Costs of clinical events in type 2 diabetes mellitus patients in the Netherlands: A systematic review

Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners

Background

Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines.

Methods

Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence.

Results

Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified.

Conclusions

The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.

Incidence of myocardial infarction in people with diabetes compared to those without diabetes: a systematic review protocol

BACKGROUND

Diabetes mellitus is an established risk factor for acute myocardial infarction (AMI). Incidence of AMI in people with diabetes remains significantly higher than in those without diabetes. However, published data are conflicting, and previous reviews in this field have some limitations regarding the definitions of AMI and source population (general population or people with diabetes as a population at risk) and concerning the statistical presentation of results.

AIMS

To analyse the incidence of AMI in people with diabetes compared to those without diabetes and to investigate time trends.

METHODS

We will perform a systematic literature search in MEDLINE, Embase and LILACS designed by an experienced information scientist. Two review authors will independently screen the abstracts and full texts of all references on the basis of inclusion criteria regarding types of study, types of population and the main outcome. Data extraction and assessment of risk of bias will be undertaken by two review authors working independently. We will assess incidence rate or cumulative incidence and relative risk of AMI comparing populations with and without diabetes.

DISCUSSION

This review will summarise the available data concerning the incidence of AMI in people with and without diabetes and will thus contribute to the assessment and interpretation of the wide variations of incidence, relative risks and time trends of AMI in these populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020145562.

Identifying and delineating the type 2 diabetes population in the Netherlands using an all-payer claims database: characteristics, healthcare utilisation and expenditures

OBJECTIVES

We aimed to identify and delineate the Dutch type 2 diabetes population and the distribution of healthcare utilisation and expenditures across the health system from 2016 to 2018 using an all-payer claims database.

DESIGN

Retrospective observational cohort study based on an all-payer claims database of the Dutch population.

SETTING

The Netherlands.

PARTICIPANTS

The whole Dutch type 2 diabetes population (n=900 522 in 2018), determined based on bundled payment codes for integrated diabetes care and medication use indicating type 2 diabetes.

OUTCOME MEASURES

Annual prevalence of type 2 diabetes, comorbidities and characteristics of the type 2 diabetes population, as well as the distribution of healthcare utilisation and expenditures were analysed descriptively.

RESULTS

In 2018, 900 522 people (6.5% of adults) were identified as having type 2 diabetes. The most common comorbidity in the population was heart disease (12.1%). Additionally, 16.2% and 5.6% of patients received specialised care for microvascular and macrovascular diabetes-related complications, respectively. Most patients with type 2 diabetes received pharmaceutical care (99.1%), medical specialist care (97.0%) and general practitioner consultations (90.5%). In total, €8173 million, 9.4% of total healthcare expenditures, was reimbursed for the type 2 diabetes population. Medical specialist care accounted for the largest share of spending (38.1%), followed by district nursing (12.4%), and pharmaceutical care (11.5%).

CONCLUSIONS

All-payer claims databases can be used to delineate healthcare use: this insight can inform health policy and practice and, thereby, support better decisions to promote long-term sustainability of healthcare systems. The healthcare utilisation of the Dutch type 2 diabetes population is distributed across the health system and utilisation of medical specialist care is high. This is likely to be due to presence of concurrent morbidities and complications. Therefore, a shift from a disease-specific approach to a person-centred and integrated care approach could be beneficial in the treatment of type 2 diabetes.

Energy-restricted interventions are effective for the remission of newly diagnosed type 2 diabetes: A systematic review of the evidence base

BACKGROUND

Type 2 diabetes (T2D) is a chronic, progressive disease. Caloric restriction and subsequent weight loss have been associated with both improvements and, in some cases, remission of T2D.

AIM

To systematically review the safety and effectiveness of calorie-restricted diets on weight change and the remission of T2D.

METHODS

Electronic databases were searched. Intervention trials including a calorie restriction, published between 2010 and 2020, evaluating the remission of T2D (HbA1c <6.5% without diabetes medication) were selected. Risk of bias was assessed.

RESULTS

Eight trials met inclusion criteria including four randomized controlled and four single-arm trials. Three controlled trials found greater remission in the calorie-restricted arm (p < 0.05). A recent diagnosis of diabetes was associated with higher remission rates (75%-80%) with an inverse association between duration of diabetes and rate of remission (r = -0.94). A higher level of remission was observed with greater calorie restriction in non-new diagnosis studies. Greater weight loss was associated with increasing rates of remission (r = 0.83). No reported adverse events led to withdrawal from trials. There was great heterogeneity in study design.

CONCLUSION

Remission rate of T2D achieved through calorie restriction is high and similar to that reported in the bariatric surgery literature. Remission should be the aim at diagnosis and calorie restriction could be used to achieve this. The target weight loss should be >10% body weight in people with obesity. More research is needed into the optimum level of calorie restriction and the support required for long-term remission. National guidelines should be updated to reflect recent evidence.

Budget impact analysis for dapagliflozin in type 2 diabetes in Egypt

Introduction: Type 2 diabetes mellitus (T2DM) is a major health problem in Egypt with a high impact on morbidity, mortality, and healthcare resources. This study evaluated the budget impact and the long-term consequences of dapagliflozin versus other conventional medications, as monotherapy, from both the societal and health insurance perspectives in Egypt.Methods: A static budget impact model was developed to estimate the financial consequences of adopting dapagliflozin on the healthcare payer budget. We measured the direct medical costs of dapagliflozin (new scenario) as monotherapy, compared to metformin, insulin, sulphonylurea, dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinedione, and repaglinide (old scenarios) over a time horizon of 3 years. Myocardial infarction (MI), ischemic stroke, hospitalization for heart failure (HHF), and initiation of renal replacement therapy (RRT) rates were captured from DECLARE TIMI 58 trial. One-way sensitivity analyses were conducted.Results: The budget impact model estimated 2,053,908 patients eligible for treatment with dapagliflozin from a societal perspective and 1,207,698 patients from the health insurance (HI) perspective. The new scenario allows for an initial savings of EGP121 million in the first year, which increased to EGP243 and EGP365 million in the second and third years, respectively. The total cumulative savings from a societal perspective were estimated at EGP731 million. Dapagliflozin allows for savings of EGP71, EGP143, and EGP215 million in the first, second and third years respectively, from the HI perspective, with total cumulative savings of EGP430 million over the 3 years.Conclusion: Treating T2DM patients using dapagliflozin instead of conventional medications, maximizes patients' benefits and decreases total costs due to drug cost offsets from fewer cardiovascular and renal events. The adoption of dapagliflozin is a budget-saving treatment option, resulting in substantial population-level health gains due to reduced event rate and cost savings from the perspective of the national healthcare system.