Cost of managing complications resulting from type 2 diabetes mellitus in Canada

Determining direct, indirect healthcare and social costs for diabetic retinopathy management: a systematic review

INTRODUCTION

Diabetic retinopathy (DR) is a rapidly growing global public health threat; it affects 1 in 3 people with diabetes and is still the leading cause of blindness among the working-age population. The management of diabetic retinopathy is becoming more advanced and effective but is highly expensive compared to other ocular diseases.

AIM

To report direct medical, indirect medical, and nonmedical costs of diabetic retinopathy in developed and developing countries through a systematic review.

METHODS

Related articles published in the PubMed, Google Scholar, and EMBASE electronic databases from 1985 to 2022 were identified using the keywords direct medical and indirect medical and social costs of diabetic retinopathy. However, previous systematic reviews, abstracts, and case reports were excluded.

RESULTS

Thirteen articles were eligible for assessing the economic burden of diabetes management and its complications. Our analysis revealed that increasing prevalence and severity of diabetic retinopathy (DR) are associated with higher direct and indirect healthcare expenditures. The impact of DR on working-age adults, leading to irreversible blindness in advanced stages, underscores the urgent need for cost-effective prevention and management strategies.

DISCUSSION

This study systematically reviewed the direct medical, indirect medical, and nonmedical costs of DR in developed and developing countries. Our findings highlight the significant economic burden of DR, emphasizing the importance of implementing effective prevention and management measures to alleviate costs and enhance patient outcomes.

CONCLUSION

The substantial financial burden of DR necessitates a re-evaluation of current screening and management programs. Revision of these programs is crucial to improve quality of care, reduce costs, and ultimately achieve Sustainable Development Goal 3, which aims to ensure good health and well-being for all.

Estimating treatment costs for uncomplicated diabetes at a hospital serving refugees in Kenya

Diabetes mellitus (DM) is increasing markedly in low- and middle-income countries where over three-quarters of global deaths occur due to non-communicable diseases. Unfortunately, these conditions are considered costly and often deprioritized in humanitarian settings with competing goals. Using a mixed methods approach, this study aimed to quantify the cost of outpatient treatment for uncomplicated type-1 (T1DM) and type-2 (T2DM) diabetes at a secondary care facility serving refugees in Kenya. A retrospective cost analysis combining micro- and gross-costings from a provider perspective was employed. The main outcomes included unit costs per health service activity to cover the total cost of labor, capital, medications and consumables, and overheads. A care pathway was mapped out for uncomplicated diabetes patients to identify direct and indirect medical costs. Interviews were conducted to determine inputs required for diabetes care and estimate staff time allocation. A total of 360 patients, predominantly Somali refugees, were treated for T2DM (92%, n = 331) and T1DM (8%, n = 29) in 2017. Of the 3,140 outpatient consultations identified in 2017; 48% (n = 1,522) were for males and 52% (n = 1,618) for females. A total of 56,144 tests were run in the setting, of which 9,512 (16.94%) were Random Blood Sugar (RBS) tests, and 90 (0.16%) HbA1c tests. Mean costs were estimated as: $2.58 per outpatient consultation, $1.37 per RBS test and $14.84 per HbA1c test. The annual pharmacotherapy regimens cost $91.93 for T1DM and $20.34 for T2DM. Investment in holistic and sustainable non-communicable disease management should be at the forefront of humanitarian response. It is expected to be beneficial with immediate implications on the COVID-19 response while also reducing the burden of care over time. Despite study limitations, essential services for the management of uncomplicated diabetes in a humanitarian setting can be modest and affordable. Therefore, integrating diabetes care into primary health care should be a fundamental pillar of long-term policy response by stakeholders.

Screening for Diabetes Complications during the COVID-19 Outbreak in South Korea

This study aimed to investigate the implementation of diabetes complications screening in South Korea during the coronavirus disease (COVID-19) outbreak. Data from the Korea Community Health Surveys conducted in 2019 and 2020 were used. This study included 51,471 participants. Multiple level analysis was used to investigate the relationships between screening for diabetic retinopathy and diabetic nephropathy and variables of both individual- and community-level factors in 2019 and 2020, before and after the COVID-19 outbreak. Diabetes nephropathy complications screening in 2020 had a lower odds ratio. However, regions heavily affected by COVID-19 showed a negative association with diabetes complications screening after the COVID-19 outbreak. For those being treated with medication for diabetes, there was a significant negative association with diabetic nephropathy screening after the outbreak. The COVID-19 outbreak was associated with a reduction in the use of diabetes nephropathy complications screening. Additionally, only regions heavily affected by COVID-19 spread showed a negative association with diabetes complications screening compared to before the COVID-19 outbreak. In this regard, it appears that many patients were unable to attend outpatient care due to COVID-19. As such, these patients should be encouraged to visit clinics for diabetes complications screening. Furthermore, alternative methods need to be developed to support these patients. Through these efforts, the development of diabetes-related complications should be prevented, and the costs associated with these complications will be reduced.

Priorities among effective clinical preventive services in British Columbia, Canada

BACKGROUND

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

METHODS

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

RESULTS

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

CONCLUSIONS

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Association of diabetes type and chronic diabetes complications with early exit from the labour force: register-based study of people with diabetes in Finland

AIMS/HYPOTHESIS

Diabetes and diabetes complications are a cause of substantial morbidity, resulting in early exits from the labour force and lost productivity. The aim of this study was to examine differences in early exits between people with type 1 and 2 diabetes and to assess the role of chronic diabetes complications on early exit. We also estimated the economic burden of lost productivity due to early exits.

METHODS

People of working age (age 17-64) with diabetes in 1998-2011 in Finland were detected using national registers (Ntype 1 = 45,756, Ntype 2 = 299,931). For the open cohort, data on pensions and deaths, healthcare usage, medications and basic demographics were collected from the registers. The outcome of the study was early exit from the labour force defined as pension other than old age pension beginning before age 65, or death before age 65. We analysed the early exit outcome and its risk factors using the Kaplan-Meier method and extended Cox regression models. We fitted linear regression models to investigate the risk factors of lost working years and productivity costs among people with early exit.

RESULTS

The difference in median age at early exit from the labour force between type 1 (54.0) and type 2 (58.3) diabetes groups was 4.3 years. The risk of early exit among people with type 1 diabetes increased faster after age 40 compared with people with type 2 diabetes. Each of the diabetes complications was associated with an increase in the hazard of early exit regardless of diabetes type compared with people without the complication, with eye-related complications as an exception. Diabetes complications partly but not completely explained the difference between diabetes types. The mean lost working years was 6.0 years greater in the type 1 diabetes group than in the type 2 diabetes group among people with early exit. Mean productivity costs of people with type 1 diabetes and early exit were found to be 1.4-fold greater compared with people with type 2 diabetes. The total productivity costs of incidences of early exits in the type 2 diabetes group were notably higher compared with the type 1 group during the time period (€14,400 million, €2800 million).

CONCLUSIONS/INTERPRETATION

We found a marked difference in the patterns of risk of early exit between people with type 1 and type 2 diabetes. The difference was largest close to statutory retirement age. On average, exits in the type 1 diabetes group occurred at an earlier age and resulted in higher mean lost working years and mean productivity costs. The potential of prevention, timely diagnosis and management of diabetes is substantial in terms of avoiding reductions in individual well-being and productivity.

Prevalence and medical expenditures of diabetes-related complications among adult Medicaid enrollees with diabetes in eight U.S. states

AIMS

To estimate the prevalence and medical expenditures of diabetes-related complications (DRCs) among adult Medicaid enrollees with diabetes.

METHODS

We estimated the prevalence and medical expenditures for 12 diabetes-related complications by Medicaid eligibility category (disability-based vs. non-disability-based) in eight states. We used generalized linear models with log link and gamma distribution to estimate the total per-person annual medical expenditures for DRCs, controlling for demographics, and other comorbidities.

RESULTS

Among non-disability-based enrollees (NDBEs), 40.1% (in California) to 47.5% (in Oklahoma) had one or more DRCs, compared to 53.6% (in Alabama) to 64.8% (in Florida) among disability-based enrollees (DBEs). The most prevalent complication was neuropathy (16.1%-27.1% for NDBEs; 20.2%-30.4% for DBEs). Lower extremity amputation (<1% for both eligibilities) was the least prevalent complication. The costliest per-person complication was dialysis (per-person excess annual expenditure of $22,481-$41,298 for NDBEs; $23,569-$51,470 for DBEs in 2012 USD). Combining prevalence and per-person excess expenditures, the three costliest complications were nephropathy, heart failure, and ischemic heart disease (IHD) for DBEs, compared to neuropathy, nephropathy, and IHD for NDBEs.

CONCLUSIONS

Our study provides data that can be used for assessing the health care resources needed for managing DRCs and evaluating cost-effectiveness of interventions to prevent and management DRCs.

Prevalence and Risk Evaluation of Diabetic Complications of the Foot Among Adults With Type 1 and Type 2 Diabetes in a Large Canadian Population (PEDAL Study)

OBJECTIVES

The lower limb complications of diabetes contribute significantly to patient morbidity and health-care costs in Canada. Despite practice guidelines, awareness of and screening for modifiable early pathologies has been inconsistent. Our study objective was to determine the prevalence and types of early foot pathology in a large, Canadian, community care-based diabetes population.

METHODS

This study was a retrospective, observational analysis of the LMC Diabetes & Endocrinology foot care program launched in 2017. We examined foot pathologies associated with vascular, nerve, nail and dermatologic complications, as well as foot deformities. Individuals ≥18 years of age and with diabetes, assessed by an LMC chiropodist in Ontario between February 2018 and April 2019, were included in the analysis.

RESULTS

Of the 5,084 individuals assessed, 470 with type 1 diabetes and 3,903 with type 2 diabetes met the study criteria. Mean age, body mass index and diabetes duration was 61.5 years, 31.3 kg/m² and 13.9 years, respectively. Reduced pedal pulses, sensory neuropathy and onychomycosis were reported in 8.9%, 16.7% and 14.5% of those in the type 1 diabetes group, and 19.4%, 26.6% and 28.7% of those in the type 2 group, respectively. Hyperkeratosis was present in 51% and foot deformities were present in 44.5% among both groups. Foot ulcer prevalence was 1.7% and pedal pulses, sensory neuropathy, hyperkeratosis and onychauxis, adjusted for age, sex, body mass index and diabetes duration, were each significantly associated with ulceration.

CONCLUSIONS

In a large foot screening program of community-based adults with diabetes, modifiable early foot pathologies were prevalent and provided further evidence of the value of consistent screening to alleviate the morbidity and economic burden of lower limb complications.

Identifying Barriers and Enablers to Attending Diabetic Retinopathy Screening in Immigrants to Canada From Ethnocultural Minority Groups: Protocol for a Qualitative Descriptive Study

Background

Immigrants to Canada belonging to ethnocultural minority groups are at increased risk of developing diabetes and complications, including diabetic retinopathy, and they are also less likely to be screened and treated. Improved attendance to retinopathy screening (eye tests) has the potential to reduce permanent complications, including blindness.

Objective

This study aims to identify the barriers and enablers of attending diabetic retinopathy screening among ethnocultural minority immigrants living with diabetes in Quebec and Ontario, Canada, to inform the development of a behavior change intervention to improve diabetic retinopathy screening attendance.

Methods

The research question draws on the needs of patients and clinicians. Using an integrated knowledge translation approach, the research team includes clinicians, researchers, and patient partners who will contribute throughout the study to developing and reviewing materials and procedures, helping to recruit participants, and disseminating findings. Using a convenience snowball strategy, we will recruit participants from three target groups: South Asian and Chinese people, and French-speaking people of African descent. To better facilitate reaching these groups and support participant recruitment, we will partner with community organizations and clinics serving our target populations in Ontario and Quebec. Data will be collected using semistructured interviews, using topic guides developed in English and translated into French, Mandarin, Hindi, and Urdu, and conducted in those languages. Data collection and analysis will be structured according to the Theoretical Domains Framework (TDF), which synthesizes predominant theories of behavior change into 14 domains covering key modifiable factors that may operate as barriers or enablers to attending eye screening. We will use directed content analysis to code barriers and enablers to TDF domains, then thematic analysis to define key themes within domains.

Results

This study was approved for funding in December 2017, and the research ethics board approved the conduct of the study as of January 13, 2018. Data collection then began in April 2018. As of August 28, 2018, we have recruited 22 participants, and analysis is ongoing, with results expected to be published in 2020.

Conclusions

Findings from this study will inform the codevelopment of theory-informed, culturally- and linguistically-tailored interventions to support patients in attending retinopathy screening.

International Registered Report Identifier (IRRID)

DERR1-10.2196/15109

Cost Effectiveness of Once-Weekly Semaglutide Versus Once-Weekly Dulaglutide in the Treatment of Type 2 Diabetes in Canada

OBJECTIVE

The aim of this study was to assess the cost effectiveness of semaglutide versus dulaglutide, as an add-on to metformin monotherapy, for the treatment of type 2 diabetes (T2D), from a Canadian societal perspective.

METHODS

The Swedish Institute for Health Economics Cohort Model of T2D was used to assess the cost effectiveness of once-weekly semaglutide (0.5 or 1.0 mg) versus once-weekly dulaglutide (0.75 or 1.5 mg) over a 40-year time horizon. Using data from the SUSTAIN 7 trial, which demonstrated comparatively greater reductions in glycated hemoglobin (HbA1c), body mass index and systolic blood pressure with semaglutide, compared with dulaglutide, a deterministic base-case and scenario simulation were conducted. The robustness of the results was evaluated with probabilistic sensitivity analyses and 15 deterministic sensitivity analyses.

RESULTS

The base-case analysis indicated that semaglutide is a dominant treatment option, compared with dulaglutide. Semaglutide was associated with lower total costs (Canadian dollars [CAN$]) versus dulaglutide for both low-dose (CAN$113,287 vs. CAN$113,690; cost-saving: CAN$403) and high-dose (CAN$112,983 vs. CAN$113,695; cost-saving: CAN$711) comparisons. Semaglutide resulted in increased quality-adjusted life-years (QALYs) and QALY gains, compared with dulaglutide, for both low-dose (11.10 vs. 11.07 QALYs; + 0.04 QALYs) and high-dose (11.12 vs. 11.07 QALYs; + 0.05 QALYs) comparisons. The probabilistic sensitivity analysis showed that for 66-73% of iterations, semaglutide was either dominant or was considered cost effective at a willingness-to-pay threshold of CAN$50,000.

CONCLUSIONS

From a Canadian societal perspective, semaglutide may be a cost-effective treatment option versus dulaglutide in patients with T2D who are inadequately controlled on metformin monotherapy.

The estimated healthcare cost of diabetic retinopathy in Indonesia and its projection for 2025

PURPOSE

To estimate the total healthcare cost associated with diabetic retinopathy (DR) in type 2 diabetes in Indonesia and its projection for 2025.

METHODS

A prevalence-based cost-of-illness model was constructed from previous population-based DR study. Projection for 2025 was derived from estimated diabetes population in 2025. Direct treatment costs of DR were estimated from the perspective of healthcare. Patient perspective costs were obtained from thorough interview including only transportation cost and lost of working days related to treatment. We developed four cost-of-illness models according to DR severity level, DR without necessary treatment, needing laser treatment, laser +intravitreal (IVT) injection and laser + IVT +vitrectomy. All costs were estimated in 2017 US$.

RESULTS

The healthcare costs of DR in Indonesia were estimated to be $2.4 billion in 2017 and $8.9 billion in 2025. The total cost in 2017 consisted of the cost for no DR and mild-moderate non-proliferative DR (NPDR) requiring eye screening ($25.9 million), severe NPDR or proliferative DR (PDR) requiring laser treatment ($0.25 billion), severe NPDR or PDR requiring both laser and IVT injection ($1.75 billion) and advance level of PDR requiring vitrectomy ($0.44 billion).

CONCLUSIONS

The estimated healthcare cost of DR in Indonesia in 2017 was considerably high, nearly 2% of the 2017 national state budget, and projected to increase significantly to more than threefold in 2025. The highest cost may incur for DR requiring both laser and IVT injection. Therefore, public health intervention to delay or prevent severe DR may substantially reduce the healthcare cost of DR in Indonesia.

Methodological approaches for assessing the cost of diabetic foot ulcers: a systematic literature review

Objective:

To evaluate the methodological approaches used to assess the cost consequences of diabetic foot ulcers (DFUs) in published scientific papers.

Method:

A systematic literature search was conducted in PubMed, Embase, Scopus, Web of Science and CINAHL. English language papers reporting on the cost of DFUs were identified. Additionally, bibliographies were inspected to identify other relevant cost studies. Following the PRISMA guidance, the review identified the study design, epidemiological approach, analytical perspective and data collection approach in each of the included studies.

Results:

Relatively few studies of the cost consequences of DFUs were found (n=27). Most studies were conducted in Western countries with only five studies from countries in Asia and Africa. The identified studies used different study designs, epidemiological approaches, data collection strategies, and data sources, which in turn made a systematic comparison of cost estimates difficult. Detailed descriptions of the applied costing method and other methodological aspects were often limited or absent. Many studies only reported costs from a health-care payer's perspective and disregarded the costs to patients, their families and wider society.

Conclusion:

The costs of DFUs have been assessed using a wide range of different methodological approaches often restricted to the healthcare payer's perspective. Therefore, the cost analyses may fail to consider the true societal costs of DFUs.

Cognitive Behavioural Therapy for Psychosis: A Health Technology Assessment

BACKGROUND

Cognitive behavioural therapy (CBT) for psychosis is a distinct type of psychotherapy that has been recommended together with antipsychotic drugs and comprehensive usual care in the management of schizophrenia, a complex mental health disorder associated with a high economic and societal burden. The objectives of this report were to assess the effectiveness, harms, cost-effectiveness, and lived experience of CBT for psychosis in improving outcomes for adults with a primary diagnosis of schizophrenia.

METHODS

We performed literature searches on March 28 and April 5, 2017, and undertook a qualitative synthesis of systematic reviews of the clinical and economic literature comparing CBT for psychosis with any comparator interventions (e.g., usual care, waitlist control, or pharmacotherapy) in adults with a diagnosis of schizophrenia as defined by any criteria (including related disorders such as schizoaffective disorder).We developed an individual-level state-transition probabilistic model for a hypothetical cohort of adults aged 18 years and older starting with first-episode psychosis. We compared three strategies: usual care, CBT for psychosis by physicians, and CBT for psychosis by regulated nonphysician therapists. The CBT was provided in person together with usual care including pharmacotherapy: 16 structured sessions (individual or group) for first-episode psychosis and 24 individual sessions for relapse or treatment-resistant disease. We calculated incremental cost-effectiveness ratios (ICERs) over 5 years using the Ontario Ministry of Health and Long-Term Care perspective and a discount rate of 1.5%. We also estimated the 5-year budget impact of publicly funding CBT for psychosis in Ontario.In addition, we interviewed 13 people with lived experience of schizophrenia and psychosis about their values and preferences surrounding CBT and other treatments.

RESULTS

CBT for psychosis compared with usual care significantly improved overall psychotic symptoms (standard mean difference [SMD] -0.33, 95% confidence interval [CI] -0.45 to -0.21), positive symptoms (e.g., hallucinations) (SMD -0.34, 95% CI -0.58 to -0.10), auditory symptoms (SMD 0.39, 95% Cl not reported, P < .005), delusions (SMD 0.33, 95% CI not reported, P < .05) and negative symptoms (e.g., blunt affect) (SMD -0.32, 95% CI -0.59 to -0.04) at end of treatment. No significant differences were observed for social function, distress associated with psychosis, relapse, or quality of life.Compared with any control, CBT for psychosis significantly improved overall psychotic symptoms, positive symptoms, auditory hallucinations, delusions, and negative symptoms. Compared with other forms of therapy, CBT for psychosis showed inconsistent results at end of treatment for overall psychotic symptoms, positive symptoms, auditory hallucinations, and delusions. In people with first-episode psychosis, CBT for psychosis was not significantly more effective for the prevention of relapse when compared with other forms of therapy or usual care (odds ratio [OR] 1.11, 95% CI 0.63-1.95 and OR 1.15, 95% CI 0.65-2.04, respectively).Low-intensity CBT for psychosis (fewer than 16 face-to-face sessions) compared with any type of treatment significantly improved overall psychotic symptoms and social function at follow-up (SMD -0.40, 95% CI -0.74 to -0.06 and SMD -0.57, 95% CI -0.81 to -0.33, respectively).In the cost-utility analysis, CBT for psychosis provided by nonphysician therapists compared with usual care was associated with increases in both quality-adjusted life-years (mean 0.1159 QALYs, 95% credible interval [CrI] 0.09-0.14) and costs (mean $2,494, 95% Crl $1,472-$3,544), yielding an ICER of $21,520 per QALY gained. CBT for psychosis provided by physicians was dominated because it was equally effective but more expensive (mean $2,976, 95% CrI $2,822-$3,129; ICER of CBT for psychosis vs. usual care: $47,196/QALY gained).Assuming a 20% increase in access per year (from 0% at baseline to 100% in year 5), we estimated the total 5-year net budget impact of publicly funding CBT for psychosis would be about $15.2 million for nonphysician providers and about $35.4 million if provided by psychiatrists. It is estimated that by the year 2021, approximately 110 nonphysician therapists or 150 physicians would be needed to provide CBT for psychosis to more than 12,000 adults with schizophrenia (including about 8,500 incident cases) in Ontario.People with schizophrenia and their family members reported positive experiences with CBT for psychosis. They felt it provided effective tools to help manage their schizophrenia but stressed that it was only effective in conjunction with medication to control psychotic episodes and overcome a patient's denial of illness. Geographic and financial barriers have restricted access to this psychotherapy.

CONCLUSIONS

Compared with usual care or any control, CBT for psychosis significantly improved psychotic symptoms, based on evidence of moderate to adequate quality; no significant improvements were observed for social function, relapse, or quality of life outcomes. People affected by schizophrenia reported that CBT for psychosis was valuable in conjunction with antipsychotic medication but that access to this type of psychotherapy is limited. Adding CBT for psychosis to usual care in the management of adult schizophrenia probably represents good value for money in Ontario. Depending on the type of provider, therapy format, and rate of access, the net budget impact to Ontario's publicly funded health system would likely be between $15 million to $35 million over the next 5 years.

Relationship Between Adiponectin and apoB in Individuals With Diabetes in the Atlantic PATH Cohort

Context

The increasing prevalence of obesity and diabetes greatly influences the risk for cardiovascular (CV) comorbidities and affects the quality of life of many people. However, the relationship among diabetes, obesity, and cardiovascular risk is complex and requires further investigation to understand the biological milieu connecting these conditions.

Objective

The aim of the current study was to explore the relationship between biological markers of adipose tissue function (adiponectin) and CV risk (apolipoprotein B) in body mass index (BMI)-matched participants with and without diabetes.

Design

Nested case-control study.

Setting

The Atlantic Partnership for Tomorrow's Health (PATH) cohort represents four Atlantic Canadian provinces: Newfoundland and Labrador, New Brunswick; Nova Scotia; and Prince Edward Island.

Participants

The study population (n = 480) was aged 35 to 69 years, 240 with diabetes and 240 without diabetes.

Main Outcome Measures

Groups with and without diabetes were matched for sex and BMI. Both measured and self-reported data were used to examine disease status, adiposity, and lifestyle factors. Immunoassays were used to measure plasma markers.

Results

In these participants, plasma adiponectin levels were lower among those with diabetes than those without diabetes; these results were sex-specific, with a strong relationship seen in women. In contrast, in participants matched for sex and adiposity, plasma apoB levels were similar between participants with and those without diabetes.

Conclusion

Measures of adiposity were higher in participants with diabetes. However, when matched for adiposity, the adipokine adiponectin exhibited a strong inverse association with diabetes.

Cost-effectiveness of magnetic resonance carotid plaque imaging for primary stroke prevention in Canada

OBJECTIVE

Magnetic resonance of the carotid arteries provides important insight into plaque composition and vulnerability in addition to the traditional measure of stenosis. The purpose of this study was to evaluate the cost-effectiveness of MR imaging as a first-line modality to assess carotid disease and guide management for high-risk patients with <50% stenosis.

METHODS

Using TreeAge Pro, a cost-effectiveness simulation was conducted comparing two strategies: (a) standard of care first-line carotid duplex ultrasound (DUS) with regular follow-up, vs (b) first-line MR assessment of stenosis and intraplaque haemorrhage (MRIPH) in which patients with IPH received annual DUS surveillance and immediate carotid endarterectomy in case of plaque progression.

RESULTS

For patients aged 70 years old, using a first-line MRIPH strategy resulted in a 16.8% relative risk reduction in strokes compared to DUS (0.080 vs 0.097 strokes per patient per lifetime), and an increased quality-adjusted-life years (12.23 vs 12.20) at an increased cost of $897.33 over a patient's lifetime ($5784.53 vs $4887.20 average total cost per patient per lifetime). The incremental cost-effectiveness ratio was $29,744 per quality-adjusted-life years. MRIPH remained cost-effective below a willingness-to-pay threshold of $50,000 for 91.8% of sensitivity analyses.

CONCLUSION

MRIPH was found to be a cost-effective first-line tool to identify asymptomatic patients at high risk for stroke requiring annual surveillance and prompt management. Advances in Knowledge: Using MR imaging as a fist-line method to detect the presence of IPH provides clinically useful and cost-effective information that allows for enhanced risk evaluation and primary stroke prevention.

Cost-effectiveness of G5 Mobile continuous glucose monitoring device compared to self-monitoring of blood glucose alone for people with type 1 diabetes from the Canadian societal perspective

AIMS

To evaluate the cost-effectiveness of real-time continuous glucose monitoring (CGM) compared to self-monitoring of blood glucose (SMBG) alone in people with type 1 diabetes (T1DM) using multiple daily injections (MDI) from the Canadian societal perspective.

METHODS

The IMS CORE Diabetes Model (v.9.0) was used to assess the long-term (50 years) cost-effectiveness of real-time CGM (G5 Mobile CGM System; Dexcom, Inc., San Diego, CA) compared with SMBG alone for a cohort of adults with poorly-controlled T1DM. Treatment effects and baseline characteristics of patients were derived from the DIAMOND randomized controlled clinical trial; all other assumptions and costs were sourced from published research. The accuracy and clinical effectiveness of G5 Mobile CGM is the same as the G4 Platinum CGM used in the DIAMOND randomized clinical trial. Base case assumptions included (a) baseline HbA1c of 8.6%, (b) change in HbA1c of -1.0% for CGM users vs -0.4% for SMBG users, and (c) disutilities of -0.0142 for non-severe hypoglycemic events (NSHEs) and severe hypoglycemic events (SHEs) not requiring medical intervention, and -0.047 for SHEs requiring medical resources. Treatment costs and outcomes were discounted at 1.5% per year.

RESULTS

The incremental cost-effectiveness ratio for the base case G5 Mobile CGM vs SMBG was $33,789 CAD/quality-adjusted life-year (QALY). Sensitivity analyses showed that base case results were most sensitive to changes in percentage reduction in hypoglycemic events and disutilities associated with hypoglycemic events. The base case results were minimally impacted by changes in baseline HbA1c level, incorporation of indirect costs, changes in the discount rate, and baseline utility of patients.

CONCLUSIONS

The results of this analysis demonstrate that G5 Mobile CGM is cost-effective within the population of adults with T1DM using MDI, assuming a Canadian willingness-to-pay threshold of $50,000 CAD per QALY.

Projecting prevalence, costs and evaluating simulated interventions for diabetic end stage renal disease in a Canadian population of aboriginal and non-aboriginal people: an agent based approach

BACKGROUND

Diabetes-related end stage renal disease (DM-ESRD) is a devastating consequence of the type 2 diabetes epidemic, both of which disproportionately affect Indigenous peoples. Projecting case numbers and costs into future decades would help to predict resource requirements, and simulating hypothetical interventions could guide the choice of best practices to mitigate current trends.

METHODS

An agent based model (ABM) was built to forecast First Nations and non-First Nations cases of DM-ESRD in Saskatchewan from 1980 to 2025 and to simulate two hypothetical interventions. The model was parameterized with data from the Canadian Institute for Health Information, Saskatchewan Health Administrative Databases, the Canadian Organ Replacement Register, published studies and expert judgement. Input parameters without data sources were estimated through model calibration. The model incorporated key patient characteristics, stages of diabetes and chronic kidney disease, renal replacement therapies, the kidney transplant assessment and waiting list processes, costs associated with treatment options, and death. We used this model to simulate two interventions: 1) No new cases of diabetes after 2005 and 2) Pre-emptive renal transplants carried out on all diabetic persons with new ESRD.

RESULTS

There was a close match between empirical data and model output. Going forward, both incidence and prevalence cases of DM-ESRD approximately doubled from 2010 to 2025, with 250-300 new cases per year and almost 1300 people requiring RRT by 2025. Prevalent cases of First Nations people with DM-ESRD increased from 19% to 27% of total DM-ESRD numbers from 1990 to 2025. The trend in yearly costs paralleled the prevalent DM-ESRD case count. For Scenario 1, despite eliminating diabetes incident cases after 2005, prevalent cases of DM-ESRD continued to rise until 2019 before slowly declining. When all DM-ESRD incident cases received a pre-emptive renal transplant (scenario 2), a substantial increase in DM-ESRD prevalence occurred reflecting higher survival, but total costs decreased reflecting the economic advantage of renal transplantation.

CONCLUSIONS

This ABM can forecast numbers and costs of DM-ESRD in Saskatchewan and be modified for application in other jurisdictions. This can aid in resource planning and be used by policy makers to evaluate different interventions in a safe and economical manner.

Description of a New Predictive Modeling Approach That Correlates the Risk and Associated Cost of Well-Defined Diabetes-Related Complications With Changes in Glycated Hemoglobin (HbA1c)

The modeling approach described here is designed to support the development of spreadsheet-based simple predictive models. It is based on 3 pillars: association of the complications with HbA1c changes, incidence of the complications, and average cost per event of the complication. For each pillar, the goal of the analysis was (1) to find results for a large diversity of populations with a focus on countries/regions, diabetes type, age, diabetes duration, baseline HbA1c value, and gender; (2) to assess the range of incidences and associations previously reported. Unlike simple predictive models, which mostly are based on only 1 source of information for each of the pillars, we conducted a comprehensive, systematic literature review. Each source found was thoroughly reviewed and only sources meeting quality expectations were considered. The approach allows avoidance of unintended use of extreme data. The user can utilize (1) one of the found sources, (2) the found range as validation for the found figures, or (3) the average of all found publications for an expedited estimate. The modeling approach is intended for use in average insulin-treated diabetes populations in which the baseline HbA1c values are within an average range (6.5% to 11.5%); it is not intended for use in individuals or unique diabetes populations (eg, gestational diabetes). Because the modeling approach only considers diabetes-related complications that are positively associated with HbA1c decreases, the costs of negatively associated complications (eg, severe hypoglycemic events) must be calculated separately.

Pharmacoeconomic evaluation of diabetic nephropathic patients attending nephrology department in a tertiary care hospital

Aims:

To evaluate the cost of pharmacotherapy and its determinants in diabetic nephropathy (DN) in the nephrology department of a tertiary care hospital.

Materials and Methods:

A prospective observational study was conducted among adult patients visiting nephrology outpatient department (February–July 2015). Data on demography, investigations, and medications prescribed, direct cost and indirect costs were analyzed. We used Chi-squared test for categorical variables and multivariate linear regression analysis to identify determinants of cost of pharmacotherapy and total cost.

Results:

Of 100 patients, 50 were above 60 years and 75 were male. Ninety-seven patients had hypertension, which was the most common comorbidity. The majority (60 patients) belonged to Stage 5 DN and 59 patients were on dialysis. The mean number of drugs per patient was 7.60 ± 2.44. The total monthly cost per patient amounted to INR 24,203.27 with total direct cost of INR 21,013.90 (87%) and indirect cost of INR 3189.30 (13%). The monthly cost of dialysis and pharmacotherapy per patient were INR 9060.00 (37%) and INR 2535.98 (11%), respectively. Stage of DN (unstandardized coefficient, B = 7553.96, 95% confidence interval [CI] [6175.09–8932.82], P < 0.001) was a significant determinant of total cost. Number of drugs (B = 636.694, 95% CI [335.670–937.718], P < 0.001) and stage of DN (B = 852.986, 95% CI [297.043–1408.928], P = 0.003) were predictors of cost of pharmacotherapy.

Conclusion:

Stage of DN and number of drugs prescribed were major determinants of cost of pharmacotherapy.

Association of good glycemic control and cost of diabetes care: Experience from a tertiary care hospital in Bangladesh

AIM

The present study was undertaken to assess the cost-effectiveness of good glycemic control in a population of Bangladeshi people with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted among 496 registered patients with >1year duration of diabetes. Glycated hemoglobin A1c level <7% was judged as the cut-off value for good glycemic control. All treatment-related records from the last year were collected from patients' guide books and all cost components were calculated.

RESULTS

Among patients, 31% had good glycemic control. The average annual cost was US$ 314 per patient. Patients with poor glycemic control were significantly more likely to have complications [(p=0.049) OR 1.5] and comorbidities [(p=0.02) OR 1.5]. The annual cost increased rapidly with complications/comorbidities. In multivariable logistic regression analysis, gender (p=0.003) and cost of care (p=0.006) were significantly associated with glycemic control, and the presence of any comorbidities/complications was associated with 1.8-fold higher odds of poor glycemic control (p=0.013 95% CI: 1.131-2.786).

CONCLUSION

Good glycemic control can lead to substantial cost saving through prevention and control of complications.

Economic analysis of insulin initiation by pharmacists in a Canadian setting: The RxING study

BACKGROUND

Conducted in Alberta, the RxING study examined the effect of a community pharmacist prescribing intervention on glycemic control in patients with uncontrolled type 2 diabetes mellitus (T2DM) using insulin glargine. The objective of this study was to assess the cost-effectiveness of pharmacists' prescribing of insulin glargine as an early intervention in uncontrolled patients with T2DM vs usual clinical practice.

METHODS

The IMS CORE diabetes Markov model was used to project long-term clinical outcomes, costs and cost-effectiveness of interventions. The efficacy of insulin glargine, in terms of hemoglobin A1c reduction and hypoglycemia rates, was obtained from the RxING study. Health utility and cost data were found in Canadian publications. The base-case analyses examined the economic and clinical effects of having pharmacists initiate insulin therapy in patients with uncontrolled T2DM in comparison to a physician initiate it up to 3 years later.

RESULTS

Insulin initiation by pharmacists with uncontrolled T2DM patients is cost-effective. Having pharmacists prescribe insulin 1 year earlier than usual clinical practice resulted in an incremental cost savings of $805 (CDN$) and a gain of 0.048 QALYs per patient. Pharmacists prescribing insulin 2 years earlier resulted in an incremental cost savings of $624 (CDN$) per year and a gain of 0.075 quality-adjusted life-years (QALYs). Prescribing 3 years earlier allowed for a minor increase of $26 and a gain of 0.086 QALYs.

CONCLUSION

Earlier initiation of insulin by pharmacists, in uncontrolled T2DM patients, resulted in cost savings and delays in the development of diabetes-related complications, leading to an improved quality of life and increased survival rates.

Physical Activity in Adults with Diabetes Following Prosthetic Rehabilitation

OBJECTIVES

To determine whether adults with diabetes and with transtibial amputations (TTAs) are meeting the recommended guidelines for physical activity intensity and daily step counts. The secondary objectives were to 1) to explore whether physical activity levels are maintained following discharge from prosthetic rehabilitation and 2) to determine whether clinical measures of physical function are associated with physical activity.

METHODS

Adults ≥40 years of age with TTAs secondary to diabetes were recruited following discharge from prosthetic rehabilitation. Outcomes included accelerometer-measured physical activity (worn on the ankle of the intact limb), the 2-minute walk test, gait speed, the L-test and balance confidence. Assessments were conducted at 3 months (baseline) and at 9 months following discharge from rehabilitation. Analyses included paired sample t tests and Pearson correlation coefficients.

RESULTS

The mean age for all participants (n=22) was 63±12 years. Participants took 3809±2189 steps per day at follow up, markedly lower than the 6500 steps per day recommended for older adults with chronic illness. Participants accumulated 24±41 minutes per week of moderate to vigorous physical activity, falling well below the recommended total of 150 minutes per week. An improvement was observed for performance on the L-test of functional mobility at follow up (-8.7 s±11.4; p=0.008). All other outcomes remained stable over time. Physical activity exhibited a good to excellent correlation with the 2-minute walk test distance (r=0.753; p<0.001) and gait speed (r=0.752; p<0.001) at discharge from rehabilitation.

CONCLUSIONS

Physical activity levels for adults with diabetes and TTAs remain stable following discharge from prosthetic rehabilitation but fall well below recommended guidelines of 6500 steps per day and 150 minutes of moderate to vigorous physical activity per week.

Economic Value of Improved Accuracy for Self-Monitoring of Blood Glucose Devices for Type 1 Diabetes in Canada

OBJECTIVE

The objective was to simulate and compare clinical and economic outcomes of self-monitoring of blood glucose (SMBG) devices along error ranges and strip price.

METHODS

We programmed a type 1 diabetes natural history and treatment cost-effectiveness model. In phase 1, using past evidence from in silico modeling validated by the Food and Drug Administration, we associated changes in SMBG error to changes in hemoglobin A1c (HbA1c) and separately, changes in severe hypoglycemia requiring an inpatient stay. In phase 2, using Markov cohort simulation modeling, we estimated clinical and economic outcomes from the Canadian payer perspective. The primary comparison was a SMBG device with strip price $0.73 Canadian dollars (CAD) and 10% error (exceeding accuracy requirements by International Organization for Standardization (ISO) 15197:2013) versus a SMBG device with strip price $0.60 CAD and 15% error (accuracy meeting ISO 15197:2013). Outcomes for the average patient, were quality-adjusted life years (QALYs), incremental cost-effectiveness ratios (ICERs), and budget impact.

RESULTS

Assuming benefits translate into HbA1c improvements only, the ICER with 10% error versus 15% was $11 500 CAD per QALY. Assuming the benefits translate into reduced severe hypoglycemia requiring an inpatient stay only, an SMBG device with 10% error dominated (ie, less costly, more effective) an SMBG device with 15% error. The 3-year budget impact findings ranged from $0.004 CAD per member per month for HbA1c improvements to cost-savings for severe hypoglycemia reductions.

CONCLUSIONS

From efficiency (cost-effectiveness) and affordability (budget impact) payer perspectives, investing in devices with improved accuracy (less error) appears to be an efficient and affordable strategy.

Economic evaluation of hormonal therapies for postmenopausal women with estrogen receptor-positive early breast cancer in Canada

BACKGROUND

Aromatase inhibitor (ai) therapy has been subjected to numerous cost-effectiveness analyses. However, with most ais having reached the end of patent protection and with maturation of the clinical trials data, a re-analysis of ai cost-effectiveness and a consideration of ai use as part of sequential therapy is desirable. Our objective was to assess the cost-effectiveness of the 5-year upfront and sequential tamoxifen (tam) and ai hormonal strategies currently used for treating patients with estrogen receptor (er)-positive early breast cancer.

METHODS

The cost-effectiveness analysis used a Markov model that took a Canadian health system perspective with a lifetime time horizon. The base case involved 65-year-old women with er-positive early breast cancer. Probabilistic sensitivity analyses were used to incorporate parameter uncertainties. An expected-value-of-perfect-information test was performed to identify future research directions. Outcomes were quality-adjusted life-years (qalys) and costs.

RESULTS

The sequential tam-ai strategy was less costly than the other strategies, but less effective than upfront ai and more effective than upfront tam. Upfront ai was more effective and less costly than upfront tam because of less breast cancer recurrence and differences in adverse events. In an exploratory analysis that included a sequential ai-tam strategy, ai-tam dominated based on small numerical differences unlikely to be clinically significant; that strategy was thus not used in the base-case analysis.

CONCLUSIONS

In postmenopausal women with er-positive early breast cancer, strategies using ais appear to provide more benefit than strategies using tam alone. Among the ai-containing strategies, sequential strategies using tam and an ai appear to provide benefits similar to those provided by upfront ai, but at a lower cost.

Economic burden of illness associated with diabetic foot ulcers in Canada

Background

The primary objective was to estimate the national burden of illness in Canada for diabetic foot ulcer (DFU) for 2011. Secondary objectives included estimating the national incidence and prevalence of DFU, and the 3-year average cost for DFU incident cases.

Methods

Analyses were conducted using four national databases for the period April 1, 2006 to March 31, 2011, with cases being identified by ICD-10 CA codes. Resource utilization and costs, expressed in 2011 Canadian dollars, were estimated for DFU-related hospitalizations, emergency care (ER), same day surgeries, home care, long term care, physician visits and caregiver time losses.

Results

In Canada in the year 2011, DFU was associated with 16,883 hospital admissions (327,140 days), 31,095 ER or clinic visits, 41,367 rehabilitation clinic visits, and 26,493 interventions, including 6,036 amputations and 5,796 surgical debridements. This acute institution care represented $320.5 M, and with an additional $125.4 M for home care and $63.1 M for long term care, the annual cost associated with DFU-related care was $547.0 M, or $21,371 annual cost per prevalent case. In 2011, the national prevalence of DFU was 25,597 cases (75.1 per 100,000 population), consisting of 16,161 men (63.1%) and 9,436 women (36.9%), and an estimated 14,449 incident cases. For an incident case of DFU, the average 3-year cumulative cost was $52,360.

Conclusion

The annual burden for DFU cases that have at least one admission or ER/clinic visit over a 5 year period is higher than previously reported.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0687-5) contains supplementary material, which is available to authorized users.

Effectiveness of the smart care service for diabetes management

Objectives

The aim of this study was to assess the effectiveness of the Smart Care service for the diabetes management.

Methods

Fifty-six patients with diabetes mellitus were recruited in Daegu, Korea. All participants completed a diabetes management education course (diet, exercise, and complications) for their self-care and received access to a care management website through a netbook and smartphone. The website accepts uploads of glucose level, body weight, HbA1c, low-density lipoprotein cholesterol level, and blood pressure. Participants communicated with the care manager through the internal management system of the website. The intervention was applied for 6 months.

Results

Participants receiving the Smart Care service had lower blood glucose and HbA1c during 6 months follow-up when 1-month values (p < 0.001) were compared. There was no significant difference in body weight and body mass index between 1 month and 6 months. The average number of remote consultation with the Smart Care service per person was 10.4 by nurses, 3.0 by nutritionists, and 1.6 by sports curers. Regression analysis indicated that the number of times counseling was offered by nurses influences body weight and that the number of minutes of telephone counseling influences both body weight and body mass index.

Conclusions

We have confirmed that the Smart Care service might be an effective system for reduction in blood glucose and HbA1c. We expect that the Smart Care service will contribute to delaying diabetes complications and improving the quality of life of patients with diabetes.

Cost-effectiveness of insulin glargine versus sitagliptin in insulin-naïve patients with type 2 diabetes mellitus

PURPOSE

In the EASIE (Evaluation of Insulin Glargine Versus Sitagliptin in Insulin-Naïve Patients) trial, insulin glargine found a significant reduction in glycosylated hemoglobin compared with sitagliptin in patients with type 2 diabetes who are inadequately controlled with metformin. The objective of this study was to assess the cost-effectiveness of insulin glargine compared with sitagliptin in type 2 diabetes patients, from the perspective of the publicly funded Canadian health care system.

METHODS

The IMS CORE Diabetes Model, a standard Markov structure and Monte Carlo simulation model, was used. The model used a lifetime horizon to capture the long-term complications associated with type 2 diabetes. The efficacy of insulin glargine and sitagliptin in terms of glycosylated hemoglobin reduction and corresponding rates of hypoglycemia were obtained from the EASIE trial. Health utility and cost data were obtained from recently published Canadian publications. Univariate and probabilistic sensitivity analyses were conducted.

FINDINGS

In the lifetime base-case analysis, treatment with insulin glargine resulted in cost savings of $1434 CAD in 2012 and a gain of 0.08 quality-adjusted life years per patient. A probabilistic sensitivity analysis found the robustness of the base-case analysis, with 88% probability of insulin glargine being dominant (ie, cost savings and more quality-adjusted life years).

IMPLICATIONS

Insulin glargine is a clinically superior and cost-effective alternative to sitagliptin in patients with type 2 diabetes who are inadequately controlled with metformin.

Incremental costs associated with myocardial infarction and stroke in patients with type 2 diabetes mellitus: an overview for economic modeling

OBJECTIVE

To identify cost estimates related to myocardial infarction (MI) or stroke in patients with type 2 diabetes mellitus (T2DM) for use in economic models.

METHODS

A systematic literature review was conducted. Electronic databases and conference abstracts were screened against inclusion criteria, which included studies performed in patients who had T2DM before experiencing an MI or stroke. Primary cost studies and economic models were included. Costs were converted to 2012 pounds sterling.

RESULTS

Fifty-four studies were identified: 13 primary cost studies and 41 economic evaluations using secondary sources for complication costs. Primary studies provided costs from 10 countries. Estimates for a fatal event ranged from £2482-£5222 for MI and from £4900-£6694 for stroke. Costs for the year a non-fatal event occurred ranged from £5071-£29,249 for MI and from £5171-£38,732 for stroke. Annual follow-up costs ranged from £945-£1616 for an MI and from £4704-£12,926 for a stroke. Economic evaluations from 12 countries were identified, and costs of complications showed similar variability to the primary studies.

DISCUSSION

The costs identified within primary studies varied between and within countries. Many studies used costs estimated in studies not specific to patients with T2DM. Data gaps included a detailed breakdown of resource use, which affected the ability to compare data across countries.

CONCLUSIONS

In the development of economic models for patients with T2DM, the use of accurate estimates of costs associated with MI and stroke is important. When country-specific costs are not available, clear justification for the choice of estimates should be provided.

Direct cost of patients with type 2 diabetes mellitus healthcare and its complications in Lithuania

OBJECTIVE

The main objective of this study was to estimate the annual direct healthcare cost of type 2 diabetes mellitus healthcare and its complications in Lithuanian population.

MATERIAL AND METHODS

The study uses a prevalence-based top-down approach. The random sample of study participants was formed using the database of the National Health Insurance Fund under the Lithuanian Ministry of Health. 762 patients with diabetes mellitus type 2 data were analyzed in this research. The data on healthcare costs was recorded between January 1, 2011 and December 31, 2011.

RESULTS

Ambulatory care cost mean per patients with diabetes mellitus type 2 in 2011 was EUR 156.14 (95% CI, 147.05-165.24). 34.4% patients had at least one hospitalization during the 2011 year. Mean annual cost per patients of hospitalization was EUR 1160.16 (95% CI, 1019.60-1300.73). Covered drugs and diabetes supplies annual direct cost mean per patients was EUR 448.34 (95% CI, 411.14-485.54). The more expensive treatment was with oral and non-insulin injectable hypoglycemic medications (P<0.001). 65.1% participants were diagnosed one or more diabetes-related chronic complications. Average annual cost per person, increased gradually with the numbers of complications from EUR 671.94 (95% CI, 575.03-768.86) in patients without complications to EUR 1588.98 (95% CI, 1052.09-2125.86) in patients with 3 and more complications (P<0.001).

CONCLUSIONS

The largest part of direct costs in diabetes mellitus healthcare composes hospital inpatient care and covered drugs expenditures. In our study we observed that the presence of microvascular, macrovascular chronic complication increased the direct cost per patient, compared with patients without complications.

The long-term cost-effectiveness of varenicline (12-week standard course and 12 + 12-week extended course) vs. other smoking cessation strategies in Canada

BACKGROUND

Smoking is the leading risk factor for preventable morbidity and mortality as a result of heart and lung diseases and various forms of cancer. Reimbursement coverage for smoking cessation therapies remains limited in Canada and the United States despite the health and economic benefits of smoking cessation.

OBJECTIVES

This study aimed to evaluate the long-term cost-effectiveness of varenicline compared with other smoking cessation interventions in Canada using the Benefits of Smoking Cessation on Outcomes (BENESCO) model.

METHODS

Efficacy rates of the standard course (12 weeks) varenicline, extended course (12 + 12 weeks) varenicline, bupropion, nicotine replacement therapy and unaided intervention were derived based on a published mixed treatment comparison methodology and analysed within a Markov cohort model to estimate their cost-effectiveness over the lifetime cycle. Study cohort, smoking rates and prevalence, incidence and mortality of smoking-related diseases were calibrated to represent the Canadian population.

RESULTS

Over the subjects' lifetime, both the standard and the extended course of varenicline are shown to dominate (e.g. less costly and more effective) all other alternative smoking cessation interventions considered. Compared with the standard varenicline treatment course, the extended course is highly cost-effective with an incremental cost-effectiveness ratio (ICER) less than $4000 per quality-adjusted life year. Including indirect cost and benefits of smoking cessation interventions further strengthens the result with the extended course of varenicline dominating all other alternatives considered.

LIMITATIONS

Evidence from complex smoking cessation models requiring numerous inputs and assumptions should be assessed in conjunction with evidence from other methodologies.

CONCLUSIONS

The standard and extended courses of varenicline are decidedly cost-effective treatment regimes compared with alternative smoking cessation interventions and can provide significant cost savings to the healthcare system.

Costs and Quality of Life in Diabetic Macular Edema: Canadian Burden of Diabetic Macular Edema Observational Study (C-REALITY)

Purpose. To characterize the economic and quality of life burden of diabetic macular edema (DME) in Canadian patients. Patients and Methods. 145 patients with DME were followed for 6 months with monthly telephone interviews and medical chart reviews at months 0, 3, and 6. Visual acuity in the worst-seeing eye was assessed at months 0 and 6. DME-related healthcare costs were determined over 6 months, and vision-related (National Eye Institute Visual Functioning Questionnaire) and generic (EQ-5D) quality of life was assessed at months 0, 3, and 6. Results. Mean age of patients was 63.7 years: 52% were male and 72% had bilateral DME. At baseline, visual acuity was categorized as normal/mild loss for 63.4% of patients, moderate loss for 10.4%, and severe loss/nearly blind for 26.2%. Mean 6-month DME-related costs/patient were as follows: all patients (n = 135), $2,092; normal/mild loss (n = 88), $1,776; moderate loss (n = 13), $1,845; and severe loss/nearly blind (n = 34), $3,007. Composite scores for vision-related quality of life declined with increasing visual acuity loss; generic quality of life scores were highest for moderate loss and lowest for severe loss/nearly blind. Conclusions. DME-related costs in the Canadian healthcare system are substantial. Costs increased and vision-related quality of life declined with increasing visual acuity severity.

Lifetime direct medical costs of treating type 2 diabetes and diabetic complications

BACKGROUND

Lifetime direct medical cost of treating type 2 diabetes and diabetic complications in the U.S. is unknown.

PURPOSE

This study provides nationally representative estimates of lifetime direct medical costs of treating type 2 diabetes and diabetic complications in people newly diagnosed with type 2 diabetes, by gender and by age at diagnosis.

METHODS

A type 2 diabetes simulation model was used to simulate the disease progression and direct medical costs among a cohort of newly diagnosed type 2 diabetes patients. The study sample used for the simulation was based on data from the 2009-2010 National Health and Nutritional Examination Survey. The costs of treating type 2 diabetes and diabetic complications were derived from published literature. Annual medical costs were accumulated over the life span of type 2 diabetes to determine the lifetime medical costs. All costs were calculated from a healthcare system perspective, and expressed in 2012 dollars.

RESULTS

In men diagnosed with type 2 diabetes at ages 25-44 years, 45-54 years, 55-64 years, and ≥ 65 years, the lifetime direct medical costs of treating type 2 diabetes and diabetic complications were $124,700, $106,200, $84,000, and $54,700, respectively. In women, the costs were $130,800, $110,400, $85,500, and $56,600, respectively. The age-gender weighted average of the lifetime medical costs was $85,200, of which 53% was due to treating diabetic complications. The cost of managing macrovascular complications accounted for 57% of the total complication cost.

CONCLUSIONS

Over the lifetime, type 2 diabetes imposes a substantial economic burden on healthcare systems. Effective interventions that prevent or delay type 2 diabetes and diabetic complications might result in substantial long-term savings in healthcare costs.

Screening for diabetic retinopathy and nephropathy in patients with diabetes: a nationwide survey in Korea

This study was performed to identify factors associated with screening for diabetic retinopathy and nephropathy. Data from the Korean National Health and Nutrition Examination Survey between 2007 and 2009 were analyzed. Of 24,871 participants, 1,288 patients diagnosed with diabetes at ≥30 years of age were included. 36.3% received screening for diabetic retinopathy, and 40.5% received screening for diabetic nephropathy during the previous year. Patients living in rural areas, those with less education, those who had not received education about diabetes care, and those who did not receive medical care for diabetes were screened less often for retinopathy or nephropathy. Patients with poorer self-reported health status were screened more often. Occupation, smoking status, and diabetes duration were associated with retinopathy screening. Lower family income was associated with decreased nephropathy screening. Receiving education about diabetes care and receiving medical care for diabetes were significant factors in patients with a shorter duration of diabetes (the significant odds ratio [OR] of not receiving education varied between 0.27 and 0.51, and that of not receiving medical care varied between 0.34 and 0.42). Sociodemographic factors and health-related factors as well as education and medical care influenced screening for diabetic complications among those with a longer duration of diabetes (for retinopathy and nephropathy, the significant OR of living in a rural area varied between 0.56 and 0.61; for retinopathy, the significant OR of current smokers was 0.55, and the p-trend of subjective health status was <0.001; for nephropathy, the significant OR of a monthly household income of <3000 dollars was 0.61 and the p-trends of education and subjective health status were 0.030 and 0.007, respectively). Efforts to decrease sociodemographic disparities should be combined with education about diabetes care to increase the screening, especially for those with a longer duration of diabetes.

Health care costs in people with diabetes and their association with glycemic control and kidney function

OBJECTIVE

To determine the association between laboratory-derived measures of glycemic control (HbA1c) and the presence of renal complications (measured by proteinuria and estimated glomerular filtration rate [eGFR]) with the 5-year costs of caring for people with diabetes.

RESEARCH DESIGN AND METHODS

We estimated the cumulative 5-year cost of caring for people with diabetes using a province-wide cohort of adults with diabetes as of 1 May 2004. Costs included physician visits, hospitalizations, ambulatory care (emergency room visits, day surgery, and day medicine), and drug costs for people >65 years of age. Using linked laboratory and administrative clinical and costing data, we determined the association between baseline glycemic control (HbA1c), proteinuria, and kidney function (eGFR) and 5-year costs, controlling for age, socioeconomic status, duration of diabetes, and comorbid illness.

RESULTS

We identified 138,662 adults with diabetes. The mean 5-year cost of diabetes in the overall cohort was $26,978 per patient, excluding drug costs. The mean 5-year cost for the subset of people >65 years of age, including drug costs, was $44,511 (Canadian dollars). Cost increased with worsening kidney function, presence of proteinuria, and suboptimal glycemic control (HbA1c >7.9%). Increasing age, Aboriginal status, socioeconomic status, duration of diabetes, and comorbid illness were also associated with increasing cost.

CONCLUSIONS

The cost of caring for people with diabetes is substantial and is associated with suboptimal glycemic control, abnormal kidney function, and proteinuria. Future studies should assess if improvements in the management of diabetes, assessed with laboratory-derived measurements, result in cost reductions.

Medical costs associated with type 2 diabetes complications and comorbidities

OBJECTIVES

To estimate the direct medical costs associated with type 2 diabetes, its complications, and its comorbidities among U.S. managed care patients.

STUDY DESIGN

Data were from patient surveys, chart reviews, and health insurance claims for 7109 people with type 2 diabetes from 8 health plans participating in the Translating Research Into Action for Diabetes (TRIAD) study between 1999 and 2002.

METHODS

A generalized linear regression model was developed to estimate the association of patients' demographic characteristics, tobacco use status, treatments, related complications, and comorbidities with medical costs.

RESULTS

The mean annualized direct medical cost was $2465 for a white man with type 2 diabetes who had been diagnosed fewer than 15 years earlier, was treated with oral medication or diet alone, and had no complications or comorbidities. We found annualized medical costs to be 10% to 50% higher for women and for patients whose diabetes had been diagnosed 15 or more years earlier, who used tobacco, who were being treated with insulin, or who had several other complications. Coronary heart disease, congestive heart failure, hemiplegia, and amputation were each associated with 70% to 150% higher costs. Costs were approximately 300% higher for end-stage renal disease treated with dialysis and approximately 500% higher for end-stage renal disease with kidney transplantation.

CONCLUSIONS

Most medical costs incurred by patients with type 2 diabetes are related to complications and comorbidities. Our cost estimates can help when determining the most cost-effective interventions to prevent complications and comorbidities.

BENEFITS OF PHARMACEUTICAL INNOVATION: THE CASE OF SIMVASTATIN IN CANADA

Background: The benefits of pharmaceutical innovations are widely diffused; they accrue to the healthcare providers, patients, employers, and manufacturers. We estimate the societal monetary benefits of simvastatin in Canada and its distribution among different beneficiaries overtime.

Methods: Monetary benefits to developing and generic manufacturers were estimated by calculating public and private revenues minus the development costs of simvastatin and the contribution toward further research and development. We used a dynamic Markov model to estimate monetary benefits to healthcare and employment sectors in terms of cost avoidance associated with prevented cardiovascular events, including stroke and myocardial infarction, and lost productivity due to disability and premature death in working population.

Results: Cumulative monetary benefits of simvastatin from 1990 to 2009 were $4.8 billion (2010 CA$), of which developing and generic manufacturers, and healthcare and employment sectors accounted for 32 percent, 27 percent, 32 percent, and 9 percent, respectively. The yearly trend showed that after the patent expired in 2002 the generic manufacturers became dominant in the market. Benefits for the healthcare sector started to decrease from 2003 corresponding to the decreasing population taking simvastatin during the same time period. Sensitivity analysis showed the higher the compliance or the efficacy, the larger the benefits to healthcare and employment sectors, while monetary benefits for manufacturers were unchanged.

Conclusions: Societal monetary benefits of simvastatin are significant and the distributions of the benefits have changed overtime. Patent, compliance, and efficacy play a vital role in the estimation of the benefits. Analysis of all beneficiaries separately overtime is important when assessing the value of pharmaceutical innovation.

Economic analysis of epoetin alfa in critically ill trauma patients

BACKGROUND

Recent randomized control trials (RCTs) suggest that epoetin alfa reduces mortality in critically ill trauma patients; however, epoetin alfa is also costly and associated with adverse events. This study evaluates the cost-effectiveness of epoetin alfa in surgical trauma patients in an intensive care unit setting.

METHODS

We constructed a decision analytic model to compare adjunctive use of epoetin alfa with standard care in trauma patients from the perspective of a Canadian payer. Baseline risks of events, relative efficacy, and resource use were obtained from RCTs and observational studies. One-way and probabilistic sensitivity analyses were conducted and longer time horizons explored through Markov models.

RESULTS

Epoetin alfa was associated with a cost per quality-adjusted life year (QALY) gained of $89,958 compared with standard care at 1 year. One-way sensitivity analyses indicated that results were sensitive to plausible ranges of mortality risk, risk of thrombosis, relative risk of mortality, relative risk of thrombosis, and quality of life estimates. Cost-effectiveness acceptability curves generated from probabilistic sensitivity analysis indicated that the probability that epoetin alfa would be considered attractive ranged from 0% to 85% over a willingness-to-pay range of $25,000 to $120,000/QALY. Consideration of lifetime time horizons reduced the cost per QALY gained to $7,203, but results were sensitive to the effect of epoetin alfa on mortality.

CONCLUSION

Although the cost per QALY gained with epoetin alfa use may fall into an acceptable range, there is significant uncertainty about its true cost-effectiveness. If data regarding long-term efficacy and safety are confirmed in future trials, epoetin alfa could potentially be cost-effective in this population.

LEVEL OF EVIDENCE

Economic analysis, level I.

[Consensus document on the management after hospital discharge of patient with hyperglycaemia]

The present document intends to adapt the general recommendations set up in a consensus to elaborate the hospital discharge report in medical specialties to the specific needs of the hospitalized diabetic population. Diabetes is an illness with a very high health cost, being the global risk of death in people with diabetes almost double than in non-diabetes people, justifying the fact that diabetes constitutes one of the most frequent diagnoses in hospitalized patients and the growing interest upon hyperglycaemia management during hospitalization and at discharge. To set up an adequate treatment plan at discharge suitable for each patient, the most important elements to take into account are the etiology and prior hyperglycaemia treatment, the patient's clinical situation and the degree of glycaemia control. Due to instability of glycaemia control, it is also needed to anticipate the educational needs for each patient, as well as to set up the monitoring schedule and follow-up at discharge, and an adequate treatment plan at discharge.

Assessing the impact of diabetes-related comorbidities and care on the hospitalization costs for patients with diabetes mellitus in Japan

OBJECTIVE

Because diabetes mellitus (DM) has been highlighted in several healthcare sectors, variations in the case mix of DM should be evaluated to promote effective disease management. Using a Japanese administrative database (2003), we investigated the impact of DM-related comorbidities and of their relevant care processes on healthcare costs incurred during hospitalization.

METHODS

Of 283,771 hospital admissions across 174 acute care hospitals, 27,853 patients with DM were analyzed. The following variables were analyzed according to age (<65 or ≥65 years), the presence of comorbidities, demographic characteristics, procedure-related complications, insulin use, surgical procedures (percutaneous minimally invasive intervention, hemodialysis, ventilation, and rehabilitation), length of stay (LOS), and total charge (TC; US$1=Y90). Multivariate analyses were applied to investigate the effects of DM-related complications and care processes associated with DM on TC.

RESULTS

The mortality and procedure-related complication rates were 2.1% and 2.7%, respectively. There were significant differences in the frequencies of comorbidities by age category. Among DM-related comorbidities, peripheral vascular disease had the greatest impact on increasing the LOS or TC. Minimally invasive procedures, hemodialysis, ventilation, and procedure-related complications were significant determinants of TC. Hemodialysis and invasive surgical procedures were independent predictors of procedure-related complications.

CONCLUSIONS

DM-related comorbidities and care process representative of the DM case mix were responsible for variations in healthcare costs during hospitalization.

Costs of diabetes mellitus in Korea

Outcome research focusing on the economics of the medical field began in the mid-1990s and has included studies about costs, cost effectiveness, and policies. According to the American Diabetes Association, the total estimated cost of diabetes in 2007 was $174 billion. The economic burden of patients with diabetes in Canada is expected to be about $12.2 billion in 2010. Recent Korean studies have analyzed the expenses associated with type 2 diabetes for patients in selected general hospitals. Type 2 diabetic patients without complications cost approximately 1,184,563 won (the equivalent of US $1,184) per patient for healthcare annually. In contrast, patients with microvascular disease due to diabetic complications cost up to 4.7 times that amount, and patients with macrovascular disease incur up to 10.7 times the annual costs for patients without diabetic complications. Diabetic complications ultimately impact the quality of life for patients and patient mortality, and are associated with higher direct medical expenses for patients. To avoid increased medical costs, appropriate management techniques must be implemented to ensure timely care for patients with diabetes.

Cost analysis for efficient management: diabetes treatment at a public district hospital in Thailand

Objective

The study estimated cost of illness from the provider's perspective for diabetic patients who received treatment during the fiscal year 2008 at Waritchaphum Hospital, a 30-bed public district hospital in Sakhon Nakhon province in northeastern Thailand.

Methods

This retrospective, prevalence-based cost-of-illness study looked at 475 randomly selected diabetic patients, identified by the World Health Organization's International Classification of Diseases, 10th revision, codes E10–E14. Data were collected from the hospital financial records and medical records of each participant and were analysed with a stepwise multiple regression.

Key findings

The study found that the average public treatment cost per patient per year was US$94.71 at 2008 prices. Drug cost was the highest cost component (25% of total cost), followed by inpatient cost (24%) and outpatient visit cost (17%). A cost forecasting model showed that length of stay, hospitalization, visits to the provincial hospital, duration of disease and presence of diabetic complications (e.g. diabetic foot complications and nephropathy) were the significant predictor variables (adjusted R2 = 0.689).

Conclusions

According to the fitted model, avoiding nephropathy and foot complications would save US$19 386 and US$39 134 respectively per year. However, these savings are missed savings for the study year and the study hospital only and not projected savings, as that would depend on the number of diabetic patients managed in the year, the ratio of complicated to non-complicated cases and effectiveness of the prevention programmes. Nonetheless, given the high avoidable cost associated with complications of diabetes, healthcare providers in Thailand should focus on initiatives that delay the progression of complications in diabetic patients.