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Tamsett Z, James S, Brown F, O'Neal DN, Ekinci EI. Modifiable factors to prevent severe hypoglycaemic and diabetic ketoacidosis presentations in people with type 1 diabetes. Diabet Med 2024; 41:e15384. [PMID: 38923618 DOI: 10.1111/dme.15384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 05/03/2024] [Accepted: 05/31/2024] [Indexed: 06/28/2024]
Abstract
AIMS In tackling rising diabetes-related emergencies, the need to understand and address emergency service usage by people with type 1 diabetes is vital. This review aimed to quantify current trends in presentations for type 1 diabetes-related emergencies and identify public health strategies that reduce the frequency of diabetes-related emergencies and improve glycaemic management. METHODS Medline (OVID), Cochrane and CINAHL were searched for studies published between 2000 and 2023, focusing on people with type 1 diabetes, severe hypoglycaemia and/or diabetic ketoacidosis, and ambulance and/or emergency department usage. There were 1313 papers identified, with 37 publications meeting review criteria. RESULTS The incidence of type 1 diabetes-related emergencies varied from 2.4 to 14.6% over one year for hypoglycaemic episodes, and between 0.07 and 11.8 events per 100 person-years for hyperglycaemic episodes. Notably, our findings revealed that ongoing diabetes education and the integration of diabetes technology, such as continuous glucose monitoring and insulin pump therapy, significantly reduced the incidence of these emergencies. However, socio-economic disparities posed barriers to accessing these technologies, subsequently shifting the cost to emergency healthcare and highlighting the need for governments to consider subsidising these technologies as part of preventative measures. CONCLUSIONS Improving access to continuous glucose monitoring and insulin pump therapy, in combination with ongoing diabetes education focusing on symptom recognition and early management, will reduce the incidence of diabetes-related emergencies. Concurrent research assessing emergency healthcare usage patterns during the implementation of such measures is essential to ensure these are cost-effective.
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Affiliation(s)
- Zacchary Tamsett
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Steven James
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- School of Health, University of the Sunshine Coast, Petrie, Queensland, Australia
| | - Fran Brown
- Melbourne Diabetes Education and Support, Heidelberg Heights, Victoria, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Parkville, Victoria, Australia
| | - Elif I Ekinci
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Parkville, Victoria, Australia
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
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Mellor J, Kuznetsov D, Heller S, Gall MA, Rosilio M, Amiel SA, Ibberson M, McGurnaghan S, Blackbourn L, Berthon W, Salem A, Qu Y, McCrimmon RJ, de Galan BE, Pedersen-Bjergaard U, Leaviss J, McKeigue PM, Colhoun HM. Risk factors and prediction of hypoglycaemia using the Hypo-RESOLVE cohort: a secondary analysis of pooled data from insulin clinical trials. Diabetologia 2024; 67:1588-1601. [PMID: 38795153 PMCID: PMC11343909 DOI: 10.1007/s00125-024-06177-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/28/2024] [Indexed: 05/27/2024]
Abstract
AIMS/HYPOTHESIS The objective of the Hypoglycaemia REdefining SOLutions for better liVES (Hypo-RESOLVE) project is to use a dataset of pooled clinical trials across pharmaceutical and device companies in people with type 1 or type 2 diabetes to examine factors associated with incident hypoglycaemia events and to quantify the prediction of these events. METHODS Data from 90 trials with 46,254 participants were pooled. Analyses were done for type 1 and type 2 diabetes separately. Poisson mixed models, adjusted for age, sex, diabetes duration and trial identifier were fitted to assess the association of clinical variables with hypoglycaemia event counts. Tree-based gradient-boosting algorithms (XGBoost) were fitted using training data and their predictive performance in terms of area under the receiver operating characteristic curve (AUC) evaluated on test data. Baseline models including age, sex and diabetes duration were compared with models that further included a score of hypoglycaemia in the first 6 weeks from study entry, and full models that included further clinical variables. The relative predictive importance of each covariate was assessed using XGBoost's importance procedure. Prediction across the entire trial duration for each trial (mean of 34.8 weeks for type 1 diabetes and 25.3 weeks for type 2 diabetes) was assessed. RESULTS For both type 1 and type 2 diabetes, variables associated with more frequent hypoglycaemia included female sex, white ethnicity, longer diabetes duration, treatment with human as opposed to analogue-only insulin, higher glucose variability, higher score for hypoglycaemia across the 6 week baseline period, lower BP, lower lipid levels and treatment with psychoactive drugs. Prediction of any hypoglycaemia event of any severity was greater than prediction of hypoglycaemia requiring assistance (level 3 hypoglycaemia), for which events were sparser. For prediction of level 1 or worse hypoglycaemia during the whole follow-up period, the AUC was 0.835 (95% CI 0.826, 0.844) in type 1 diabetes and 0.840 (95% CI 0.831, 0.848) in type 2 diabetes. For level 3 hypoglycaemia, the AUC was lower at 0.689 (95% CI 0.667, 0.712) for type 1 diabetes and 0.705 (95% CI 0.662, 0.748) for type 2 diabetes. Compared with the baseline models, almost all the improvement in prediction could be captured by the individual's hypoglycaemia history, glucose variability and blood glucose over a 6 week baseline period. CONCLUSIONS/INTERPRETATION Although hypoglycaemia rates show large variation according to sociodemographic and clinical characteristics and treatment history, looking at a 6 week period of hypoglycaemia events and glucose measurements predicts future hypoglycaemia risk.
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Affiliation(s)
- Joseph Mellor
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK.
| | | | - Simon Heller
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Mari-Anne Gall
- Medical & Science, Insulin, Clinical Drug Development, Novo Nordisk A/S, Soeberg, Denmark
| | - Myriam Rosilio
- Eli Lilly and Company, Diabetes Medical Unit, Neuilly sur seine, France
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Mark Ibberson
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Stuart McGurnaghan
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Luke Blackbourn
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - William Berthon
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Adel Salem
- RW Data Assets, AI & Analytics (AIA), Novo Nordisk A/S, Soeberg, Denmark
| | - Yongming Qu
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Bastiaan E de Galan
- Department of Internal Medicine, Division of Endocrinology and Metabolic Disease, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Paul M McKeigue
- Usher Institute, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Helen M Colhoun
- Institute of Genetics and Cancer, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
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Mustonen J, Rautiainen P, Lamidi ML, Lavikainen P, Martikainen J, Laatikainen T. The use of isCGM leads to marked reduction in severe hypoglycemia requiring emergency medical service or hospital admission and diabetic ketoacidosis in adult type 1 diabetes patients. Acta Diabetol 2023; 60:891-898. [PMID: 36977968 DOI: 10.1007/s00592-023-02079-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
AIMS To determine the effect of the use of intermittently scanned continuous glucose monitoring (isCGM) on acute diabetes-related complications in adult type 1 diabetes patients. METHODS Six hundred and forty-two adult type 1 diabetes patients with isCGM were identified from electronic health records in Siun sote region in Eastern Finland. A retrospective real-world analysis was conducted combining hospital admission and prehospital emergency service data to compare incidences of hypoglycemia requiring emergency medical support (EMS) involvement or hospital admission and diabetic ketoacidosis (DKA) before and after the start of isCGM. Data were collected from January 2015 to April 2020. Primary outcome was the rate of hypoglycemia requiring EMS involvement or hospital admission and DKA events. HbA1c was recorded at the start of isCGM and was compared with the last known HbA1c during the use of isCGM. The isCGM used in the study did not contain alarm functions. RESULTS Altogether 220 hypoglycemic events were identified during the study period. Incidence rate of hypoglycemic events decreased after the start of isCGM (72 events, incidence rate 50 events/1000 person-years) compared with the time before the start (148 events, incidence rate 76 events/1000 person-years) (p = 0.043). The incidence rate of DKA decreased after the start of isCGM compared with time before isCGM use (4 and 15 events/1000 person-years, respectively; p = 0.002). The change in mean HbA1c was - 0.28% (- 3.1 mmol/mol) between baseline and the last HbA1c measurement (p < 0.001). CONCLUSIONS In addition to lowering HbA1c in type 1 diabetes patients, isCGM is also effective in preventing acute diabetes-related complications such as hypoglycemia requiring EMS involvement or hospital admission and DKA.
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Affiliation(s)
- Jyrki Mustonen
- Department of Internal Medicine, Joint Municipal Authority for North Karelia Social and Health Services (Siun Sote), Tikkamäentie 16, 80210, Joensuu, Finland.
| | - Päivi Rautiainen
- Department of Internal Medicine, Joint Municipal Authority for North Karelia Social and Health Services (Siun Sote), Tikkamäentie 16, 80210, Joensuu, Finland
| | - Marja-Leena Lamidi
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
| | - Piia Lavikainen
- School of Pharmacy, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
| | - Janne Martikainen
- School of Pharmacy, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Yliopistonranta 1, 70210, Kuopio, Finland
- Department of Public Health and Welfare, National Institute for Health and Welfare (THL), Helsinki, Finland
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Sharma S, Gillespie P, Hobbins A, Dinneen SF. Estimating the cost of type 1 diabetes in Ireland. Diabet Med 2022; 39:e14779. [PMID: 34958713 DOI: 10.1111/dme.14779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 12/24/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Type 1 diabetes is a chronic disease, which given its existing and projected prevalence, is likely to pose a significant economic burden, both in terms of directs costs to the healthcare system and indirect costs to society. We aimed to estimate the economic burden of type 1 diabetes in Ireland, which at present, is unknown. METHODS A cost of illness study was undertaken to estimate the cost of type 1 diabetes in Ireland for 2018. Data for prevalence, morbidity, mortality, healthcare resource use, absenteeism, and unit costs were obtained from national, and where necessary, international sources. Direct healthcare costs were estimated for primary care, outpatient, emergency and inpatient care, for associated complications, structured education programmes, insulin and related care. Additionally, indirect costs from lost earnings due to premature death and employee absenteeism were estimated. RESULTS Type 1 diabetes was estimated to cost €129 million in Ireland in 2018, with direct healthcare costs accounting for €81.5 million or 63% and indirect costs for €47.5 million or 37% of the total. On average, this amounted to €3994 per patient in direct healthcare costs and €2326 per patient in indirect costs. CONCLUSION Type 1 diabetes is a leading public health problem. Our study is the first to assess the economic burden of type 1 diabetes in Ireland, and our results should be informative to policymakers tasked with prioritising healthcare and research funding resource allocation.
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Affiliation(s)
- Shikha Sharma
- Health Economics & Policy Analysis Centre, National University of Ireland, Galway, Ireland
| | - Paddy Gillespie
- Health Economics & Policy Analysis Centre, National University of Ireland, Galway, Ireland
- CURAM, Science Foundation Ireland (SFI) Research Centre for Medical Devices, National University of Ireland, Galway, Ireland
| | - Anna Hobbins
- Health Economics & Policy Analysis Centre, National University of Ireland, Galway, Ireland
- CURAM, Science Foundation Ireland (SFI) Research Centre for Medical Devices, National University of Ireland, Galway, Ireland
| | - Sean F Dinneen
- School of Medicine, National University of Ireland, Galway and Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
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Liu SL, Columbus MP, Peddle M, Mahon JL, Spaic T. Hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada: a population-based retrospective cohort study. CMAJ Open 2021; 9:E1260-E1268. [PMID: 34933884 PMCID: PMC8695532 DOI: 10.9778/cmajo.20200184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND People with diabetes mellitus commonly experience hypoglycemia, but they may not necessarily present to hospital after severe hypoglycemia requiring paramedic assistance. We sought to describe the incidence and characteristics of calls for hypoglycemia requiring paramedic assistance among adults in southwestern Ontario, Canada, and to determine predictors of hospital transport. METHODS This population-based retrospective cohort study used data extracted from ambulance call reports (ACRs) of 8 paramedic services of the Southwest Ontario Regional Base Hospital Program from January 2008 to June 2014. We described calls in which treatment for hypoglycemia was administered, summarized the incidence of hypoglycemia calls and performed logistic regression to determine predictors of hospital transport. RESULTS Out of 470 467 ACRs during the study period, 9185 paramedic calls occurred in which hypoglycemia treatment was administered to an adult (mean age 60.2 yr, 56.8% male, 81.1% with documented diabetes). Refusal of hospital transport occurred in 2243 (24.4%) of calls. Documented diabetes diagnosis (adjusted odds ratio [OR] 0.82, 95% confidence interval [CI] 0.69-0.96), higher capillary blood glucose (adjusted OR 0.31, 95% CI 0.22-0.44) and overnight calls (adjusted OR 0.80, 95% CI 0.72-0.91) were associated with lower odds of hospital transport. Higher-acuity calls (adjusted OR 2.05, 95% CI 1.58-2.66) were associated with higher odds of transport. The estimated annual incidence rate of hypoglycemia requiring paramedic assistance was 108 per 10 000 people with diabetes per year. INTERPRETATION Hypoglycemia requiring paramedic assistance in southwestern Ontario is common, and close to 25% of calls do not result in hospital transport. Physicians managing diabetes care may be unaware of patients' hypoglycemia requiring paramedic care, suggesting a potential gap in follow-up care; we suggest that paramedics play an important role in identifying those at high recurrence risk and communicating with their care providers.
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Affiliation(s)
- Selina L Liu
- Division of Endocrinology and Metabolism (Liu, Mahon, Spaic), Department of Medicine, Schulich School of Medicine & Dentistry, Western University; St. Joseph's Health Care London (Liu, Mahon, Spaic); Division of Emergency Medicine (Columbus, Peddle), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.
| | - Melanie P Columbus
- Division of Endocrinology and Metabolism (Liu, Mahon, Spaic), Department of Medicine, Schulich School of Medicine & Dentistry, Western University; St. Joseph's Health Care London (Liu, Mahon, Spaic); Division of Emergency Medicine (Columbus, Peddle), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Michael Peddle
- Division of Endocrinology and Metabolism (Liu, Mahon, Spaic), Department of Medicine, Schulich School of Medicine & Dentistry, Western University; St. Joseph's Health Care London (Liu, Mahon, Spaic); Division of Emergency Medicine (Columbus, Peddle), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Jeffrey L Mahon
- Division of Endocrinology and Metabolism (Liu, Mahon, Spaic), Department of Medicine, Schulich School of Medicine & Dentistry, Western University; St. Joseph's Health Care London (Liu, Mahon, Spaic); Division of Emergency Medicine (Columbus, Peddle), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Tamara Spaic
- Division of Endocrinology and Metabolism (Liu, Mahon, Spaic), Department of Medicine, Schulich School of Medicine & Dentistry, Western University; St. Joseph's Health Care London (Liu, Mahon, Spaic); Division of Emergency Medicine (Columbus, Peddle), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont
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Holstein DJF, Holstein JD, Fischer D, Mende M, Frier BM, Holstein A. Out-of-Hospital Management of Diabetic Emergencies in Germany: Structural and Process Quality. Exp Clin Endocrinol Diabetes 2021; 130:454-461. [PMID: 34284506 DOI: 10.1055/a-1523-7562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AIMS To collect and analyse representative data of structural and process quality in the management of diabetic emergencies in Germany in 2020. METHODS A standardised questionnaire comprising detailed items concerning clinically relevant parameters on the structural and process quality of out-of-hospital management of diabetic emergencies was sent nationwide to medical directors of emergency medical service districts (EMSDs). Results were compared with those from a similar study conducted in 2001. RESULTS The return rate of the questionnaires represented 126 EMSDs, serving a total population of > 40.1 million. Only 4% of ambulances carried glucagon (6% in 2001). In 2020, blood glucose determination increased significantly to 71% of all emergency interventions and to 29% of suspected cardiac emergencies (24% and 15%, respectively, in 2001). In 100% of EMSDs severe hypoglycaemia (SH) was treated by paramedics by administering intravenous dextrose before the arrival of a doctor compared to 63% in 2001. The potential value of nasal glucagon was acknowledged by 43% of responders. In selected patients, treatment of SH was conducted without hospital admission in 78% of EMDs (60% in 2001). Fifty-three percent of medical directors acknowledged the need for further training in diabetic emergencies (47% in 2001). Cooperation for medical education between emergency teams and a diabetes centre was reported by 14% (41% in 2001). CONCLUSION Structural and process quality of the management of diabetic emergencies in Germany has improved considerably since 2001. Persisting deficiencies could be improved by providing better medical equipment in ambulances and ongoing education to the entire emergency teams.
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Affiliation(s)
- David J F Holstein
- Integrated Research and Treatment Center Adiposity Diseases, University of Leipzig, Germany
| | - Judith D Holstein
- Division of Nephrology and Internal Intensive Care Medicine, Charite' University Medicine Berlin, Germany
| | - Daniel Fischer
- Department of Emergency Medicine, Lippe-Detmold Hospital, Germany
| | - Meinhard Mende
- Clinical Trial Centre and Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Germany
| | - Brian M Frier
- The Queen's Medical Research Institute, University of Edinburgh, Scotland, UK
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Bengtsen MB, Knudsen JS, Bengtsen MB, Møller N, Thomsen RW. Hospitalization for hypoglycaemia in people with diabetes in Denmark, 1997-2017: Time trends in incidence and HbA 1c and glucose-lowering drug use before and after hypoglycaemia. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00227. [PMID: 34277957 PMCID: PMC8279622 DOI: 10.1002/edm2.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/09/2020] [Accepted: 01/09/2021] [Indexed: 11/24/2022]
Abstract
Objective To assess incidence trends of first hospitalization for hypoglycaemia in Denmark and to examine HbA1c levels and glucose‐lowering drug use before and after hospitalization among individuals with type 1 or type 2 diabetes. Research Design and Methods We performed a population‐based study linking diagnosis, prescription and laboratory data. Standardized incidence of first hospitalization for hypoglycaemia in Denmark was assessed for each calendar year 1997–2017. HbA1c and glucose‐lowering drug use was compared with age‐ and sex‐matched diabetes comparisons without hospitalization for hypoglycaemia. Results The annual age‐ and sex‐standardized incidence rate of first hospitalization for hypoglycaemia per 100,000 person‐years increased during 1997–2003 (from 17.7 to 30.3 per 100,000 person‐years), remained stable until 2010 (30.4) and gradually declined until 2017 (22.0). During this period, we identified 3,479 people with type 1 diabetes and 15,329 people with type 2 diabetes experiencing first hospitalization for hypoglycaemia. Both diabetes groups experienced a mean HbA1c decrease of ~12%–15% in the months preceding first hospitalization, followed by a gradually increasing HbA1c afterwards. People with type 1 diabetes and hospitalization used similar insulin therapies as those without hospitalization. People with type 2 diabetes and hospitalization more often received insulin (55%) than comparisons (45%), and 45% discontinued insulin or stopped all glucose‐lowering therapy after first hospitalization. Conclusions Incidence of hospitalizations for hypoglycaemia has declined by one fourth the last decade in the Danish population. A HbA1c decrease precedes first hospitalization for hypoglycaemia in individuals with diabetes, and profound changes in glucose‐lowering drug therapy for type 2 diabetes occur after hospitalization.
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Affiliation(s)
- Mads Bisgaard Bengtsen
- Department of Endocrinology and Internal Medicine Aarhus University Hospital Aarhus Denmark.,Department of Internal Medicine Regional Hospital of Horsens Horsens Denmark
| | - Jakob Schöllhammer Knudsen
- Department of Clinical Epidemiology Institute of Clinical Medicine Aarhus University Hospital Aarhus Denmark.,Department of Clinical Pharmacology Aarhus University Hospital Aarhus Denmark
| | - Maria Bisgaard Bengtsen
- Department of Clinical Epidemiology Institute of Clinical Medicine Aarhus University Hospital Aarhus Denmark
| | - Niels Møller
- Department of Endocrinology and Internal Medicine Aarhus University Hospital Aarhus Denmark
| | - Reimar Wernich Thomsen
- Department of Clinical Epidemiology Institute of Clinical Medicine Aarhus University Hospital Aarhus Denmark
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Stedman M, Lunt M, Davies M, Livingston M, Duff C, Fryer A, Anderson SG, Gadsby R, Gibson M, Rayman G, Heald A. Cost of hospital treatment of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) compared to the non-diabetes population: a detailed economic evaluation. BMJ Open 2020; 10:e033231. [PMID: 32376746 PMCID: PMC7223153 DOI: 10.1136/bmjopen-2019-033231] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Other than age, diabetes is the largest contributor to overall healthcare costs and reduced life expectancy in Europe. This paper aims to more exactly quantify the net impact of diabetes on different aspects of healthcare provision in hospitals in England, building on previous work that looked at the determinants of outcome in type 1 diabetes (T1DM) and type 2 diabetes (T2DM). SETTING NHS Digital Hospital Episode Statistics (HES) in England was combined with the National Diabetes Audit (NDA) to provide the total number in practice of people with T1DM/T2DM. OUTCOME MEASURES We compared differences between T1DM/T2DM and non-diabetes individuals in relation to hospital activity and associated cost. RESULTS The study captured 90% of hospital activity and £36 billion/year of hospital spend. The NDA Register showed that out of a total reported population of 58 million, 2.9 million (6.5%) had T2DM and 240 000 (0.6%) had T1DM. Bed-day analysis showed 17% of beds are occupied by T2DM and 3% by T1DM. The overall cost of hospital care for people with diabetes is £5.5 billion/year. Once the normally expected costs including the older age of T2DM hospital attenders are allowed for this fell to £3.0 billion/year or 8% of the total captured secondary care costs. This equates to £560/non-diabetes person compared with £3280/person with T1DM and £1686/person with T2DM. For people with diabetes, the net excess impact on non-elective/emergency work is £1.2 billion with additional estimated diabetes-related accident & emergency attendances at 440 000 costing the NHS £70 million/year. T1DM individuals required five times more secondary care support than non-diabetes individuals. T2DM individuals, even allowing for the age, require twice as much support as non-diabetes individuals. CONCLUSIONS This analysis shows that additional cost of provision of hospital services due to their diabetes comorbidities is £3 billion above that for non-diabetes, and that within this, T1DM has three times as much cost impact as T2DM. We suggest that supporting patients in diabetes management may significantly reduce hospital activity.
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Affiliation(s)
| | - Mark Lunt
- ARC Epidemiology Unit, University of Manchester, Manchester, UK
| | - Mark Davies
- Health Research, Res Consortium, Andover, UK
| | - Mark Livingston
- Clinical Biochemistry, Walsall Healthcare NHS Trust, Walsall, Walsall, UK
| | - Christopher Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, Staffordshire, UK
| | - Anthony Fryer
- Institute for Science & Technology in Medicine, Keele University, Stoke on Trent, UK
| | - Simon George Anderson
- The George Alleyne Chronic Disease Research Centre, University of the West Indies Cave Hill Campus, Bridgetown, Saint Michael, Barbados
| | - Roger Gadsby
- Medical School, University of Warwick, Coventry, Coventry, UK
| | - Martin Gibson
- Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Adrian Heald
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
- Faculty of Biology, Medicine & Health, and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
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Villani M, Earnest A, Smith K, Giannopoulos D, Soldatos G, de Courten B, Zoungas S. Outcomes of people with severe hypoglycaemia requiring prehospital emergency medical services management: a prospective study. Diabetologia 2019; 62:1868-1879. [PMID: 31309262 DOI: 10.1007/s00125-019-4933-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to investigate clinical outcomes following severe hypoglycaemia requiring prehospital emergency medical services (EMS) management. METHODS We carried out a prospective, observational study of adults with diabetes attended by prehospital EMS for management of severe hypoglycaemia between April 2016 and July 2017. Information on precipitants, hospitalisation, length of hospital stay and recurrence was collected at 1 and 3 months following the episode of severe hypoglycaemia. Median and logistic regression models examined predictive factors. RESULTS Five hundred and five adults (61% male, median age 67 years) participated in the study. Fifty-two per cent had type 1 diabetes, 43% type 2 diabetes and 5% were unsure of their diabetes type. Following EMS management of the index episode of severe hypoglycaemia, 50.3% were transported to hospital. Of those transported, 41.3% were admitted to hospital for ongoing management (20.8% of all participants). The following factors predicted hospital admission: older age (OR 1.28 [95% CI 1.02, 1.60] per 10 years), greater number of comorbidities (OR 1.27 [95% CI 1.08, 1.48] per morbidity), moderate-severe injury accompanying the hypoglycaemia (OR 5.24 [95% CI 1.07, 25.8] compared with nil-mild injury) and unknown cause of hypoglycaemia (OR 2.21 [95% CI 1.24, 3.94] compared with known cause). The median (interquartile range) length of hospital stay was 4 (2-7) days. During follow-up, recurrent severe hypoglycaemia attended by prehospital EMS was experienced by 10.7% of participants. Predictive factors of recurrent severe hypoglycaemia in 3 months were decreased HbA1c (OR 1.97 [95% CI 1.27, 3.06] per 10 mmol/mol decrease) and a greater number of antecedent severe hypoglycaemia episodes (OR 1.12 [95% CI 1.03, 1.23] per episode). CONCLUSIONS/INTERPRETATION Following an episode of severe hypoglycaemia managed by EMS, one-fifth of participants required hospital admission, more likely in those with advancing age, increasing comorbidities and injury and one-tenth required EMS again for severe hypoglycaemia in a 3 month period, more likely in those with a greater number of antecedent episodes and lower HbA1c. Knowledge of these factors associated with admission and recurrence provides an opportunity for development of targeted strategies aimed at prevention of severe hypoglycaemia in those most vulnerable.
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Affiliation(s)
- Melanie Villani
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Center for Research and Evaluation, Ambulance Victoria, Blackburn, VIC, Australia
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Center for Research and Evaluation, Ambulance Victoria, Blackburn, VIC, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Frankston, VIC, Australia
| | - Dimitra Giannopoulos
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Georgia Soldatos
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia
| | - Barbora de Courten
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia
| | - Sophia Zoungas
- School of Public Health and Preventive Medicine, Monash University, 3rd Floor, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
- Diabetes and Vascular Medicine Unit, Monash Health, Clayton, VIC, Australia.
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Davis TME, Bruce DG, Finn J, Curtis BH, Barraclough H, Davis WA. Temporal changes in the incidence and predictors of severe hypoglycaemia in type 2 diabetes: The Fremantle Diabetes Study. Diabetes Obes Metab 2019; 21:648-657. [PMID: 30370611 DOI: 10.1111/dom.13568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 10/22/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022]
Abstract
AIM To determine the incidence of severe hypoglycaemia and its predictors in community-based patients with type 2 diabetes studied between 2008 and 2013 compared with those in a cohort of patients with type 2 diabetes from the same geographical area assessed a decade earlier. METHODS We studied 1551 participants (mean age 65.7 years, 51.9% men) with type 2 diabetes from the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). Severe hypoglycaemia was ascertained as that requiring ambulance attendance, emergency department services and/or hospitalization. Cox proportional hazards modelling was used to determine predictors of a first episode of severe hypoglycaemia, and negative binomial regression was used to identify predictors of frequency. RESULTS Sixty-three participants (4.1%) experienced 83 episodes, representing an incidence of 1.34/100 participant-years (95% confidence interval [CI] 1.08 to 1.67; vs 1.67/100 participant-years [95% CI 1.31-2.13] in the Fremantle Diabetes Study Phase I [FDS1]; P = 0.18). Those experiencing severe hypoglycaemia experienced one to four episodes in both cohorts. The independent predictors of incident severe hypoglycaemia in the FDS2 were: older age; higher educational attainment; alcohol consumption; current smoking; sulphonylurea/insulin treatment; prior severe hypoglycaemia; renal impairment; and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP). The same variables except smoking were associated with frequency of severe hypoglycaemia. Most of these risk factors paralleled those in the FDS1, but current smoking and plasma NT-proBNP were novel. CONCLUSIONS The incidence and frequency of severe hypoglycaemia did not change between the Fremantle Diabetes Study phases but novel risk factors, including plasma NT-proBNP, were observed in the FDS2.
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Affiliation(s)
- Timothy M E Davis
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - David G Bruce
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Judith Finn
- School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, Western Australia, Australia
| | - Bradley H Curtis
- Eli Lilly Australia and New Zealand, West Ryde, New South Wales, Australia
| | - Helen Barraclough
- Eli Lilly Australia and New Zealand, West Ryde, New South Wales, Australia
| | - Wendy A Davis
- Medical School, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
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11
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Field BCT, Nayar R, Kilvert A, Baxter M, Hickey J, Cummings M, Bain SC. A retrospective observational study of people with Type 1 diabetes with self-reported severe hypoglycaemia reveals high level of ambulance attendance but low levels of therapy change and specialist intervention. Diabet Med 2018; 35:1223-1231. [PMID: 29766565 DOI: 10.1111/dme.13670] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
Abstract
AIM To evaluate the impact of severe hypoglycaemia on NHS resources and overall glycaemic control in adults with Type 1 diabetes. METHODS An observational, retrospective study of adults (aged ≥ 18 years) with Type 1 diabetes reporting one or more episodes of severe hypoglycaemia during the preceding 24 months in 10 NHS hospital diabetes centres in England and Wales. The primary outcome was healthcare resource utilization associated with severe hypoglycaemia. Secondary outcomes included demographic and clinical characteristics, diabetes control and pathway of care. RESULTS Some 140 episodes of severe hypoglycaemia were reported by 85 people during the 2-year observation period. Ambulances were called in 99 of 140 (71%) episodes and Accident and Emergency attendance occurred in 26 of 140 (19%) episodes, whereas 29 of 140 (21%) episode required no immediate help from healthcare providers. Participants attended a median of 5 (range 0-58) diabetes clinic consultations during the observation period; 13% (70 of 552) of all consultations were severe hypoglycaemia-related. Of the HbA1c measurements recorded closest prior to severe hypoglycaemia (n = 119), only 7 of 119 measurements were < 48 mmol/mol (< 6.5%) and mean HbA1c was 70 (sd 19) mmol/mol (8.5%, sd 1.7%). Some 119 changes to diabetes treatment were recorded during the observation period (median/person 0;, range 0-11), of which 52 of 119 changes (44%) followed severe hypoglycaemic events. CONCLUSIONS We observed a high level of ambulance service intervention but surprisingly low levels of hypoglycaemia follow-up, therapy change and specialist intervention in people self-reporting severe hypoglycaemia. These results suggest there may be important gaps in care pathways for people with Type 1 diabetes self-reporting severe hypoglycaemia.
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Affiliation(s)
- B C T Field
- Endocrinology and Diabetes, East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - R Nayar
- Endocrinology, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - A Kilvert
- Diabetes Centre, Northampton General Hospital, Northampton NHS Trust, Northampton, UK
| | - M Baxter
- Medical Affairs - Diabetes, Sanofi, Guildford, UK
| | | | - M Cummings
- Diabetes Centre, Queen Alexandra Hospital, Portsmouth NHS Trust, Portsmouth, UK
| | - S C Bain
- Diabetes Research Unit Cymru, Swansea University Medical School, Swansea, UK
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