Diabetes mellitus and the St Vincent Declaration. The economic implications

Lifestyle and metabolic risk factors, and diabetes mellitus prevalence in European countries from three waves of the European Health Interview Survey

Population shift towards healthier lifestyles can help reduce the burden of type 2 diabetes mellitus (DM), therefore understanding and monitoring the lifestyle-related risk factors are crucial for setting up effective preventive strategies and disease management. The present study aimed to explore the changes in prevalence of DM and major risk factors including smoking, physical activity, fruit and vegetable consumption, as well as body mass index (BMI) over three waves of European Health Interview Survey, and to investigate the association between risk factors and presence of DM across 11 European Union member states. Poisson regression models were used to evaluate the association between risk factors and DM, adjusted for demographic and socioeconomic variables. The estimated age-standardized prevalence of DM increased from 7.01% in 2009 to 7.96% in 2019, with substantial increase in subgroups with higher BMI and unhealthy lifestyle including physically inactive people, or current smokers. Obesity and overweight and physical inactivity were significantly associated with DM in all survey waves. Our findings underline that obesity prevention and weight loss promotion along with physical activity promotion are the subject of lifestyle interventions to reduce the burden of DM in EU member states.

An Exploratory Research of 18 Years on the Economic Burden of Diabetes for the Romanian National Health Insurance System

The prevalence of diabetes mellitus (DM) rises constantly each year worldwide. Because of that, the funds allocated for the DM treatment have increased over time. Regarding the number of DM cases, Romania is among the top ten countries in Europe. Based on the National Diabetes Programme (NDP), antidiabetic drugs and other expenditures (Self-monitoring blood glucose (SMBG) test, HbA1c, insulin pumps/insulin pumps supplies) are free of charge. This programme has undergone many changes in drugs supply, in the last two decades: re-organizing the NDP, authorization of new molecules with high prices (e.g., SGLT-2 inhibitors, etc.) or new devices (e.g., insulin pumps, etc.) The main purpose of this study is to identify and analyse the impact of the DM costs on the Romanian health budget and to highlight the evolution of these costs. A retrospective longitudinal research on the official data regarding the DM costs from 2000 to 2017 was performed. The DM funds (DMF) were adjusted with the inflation rate. In this period, the average share of DMF in the total funds allocated for health programmes was 21.3 ± 3.4%, and DMF average growth rate was 25.4% (r = 0.488, p = 0.047). On the other hand, the DMF increased more than 14 times, in spite of the patients' number having increased only about 2.5 times. Referring to the structure of DMF, the mean value of the antidiabetic drugs cost was of 96,045 ± 67,889 thousand EUR while for other expenditures it was of 11,530 ± 7922 thousand EUR (r = 0.945, p < 0.001). Between 2008 and 2017, the total DMF was 181,252 ± 74,278 thousand EUR/year. Moreover, the average patients' number was 667,384 ± 94,938 (r = 0.73, p = 0.016), and the cost of treatment was 215 ± 36 EUR/patient/year. Even if the cost is rising, the correct and optimal treatment is a main condition for the diabetic patient's health and for the prevention of its complications, which have multiple socio-economic repercussions.

Effects of Diabetic Complications on Health-Related Quality of Life Impairment in Vietnamese Patients with Type 2 Diabetes

Complications of type 2 diabetes mellitus (T2DM) adversely influence patients' health-related quality of life (HRQOL). This study is aimed at examining HRQOL of T2DM patients, as well as the effects of diabetic complications and comorbidities on HRQOL in this population. This was a hospital-based cross-sectional study on 214 T2DM patients in Hanoi, Vietnam. Short-form 12 version 2 (SF-12v2) and EuroQOL-5 Dimensions-5 Levels (EQ-5D-5L) were employed to measure the HRQOL. The median physical component summary score (PCS), mental component summary score (MCS), and EQ-5D index were 45.6, 56.3, and 0.94, respectively. Having at least one diabetic complication was associated with the reduction of SF-12 scores in social functioning (Diff. = -5.69, 95%CI = -9.24; -2.13), role emotional (Diff. = -1.81, 95%CI = -3.12; -0.51), and MCS (Diff. = -2.55, 95%CI = -5.01; -0.1). Significant decrement of physical functioning, role physical, social functioning, role emotional, and MCS was found in patients having diabetic heart diseases compared to those without diabetic complications. The study revealed that HRQOL of Vietnamese patients with diabetic complications was moderately low, especially in social and mental health perspectives. Strategies to prevent the onset of diabetic complications should be developed as a priority in diabetes management.

Diabetic Kidney Disease: A Syndrome Rather Than a Single Disease

The term "diabetic kidney" has recently been proposed to encompass the various lesions, involving all kidney structures that characterize protean kidney damage in patients with diabetes. While glomerular diseases may follow the stepwise progression that was described several decades ago, the tenet that proteinuria identifies diabetic nephropathy is disputed today and should be limited to glomerular lesions. Improvements in glycemic control may have contributed to a decrease in the prevalence of glomerular lesions, initially described as hallmarks of diabetic nephropathy, and revealed other types of renal damage, mainly related to vasculature and interstitium, and these types usually present with little or no proteinuria. Whilst glomerular damage is the hallmark of microvascular lesions, ischemic nephropathies, renal infarction, and cholesterol emboli syndrome are the result of macrovascular involvement, and the presence of underlying renal damage sets the stage for acute infections and drug-induced kidney injuries. Impairment of the phagocytic response can cause severe and unusual forms of acute and chronic pyelonephritis. It is thus concluded that screening for albuminuria, which is useful for detecting "glomerular diabetic nephropathy", does not identify all potential nephropathies in diabetes patients. As diabetes is a risk factor for all forms of kidney disease, diagnosis in diabetic patients should include the same combination of biochemical, clinical, and imaging tests as employed in non-diabetic subjects, but with the specific consideration that chronic kidney disease (CKD) may develop more rapidly and severely in diabetic patients.

Health-related quality of life in diabetic people with different vascular risk

BACKGROUND

The number of papers on the health related quality of life of patients with DM has grown in recent years but fewer studies have drawn comparisons between diabetic persons and the general population considering different risk groups. The aim of this study is to examine health related quality of life (HRQOL) in people with diabetes mellitus (DM) and to analyze the differences in HRQOL adjusting by vascular risk.

METHODS

The data used in this analysis was obtained from the responses of 15,926 individuals who participated in the 2006 Catalonia Health Survey. Our analysis provides a number of multivariate statistical models designed for studying HRQOL, based on the EQ-5D questionnaire, controlling for demographic factors of survey participants and variables that identify diagnosed illnesses and health problems.

RESULTS

Our findings suggest there is a significant, moderate negative relationship between DM and HRQOL in comparison with non diabetic people (absolute value of the coefficient ranges between -0.04 and -0.054 points on a scale of 1). A further analysis of subgroups reveals that diabetics who have not had vascular risk factors neither vascular diseases do not have a diminished HRQOL when compared to the non-diabetic population in general, when other factors are controlled for. In contrast, a comparison of diabetics and non-diabetics who exhibit vascular disease or risk factors for vascular disease reveals HRQOL is significantly diminished to a greater extent for those with diabetes (between 0.152 and 0.175 points loss when comparing a non-diabetic person with a diabetic with vascular disease). Also, HRQOL in diabetic patients who have additional risk factors or a vascular disease are lower than people non-diabetic who have additional risk factors or a vascular disease. When we focus our analysis to the EQ-5D dimensions, we observe that diabetic persons who are neither at risk for nor have a diagnosed vascular disease are no more likely than non-diabetics to report problems. However, diabetic patients who have additional risk factors for vascular disease or a diagnosed vascular disease are significantly more likely to report moderated or severe problems in 4 of the 5 dimensions of EQ-5D.

CONCLUSIONS

The HRQOL of a person who has diabetes is not necessarily lower than for a non-diabetic. Control of risk factors associated to vascular diseases is a key factor for an enhanced quality of life. Vascular disease or risk factors for vascular disease, on the other hand, are associated with a significantly diminished quality of life for diabetic persons.

Estimated costs of acute hospital care for people with diabetes in the United Kingdom: a routine record linkage study in a large region

AIMS

Diabetes represents a notable burden to health payers. The purpose of this study was to estimate acute hospital care costs of treating people with diabetes with reference to the costs of treating those without.

METHODS

This was a retrospective study. Data from routine hospital practice were available from a large health region (439 000 people), with an estimated prevalence of diabetes of 3.4%. Common records were identified using probabilistic record linkage. Cost estimates were attributed to admissions using healthcare resource group software. Outpatient costs were attributed using published values. Data described are for 2004, and prices in pounds sterling for 2005. Standardised cost ratios were estimated to compare the costs observed in the diabetes population with those expected from the non-diabetic reference population.

RESULTS

The total annual cost of admissions was pound28 944 811 per 100 000 people, of which pound3 650 869 per 100 000 (12.6%) was diabetes related. The standardised cost rate of inpatient treatment was 2.9. The total cost of outpatient attendances was pound6 589 971 per 100 000, of which pound711 431 per 100 000 (10.8%) was diabetes related. The standardised cost ratio for outpatient care was 4.1. The total cost of hospital care for patients with diabetes was pound11 206 986 per 100 000, or 12.3% of acute hospital expenditure. The combined standardised cost ratio was 3.1. Costs of care for inpatient treatment increased from 8.7% of revenue in 1994 to 12.3% in 2004.

CONCLUSIONS

The costs of acute hospital care for treating people with diabetes increased markedly over a decade, and now exceed 12% of revenue.

Physician Process and Patient Outcome Measures for Diabetes Care

BACKGROUND

Optimal diabetes management relies on providers adhering to evidence-based practice guidelines in the processes of care delivery and patients adhering to self-management recommendations to maximize patient outcomes.

PURPOSE

To explore: (1) the degree to which providers adhere to the guidelines; (2) the extent of glycemic, lipid, and blood pressure control in patients with diabetes; and (3) the roles of organizational and patient population characteristics in affecting both provider adherence and patient outcome measures for diabetes.

DESIGN

Secondary data analysis of provider adherence and patient outcome measures from chart reviews, along with surveys of facility quality managers.

SAMPLE

We sampled 109 Veterans Affairs medical centers (VAMCs).

RESULTS

Analyses indicated that provider adherence to diabetes guidelines (ie, hemoglobin A1c, foot, eye, renal, and lipid screens) and patient outcome measures (ie, glycemic, lipid, and hypertension control plus nonsmoking status) are comparable or better in VAMCs than reported elsewhere. VAMCs with higher levels of provider adherence to diabetes guidelines had distinguishing organizational characteristics, including more frequent feedback on diabetes quality of care, designation of a guideline champion, timely implementation of quality-of-care changes, and greater acceptance of guideline applicability. VAMCs with better patient outcome measures for diabetes had more effective communication between physicians and nurses, used educational programs and Grand Rounds presentations to implement the diabetes guidelines, and had an overall patient population that was older and with a smaller percentage of black patients.

CONCLUSIONS

Healthcare organizations can adopt many of the identified organizational characteristics to enhance the delivery of care in their settings.

The prevalence and cost of diabetes in metropolitan France: what trends between 1998 and 2000?*

OBJECTIVES

Our aim was to update available data concerning the prevalence and cost of diabetes in metropolitan France.

METHODS

We performed a retrospective study using patient reimbursement data from all the 128 local health offices (CPAM) in metropolitan France. We selected patients who received reimbursements for an oral hypoglycemic agent or insulin. Thus, 704,423 patients were studied by using 1998 data and 1,145,603 patients were studied by using data from 2000. The expenditures studied represented the total amount reimbursed by national health insurance to diabetic patients. The cost differential which could be attributed to diabetes was calculated by determining the difference between costs generated by diabetic patients to those generated by the rest of the population of the same age.

RESULTS

Between 1998 and 2000, the prevalence of diabetes treated in the population of affiliates covered by the general scheme increased from 2.78% to 2.96%. The total amount paid by the general scheme for care to diabetic patients (related to diabetes or not) was 5.710 billion euros in 2000 compared to 4.862 billion euros in 1998. The amount which can be attributed to diabetes alone can be estimated to be 2.414 billion euros in 2000 compared to 2.021 billion euros in 1998. After considering the impact of the increase in the number of treated diabetics, a modification in the modalities of medical care probably accounts for 183 million euros of the cost increase. Medical equipment (self blood glucose monitoring devices, reagent strips, finger lancets...) accounts for 39.3% (72 million euros) of this cost differential, medications account for 34.4% (63 million euros) and nursing care 16.9% (31 million euros). There was no change in the cost of diabetes with relation to expenses for medical consultations.

[The cost of type 2 diabetes in Spain: the CODE-2 study]

OBJECTIVE

To estimate the cost of providing health care to patients with type 2 diabetes, by differentiating costs of the disease, costs of complications, and other unrelated health costs.

METHODS

Data on resource use were retrospectively collected from medical records and personal interviews in 29 primary health care centers in Spain. Patients were randomly selected from each center's diabetes registry.

RESULTS

We evaluated 1004 patients (561 women) with a mean age of 67.42 years and a mean disease duration of 10.07 years. A total of 50.9% had no complications, 17.7% had macrovascular complications only, 19.5% had microvascular complications only and 11.9% presented both types of complication. The annual health cost per patient was 1305.15 euros. Of this cost, 28.6% (373.27 euros) was directly related to diabetes control, 30.51% (398.20 euros) was related to complications of the disease, and 40.89% (533.68 euros) was unrelated. The mean cost of patients with no complications was 883 euros compared with 1403 euros for those with microvascular complications, 2022 euros for those with macrovascular complications and 2133 euros for patients with both types of complication.

CONCLUSIONS

Because of the high cost of treating type 2 diabetes and its complications, preventive measures should be implemented and control of the disease should be improved to reduce the costs associated with chronic complications.

The outpatient cost of diabetes care in Italian diabetes centers

OBJECTIVE

To provide resource utilization patterns and cost estimates of outpatient care for types I and II diabetes mellitus in Italy, based on retrospectively collected data.

DESIGN

Multicenter, retrospective observational study analyzing individual costs in a sample of patients with diabetes mellitus.

STUDY POPULATION

A total of 2260 patients were stratified into eight groups by type of diabetes, glycemic control, and age.

SETTING

Thirty-five centers for diabetes care in Italy.

RESULTS

The per-patient cost of treatment was [symbol: see text] 136.8 in two months for type I diabetes (N = 592) and [symbol: see text] 123.3 for type II diabetes (N = 1668). Pharmaceutical therapy consisting of antidiabetic drugs only accounted for only 32% to 36% of treatments cost in type I patients and between 13% and 24% in type II. Diagnostic tests accounted for 27% to 42% of treatment costs in patients with both type I and type II diabetes, day-hospital days accounted for 15% to 22% in type I, 25% to 27% in type II, and consultations accounted for 16% to 20% in type I patients and between 17% and 21% in type II diabetes.

CONCLUSION

Despite limitations caused by the short period considered, and considering that in Italy the cost of diabetes has received limited attention, we believe this study presents some interesting information on the burden of diabetes in this country.

Cost and resource utilization for prevention and treatment of foot lesions in a diabetic foot clinic in Belgium

This prospective observational study was carried out to assess the annual preventive and curative treatment costs for diabetic foot problems. Measures of resource use over the 1-year study period were taken for 151 patients whose lesions covered the entire Wagner classification. Treatment was provided under the current protocols of a multidisciplinary team. The 1993 market prices for health services were used to convert units of health service utilization to expenditures by the social insurance system and the patients. The severity of the foot problems determined the medical cost. Preventive care (47 cases), represented an average cost per case of US$ 880 (1US$ 1993=BEF 30.65). Curative care (120 cases), including diagnostic tests, wound dressings, antibiotic therapy, revascularization and off loading techniques resulted in a mean cost of US$ 5227 per ulcer. Care for the 16 most severe wounds and amputations involved hospitalization and surgery at a mean cost per ulcer of US$ 31716. The most important cost contributers were hospitalizations (72%), drugs (11%) and diagnostic examinations (4%). Preventive treatment for diabetic foot problems can represent a significant saving for the social insurance system as well as for the patients.

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention

AIM

To evaluate the role of preventative strategies in reducing foot ulcers in patients with Type 2 diabetes mellitus, both in the general population and those identified to be at a raised risk.

METHOD

A systematic review of interventions to prevent diabetic foot ulcers.

RESULTS

Available studies are generally unsatisfactory in their ability to answer the important questions relating to prevention. However, where people with diabetes receive well-organized and regular care with rapid referral to appropriate specialist multidisciplinary teams when problems (or their precursors) occur, ulcer morbidity can be substantially reduced.

CONCLUSION

Foot ulcers are common in people with diabetes and are costly in terms of both patient morbidity and the use of healthcare resources. Although it is nearly a decade since the St Vincent Declaration called for a marked reduction in morbidity to be achieved through better patient management, available evidence suggests that the process of care in Britain is still very variable in quality. Foot care for people with diabetes must be organized to provide monitoring, education and referral in a manner acceptable to patients and realistic for local healthcare providers.