonal effects, and pandemic effects were used to analyse the incidence trend and to assess the effect of the pandemic.

RESULTS

Overall, 745,861 new cases of type 2 diabetes were diagnosed between 2012 and 2021: 50.4% (376,193 cases) in women. The male/female ratio remained stable over the observation period, while the median age at diagnosis decreased from 61 to 58 years in men and from 66 years to 61 years in women. ASIR were consistently higher for men compared with women, with the yearly difference remaining stable over time (2012: 18%; 2021: 20%). An overall decreasing trend in ASIR was observed during the study period, with a strong decrease from 2012 to 2017, followed by a less pronounced decline from 2018 to 2021 for both sexes. For men, ASIR decreased from 1514 per 100,000 person-years in 2012 to 995 per 100,000 person-years in 2021 (4.6% average annual reduction), and for women from 1238 per 100,000 person-years in 2012 to 796 per 100,000 person-years in 2021 (4.8% average annual reduction). This downward trend was also observed for age groups above 50 years. Regression analyses showed no significant change in incidence rates during the pandemic period (2020 and 2021) compared with the pre-pandemic period.

CONCLUSIONS/INTERPRETATION

For the first time, a 10-year incidence trend of type 2 diabetes is reported for Germany, showing a strong decline from 2012 to 2017, followed by a less pronounced decline from 2018 to 2021. The incidence trend of type 2 diabetes appears not to have been affected by the first 2 years of the COVID-19 pandemic. Despite an overall increasing prevalence, the incidence is decreasing, potentially resulting from robust screening by family physicians, reducing the median age at diagnosis by 3 to 5 years. However, further investigation is needed to fully identify the reasons for the declining incidence trend. Continued incidence monitoring is necessary to identify the long-term trend and the potential effect of the pandemic on diagnoses of type 2 diabetes.

A systematic review of the economic burden of diabetes mellitus: contrasting perspectives from high and low middle-income countries

Introduction

Diabetes increases preventative sickness and costs healthcare and productivity. Type 2 diabetes and macrovascular disease consequences cause most diabetes-related costs. Type 2 diabetes greatly costs healthcare institutions, reducing economic productivity and efficiency. This cost of illness (COI) analysis examines the direct and indirect costs of treating and managing type 1 and type 2 diabetes mellitus.

Methodology

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Cochrane, PubMed, Embase, CINAHL, Scopus, Medline Plus, and CENTRAL were searched for relevant articles on type 1 and type 2 diabetes illness costs. The inquiry returned 873 2011-2023 academic articles. The study included 42 papers after an abstract evaluation of 547 papers.

Results

Most articles originated in Asia and Europe, primarily on type 2 diabetes. The annual cost per patient ranged from USD87 to USD9,581. Prevalence-based cost estimates ranged from less than USD470 to more than USD3475, whereas annual pharmaceutical prices ranged from USD40 to more than USD450, with insulin exhibiting the greatest disparity. Care for complications was generally costly, although costs varied significantly by country and problem type.

Discussion

This study revealed substantial heterogeneity in diabetes treatment costs; some could be reduced by improving data collection, analysis, and reporting procedures. Diabetes is an expensive disease to treat in low- and middle-income countries, and attaining Universal Health Coverage should be a priority for the global health community.

Direct diabetes-related healthcare expenditures in Slovenia: recent evolution and future projections based on population-level data

OBJECTIVE

The burden of diabetes on individuals, healthcare systems, and society must be explored to improve and sustain diabetes care. With this aim, we estimated both past and future diabetes-related direct health expenditures in Slovenia.

METHODS

Analysis of expenditures from the healthcare payer perspective during the 2019-2022 period was based on individual patient data on expenditures for seven groups of diabetes-related medical conditions from the population-level database of the Health Insurance Institute of Slovenia. Expenditure projections were prepared using the European Commission's methodology for budgetary projections.

RESULTS

In the 2019-2022 period, average annual diabetes-related expenditures equaled €174.1 million (€1,108 per patient), with their average annual growth rate reaching 12.5%. Expenditures due to inpatient care (33%) and drugs used in diabetes (24%) had the highest shares. More than half of the expenditures were due to complications of diabetes. The diabetes-related expenditures as a share of GDP are projected to increase by 19.2% from 2019 to 2030, with slower yet continued growth up to 2050.

CONCLUSIONS

Diabetes-related expenditures in Slovenia continue to rise. By focusing on the prevention and optimal management of diabetes, its impact on the healthcare system could be reduced significantly, given the magnitude of expenditures attributed to complications.

Predictors of frequency of 1-year readmission in adult patients with diabetes

Diabetes mellitus (DM) is the third most common chronic condition associated with frequent hospital readmissions. Predictors of the number of readmissions within 1 year among patients with DM are less often studied compared with those of 30-day readmission. This study aims to identify predictors of number of readmissions within 1 year amongst adult patients with DM and compare different count regression models with respect to model fit. Data from 2008 to 2015 were extracted from the electronic medical records of the National University Hospital, Singapore. Inpatients aged ≥ 18 years at the time of index admission with a hospital stay > 24 h and survived until discharge were included. The zero-inflated negative binomial (ZINB) model was fitted and compared with three other count models (Poisson, zero-inflated Poisson and negative binomial) in terms of predicted probabilities, misclassification proportions and model fit. Adjusted for other variables in the model, the expected number of readmissions was 1.42 (95% confidence interval [CI] 1.07 to 1.90) for peripheral vascular disease, 1.60 (95% CI 1.34 to 1.92) for renal disease and 2.37 (95% CI 1.67 to 3.35) for Singapore residency. Number of emergency visits, number of drugs and age were other significant predictors, with length of stay fitted as a zero-inflated component. Model comparisons suggested that ZINB provides better prediction than the other three count models. The ZINB model identified five patient characteristics and two comorbidities associated with number of readmissions. It outperformed other count regression models but should be validated before clinical adoption.

Projected health and economic impacts of sugar-sweetened beverage taxation in Germany: A cross-validation modelling study

BACKGROUND

Taxes on sugar-sweetened beverages (SSBs) have been implemented globally to reduce the burden of cardiometabolic diseases by disincentivizing consumption through increased prices (e.g., 1 peso/litre tax in Mexico) or incentivizing industry reformulation to reduce SSB sugar content (e.g., tiered structure of the United Kingdom [UK] Soft Drinks Industry Levy [SDIL]). In Germany, where no tax on SSBs is enacted, the health and economic impact of SSB taxation using the experience from internationally implemented tax designs has not been evaluated. The objective of this study was to estimate the health and economic impact of national SSBs taxation scenarios in Germany.

METHODS AND FINDINGS

In this modelling study, we evaluated a 20% ad valorem SSB tax with/without taxation of fruit juice (based on implemented SSB taxes and recommendations) and a tiered tax (based on the UK SDIL) in the German adult population aged 30 to 90 years from 2023 to 2043. We developed a microsimulation model (IMPACTNCD Germany) that captures the demographics, risk factor profile and epidemiology of type 2 diabetes, coronary heart disease (CHD) and stroke in the German population using the best available evidence and national data. For each scenario, we estimated changes in sugar consumption and associated weight change. Resulting cases of cardiometabolic disease prevented/postponed and related quality-adjusted life years (QALYs) and economic impacts from healthcare (medical costs) and societal (medical, patient time, and productivity costs) perspectives were estimated using national cost and health utility data. Additionally, we assessed structural uncertainty regarding direct, body mass index (BMI)-independent cardiometabolic effects of SSBs and cross-validated results with an independently developed cohort model (PRIMEtime). We found that SSB taxation could reduce sugar intake in the German adult population by 1 g/day (95%-uncertainty interval [0.05, 1.65]) for a 20% ad valorem tax on SSBs leading to reduced consumption through increased prices (pass-through of 82%) and 2.34 g/day (95%-UI [2.32, 2.36]) for a tiered tax on SSBs leading to 30% reduction in SSB sugar content via reformulation. Through reductions in obesity, type 2 diabetes, and cardiovascular disease (CVD), 106,000 (95%-UI [57,200, 153,200]) QALYs could be gained with a 20% ad valorem tax and 192,300 (95%-UI [130,100, 254,200]) QALYs with a tiered tax. Respectively, €9.6 billion (95%-UI [4.7, 15.3]) and €16.0 billion (95%-UI [8.1, 25.5]) costs could be saved from a societal perspective over 20 years. Impacts of the 20% ad valorem tax were larger when additionally taxing fruit juice (252,400 QALYs gained, 95%-UI [176,700, 325,800]; €11.8 billion costs saved, 95%-UI [€6.7, €17.9]), but impacts of all scenarios were reduced when excluding direct health effects of SSBs. Cross-validation with PRIMEtime showed similar results. Limitations include remaining uncertainties in the economic and epidemiological evidence and a lack of product-level data.

CONCLUSIONS

In this study, we found that SSB taxation in Germany could help to reduce the national burden of noncommunicable diseases and save a substantial amount of societal costs. A tiered tax designed to incentivize reformulation of SSBs towards less sugar might have a larger population-level health and economic impact than an ad valorem tax that incentivizes consumer behaviour change only through increased prices.

Patient-reported, health economic and psychosocial outcomes in patients with Friedreich ataxia (PROFA): protocol of an observational study using momentary data assessments via mobile health app

INTRODUCTION

Friedreich ataxia (FA) is the most common hereditary ataxia in Europe, characterised by progressively worsening movement and speech impairments with a typical onset before the age of 25 years. The symptoms affect the patients' health-related quality of life (HRQoL) and psychosocial health. FA leads to an increasing need for care, associated with an economic burden. Little is known about the impact of FA on daily lives and HRQoL. To fill that gap, we will assess patient-reported, psychosocial and economic outcomes using momentary data assessment via a mobile health application (app).

METHODS AND ANALYSIS

The PROFA Study is a prospective observational study. Patients with FA (n=200) will be recruited at six European study centres (Germany, France and Austria). We will interview patients at baseline in the study centre and subsequently assess the patients' health at home via mobile health app. Patients will self-report ataxia severity, HRQoL, speech and hearing disabilities, coping strategies and well-being, health services usage, adverse health events and productivity losses due to informal care on a daily to monthly basis on the app for 6 months. Our study aims to (1) validate measurements of HRQoL and psychosocial health, (2) assess the usability of the mobile health app, and (3) use descriptive and multivariate statistics to analyse patient-reported and economic outcomes and the interaction effects between these outcomes. Insights into the app's usability could be used for future studies using momentary data assessments to measure outcomes of patients with FA.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Ethics Committee of the University Medicine of Greifswald, (BB096/22a, 26 October 2022) and from all local ethics committees of the participating study sites. Findings of the study will be published in peer-reviewed journals, presented at relevant international/national congresses and disseminated to German and French Patient Advocacy Organizations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05943002); Pre-results.

The True Price of External Health Effects from Food Consumption

Although global food consumption costs more in terms of impact on human life than money is spent on it, health costs have not been consistently quantified or included in food prices to date. In this paper, a method to determine the external health costs of nutrition and dietetics is developed by employing the cost-of-illness (COI) and true cost accounting (TCA) approaches. This is done exemplarily for the reference country Germany. The results show that 601.50 € per capita and 50.38 billion € in total external health costs are incurred annually due to nutrition. Overall, most costs are accrued through excessive meat consumption (32.56% of costs), deficient whole grain intake (15.42% of costs), and insufficient uptake of legumes (10.19% of costs). Comparing the external health costs with the external environmental costs in Germany, it can be seen that of the total annual costs of around 153.86 billion €, 67.26% originate from environmental impacts and 32.74% from impacts on human life. In order to achieve the 17 Sustainable Development Goals and to increase family as well as public health, there is a need to internalise these external costs into actual food prices.

Understanding health behavior change by motivation and reward mechanisms: a review of the literature

The global rise of lifestyle-related chronic diseases has engendered growing interest among various stakeholders including policymakers, scientists, healthcare professionals, and patients, regarding the effective management of health behavior change and the development of interventions that facilitate lifestyle modification. Consequently, a plethora of health behavior change theories has been developed with the intention of elucidating the mechanisms underlying health behavior change and identifying key domains that enhance the likelihood of successful outcomes. Until now, only few studies have taken into account neurobiological correlates underlying health behavior change processes. Recent progress in the neuroscience of motivation and reward systems has provided further insights into the relevance of such domains. The aim of this contribution is to review the latest explanations of health behavior change initiation and maintenance based on novel insights into motivation and reward mechanisms. Based on a systematic literature search in PubMed, PsycInfo, and Google Scholar, four articles were reviewed. As a result, a description of motivation and reward systems (approach/wanting = pleasure; aversion/avoiding = relief; assertion/non-wanting = quiescence) and their role in health behavior change processes is presented. Three central findings are discussed: (1) motivation and reward processes allow to distinguish between goal-oriented and stimulus-driven behavior, (2) approach motivation is the key driver of the individual process of behavior change until a new behavior is maintained and assertion motivation takes over, (3) behavior change techniques can be clustered based on motivation and reward processes according to their functional mechanisms into facilitating (= providing external resources), boosting (= strengthening internal reflective resources) and nudging (= activating internal affective resources). The strengths and limitations of these advances for intervention planning are highlighted and an agenda for testing the models as well as future research is proposed.

Health State Utility Values of Type 2 Diabetes Mellitus and Related Complications: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aims to synthesize health state utility values (HSUVs) of type 2 diabetes mellitus (T2DM) and its related complications published in the literature, conducting a meta-analysis of the data when possible.

METHODS

We conducted a systematic search in MEDLINE and School of Health and Related Research Health Utilities Database repository. Studies focused on T2DM and its complications reporting utility values elicited using direct and indirect methods were selected. We categorized the results according to the instrument to describe health and meta-analyzed them accordingly. Data included in the analysis were pooled in a fixed-effect model by the inverse of variance mean and random-effects DerSimonian-Laird method. Two approaches on sensitivity analysis were performed: leave-one-out method and including data of HSUVs obtained by foreign population value sets.

RESULTS

We identified 70 studies for the meta-analysis from a total of 467 studies. Sufficient data to pool T2DM HSUVs from EQ-5D instrument, hypoglycemia, and stroke were obtained. HSUVs varied from 0.7 to 0.92 in direct valuations, and the pooled mean of 3-level version of EQ-5D studies was 0.772 (95% confidence interval 0.763-0.78) and of 5-level version of EQ-5D 0.815 (95% confidence interval 0.808-0.823). HSUVs of complications varied from 0.739 to 0.843, or reductions of HSUVs between -0.014 and -0.094. In general, HSUVs obtained from 3-level version of EQ-5D and Health Utility Index 3 instruments were lower than those directly elicited. A considerable amount of heterogeneity was observed. Some complications remained unable to be pooled due to scarce of original articles.

CONCLUSIONS

T2DM and its complications have a considerable impact on health-related quality of life. 5-level version of EQ-5D estimates seems comparable with direct elicited HSUVs.

Economic burden of type 2 diabetes in Iran: A cost-of-illness study

Background and Aims

Type 2 diabetes mellitus (T2DM) is a prevalent public health problem worldwide, and the economic burden of the disease poses one of the main challenges for health systems in low- and middle-income countries. This study aimed to estimate the economic burden of T2DM in Iran, in 2018.

Methods

This was a cost-of-illness study. Three hundred and seventy-five patients with T2DM who were referred to Imam Reza and Sina's educational and therapeutic centers and Asad Abadi clinic in Tabriz, Iran, in 2018 were included. A researcher-constructed checklist was used for data collection. Data were analyzed using EXCEL and SPSS software version 22.

Results

Total economic burden of diabetes was estimated at 152,443,862,480.3 (purchasing power parity [PPP], Current International $) (approximately 7.69% of GDP, PPP, Current International $). The mean total direct and indirect costs were 11,278.68 (PPP) (62.35% of mean total cost) and 6808.88 (PPP, Current International $) (37.64% of the total cost), respectively. The mean total direct medical cost and the direct nonmedical cost were 10,819.43 (PPP, Current International $) (59.81% of mean total cost) and 459.24 (PPP, Current International $) (2.53% of mean total cost) per patient, respectively. Besides, the mean direct medical cost was 6.18 times the total per capita expenditure on health, and the total direct medical cost was 8.9% times the total expenditure on health.

Conclusion

Diabetes imposes a substantial economic burden on patients, health systems, and the whole economy. Besides, since the cost of the disease in patients treated with insulin and those with diabetes complications is significantly higher, the reinforcement of self-care measures and focusing on modifying lifestyle (dietary modification and physical activity) in patients with T2DM can significantly reduce the costs of the disease.

Utilization and cost of drugs for diabetes and its comorbidities and complications in Kuwait

Background

Diabetes imposes a large burden on countries’ healthcare expenditures. In Kuwait, diabetes prevalence in adults is estimated at 22.0%%—double the worldwide prevalence (9.3%). There is little current data on pharmaceutical costs in Kuwait of managing diabetes and diabetes-related complications and comorbidities.

Objectives

Estimate the utilization and cost of drugs for diabetes and diabetes-related complications and comorbidities in Kuwait for year 2018, as well determinants of costs.

Methods

This cross-sectional study used a multi-stage stratified sampling method. Patients were Kuwaiti citizens with diabetes, aged 18–80, recruited from all six governorates. Physicians collected demographic data, clinical data, and current drug prescription for each patient which was extrapolated for the full year of 2018. A prevalence-based approach and bottom-up costing were used. Data were described according to facility type (primary care vs. hospital). A generalized linear model with log function and normal distribution compared drug costs for patients with and without comorbidities/complications after adjustments for demographic and health confounders (gender, age group, disease duration, and obesity).

Results

Of 1182 diabetes patients, 64.0% had dyslipidemia and 57.7% had hypertension. Additionally, 40.7% had diabetes-related complications, most commonly neuropathy (19.7%). Of all diabetes patients, 85.9% used oral antidiabetics (alone or in combinations), 49.5% used insulin alone or in combinations, and 29.3% used both oral antidiabetics and insulin. The most frequently used oral drug was metformin (75.7%), followed by DPP4 inhibitors (40.2%) and SGLT2 inhibitors (23.8%). The most frequently used injectables were insulin glargine (36.6%), followed by GLP-1 receptor agonists (15.4%). Total annual drug cost for Kuwait’s diabetic population for year 2018 was US$201 million (US$1,236.30 per patient for antidiabetics plus drugs for comorbidities/complications).

Conclusions

Drug costs for treating diabetes and comorbidities/complications accounted for an estimated 22.8% of Kuwait’s 2018 drug expenditures. Comorbidities and complications add 44.7% to the average drug cost per diabetes patient.

The Place and Value of Sodium-Glucose Cotransporter 2 Inhibitors in the Evolving Treatment Paradigm for Type 2 Diabetes Mellitus: A Narrative Review

Over recent years, the expanding evidence base for sodium-glucose cotransporter-2 inhibitor (SGLT2i) therapies has revealed benefits beyond their glucose-lowering efficacy in the treatment of Type 2 diabetes mellitus (T2DM), resulting in their recognition as cardiorenal medicines. While SGLT2is continue to be recommended among the second-line therapies for the treatment of hyperglycaemia, their true value now extends to the prevention of debilitating and costly cardiovascular and renal events for high-risk individuals, with particular benefit shown in reducing major adverse cardiac events and heart failure (HF) and slowing the progression of chronic kidney disease. However, SGLT2i usage is still suboptimal among groups considered to be at greatest risk of cardiorenal complications. The ongoing coronavirus disease 2019 (COVID-19) pandemic has intensified financial pressures on healthcare systems, which may hamper further investment in newer effective medicines. Emerging evidence indicates that glycaemic control should be prioritised for people with T2DM in the era of COVID-19 and practical advice on the use of T2DM medications during periods of acute illness remains important, particularly for healthcare professionals working in primary care who face multiple competing priorities. This article provides the latest update from the Improving Diabetes Steering Committee, including perspectives on the value of SGLT2is as cost-effective therapies within the T2DM treatment paradigm, with particular focus on the latest published evidence relating to the prevention or slowing of cardiorenal complications. The implications for ongoing and future approaches to diabetes care are considered in the light of the continuing coronavirus pandemic, and relevant aspects of international treatment guidelines are highlighted with practical advice on the appropriate use of SGLT2is in commonly occurring T2DM clinical scenarios. The 'SGLT2i Prescribing Tool for T2DM Management', previously published by the Steering Committee, has been updated to reflect the latest evidence and is provided in the Supplementary Materials to help support clinicians delivering T2DM care.

How do individuals with alcohol problems use social and healthcare services in Finland? Comparison of service use patterns between two high-need patient groups

Aims:

Alcohol use disorders (AUDs) are associated with high risk of comorbidities and excess use of social and healthcare services. We examined health service use (HSU) frequencies of patients with AUD in comparison to those with type 2 diabetes mellitus (T2DM).

Design:

A random sample of individuals with AUD (n = 396) were identified based on ICD-10 codes and HSU patterns, morbidity and mortality were compared with age- and gender-matched T2DM controls (n = 792) using logistic regression analysis. Six years (2011–2016) of electronic health record (EHR) data from the North Karelia district in Finland were used.

Results:

Similarities in comorbidity patterns existed, although mental health comorbidity (odds ratio [OR] 1.86) was more prevalent in the AUD group. The average annual HSU varied according to the groups: T2DM patients had more continuous contact with public health nurses in primary care, whereas AUD patients were more likely to experience somatic specialised care hospitalisations (OR 11.30) and have frequent somatic primary healthcare doctor visits (OR 3.30) and frequent emergency room doctor visits in specialised care (OR 8.89). Furthermore, patients with AUD had a 7.5 times higher risk of death compared with T2DM patients.

Conclusions:

This study identified rather similar comorbidity status for the AUD and T2DM patients, but their HSU patterns differed noticeably. AUD patients had higher frequencies of hospitalisation periods and emergency service use and were at a higher risk of death compared with T2DM patients, indicating greater challenges in the organisation of care for AUD patients compared with those having T2DM.

Functional Mechanisms of Health Behavior Change Techniques: A Conceptual Review

Background

Health behavior change is among the top recommendations for improving health of patients with lifestyle-related chronic diseases. An array of behavior change techniques (BCTs) have been developed to support behavior change initiation and maintenance. These BCTs often show limited success when they are not informed by theory, leading to a mismatch between the intention of the BCT and patients' needs or expectations. Previous studies have identified a number of resources (domains) which patients may require to initiate and maintain health behavior change. Indeed, not yet well established is how BCTs address these resources, i.e., the functional mechanisms of BCTs.

Purpose

Provide a theoretical framework of the functional mechanisms of BCTs for developing and implementing successful interventions for health behavior change.

Methods

Conceptual review, including literature analysis and synthesis as well as conceptualization of a new model based on the synthesis.

Results

Through the integration of dual-process models as well as reward and motivation proceeding, i.e., affective, emotional, or intuitive neurobiological cues, into the rational framework of rather linear cognitive or task-related decision progress, we categorize previously identified resources into three distinct sets: external, internal reflective, and internal affective resources. Based on this triad, we classify BCTs according to their functional mechanisms into facilitating (=providing external resources), boosting (=strengthening internal reflective resources), and nudging (=activating internal affective resources). Consequently, we present a simplified Behavior Change Resource Model (BCRM) that is centered on patients' resources.

Conclusion

The model can be applied to develop health behavior change interventions, which promote engagement and empowerment. Future studies should aim at testing the applicability and practicality of the BCRM.

Impact of Policies in Nutrition and Physical Activity on Diabetes and Its Risk Factors in the 28 Member States of the European Union

Since healthy eating and physically active lifestyles can reduce diabetes mellitus (DM) risk, these are often addressed by population-based interventions aiming to prevent DM. Our study examined the impact of nutritional and physical activity policies, national diabetes plans and national diabetes registers contribute to lower prevalence of DM in individuals in the member states of the European Union (EU), taking into account the demographic and socioeconomic status as well as lifestyle choices. Datasets on policy actions, plans and registers were retrieved from the World Cancer Research Fund International’s NOURISHING and MOVING policy databases and the European Coalition for Diabetes report. Individual-based data on DM, socioeconomic status and healthy behavior indicators were obtained via the European Health Interview Survey, 2014. Our results showed variation in types and numbers of implemented policies within the member states, additionally, the higher number of these actions were not associated with lower DM prevalence. Only weak correlation between the prevalence of DM and preventive policies was found. Thus, undoubtedly policies have an impact on reducing the prevalence of DM, its increasing burden could not be reversed which underlines the need for applying a network of preventive policies.

Excess costs of type 2 diabetes and their sociodemographic and clinical determinants: a cross-sectional study using data from the German Health Interview and Examination Survey for Adults (DEGS1)

OBJECTIVES

The objectives of this study were to estimate the direct and indirect excess costs of type 2 diabetes mellitus (T2D) using data representative for the German adult population and to investigate the association of sociodemographic and clinical determinants with these excess costs.

SETTING

We calculated mean annual costs for individuals with T2D and a control group without diabetes, using data on healthcare utilisation and productivity losses from the cross-sectional German Health Interview and Examination Survey for Adults. We adjusted for group differences using entropy balancing and estimated excess costs for total, direct, indirect costs and additional cost categories using generalised linear models. We performed subgroup analyses to investigate the association of sociodemographic (age, sex and education) and clinical determinants (diabetes duration, glycaemic index and complications) with excess costs.

PARTICIPANTS

The final study sample included n=325 individuals with T2D and n=4490 individuals without diabetes in the age between 18 and 79 years.

RESULTS

Total excess costs amounted to €927, of which €719 were attributable to direct and €209 to indirect excess costs. Total costs were significantly increased by 28% for T2D compared with controls. Group differences in direct, outpatient and medication costs were statistically significant. Medication costs were 88% higher for T2D and had the highest share in direct excess costs. With respect to specific determinants, direct excess costs ranged from €203 for 4-10 years diabetes duration to €1405 for diabetes complications. Indirect excess costs ranged from €-544 for >10 years diabetes duration to €995 for high education.

CONCLUSIONS

T2D was associated with high costs, mainly due to direct costs. As pointed out by our results, diabetes complications and comorbidities have a large impact on the costs, leaving medication costs as main contributor of T2D excess costs.

Real-world clinical outcomes and costs in type 2 diabetes mellitus patients after initiation of insulin therapy: A German claims data analysis

BACKGROUND

This study describes real-world treatment-related outcomes and healthcare costs of German type 2 diabetes mellitus (T2D) patients who initiated insulin therapy.

METHODS

This retrospective analysis includes German claims data from 01/01/2012 until 31/12/2016. Identification of eligible patients took place between 01/01/2013 and 31/12/2015, allowing for at least 1 year of follow-up. Clinical outcomes, such as HbA1c values and body mass index, were observed in a subpopulation participating in a Disease Management Program. Healthcare expenditures were evaluated for the first year of therapy.

RESULTS

Overall, 27,340 insulin starters with T2D were observed (mean age: 72.2 years, female: 51.4%). Treatment-related outcomes were evaluated in a subsample of 12,034 patients. Patients who started insulin combined with other antidiabetic drugs (ADs) achieved their HbA1c goals more frequently than patients on insulin monotherapy (+10.7 percentage points [pp] vs. +21.1 pp for insulin plus metformin). All-cause costs were by far highest among patients with insulin monotherapy (€ 12,283 per patient-year) compared with patients receiving a combined AD regimen (€ 9,947-10,509 per patient-year).

CONCLUSIONS

Changes in HbA1c values were not in favor of insulin monotherapy, compared to regimens including other ADs. It was also associated with higher costs, suggesting that insulin alone is a suboptimal treatment.

Utility Decrements Associated With Diabetes and Related Complications: Estimates From a Population-Based Study in Germany

OBJECTIVES

Health utility decrement estimates for diabetes and complications are needed for parametrization of simulation models that aim to assess the cost-utility of diabetes prevention and care strategies. This study estimates health utility decrements associated with diabetes and cardiovascular and microvascular complications from a population-based German study.

METHODS

Data were obtained from the population based cross-sectional KORA (Cooperative Health Research in the Augsburg Region) health questionnaire 2016 and comprised n = 1072 individuals with type 2 diabetes and n = 7879 individuals without diabetes. Health utility was assessed through the EQ-5D-5L. We used linear regression models with interaction terms between type 2 diabetes and different cardiovascular and microvascular complications while adjusting for demographic and socio-economic factors and other comorbidities.

RESULTS

Type 2 diabetes (β = -0.028, standard error [SE] = 0.014), stroke (β = -0.070, SE = 0.010), cardiac arrhythmia (β = -0.031, SE = 0.006), heart failure (β = -0.073, SE = 0.009), coronary heart disease (β = -0.028, SE = 0.010), myocardial infarction (β = -0.020, SE = 0.011, estimates of main effect), and neuropathy (β = -0.067, SE = 0.020), diabetic foot (β = -0.042, SE = 0.030), nephropathy (β = -0.032, SE = 0.025), and blindness (β = -0.094, SE = 0.056, estimates of interaction terms) were negatively associated with health utility. The interaction term for diabetes x stroke (β = -0.052, SE = 0.021) showed that the utility decrement for stroke is significantly larger in people with type 2 diabetes than in people without diabetes.

CONCLUSIONS

Diabetes, cardiovascular, and microvascular conditions are associated with significant health utility decrements. Utility decrements for some conditions differ between people with and without type 2 diabetes. These results are of high relevance for the parametrization of decision analytic simulation models and applied health economic evaluations in the field of prevention and management of type 2 diabetes in Germany.

Motivation and reward mechanisms in health behavior change processes

With increasing prevalence of lifestyle-related chronic diseases worldwide, understanding health behavior change and the development of successful interventions to support lifestyle modification is gaining increasing interest among politicians, scientists, therapists and patients alike. A number of health behavior change theories have been developed aiming at explaining health behavior change and understanding the domains that make change more likely. Until now, only few studies have taken into account automatic, implicit or non-cognitive aspects of behavior, including emotion and positive affect. Recent progress in the neuroscience of motivation and reward systems can provide further insights into the relevance of such domains. In this integrative review, we present a description of the possible motivation and reward systems (approach/wanting = pleasure; aversion/avoiding = relief; assertion/non-wanting = quiescence) involved in behavior change. Therefore, based on established theories encompassing both initiation and maintenance of behavior change, we create a flexible seven-stage behavior change process with three engagement phases (non-engagement, motivational engagement, executive engagement) and relate the motivation and reward systems to each of these stages. We propose that either appetitive (preferably) or aversive motivational salience is activated during motivational engagement, that learning leads to continued behavior and that assertive salience prevails when the new behavior has become habitual. We discuss under which circumstances these mechanisms and reward-motivation pathways are likely to occur and address potential shortcomings of our proposed theoretical framework. We highlight implications for future interventions aiming at lifestyle modification.

Status of Telemonitoring Services in Diabetes Care in Germany: A Narrative Review

BACKGROUND

Diabetes mellitus (DM) as a chronic disease is a great medical, organizational, and financial burden on the German healthcare system, and it has risen in epidemiological importance. To ensure healthcare against the background of rising prevalence rates and to reduce costs, it makes sense to supplement treatment of diabetes patients with telemedical services.

OBJECTIVES

The aim was to evaluate telemonitoring services for DM patients in Germany and the political/legal environment.

MATERIALS AND METHODS

A narrative review was conducted to provide a comprehensive and critical analysis of the current knowledge on interactive telemonitoring offerings and influencing factors. A total of 19 publications were considered as relevant in the screening process, and were included in the content analysis.

RESULTS

The results can be differentiated in terms of political/legal requirements, needs, and supply-related aspects. Only four studies focused on the individual care aspects of telemedical care of DM patients.

CONCLUSION

Telemonitoring measures for chronic diseases in general and for DM in particular have hardly been implemented in Germany so far. Based on the deficiencies and research gaps described earlier, some recommendations can be made. There is a need to set up structure for more interactivity, to expand technical infrastructure, and to close legal gaps. More research focusing on clinical effectiveness is necessary.

Toward targeted prevention: risk factors for prediabetes defined by impaired fasting glucose, impaired glucose tolerance and increased HbA1c in the population-based KORA study from Germany

AIMS

To identify socioeconomic, behavioral and clinical factors that are associated with prediabetes according to different prediabetes definition criteria.

METHODS

Analyses use pooled data of the population-based Cooperative Health Research in the Region of Augsburg (KORA) studies (n = 5312 observations aged ≥ 38 years without diabetes). Prediabetes was defined through either impaired fasting glucose (IFG), impaired glucose tolerance (IGT) or elevated HbA1c according to thresholds of the American Diabetes Association. Explanatory variables were regressed on prediabetes using generalized estimating equations.

RESULTS

Mean age was 58.4 years; 50% had prediabetes (33% had IFG, 16% IGT, and 26% elevated HbA1c, 10% fulfilled all three criteria). Age, obesity, hypertension, low education, unemployment, statutory health insurance, urban residence and physical inactivity were associated with prediabetes. Male sex was a stronger risk factor for IFG (OR = 2.5; 95%-CI: 2.2-2.9) than for IGT or elevated HbA1c, and being unemployed was a stronger risk factor for IGT (OR = 3.2 95%-CI: 2.6-4.0) than for IFG or elevated HbA1c.

CONCLUSIONS

The overlap of people with IFG, IGT and elevated HbA1c is small, and some factors are associated with only one criterion. Knowledge on sociodemographic and socioeconomic risk factors can be used to effectively target interventions to people at high risk for type 2 diabetes.

Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: a systematic review of economic studies

BACKGROUND

Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.

METHODS

A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.

RESULTS

From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.

CONCLUSIONS

Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers.

Costs and where to find them: identifying unit costs for health economic evaluations of diabetes in France, Germany and Italy

BACKGROUND

Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes.

METHODS

A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications.

RESULTS

An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources.

CONCLUSIONS

This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes.

Assessment of excess medical costs for persons with type 2 diabetes according to age groups: an analysis of German health insurance claims data

AIM

This cross-sectional study used a large nationwide claims data set to assess the excess medical costs of people with type 2 diabetes according to age group in 2015.

METHODS

Data from 291 709 people with diabetes and 291 709 age- and sex-matched controls were analysed. Total costs (expressed as 2015 euros) of outpatient and inpatient services, medication, rehabilitation, and the provision of aids and appliances were examined. Overall and age-stratified excess costs of people with diabetes were estimated using gamma regression with a log-link.

RESULTS

Overall, the estimated total direct costs of a person with type 2 diabetes are approximately double those of a person without diabetes: €4727 vs. €2196, respectively. Absolute excess costs were approximately the same in all age groups (around €2500), however, relative excess costs of persons with diabetes were much higher in younger (~ 334% for < 50 years) than in older age groups (~ 156% for ≥ 80 years). Regional costs, both absolute and excess, partly differed from the national level.

CONCLUSIONS

This study complements and updates previous studies on the excess medical costs of people with diabetes in Germany. The results indicate the importance of preventing the development of type 2 diabetes, especially in younger age groups. Longitudinal and regional studies examining changes in prevalence and the development of excess costs in groups with different types of diabetes, and according to age, would be of interest to validate our findings and better understand the avoidable burden of having diabetes.

Burden of disease and costs associated with type 2 diabetes in emerging and established markets: systematic review analyses

Objectives: To estimate the clinical and economic burden of type 2 diabetes (T2D) in established (EST) and emerging markets (EMG).Methods: Three systematic literature reviews were conducted in MEDLINE and Embase to capture all relevant publications reporting 1) the epidemiology of T2D and complications in T2D and 2) the economic burden of T2D and associated complications.Results: In total, 294 studies were included in this analysis. Evidence indicates a high and increasing overall prevalence of T2D globally, ranging up to 23% in EMG markets and 14% in EST markets. Undiagnosed cases were higher in EMG versus EST markets (up to 67% vs 38%), potentially due to a lack of education and disease awareness in certain regions, that could lead to important clinical and economic consequences. Poor glycemic control was associated with the development of several complications (e.g. retinopathy, cardiovascular diseases and nephropathy) that increase the risk of morbidity and mortality. Direct costs were up to 9-fold higher in patients with vs without T2D-related complications.Conclusions: The burden of T2D, related complications and inherent costs are higher in emerging versus established market countries. This review explores potential strategies to reduce costs and enhance outcomes of T2D treatment in developing countries.

Association between unrealistic comparative optimism and self-management in individuals with type 2 diabetes: Results from a cross-sectional, population-based study

BACKGROUND AND AIMS

Unrealistic comparative optimism (UO), as the erroneous judgement of personal risks to be lower than the risks of others, could help explain differences in diabetes self-management. The present study tested the hypothesis that individuals with type 2 diabetes who underestimate their comparative heart attack risk, have a lower adherence regarding recommended self-management.

METHODS

We used data from individuals with type 2 diabetes participating in the German KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 (self-administered health questionnaire 2016) study. UO was estimated by comparing participants' subjective comparative risk for having a heart attack within the next 5-years (ie, "higher than others," "average," "lower than others"), with their objective comparative 10-year cardiovascular disease risk based on the Framingham equations. We estimated binary logistic and linear regression models to analyze which characteristics were associated with UO and to test the association between UO and participants' self-management behaviors (ie, regular self-monitoring of body weight, blood sugar, and blood pressure, regular foot care, keeping a diabetes diary, and having a diet plan), and their sum score, respectively. All models were adjusted for socio-demographic and disease-related variables.

RESULTS

The studied sample included n = 633 individuals with type 2 diabetes (mean age 70.7 years, 45% women). Smokers and males were more likely to show UO than nonsmokers and females. Furthermore, a higher blood pressure and a higher body mass index were associated with a higher likelihood of UO regarding heart attack risk. However, UO was not significantly associated with patient self-management.

CONCLUSIONS

Unfavorable health behavior and risk factors are associated with UO. However, our results suggest that UO with regard to perceived heart attack risk may not be a relevant factor for patient self-management in those with type 2 diabetes.

Health App Use and Its Correlates Among Individuals With and Without Type 2 Diabetes: Nationwide Population-Based Survey

Background

Evidence suggests that mobile health app use is beneficial for the prevention and management of type 2 diabetes (T2D) and its associated complications; however, population-based research on specific determinants of health app use in people with and without T2D is scarce.

Objective

This cross-sectional study aimed to provide population-based evidence on rates and determinants of health app use among adults with and without T2D, thereby covering a prevention perspective and a diabetes management perspective, respectively.

Methods

The study population included 2327 adults without a known diabetes diagnosis and 1149 adults with known T2D from a nationwide telephone survey in Germany conducted in 2017. Rates of smartphone ownership and health app use were estimated based on weighted sample proportions. Among smartphone owners, determinants of health app use were identified for both groups separately in multivariable logistic regression models. Sociodemographic factors, diabetes-related factors or indicators, psychological and health-related factors, and physician-provided information were selected as potential determinants.

Results

Among participants without known diabetes, 74.72% (1690/2327) were smartphone owners. Of those, 49.27% (717/1690) used health apps, most often to improve regular physical activity. Among participants with T2D, 42.26% (481/1149) were smartphone owners. Of those, 41.1% (171/481) used health apps, most commonly to target a healthy diet. Among people without known diabetes, determinants significantly (all P values <.05) associated with an increased likelihood of health app use compared with their reference group were as follows: younger and middle age of 18 to 44 or 45 to 64 years (odds ratios [ORs] 3.89; P<.001 and 1.76; P=.004, respectively), overweight or obesity (ORs 1.58; P<.001 and 2.07; P<.001, respectively), hypertension diagnosis (OR 1.31; P=.045), former or current smoking (ORs 1.51; P=.002 and 1.58; P<.001, respectively), perceiving health as very good (OR 2.21; P<.001), other chronic diseases (OR 1.48; P=.002), and having received health advice from a physician (OR 1.48; P<.001). A slight or high perceived diabetes risk (ORs 0.78; P=.04 and 0.23; P<.001, respectively) was significantly associated with a decreased likelihood of health app use. Among people with T2D, younger and middle age (18-64 years; OR 1.84; P=.007), female gender (OR 1.61; P=.02), and using a glucose sensor in addition or instead of a glucose meter (OR 2.74; P=.04) were significantly positively associated with health app use.

Conclusions

In terms of T2D prevention, age, diabetes-related risk factors, psychological and health-related factors, and medical health advice may inform app development for specific target groups. In addition, health professionals may encourage health app use when giving advice on health behaviors. Concerning T2D management, only a few determinants seem relevant for explaining health app use among people with T2D, indicating a need for more future research on which people with T2D use health apps and why.

Effectiveness and safety of insulin glargine 300 U/mL in insulin-naïve patients with type 2 diabetes after failure of oral therapy in a real-world setting

AIM

To evaluate the effectiveness and safety of initiating basal insulin-supported oral therapy (BOT) with insulin glargine 300 U/mL (Gla-300) in patients with type 2 diabetes inadequately controlled on oral antidiabetic drugs (OADs).

MATERIALS AND METHODS

This non-interventional, multi-centre, prospective 52-week study, conducted in Germany and Switzerland, documented patients with type 2 diabetes with an HbA1c of between 7.5% and 10.0%, currently treated with OADs, after the physician had decided to start a BOT regimen with Gla-300. The primary endpoint was the rate of achievement of the individualized predefined HbA1c target.

RESULTS

Of 1748 patients included, 1153 comprised the full analysis set, of whom 721 completed documentation of 12 months of Gla-300 treatment. Twelve months after starting Gla-300, 49.9% achieved their individualized HbA1c target, and 61.1% achieved either their HbA1c target or a fasting plasma glucose (FPG) of ≤110 mg/dL. Mean HbA1c decreased by -1.22% ± 1.05% to 7.28% ± 0.92% and mean FPG by -51.5 (±48.63) mg/dl to 132.9 ± 33.0 mg/dL. Median duration of HbA1c target achievement was 341 days and probability to remain on target after 6 months was 81%. Hypoglycaemia incidence and rates remained low after 12 months of Gla-300 treatment; no severe or severe nocturnal hypoglycaemia was observed. Body weight remained unchanged.

CONCLUSIONS

Starting a BOT regimen with Gla-300 allowed about 60% of 721 German and Swiss patients with inadequately controlled type 2 diabetes to achieve glycaemic control within 12 months in daily clinical practice. Glycaemic control was achieved without weight gain or increased risk of nocturnal or severe hypoglycaemia.

Individual differences in impulsivity and need for cognition as potential risk or resilience factors of diabetes self-management and glycemic control

Objective

Impulsivity is marked by insufficient reflection and forethought, whereas Need for Cognition (NFC) also referred to as cognitive motivation or intellectual engagement is marked by elaborated thinking. The aim of this study was to investigate the potential role of these personality traits as resilience or risk factors, respectively, in diabetes self-management and glycaemic control. Further, it was examined whether diabetes-specific self-efficacy could serve as a mediator of these relationships.

Design/Measures

Data of 77 participants with type 2 diabetes was ascertained, using self-report instruments for NFC, impulsivity, diabetes-specific self-efficacy, and diabetes self-management. Glycemic control was assessed by the biomarker HbA_1c.

Results

While NFC was strongly positively associated with diabetes self-management and glycemic control, impulsivity showed a reverse pattern. Results of simple and serial mediation models showed that the effects on diabetes self-management and HbA1c of both, impulsivity and NFC, were mediated by self-efficacy.

Conclusion

The moderate to high standardized coefficients suggests that NFC might be an important protective factor and impulsivity a possible risk factor for effective diabetes self-management and glycemic control. These traits could be applied for an easy-to-use questionnaire-based patient screening, enabling trait-tailored treatments and programs which in turn may lower economic and health costs associated with poor diabetes-care.

How Serious is the Economic Burden of Diabetes Mellitus in Hainan Province? A Study Based on "System of Health Account 2011"

INTRODUCTION

The treatment of diabetes requires extensive use of healthcare resources, resulting in high medical costs, which in turn places a heavy economic burden on society, patients and their families.

METHODS

A multi-stage stratified random sampling method was used to investigate 283 medical and health institutions in Hainan Province. The total medical expenses relating to diabetes in Hainan Province in 2016, institutional flow directions, the composition of service functions and the distribution of the healthcare costs to beneficiaries were analyzed based on the System of Health Account 2011. The STATA version 12.0 statistical software package was used to collate operation data, and SPSS software was used to carry out regression analysis on the factors affecting hospitalization costs.

RESULTS

In 2016, the total medical expenses for the treatment of diabetes in Hainan Province was 242.17 billion renminbi (RMB), of which 81.95% was spent in high-level hospitals and 14.71% was spent in medical institutions providing primary care. There was little difference between outpatient and hospitalization expenses (53.01 and 46.99%, respectively). Hospitalization accounted for 77.62% of the expenses of medical institutions providing primary care. Older patients were found to spend more on medical and drug expenditure.

CONCLUSION

The economic burden of healthcare expenses for the treatment of diabetes in Hainan Province is massive, and patient treatment is concentrated in large hospitals. It is necessary to inform patients to focus more on medical institutions that provide primary care, adjust the proportion of medical insurance reimbursement, control the cost of hospitalization and strengthen the healthcare management of middle-aged and elderly diabetic patients. Only in this way can costs be reduced and the economic burden be eased.

Type 2 diabetes remission: economic evaluation of the DiRECT/Counterweight-Plus weight management programme within a primary care randomized controlled trial

AIM

The Counterweight-Plus weight management programme achieved 46% remission of Type 2 diabetes at 1 year in the DiRECT trial. We estimated the implementation costs of the Counterweight-Plus programme and its 1-year cost-effectiveness in terms of diabetes remission, compared with usual care, from the UK National Health Service (NHS) perspective.

METHODS

Within-trial total costs included programme set-up and running costs (practitioner appointment visits, low-energy formula diet sachets and training), oral anti-diabetes and anti-hypertensive medications, and healthcare contacts. Total costs were calculated for aggregated resource use for each participant and 95% confidence intervals (CI) were based on 1000 non-parametric bootstrap iterations.

RESULTS

One-year programme costs under trial conditions were estimated at £1137 per participant (95% CI £1071, £1205). The intervention led to a significant cost-saving of £120 (95% CI £78, £163) for the oral anti-diabetes drugs and £14 (95% CI £7.9, £22) for anti-hypertensive medications compared with the control. Deducting the cost-savings of all healthcare contacts from the intervention cost resulted an incremental cost of £982 (95% CI £732, £1258). Cost per 1 year of diabetes remission was £2359 (95% CI £1668, £3250).

CONCLUSIONS

Remission of Type 2 diabetes within 1-year can be achieved at a cost below the annual cost of diabetes (including complications). Providing a reasonable proportion of remissions can be maintained over time, with multiple medical gains expected, as well as immediate social benefits, there is a case for shifting resources within diabetes care budgets to offer support for people with Type 2 diabetes to attempt remission. (Clinical Trial Registry No.: ISRCTN03267836).

Direct medical cost of diabetes in rural China using electronic insurance claims data and diabetes management data

AIMS/INTRODUCTION

To evaluate the annual direct medical cost attributable to type 2 diabetes mellitus according to socioeconomic factors, medical conditions and complications categories.

MATERIALS AND METHODS

We created uniquely detailed data from merging datasets of the local diabetes management system and the social security system in Tongxiang, China. We calculated the type 2 diabetes mellitus-related total cost and out-of-pocket cost for inpatient admissions and outpatient visits, and compared the cost for patients with or without complications by different healthcare items.

RESULTS

A total of 16,675 patients were eligible for analysis. The type 2 diabetes mellitus-related cost accounted for 40.6% of the overall cost. The cost per patient was estimated to be a median of 1,067 Chinese Yuan, 7,114 Chinese Yuan and 969 Chinese Yuan for inpatient and outpatient cost, respectively. The median total cost for hospital-based care was 3.69-fold higher than that for primary care. The median cost of patients with complications was 3.46-fold higher than that of those without complications. The median cost for a patient with only macrovascular, only microvascular or both macrovascular and microvascular complications were 3.13-, 3.79- and 10.95-fold higher than that of patients without complications. Pharmaceutical expenditure accounted for 51.8 and 79.7% of the total cost for patients with or without complications, respectively.

CONCLUSIONS

Although the type 2 diabetes mellitus-related cost per patient was relatively low, it accounted for a great proportion of the overall cost. Complications obviously aggravated the economic burden of type 2 diabetes mellitus. Proper management and the prevention of diabetes and its complications are urgently required to curtail the economic burden.

Creating a Culture of Health in Planning and Implementing Innovative Strategies Addressing Non-communicable Chronic Diseases

Ongoing demographic changes are challenging health systems worldwide especially in relation to increasing longevity and the resultant rise of non-communicable diseases (NCDs). To meet these challenges, a paradigm shift to a more proactive approach to health promotion, and maintenance is needed. This new paradigm focuses on creating and implementing an ecological model of Culture of Health. The conceptualization of the Culture of Health is defined as one where good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities where citizens have the opportunity to make choices and be co-producers of healthy lifestyles. Based on Antonovsky's Salutogenesis model which asserts that the experience of health moves along a continuum across the lifespan, we will identify the key drivers for achieving a Culture of Health. These include mindset/expectations, sense of community, and civic engagement. The present article discusses these drivers and identifies areas where policy and research actions are needed to advance positive change on population health and well-being. We highlight empirical evidence of drivers within the EU guided by the activities within the thematic Action Groups of the European Innovation Partnership on Active and Healthy Aging (EIP on AHA), focusing on Lifespan Health Promotion and Prevention of Age-Related Frailty and Disease (A3 Action Group). We will specifically focus on the effect of Culture on Health, highlighting cross-cutting drivers across domains such as innovations at the individual and community level, and in synergies with business, policy, and research entities. We will present examples of drivers for creating a Culture of Health, the barriers, the remaining gaps, and areas of future research to achieve an inclusive and sustainable asset-based community.

Time preference, outcome expectancy, and self-management in patients with type 2 diabetes

BACKGROUND

Patient self-management is crucial to prevent complications and mortality in type 2 diabetes. From an economic perspective, time preference predicts short-sighted decision making and thus might help to explain non-adherence to self-anagement recommendations. However, recent studies on this association have shown mixed results.

PURPOSE

In this study, we tested whether the combination of time preference and outcome expectancy can improve the predictions of self-management behavior.

PATIENTS AND METHODS

Data from 665 patients with type 2 diabetes were obtained from the cross-sectional KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 study. Time preference and outcome expectancy were measured by one question each, which were answered on a 4-point Likert scale. Their association with six self-managing behaviors was tested in logistic and linear regression analyses. Likewise, we examined the association between self-management and the interaction of outcome expectancy and time preference.

RESULTS

A high time preference was associated with a significantly lower sum of self-management behaviors (β=-0.29, 95% CI [-0.54, -0.04]). Higher outcome expectancy was associated with a higher self-management score (β=0.21, 95% CI [-0.03, 0.45]). The interaction model showed that low time preference was only associated with better self-management when combined with a high outcome expectancy (β=0.05, 95% CI [-0.28, 0.39] vs β=0.27, 95% CI [-0.09, 0.63]).

CONCLUSION

Time preference and outcome expectancy are interrelated predictors of patient self-management and could be used to identify and to intervene on patients with a potentially poor self-management.

Advancing Measurement of Diabetes at the Population Level

PURPOSE

The measurement and estimation of diabetes in populations guides resource allocation, health priorities, and can influence practice and future research. To provide a critical reflection on current diabetes surveillance, we provide in-depth discussion about how upstream determinants, prevalence, incidence, and downstream impacts of diabetes are measured in the USA, and the challenges in obtaining valid, accurate, and precise estimates.

FINDINGS

Current estimates of the burden of diabetes risk are obtained through national surveys, health systems data, registries, and administrative data. Several methodological nuances influence accurate estimates of the population-level burden of diabetes, including biases in selection and response rates, representation of population subgroups, accuracy of reporting of diabetes status, variation in biochemical testing, and definitions of diabetes used by investigators. Technological innovations and analytical approaches (e.g., data linkage to outcomes data like the National Death Index) may help address some, but not all, of these concerns, and additional methodological advances and validation are still needed. Current surveillance efforts are imperfect, but measures consistently collected and analyzed over several decades enable useful comparisons over time. In addition, we proposed that focused subsampling, use of technology, data linkages, and innovative sensitivity analyses can substantially advance population-level estimation.

Cost Calculation for a Flash Glucose Monitoring System for Adults with Type 2 Diabetes Mellitus Using Intensive Insulin - a UK Perspective

Aims: Estimate the costs associated with flash glucose monitoring as a replacement for routine self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes mellitus (T2DM) using intensive insulin, from a UK National Health Service (NHS) perspective. Methods: The base-case cost calculation used the frequency of SMBG and healthcare resource use observed in the REPLACE trial. Scenario analyses considered SMBG at the flash monitoring frequencies observed in the REPLACE trial (8.3 tests per day) and a real-world analysis (16 tests per day). Results: Compared with 3 SMBG tests per day, flash monitoring would cost an additional £585 per patient per year, offset by a £776 reduction in healthcare resource use, based on reductions in emergency room visits (41%), ambulance call-outs (66%) and hospital admissions (77%) observed in the REPLACE trial. Per patient, the estimated total annual cost for flash monitoring was £191 (13.4%) lower than for SMBG. In the scenarios based on acquisition cost alone, flash monitoring was cost-neutral versus 8.3 SMBG tests per day (5% decrease) and cost-saving at higher testing frequencies. Conclusion: From a UK NHS perspective, for patients with T2DM using intensive insulin, flash monitoring is potentially cost-saving compared with routine SMBG irrespective of testing frequency.

Association between depression and persistence with oral antihyperglycemic drugs in type 2 diabetes mellitus patients in Germany

The goal of the present work was to study the impact of depression on persistence with oral antihyperglycemic drugs in type 2 diabetes mellitus (T2DM) patients followed in general practices in Germany. We included T2DM patients who were treated with oral antihyperglycemic drugs and had an initial diagnosis of depression from 1262 general practices in Germany between January 2013 and December 2015. T2DM controls without depression were included and matched (1:1) to T2DM cases with depression based on age, sex, physician, and initial antihyperglycemic therapy, using a propensity score method. Persistence was estimated as therapy duration without treatment disruption, which was defined as at least 3 months without oral antihyperglycemic drugs. This study included 6449 T2DM patients with depression and 6449 T2DM patients without depression. After 12 months of follow-up, 67.5% of cases with depression and 69.7% of controls without depression were found to be persistent with oral antihyperglycemic drugs (p = 0.627). Depression had no significant impact on persistence with antihyperglycemic drugs in the entire population (HR = 1.03) or in the different subgroups (HRs ranging from 1.00 to 1.06). Depression was not significantly associated with persistence with antihyperglycemic drugs in Germany.

Low annual frequency of HbA1c testing in people with Type 2 diabetes in primary care practices in Germany

AIMS

To analyse the annual frequency of HbA_1c testing, as well as the factors associated with higher or lower testing frequency, in people with Type 2 diabetes mellitus in general practices and specialist diabetes practices in Germany.

METHODS

A total of 43 509 people diagnosed with Type 2 diabetes between January 2016 and December 2016 in 557 medical practices (51% of all practices) were included in this study. The primary outcome was the annual recorded frequency of HbA_1c testing in 2016. Multivariable logistic regression analyses were performed to identify variables associated with the odds of HbA_1c concentration being tested at least twice in 2016, using predefined demographic and clinical variables.

RESULTS

The mean (sd) number of reported HbA_1c tests was 2.7 (1.6) in 2016. Overall, 74% of individuals had at least two annual HbA_1c measurements. The likelihood of receiving ≥2 HbA_1c tests was inversely associated with stroke (odds ratio 0.81, 95% CI 0.74-0.89), shorter diabetes duration (≤1 year: odds ratio 0.77, 95% CI 0.70-0.84) and higher mean HbA_1c concentration (≥8.5%: odds ratio 0.85, 95% CI 0.76-0.94) and was positively associated with specialist diabetes care (odds ratio 1.24, 95% CI 1.14-1.36), hypertension (odds ratio 1.10, 95% CI 1.04-1.17), hyperlipidaemia (odds ratio 1.48, 95% CI 1.41 to 1.55), renal complications (odds ratio 1.41, 95% CI 1.32 to 1.50), neuropathy (odds ratio 1.27, CI 1.20 to 1.35) and retinopathy (odds ratio 1.38, 95% CI 1.25 to 1.52).

CONCLUSIONS

Only three out of four individuals with Type 2 diabetes underwent at least two HbA_1c tests in Germany in 2016, which means that 25% of individuals underwent fewer tests than required by German guidelines.

Persistence With Oral Antihyperglycemic Drugs in Type 2 Diabetes Mellitus Patients With Dementia in Germany

BACKGROUND

The aim of this study was to analyze the persistence with oral antihyperglycemic drugs in type 2 diabetes mellitus (T2DM) patients with dementia in Germany.

METHODS

This study included adults with T2DM who were treated with oral antihyperglycemic drugs and were diagnosed with dementia in 1262 German general practices between January 2013 and December 2015 (index date). Dementia cases were matched (1:1) to controls without dementia by age, gender, type of practice, type of residence, physician, and initial antihyperglycemic therapy, using a propensity score method. The primary outcome of the study was the rate of persistence with oral antihyperglycemic drugs in dementia cases and controls without dementia in the year following the index date. Persistence was estimated as therapy time without treatment discontinuation, which was defined as at least 90 days without oral antihyperglycemic therapy. Cox regressions were used to determine the impact of dementia on persistence with oral antihyperglycemic treatment in the entire population and in different subgroups.

RESULTS

This study included 848 T2DM patients with dementia and 848 T2DM patients without dementia. In the dementia group, 39.2% of patients were men, while the control group included 40.8% men. After 12 months of follow-up, 72.7% of dementia cases and 71.4% of controls without dementia were persistent ( P = .291). No significant association was found between dementia and persistence with oral antihyperglycemic drugs in the entire population and in different subgroups (HR ranging from 0.84 to 1.25).

CONCLUSIONS

Dementia did not have a significant impact on persistence with oral antihyperglycemic drugs in T2DM patients in Germany.

Linagliptin versus sitagliptin in patients with type 2 diabetes mellitus: a network meta-analysis of randomized clinical trials

Background

Diabetes is one of the most common chronic and costly diseases worldwide and type 2 diabetes is the most common type which accounts for about 90% of cases with diabetes. New medication-therapy regimens such as those containing linagliptin alone or in combination with other medications (within the category of DDP-4 inhibitors) must be evaluated in terms of efficacy and compared with other currently used drugs and then enter the medication list of the country. Hence, this study aimed to compare the clinical efficacy of the two drugs, i.e. linagliptin and sitagliptin, in patients with type 2 diabetes.

Methods

A systematic review was conducted to identify all clinical trials published by 2015 which compared the two drugs in patients with type 2 diabetes. Using keywords such as “linagliptin”, “type 2 diabetes mellitus”, “sitagliptin” and related combinations, we searched databases including Scopus, PubMed, and Web of Science. The quality of the selected studies was evaluated using the Jadad score. Considering primary and secondary outcomes extracted from the reviewed studies, a network meta-analysis was used to conduct a systematic comparison between the two studied drugs.

Results

This network meta-analysis included 32 studies (Linagliptin vs PLB: n = 8, Sitagliptin vs PLB: n = 13, Linagliptin + MET vs PLB + MET: n = 4, and Sitagliptin + MET vs PLB + MET: n = 7) and a total of 13,747 patients. The results showed no significant difference between linagliptin and sitagliptin in terms of key efficacy and safety outcomes such as HbA1c changes from baseline, body weight change from baseline, percentage of patients achieving HbA1c <7, and percentage of patients experiencing hypoglycemic events (p > 0.05). The results showed that the efficacy of the two drug regimens was the same.

Conclusions

Based on the results, there was no significant difference between the two drugs, i.e. linagliptin and sitagliptin, in terms of efficacy; in other words, the efficacy of the two drugs was the same. Therefore, the use of these two drugs depends on their availability and cost.

Graphical abstract

Graphical abstract of the network meta-analysis performed to evaluate the alternatives under the study.

Electronic supplementary material

The online version of this article (10.1186/s40199-017-0189-6) contains supplementary material, which is available to authorized users.

Metabolomics applied to diabetes-lessons from human population studies

The 'classical' distribution of type 2 diabetes (T2D) across the globe is rapidly changing and it is no longer predominantly a disease of middle-aged/elderly adults of western countries, but it is becoming more common through Asia and the Middle East, as well as increasingly found in younger individuals. This global altered incidence of T2D is most likely associated with the spread of western diets and sedentary lifestyles, although there is still much debate as to whether the increased incidence rates are due to an overconsumption of fats, sugars or more generally high-calorie foods. In this context, understanding the interactions between genes of risk and diet and how they influence the incidence of T2D will help define the causative pathways of the disease. This review focuses on the use of metabolomics in large cohort studies to follow the incidence of type 2 diabetes in different populations. Such approaches have been used to identify new biomarkers of pre-diabetes, such as branch chain amino acids, and associate metabolomic profiles with genes of known risk in T2D from large scale GWAS studies. As the field develops, there are also examples of meta-analysis across metabolomics cohort studies and cross-comparisons with different populations to allow us to understand how genes and diet contribute to disease risk. Such approaches demonstrate that insulin resistance and T2D have far reaching metabolic effects beyond raised blood glucose and how the disease impacts systemic metabolism.

Indirect costs of diabetes and its impact on the public finance: the case of Poland

BACKGROUND

Growing public and private expenditure on healthcare results i.a. from the spreading of chronic diseases. Diabetes belongs to the most frequent ones, beyond neoplasms and cardiological diseases, and hence generates a significant burden for the public finance in terms of the direct costs. However, the economy suffers also from the indirect cost of diabetes that manifests itself in the loss in Gross Domestic Product (GDP) and general government revenues.

METHODS

This paper aims to measure this indirect cost, both in terms of GDP drop (social perspective) and public revenue drop (public finance perspective), in the case of Poland in 2012-2014. We use a modified human capital approach and unique dataset provided by the Social Security institution in Poland and the Polish Central Statistical Office.

RESULTS

Diabetes is a substantial and growing burden for the Polish economy. In the years 2012, 2013 and 2014 the indirect cost (output loss) amounted to 1.85 bn USD, 1.94 bn USD and 2.00 bn USD respectively.

CONCLUSIONS

Estimated indirect cost of diabetes can be a useful input for health technology analyses of drugs or economic impact assessments of public health programmes.

Healthcare costs of Type 2 diabetes in Germany

AIM

To describe for the first time the direct costs of Type 2 diabetes treatment by analysing nationwide routine data from statutory health insurance in Germany.

METHODS

This cost-of-illness-study was based on a 6.8% random sample of all German people with statutory health insurance (4.3 out of 70 million people). The healthcare expenses show direct per capita costs from the payer perspective. Healthcare expenses for physicians, dentists, pharmacies, hospitals, sick benefits and other healthcare costs were considered. Per capita costs, cost ratios for people with Type 2 diabetes and without diabetes as well as diabetes-attributable costs were calculated.

RESULTS

Per capita costs for people with Type 2 diabetes amounted to €4,957 in 2009 and €5,146 in 2010. People with Type 2 diabetes had 1.7-fold higher health expenses than people without diabetes. The largest differences in health expenses were found for prescribed medication from pharmacies (cost ratio diabetes/no diabetes: 2.2) and inpatient treatment (1.8). Ten percent of the total statutory health insurance expense, in total €16.1 billion, was attributable to the medical care of people with Type 2 diabetes.

CONCLUSIONS

This nationwide study indicates that one in 10 Euros of healthcare expenses is spent on people with Type 2 diabetes in Germany. In the future, national statutory health insurance data can be used to quantify time trends of costs in the healthcare system.