The direct and indirect cost of diabetes in Italy: a prevalence probabilistic approach

An Analysis of the Distribution of Direct Cost of Diabetes Care in Selected Districts in Italy

INTRODUCTION

This study aims to define the distribution of direct healthcare costs for people with diabetes treated in two healthcare regions in Italy, based on number of comorbidities and treatment regimen.

METHODS

This was a retrospective analysis using data from two local health authority administrative databases (Campania and Umbria) in Italy for the years 2014-2018. Data on hospital care, pharmaceutical and specialist outpatient and laboratory assistance were collected. All people with diabetes in 2014-2018 were identified on the basis of at least one prescription of hypoglycemic drugs (ATC A10), hospitalization with primary or secondary diagnosis of diabetes mellitus (ICD9CM 250.xx) or diabetes exemption code (code 013). Subjects were stratified into three groups according to their pharmaceutical prescriptions during the year: Type 1/type 2 diabetes (T1D/T2D) treated with multiple daily injections with insulin (MDI), type 2 diabetes on basal insulin only (T2D-Basal) and type 2 diabetes not on insulin therapy (T2D-Oral).

RESULTS

We identified 304,779 people with diabetes during the period for which data was obtained. Analysis was undertaken on 288,097 subjects treated with glucose-lowering drugs (13% T1D/T2D-MDI, 13% T2D-Basal, 74% T2D-Oral). Average annual cost per patient for the year 2018 across the total cohort was similar for people with T1D/T2D-MDI and people with T2D-Basal (respectively €2580 and €2254) and significantly lower for T2D-Oral (€1145). Cost of hospitalization was the main driver (47% for T1D/T2D-MDI, 45% for T2D-Basal, 45% for T2D-Oral) followed by drugs/devices (35%, 39%, 43%) and outpatient services (18%, 16%, 12%). Average costs increased considerably with increasing comorbidities: from €459 with diabetes only to €7464 for a patient with four comorbidities. Similar trends were found across all subgroups analysis.

CONCLUSION

Annual cost of treatment for people with diabetes is similar for those treated with MDI or with basal insulin only, with hospitalization being the main cost driver. This indicates that both patient groups should benefit from having access to scanning continuous glucose monitoring (CGM) technology which is known to be associated with significantly reduced hospitalization for acute diabetes events, compared to self-monitored blood glucose (SMBG) testing.

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

Introduction

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

Methodology

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

Results

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

Discussion

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

Rekindling Hope for Remission: Current Impact of Diabetes for Our World's Future Health and Economy

The individual and societal burdens of living with a chronic disease are a global issue. Diabetes directly increases health care costs to manage the disease and the associated complications and indirectly increases the economic burden through long-term complications that hinder the productivity of humans worldwide. Thus, it is crucial to have accurate information on diabetes-related costs and the geographic and global economic impact when planning interventions and future strategies. Health care systems must work with government agencies to plan national-level pre diabetes and diabetes strategies and policies. Public health services must focus on diabetes screening prevention and remission.

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

Background and Aims

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

Methods

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

Results

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

Conclusion

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

Hospital resource utilisation from HPV-related diseases in England: a real-world cost analysis

BACKGROUND AND OBJECTIVE

HPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The objective of this study was to quantify the lifetime economic burden of HPV-related diseases based on hospital resources from the perspective of National Health Service (NHS) in England.

METHODS

Patients' data were extracted, anonymised and aggregated by NHS digital from Hospital Episode Statistics (HES) database of patients admitted in 2015 and followed for three years. Data on hospitalizations were identified according to the International Classification of Diseases (ICD-10 CM). Health Resource Group (HRG) tariffs and National Reference Costs were used to estimate the hospitalization costs of anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia.

RESULTS

A total of 19,296 hospitalized patients were included in the estimation model, (39% was male and 61% female. At admission, the average age was 60 and 50 years old, respectively). Life-time costs per patients diagnosed with oropharyngeal cancer were £16,911 (£17,142 for male and £16,334 for female), penile cancer £12,539, vaginal cancer £12,676, anal cancer £13.773 (£12,590 for male, £14,525 for female). Cervical cancer accounted for £12,721, whereas cervical dysplasia for £3932. Resource used for hospitalized patients with anogenital warts was equal to £872 (£884 and £856 for men and women, respectively). On average, outpatient accounted for 39% of the total lifetime costs.

CONCLUSION

The results of this study highlight that a substantial amount of resources is utilized for the treatment of HPV-related diseases at hospital level in England. These measures have the potential to inform policy decisions to ensure an optimal use of the NHS resources.

La pandemia diabete in Italia

In Italia vivono circa 4 milioni di persone con il diabete e ogni anno ci sono circa 350 mila nuove diagnosi. Le persone con diabete ricevono prescrizioni di farmaci, esami di laboratorio e strumentali e richiedono ricoveri ospedalieri più spesso delle persone senza il diabete. Il diabete è gravato da aumentata mortalità e accorcia la vita, soprattutto nelle persone di media età. La qualità della cura nelle persone con diabete è subottimale, soprattutto fra chi non è assistito nei centri diabetologici (che, peraltro, rappresentano dei luoghi “salvavita”). Il diabete contribuisce fortemente alla spesa sanitaria e comporta ingenti spese, non tutte specificamente sanitarie. Nonostante tutto questo e nonostante leggi nazionali e regionali, documenti di indirizzo nazionali e regionali, PDTA regionali e locali, promesse e proponimenti di varia provenienza, la pandemia diabete non riceve le attenzioni che merita.

Applications for social security benefits related to diabetes in the working age in Italy between 2009 and 2019: a nationwide retrospective cohort study

OBJECTIVES

The aim of this study is to estimate the average number of claims for social security benefits from workers with diabetes-related disability.

DESIGN

Nationwide retrospective cohort study.

SETTING

The database of the Italian Social Security Institute (INPS) was used to analyse the trends and the breakdown of all claims for social security benefit with diabetes as primary diagnosis from 2009 to 2019.

PARTICIPANTS

We selected all the applications with the 250.xx International Classification of Diseases, Ninth Revision-CM diagnosis code from 2009 to 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

The ratio between accepted or rejected claims for both ordinary incapacity benefit (OIB) and disability pension (DP) and total submitted claims over a 10-year period was computed.

RESULTS

From 2009 to 2019, 40 800 applications for social security benefits were filed with diabetes as the principal diagnosis, with an annual increase of 30% per year. Throughout the study decade, there was a higher rate of rejected (67.2%) than accepted (32.8%) applications. Among the accepted requests, most of them (30.7%) were recognised as OIB and the remaining 2.1% were recognised as DP. When related to the total number of claims presented per year, there was a 8.8% decrease of rejected applications, associated with a 20.6% increase of overall acceptance rate. In terms of time trends, the overall rise of submitted requests from 2009 to 2019 resulted in an increase in both rejected (+18%) and accepted (+61% for OIB, +11% for DP) applications. The higher rate of accepted requests was for workers aged 51-60 years, with 52% of admitted applications.

CONCLUSIONS

Between 2009 and 2019, the number of applications for social security benefits due to diabetes in Italy increased significantly, and so did the number of applications approved, mainly represented by the OIBs.

The invisible costs of obstructive sleep apnea (OSA): Systematic review and cost-of-illness analysis

BACKGROUND

Obstructive sleep apnea (OSA) is a risk factor for several diseases and is correlated with other non-medical consequences that increase the disease's clinical and economic burden. However, OSA's impact is highly underestimated, also due to substantial diagnosis gaps.

OBJECTIVE

This study aims at assessing the economic burden of OSA in the adult population in Italy by performing a cost-of-illness analysis with a societal perspective. In particular, we aimed at estimating the magnitude of the burden caused by conditions for which OSA is a proven risk factor.

METHODS

A systematic literature review on systematic reviews and meta-analyses, integrated by expert opinion, was performed to identify all clinical and non-clinical conditions significantly influenced by OSA. Using the Population Attributable Fraction methodology, a portion of their prevalence and costs was attributed to OSA. The total economic burden of OSA for the society was estimated by summing the costs of each condition influenced by the disease, the costs due to OSA's diagnosis and treatment and the economic value of quality of life lost due to OSA's undertreatment.

RESULTS

Twenty-six clinical (e.g., diabetes) and non-clinical (e.g., car accidents) conditions were found to be significantly influenced by OSA, contributing to an economic burden ranging from €10.7 to €32.0 billion/year in Italy. The cost of impaired quality of life due to OSA undertreatment is between €2.8 and €9.0 billion/year. These costs are substantially higher than those currently borne to diagnose and treat OSA (€234 million/year).

CONCLUSIONS

This study demonstrates that the economic burden due to OSA is substantial, also due to low diagnosis and treatment rates. Providing reliable estimates of the economic impact of OSA at a societal level may increase awareness of the disease burden and help to guide evidence-based policies and prioritisation for healthcare, ultimately ensuring appropriate diagnostic and therapeutic pathways for patients.

The economic burden of obesity in Italy: a cost-of-illness study

BACKGROUND

Obesity is a complex health disorder that significantly increases the risk of several chronic diseases, and it has been associated with a 5-20-year decrease in life expectancy. The prevalence of obesity is increasing steadily worldwide and Italy follows this trend with an increase of almost 30% in the adult obese population in the last 3 decades. Previous studies estimated that 2-4% of the total health expenditure in Europe is attributed to obesity and it is projected to double by 2050. Currently, there is a lack of sufficient knowledge on the burden of obesity in Italy and most relevant estimates are derived from international studies. The aim of this study is to estimate the direct and indirect costs of obesity in Italy, taking 2020 as the reference year.

METHODS

Based on data collected from the literature, a quantitative cost-of-illness (COI) study was performed from a societal perspective focussing on the adult obese population (Body Mass Index (BMI) ≥ 30 kg/m²) in Italy.

RESULTS

The study indicated that the total costs attributable to obesity in Italy amounted to €13.34 billion in 2020 (95% credible interval: €8.99 billion < µ < €17.80 billion). Direct costs were €7.89 billion, with cardiovascular diseases (CVDs) having the highest impact on costs (€6.66 billion), followed by diabetes (€0.65 billion), cancer (€0.33 billion), and bariatric surgery (€0.24 billion). Indirect costs amounted to €5.45 billion, with almost equal contribution of absenteeism (€2.62 billion) and presenteeism (€2.83 billion).

CONCLUSIONS

Obesity is associated with high direct and indirect costs, and cost-effective prevention programmes are deemed fundamental to contain this public health threat in Italy.

Human papillomavirus in Italy: retrospective cohort analysis and preliminary vaccination effect from real-world data

INTRODUCTION

The objective of this study was to estimate the lifetime risk of hospitalization associated with all major human papillomavirus (HPV)-related diseases in Italy. Moreover, a preliminary vaccination effect was also performed.

METHODS

A retrospective, nonrandomized, observational study was developed based on patients hospitalized between 2006 and 2018 in Italy. All hospitalizations were identified through administrative archives, according to the International Classification of Diseases (ICD-9 CM). Information related to the hospital discharges of all accredited public and private hospitals, both for ordinary and day care regimes, was taken into account. We included hospitalizations related to resident patients presenting one of the ICD-9-CM codes as primary or secondary diagnosis: genital warts (GW); 'cervical intraepithelial neoplasia (CIN)' (067.32-067.33); 'condyloma acuminatum' (078.11); 'anal cancers' (AC) (154.2-154.8); oropharyngeal cancers (OC): 'oropharyngeal cancer'(146.0-146.9) and 'head, face and neck cancers' (171.0); genital cancers (GC): 'penis cancer' (187.1-187.9) and 'cervical cancer' (180.0-180.9). Data were stratified by birth year and divided into two groups: (a) cohort born before 1996 (not vaccinable) and (b) cohort born after 1997 (vaccinable-first cohort that could be vaccinated at the beginning of immunization schedule in girls since 2008 in Italy). Disease-specific hospitalization risks for both groups were estimated by sex, year and age.

RESULTS

Epidemiological data demonstrate that the peak hospitalization risk occurred at 24-26 years of age for GW (both male and female); 33-41 and 47-54 years for AC males and females, respectively; 53-59 and 52-58 years for OC males and females, respectively; and 54-60 and 39-46 years for GC males and females, respectively. Focusing on GW and GC, vaccinable females demonstrate a significant reduction in hospitalization risks (- 54% on average) compared to nonvaccinable females until 21 years of age (maximum follow-up available for girls born after 1997). Comparing the same birth cohort of males, no differences in hospitalization risk were found.

CONCLUSIONS

These results support the importance of primary prevention strategies in Italy and suggest that increased VCRs and time of observation (genital cancers for which vaccination is highly effective, have a latency of some decades) will provide useful information for decision-makers.

Evaluating Effectiveness of Outpatient Monitoring in Type 2 Diabetes: The One-Year Experience in an Italian Group of Primary Care

Nowadays, chronic disease management is the primary challenge of the healthcare system. From 2015, in the Veneto region (Italy), patients with a diagnosis of type 2 diabetes mellitus (T2DM) have been included in the diagnostic-therapeutic pathway (PDTA) program, and their clinical condition has been continuously monitored. The aim of this retrospective study is to determine the effectiveness of PDTA intervention, alone or in combination with a specialized one, in subjects with diagnosis of T2DM. Clinical and behavioral characteristics were collected at baseline and after 1 year of follow-up. Two subgroups were considered: subjects enrolled in PDTA only and subjects enrolled in both the PDTA program and in the care plan proposed by the specialized medical center (CAD group). Longitudinal analysis showed a relevant positive effect of time on diastolic blood pressure, while CAD enrollment appears to be related to higher levels of glycated hemoglobin. When included together in the same model, interaction between time and CAD covariates results in completely nonsignificant effects. As long-term management of chronic disorders, such as T2DM, is often difficult due to disease characteristics and problems in healthcare organization, monitoring programs, such as PDTA, and specialized care programs, such as CAD, do not show a clinically relevant effect in the first year of follow-up. Therefore, they should be analyzed over a longer period. However, they should also carefully consider the need for adequate tools for data collection and sharing, in addition to the context of application, patient expectations and the need for a long-term educational program.

Effects of Urtica dioica on Metabolic Profiles in Type 2 Diabetes: A Systematic Review and Meta-Analysis of Clinical Trials

BACKGROUND

Several studies have investigated the effect of Urtica dioica (UD) consumption on metabolic profiles in patients with type 2 diabetes mellitus (T2DM); however, the findings are inconsistent. This systematic review and meta-analysis of clinical trials was performed to summarize the evidence of the effects of UD consumption on metabolic profiles in patients with T2DM.

METHODS

Eligible studies were retrieved from searches of PubMed, Embase, Scopus, Web of Science, Cochrane Library and Google Scholar databases until December 2019. Cochran (Q) and I-square statistics were used to examine heterogeneity across included clinical trials. Data were pooled by using fixed-effect or random-effects model and expressed as weighted mean difference (WMD) and 95% confidence interval (CI).

RESULTS

Among 1485 citations, thirteen clinical trials were found to be eligible for the current meta-analysis. UD consumption significantly decreased levels of fasting blood glucose (FBG) (WMD= -17.17 mg/dl, 95% CI: -26.60, -7.73, I2= 93.2%), hemoglobin A1c (HbA1c) (WMD= -0.93, 95% CI: -1.66, -0.17, I2= 75.0%), C-reactive protein (CRP) (WMD= -1.09 mg/dl, 95% CI: -1.64, -0.53, I2= 0.0%), triglycerides (WMD = -26.94 mg/dl, 95 % CI = [-52.07, -1.82], P = 0.03, I2 = 90.0%), systolic blood pressure (SBP) (WMD= -5.03 mmHg, 95% CI = -8.15, -1.91, I2= 0.0%) in comparison to the control groups. UD consumption did not significantly change serum levels of insulin (WMD= 1.07 μU/ml, 95% CI: -1.59, 3.73, I2= 63.5%), total-cholesterol (WMD= -6.39 mg/dl, 95% CI: -13.84, 1.05, I2= 0.0%), LDL-cholesterol (LDL-C) (WMD= -1.30 mg/dl, 95% CI: -9.95, 7.35, I2= 66.1%), HDL-cholesterol (HDL-C) (WMD= 6.95 mg/dl, 95% CI: -0.14, 14.03, I2= 95.4%), body max index (BMI) (WMD= -0.16 kg/m2, 95% CI: -1.77, 1.44, I2= 0.0%), and diastolic blood pressure (DBP) (WMD= -1.35 mmHg, 95% CI: -2.86, 0.17, I2= 0.0%) among patients with T2DM.

CONCLUSION

UD consumption may result in an improvement in levels of FBS, HbA1c, CRP, triglycerides and SBP, but did not affect on levels of insulin, total-, LDL-, and HDL-cholesterol, BMI, and DBP in patients with T2DM.

A Deep Learning Approach to Predict Diabetes' Cardiovascular Complications From Administrative Claims

People with diabetes require lifelong access to healthcare services to delay the onset of complications. Their disease management processes generate great volumes of data across several domains, from clinical to administrative. Difficulties in accessing and processing these data hinder their secondary use in an institutional setting, even for highly desirable applications, such as the prediction of cardiovascular disease, the main driver of excess mortality in diabetes. Hence, in the present work, we propose a deep learning model for the prediction of major adverse cardiovascular events (MACE), developed and validated using the administrative claims of 214,676 diabetic patients of the Veneto region, in North East Italy. Specifically, we use a year of pharmacy and hospitalisation claims, together with basic patient's information, to predict the 4P-MACE composite endpoint, i.e., the first occurrence of death, heart failure, myocardial infarction, or stroke, with a variable prediction horizon of 1 to 5 years. Adapting to the time-to-event nature of this task, we cast our problem as a multi-outcome (4P-MACE and components), multi-label (1 to 5 years) classification task with a custom loss to account for the effect of censoring. Our model, purposefully specified to minimise data preparation costs, exhibits satisfactory performance in predicting 4P-MACE at all prediction horizons: AUROC from 0.812 (C.I.: 0.797 - 0.827) to 0.792 (C.I.: 0.781 - 0.802); C-index from 0.802 (C.I.: 0.788 - 0.816) to 0.770 (C.I.: 0.761 - 0.779). Components' prediction performance is also adequate, ranging from death's 0.877 1-year AUROC to stroke's 0.689 5-year AUROC.

The financial burden of non-communicable diseases in the European Union: a systematic review

BACKGROUND

Non-communicable diseases (NCDs) impose a significant and growing burden on the health care system and overall economy of developed (and developing) countries. Nevertheless, an up-to-date assessment of this cost for the European Union (EU) is missing from the literature. Such an analysis could however have an important impact by motivating policymakers and by informing effective public health policies.

METHODS

Following the PRISMA protocol, we conduct a systematic review of electronic databases (PubMed/Medline, Embase, Web of Science Core Collection) and collect scientific articles that assess the direct (health care-related) and indirect (economic) costs of four major NCDs (cardiovascular disease, cancer, type-2 diabetes mellitus and chronic respiratory disease) in the EU, between 2008 and 2018. Data quality was assessed through the Newcastle-Ottawa Scale.

RESULTS

We find 28 studies that match our criteria for further analysis. From our review, we conclude that the four major NCDs in the EU claim a significant share of the total health care budget (at least 25% of health spending) and they impose an important economic loss (almost 2% of gross domestic product).

CONCLUSION

The NCD burden forms a public health risk with a high financial impact; it puts significant pressure on current health care and economic systems, as shown by our analysis. We identify a further need for cost analyses of NCDs, in particular on the impact of comorbidities and other complications. Aside from cost estimations, future research should focus on assessing the mix of public health policies that will be most effective in tackling the NCD burden.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical burden of diabetes in Italy in 2018: a look at a systemic disease from the ARNO Diabetes Observatory

INTRODUCTION

Diabetes is a highly prevalent disease worldwide and represents a challenge for patients and healthcare systems. This population-based study evaluated diabetes burden in Italy in 2018 by assessing all aspects of outpatient and hospital care.

RESEARCH DESIGN AND METHODS

We investigated data of 11 300 750 residents in local health districts contributing to ARNO Diabetes Observatory (~20% of Italian inhabitants). All administrative healthcare claims were analyzed to gather information on access to medical resources. Subjects with diabetes, identified by antihyperglycemic drug prescriptions, disease-specific copayment exemption and hospital discharge codes, were compared with age, sex and residency-matched non-diabetic individuals.

RESULTS

We identified 697 208 subjects with ascertained diabetes, yielding a prevalence of 6.2% (6.5% in men vs 5.9% in women, p<0.001). Age was 69±15 (mean±SD). As compared with non-diabetic subjects, patients with diabetes received more prescriptions of any drugs (+30%, p<0.001), laboratory tests, radiologic exams and outpatient specialist consultations (+20%, p<0.001) and were hospitalized more frequently (+86%, p<0.001), with a longer stay (+1.4 days, p<0.001). Although cardiovascular diseases accounted for many hospital discharge diagnoses, virtually all diseases contributed to the higher rate of hospital admissions in diabetic subjects (235 vs 99 per 1000 person-years, p<0.001). Healthcare costs were >2-fold higher in subjects with diabetes, mainly driven by hospitalizations and outpatient care related to chronic complications rather than to glucose-lowering drugs, diabetes-specific devices, or metabolic monitoring.

CONCLUSIONS

The burden of diabetes in Italy is particularly heavy and, as a systemic disease, it includes all aspects of clinical medicine, with consequent high expenses in all areas of healthcare.

The burden of type 2 diabetes in Europe: Current and future aspects of insulin treatment from patient and healthcare spending perspectives

Due to the progressive nature of type 2 diabetes (T2DM), initiation of insulin therapy is very likely in the disease continuum. This article aims at highlighting the current situation with regard to insulin therapy in people with T2DM in Europe and at presenting the associated unmet need. Challenges for both people with T2DM and healthcare professionals include clinical inertia also derived from fear of hypoglycaemia, weight gain and injections as well as increased need for a comprehensive diabetes management. We compare national and international guidelines and recommendations for the initiation and intensification of insulin therapy with the real-world situation in six European countries, demonstrating that glycaemic targets are only met in a minority of people with T2DM on insulin therapy. Furthermore, this work evaluates currently recorded numbers of people with T2DM treated with insulin in Europe, the proportion not achieving the stated glycaemic targets and thus in need to enhance insulin therapy e.g. by a change in means of insulin delivery including, but not limited to, insulin pens, wearable mealtime insulin delivery patches, patch pumps, and conventional insulin pumps with continuous subcutaneous insulin infusion.

Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis

BACKGROUND AND OBJECTIVES

Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients' heterogeneity is rarely taken into account. The aim of this study was to stratify patients with type 2 diabetes into homogeneous cost groups based on demographic and clinical characteristics.

METHODS

We conducted a retrospective cost-of-illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of the regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis.

RESULTS

The study population consisted of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified ten patient subgroups with different costs, ranging from a median of €483 to €39,578. The two subgroups with highest costs comprised dialysis patients, and the largest subgroup (57.9%) comprised patients aged ≥ 65 years without renal, cardiovascular and cerebrovascular complications.

CONCLUSIONS

Classification of patients into homogeneous cost subgroups can be used to improve the management of, and budget allocation for, patients with type 2 diabetes.

Detecting Undiagnosed Diabetes: Proof-of-Concept Based on the Health-Information Exchange System of the Veneto Region (North-East Italy)

Diabetes is a chronic illness characterised by elevated blood glucose levels, driving excess mortality. Its prompt detection and accurate management are critical for delaying complications. Nevertheless, diabetes can remain undiagnosed for years from the onset. The identification of undiagnosed diabetes is a public health priority: in Italy, it is estimated that up to 30% of diabetes cases remain undetected, i.e., that ~1.8 million citizens may be unaware they need medical help. Sometimes, this happens even though these subjects undergo routine or emergency check-ups. Veneto, a region in North-East Italy with 4.9 million residents, implements a regional Health Information Exchange system (rHIE) to collect healthcare data, including laboratory reports, and integrate them with administrative claims. Their combination may be instrumental in finding otherwise undetected cases of diabetes. On the one hand, known diabetic patients should have disease management-generated claims; on the other, laboratory test results can be independently evaluated against diagnostic criteria. In the present work, we examined the anonymised claims and laboratory data, extracted from the rHIE, of 23,376 citizens of the Veneto region. We compared their exemptions, diabetes-related hospitalisation discharge codes, and antidiabetic drugs between 2012 and 2018 to the results of their fasting glucose, glycated haemoglobin, and oral glucose tolerance tests in 2017-2018. We identified 1,407 (6.02%) subjects who, according to administrative claims, appear to be free from diabetes, but met at least one laboratory diagnostic criterion. Such a discrepancy suggests that these people may be undiagnosed diabetic patients. To the best of our knowledge, this is the first proof of concept of an automatic system for the detection of undiagnosed diabetes in Italy. Its full integration in the rHIE and its consequent capillary application could potentially reveal thousands of hidden cases throughout Veneto.

Diabetes diagnosis from administrative claims and estimation of the true prevalence of diabetes among 4.2 million individuals of the Veneto region (North East Italy)

BACKGROUND AND AIMS

Diabetes can often remain undiagnosed or unregistered in administrative databases long after its onset, even when laboratory test results meet diagnostic criteria. In the present work, we analyse healthcare data of the Veneto Region, North East Italy, with the aims of: (i) developing an algorithm for the identification of diabetes from administrative claims (4,236,007 citizens), (ii) assessing its reliability by comparing its performance with the gold standard clinical diagnosis from a clinical database (7525 patients), (iii) combining the algorithm and the laboratory data of the regional Health Information Exchange (rHIE) system (543,520 subjects) to identify undiagnosed diabetes, and (iv) providing a credible estimate of the true prevalence of diabetes in Veneto.

METHODS AND RESULTS

The proposed algorithm for the identification of diabetes was fed by administrative data related to drug dispensations, outpatient visits, and hospitalisations. Evaluated against a clinical database, the algorithm achieved 95.7% sensitivity, 87.9% specificity, and 97.6% precision. To identify possible cases of undiagnosed diabetes, we applied standard diagnostic criteria to the laboratory test results of the subjects who, according to the algorithm, had no diabetes-related claims. Using a simplified probabilistic model, we corrected our claims-based estimate of known diabetes (6.17% prevalence; 261,303 cases) to account for undiagnosed cases, yielding an estimated total prevalence of 7.50%.

CONCLUSION

We herein validated an algorithm for the diagnosis of diabetes using administrative claims against the clinical diagnosis. Together with rHIE laboratory data, this allowed to identify possibly undiagnosed diabetes and estimate the true prevalence of diabetes in Veneto.

Type 2 diabetes and healthcare resource utilisation in the Kingdom of Bahrain

Background

Type 2 diabetes is a growing health challenge in the Kingdom of Bahrain, and the disease exerts significant pressure on the healthcare system. The aim of this study was to assess the annual costs and understand the drivers of those costs in the country.

Methods

A sample of 628 patients diagnosed with type 2 diabetes were randomly selected from primary healthcare diabetes clinics, and the direct medical and indirect costs due to type 2 diabetes were analysed for a one-year period. The study used patients’ medical records, interviews and standardised frequency questionnaires to obtain data on demographic and clinical characteristics, complication status, treatment profile, healthcare resource utilisation and absenteeism due to diabetes. The indirect costs were estimated by using the human capital approach. The direct medical and indirect costs attributable to type 2 diabetes were extrapolated to the type 2 diabetes population in Bahrain.

Results

In 2015, the total direct medical cost of type 2 diabetes was 104.7 million Bahraini dinars (BHD), or 277.9 million US dollars (USD), and the average unit cost per person with type 2 diabetes (1162 BHD, or 3084 USD) was more than three times higher than for a person without the condition (372 BHD, or 987 USD). The healthcare costs for patients with both micro- and macrovascular complications were more than three times higher than for patients without complications. Thus, 9% of the patients consumed 21% of the treatment costs due to complications. Complications often lead to hospital admission, and 20% of the patients consumed almost 60% of the healthcare costs attributable to type 2 diabetes due to hospital admissions. The indirect cost due to absenteeism was 1.23 million BHD (3.26 million USD).

Conclusion

Type 2 diabetes exerts significant pressure on Bahrain’s healthcare system – primarily due to costly diabetes-related complications. It is therefore important to optimise the management and control of type 2 diabetes, thereby reducing the risk of disabling and expensive complications.

Impact of type 2 diabetes on health expenditure: estimation based on individual administrative data

Only limited data are available in France on the incidence and health expenditure of type 2 diabetes. The objective of this study, based on national health insurance administrative database, is to describe the expenditure reimbursed to patients newly treated for type 2 diabetes and the proportion of expenditure attributable to diabetes. The study is conducted over a 6-year period from 2008, the year of incidence of treated diabetes, to 2014. Type 2 diabetic patients aged 45 years and older are identified on the basis of their drug consumption. To estimate expenditure attributable to diabetes, a matched control group is selected among more than 13 million beneficiaries over 44 years old not taking antidiabetic treatment. The expenditure attributable to diabetes is estimated by two methods: simple comparison of reimbursed health expenditure between both groups, and a difference-in-differences method including control variables. The cohort of incident type 2 diabetic patients comprises 170,013 patients in 2008. Mean global reimbursed expenditure is €4700 per patient in 2008 and €5500 in 2015. Expenditure attributable to diabetes, estimated by direct comparison with controls, is €1500 in the first year. We, thus, observe a decrease in the following year due to decreased hospitalisations, and then expenditure increase by an average of 7% per year to reach €1900 in the eighth year after the initiation of treatment.

Excess Burden of Mental Illness and Hospitalization in Young-Onset Type 2 Diabetes: A Population-Based Cohort Study

BACKGROUND

Type 2 diabetes (T2D) increases hospitalization risk. Young-onset T2D (YOD) (defined as onset before age 40 years) is associated with excess morbidity and mortality, but its effect on hospitalizations is unknown.

OBJECTIVE

To determine hospitalization rates among persons with YOD and to examine the effect of age at onset on hospitalization risk.

DESIGN

Prospective cohort study.

SETTING

Hong Kong.

PARTICIPANTS

Adults aged 20 to 75 years in population-based (2002 to 2014; n = 422 908) and registry-based (2000 to 2014; n = 20 886) T2D cohorts.

MEASUREMENTS

All-cause and cause-specific hospitalization rates. Negative binomial regression models estimated effect of age at onset on hospitalization rate and cumulative bed-days from onset to age 75 years for YOD.

RESULTS

Patients with YOD had the highest hospitalization rates by attained age. In the registry cohort, 36.8% of YOD bed-days before age 40 years were due to mental illness. The adjusted rate ratios showed increased hospitalization in YOD versus usual-onset T2D (onset at age ≥40 years) (all-cause, 1.8 [95% CI, 1.7 to 2.0]; renal, 6.7 [CI, 4.2 to 10.6]; diabetes, 3.7 [CI, 3.0 to 4.6]; cardiovascular, 2.1 [CI, 1.8 to 2.5]; infection, 1.7 [CI, 1.4 to 2.1]; P < 0.001 for all). Models estimated that intensified risk factor control in YOD (hemoglobin A1c level <6.2%, systolic blood pressure <120 mm Hg, low-density lipoprotein cholesterol level <2.0 mmol/L [<77.3 mg/dL], triglyceride level <1.3 mmol/L [<115.1 mg/dL], waist circumference of 85 cm [men] or 80 cm [women], and smoking cessation) was associated with a one-third reduction in cumulative bed-days from onset to age 75 years (97 to 65 bed-days).

LIMITATION

Possible residual confounding.

CONCLUSION

Adults with YOD have excess hospitalizations across their lifespan compared with persons with usual-onset T2D, including an unexpectedly large burden of mental illness in young adulthood. Efforts to prevent YOD and intensify cardiometabolic risk factor control while focusing on mental health are urgently needed.

PRIMARY FUNDING SOURCE

Asia Diabetes Foundation.

Evaluation of Health Status of Type 2 Diabetes Outpatients Receiving Care in a Tertiary Hospital in Nigeria

OBJECTIVES

The aim of this study was to determine the health status of type 2 diabetes patients in a Nigerian tertiary hospital, and examine the sociodemographic and clinical variables that predicted the health status of type 2 diabetes patients in terms of utility valuations and EuroQol Visual Analogue Scale (EQ-VAS) score.

METHODS

This was a cross-sectional study of 147 diabetes patients attending the University of Nigeria Teaching Hospital, Enugu State, Nigeria. The EQ-5D-5L instrument, version 2.1, was used to evaluate patients' self-reported health status, and patients who gave informed consent completed the questionnaire while waiting to see a doctor. Descriptive and multiple linear regression analyses were performed using SPSS version 20.

RESULTS

Overall, 147 patients participated in this study, with a mean age (± standard deviation) of 56.7 years (± 10.33). Over half of the respondents were females (55.1%) and more than half were older than 60 years of age. The mean EQ-VAS and utility valuations of respondents were 72.59 ± 10.51 and 0.72 ± 0.13, respectively. The age of respondents independently and significantly predicted EQ-VAS by -2.659 per year, while the age of respondents, level of education, duration of diabetes, and presence of other illnesses independently and significantly predicted utility valuations by -0.020 per year, +0.029 per level of education, -0.008 per year, and -0.044 per illness, respectively. Less than 39% of patients experienced no problems for each of the dimensions, except self-care (68%).

CONCLUSION

The results of this study revealed a relatively low health status among type 2 diabetic patients in Nigeria. Old age, duration of diabetes and the presence of other illnesses were major contributors to the negative impact on health status, while a higher level of education contributed positively to health status. Adequate family support, as well as regular and effective patient counseling and education, may be worthwhile.

Cost-of-Illness Analysis of Type 2 Diabetes Mellitus in the Russian Federation: Results from Russian multicenter observational pharmacoepidemiologic study of diabetes care for patients with type 2 diabetes mellitus (FORSIGHT-Т2DM)

Background: Cost-of-Illness Analysis (COI) constitutes the basis for the decision-making process on the budget and allocation in a modern health care system. Considering the wide prevalence of type 2 diabetes mellitus (Т2DM), it is important to perform COI in the Russian Federation (RF). Aim: The aim of the secondary objective FORSIGHT-Т2DM study was to conduct Cost-of-Illness Analysis (COI) of Т2DM in the Russian Federation in relation to taking into consideration the presence of complications and concomitant diseases. Materials and methods: COI of Т2DM was performed using the data obtained in Russian multicenter observational, pharmacoepidemiologic cross-sectional study of diabetes care for assessing routine healthcare pattern of T2DM in the Russian Federation (FORSIGHT-Т2DM). Information for each patient was collected from primary medical records and By asking patients to fill out a questionnaire. Total costs were calculated as the sum of direct medical costs (DCm), direct non-medical costs (DCn) and indirect costs (IC). Results: The final analysis included data from 2014 patients with T2DM residing in 45 cities of RF. Total direct medical costs (DCm) of treating Т2DM and its complications and comorbidities amounted to 105 337 rubles ($2742) per patient per year; direct non-medical costs (DCn) amounted to 24 518 rubles ($638) per patient per year; indirect costs (IC) amounted to 149 754 rubles ($3898) per patient per year. The total cost of T2DM in RF in 2014 year amounted to 279 609 rubles ($7278) per patient. The total cost of T2DM in RF in 2014 amounted to 279 609 rubles per patient. Conclusions: More than half (53,5%) of the total cost of T2DM is the loss of GDP due to patients disability. The DCm constitute 37,7% of the total cost of the disease, of which 57% is spent on treatment of T2DM complications and concomitant diseases, while only 10% is spent on glucose-lowering therapies.

Economic burden of schizophrenia in Italy: a probabilistic cost of illness analysis

OBJECTIVES

Schizophrenia is a chronic, debilitating psychiatric disease with highly variable treatment pathways and consequent economic impacts on resource utilisation. The aim of the study was to estimate the economic burden of schizophrenia in Italy for both the societal and Italian National Healthcare perspective.

METHODS

A probabilistic cost of illness model was applied. A systematic literature review was carried out to identify epidemiological and economic data. Direct costs were calculated in terms of drugs, hospitalisations, specialist services, residential and semiresidential facilities. Indirect costs were calculated on the basis of patients' and caregivers' loss of productivity. In addition, the impact of disability compensation was taken into account using a database from the Italian National Social Security Institute -Italy (INPS).

RESULTS

Overall, 303 913 prevalent patients with schizophrenia were estimated. Of these, 212 739 (70%) were diagnosed and 175 382 (82%) were treated with antipsychotics. The total economic burden was estimated at €2.7 billion (95% CI €1771.93 to €3988.65), 50.5% due to indirect costs and 49.5% to direct costs. Drugs corresponded to 10% of direct costs and hospitalisations (including residential and semiresidential facilities) accounted for 81%.

CONCLUSIONS

This study highlighted that indirect costs and hospitalisations (including residential and semiresidential facilities) play a major role within the expenses associated with schizophrenia in Italy, and this may be considered as a tool for public decision-makers.

Economic burden of the management of metastatic castrate-resistant prostate cancer in Italy: a cost of illness study

Background

Prostate cancer (PCa) accounts for 20% of all cancers in subjects over 50 years in Italy. The majority of patients with PCa present with localized disease at the time of diagnosis, but many patients develop recurrent metastatic disease after treatment with curative intent. Androgen deprivation therapy is the standard of care for metastatic PCa patients; unfortunately, most of them progress to castrate-resistant prostate cancer (CRPC) within 5 years. Metastatic CRPC (mCRPC) heavily affects patients in terms of quality of life, side effects, and survival, and greatly impacts economic costs. The approval of new effective agents in recent years, including cabazitaxel, abiraterone acetate, enzalutamide, and radium-223, has dramatically changed patient management.

Materials and methods

Here, we aimed to estimate the current costs of illness of mCRPC in Italy. All patients affected by mCRPC and treated with a single agent in an annual time horizon were considered. Therefore, the analysis was not focused on the management pathway of single patients through different lines of treatment. Direct medical costs referred to therapy, adverse event management, and skeletal-related event management were analyzed. A bottom-up approach was used to estimate the resource consumption: through national guidelines and expert opinions, the mean cost per patient was estimated and then multiplied by the total number of patients diagnosed with mCRPC.

Results

Direct medical costs ranged from €196.5 million to €228.0 million, representing ~0.2% of the financing of the Italian National Health Service in 2016. The main cost driver was the cost of treatment, which represented more than 77% of the overall economic burden.

Conclusion

Our analysis, reflective of real clinical practice, shows for the first time the high economic cost of mCRPC in Italy.

Cost-consequence analysis of sitagliptin versus sulfonylureas as add-on therapy for the treatment of diabetic patients in Italy

Objective

Diabetes mellitus is a chronic disease related to a significant impact in both epidemiologic and economic terms. In Italy, around 3.6 million people are affected by diabetes and this number is expected to increase significantly in the next few years. As recommended by current national and international guidelines, metformin (Met) is prescribed as first-line pharmacological treatment, and many pharmacological alternatives are available for patients uncontrolled with Met monotherapy. Despite the availability of many innovative oral antidiabetic drugs (OADs), such as dipeptidyl peptidase 4 inhibitors (DPP4-i) and its first-in-class sitagliptin (SITA), which entered the Italian market in the last 10 years, their usage is consistently lower than traditional drugs such as sulfonylureas (SUs). In fact, due to higher acquisition costs, the prescription of innovative OADs in Italy is restricted to specialist, resulting in a prominent usage of traditional OAD that can be prescribed also by general practitioners (GPs). A cost consequence analysis (CCA) was performed in order to compare SITA with SU, as second-line therapy in add-on to Met, in terms of costs and related clinical events over 36 months.

Methods

A CCA was conducted on a hypothetical cohort of 100,000 type 2 diabetes mellitus (T2DM) patients uncontrolled with Met monotherapy, from both the Italian National Health Service (INHS) and societal perspective. Therefore, both direct (drugs, self-monitoring, hypoglycemia, major cardiovascular events [MACEs], and switch to insulin) and indirect costs (expressed in terms of productivity losses) were evaluated. Clinical and economic data were collected through Italian national tariffs, literature, and experts' opinions. Three expert clinicians finally validated data inputs. To assess robustness of base case results, a one-way sensitivity analysis (OWSA) and a conservative scenario analysis - excluding MACEs - were carried out.

Results

In the base case analysis, the higher drug costs related to SITA were offset by other management costs (ie, lower use of devices for glycemia self-monitoring, lower incidence of hypoglycemia and MACE, and delay to insulin switch). As a result, the economic evaluation showed that, compared to SU, SITA was cost saving from both societal (-€61,217,723) and INHS (-€51,846,442) perspectives over 3 years as add-on to Met. The base case results were also confirmed by the scenario analysis and by the OWSA performed on the key parameters. The adoption of SITA, in a cohort of 100,000 diabetes patients, would avoid 26,882 non-severe hypoglycemic events, 6,528 severe hypoglycemic events, and 1,562 MACEs.

Conclusion

This analysis suggests that, compared to SU, SITA could be a sustainable and cost-saving alternative for the management of T2DM patients uncontrolled with Met monotherapy from both clinical and economic perspectives.

Economic burden of diverticular disease: An observational analysis based on real world data from an Italian region

INTRODUCTION

Diverticular disease (DD), a herniation of the colonic mucosa through the muscle layer, covers a wide variety of conditions associated with the presence of diverticula in the colon. The most serious form is an acute episode of diverticulitis, which can lead to hospitalization and surgery with various types of consequences. The main aim of this study is to evaluate the economic burden of hospitalizations arising from acute episodes of diverticulitis using data from the administrative databases used in the Marche region in Italy and, as a secondary objective of this real-world data analysis, to study patient outcome variables following initial hospitalization for diverticulitis.

METHOD

A deterministic linkage was performed at individual user level between the different administrative sources of the Marche region through anonymous ID number for a period of analysis between 1 January, 2008 and 31 December, 2014. We enrolled all patients with at least one hospitalization for "diverticulitis of the colon without mention of haemorrhage" (ICD-9-CM code 562.11) or "diverticulitis of the colon with haemorrhage" (ICD-9-CM code 562.13) as primary or secondary diagnosis. For each patient we assessed the cost of hospitalization, of medicines and of specialist services considering a time-scale of one year or cohort analysis 365days after first admission.

RESULTS

The total number of residents in the Marche region who had at least one hospitalization for diverticulitis in the period 2008-2014 was 2987 (427 patients a year, corresponding to about 35 patients per 100,000 adult residents); the total number of admissions was 3453 (just over 490 a year). The direct healthcare costs incurred by the Marche region for episodes of diverticulitis in 2008-2014 amounted to approximately €11.4 million (€1.6 million a year), of which €10.9 million (95.5%) for the hospitalizations, € 246,000 (2.1%) for pharmaceutical treatment and €270,000 (2.4%) for specialist outpatient services. The average annual cost per patient was €3826, of which €3653 was for hospitalization, while pharmaceutical expenditure and specialist services accounted for €83 and €90, respectively. The cohort of patients undergoing a first admission for diverticulitis between 2010 and 2013 was made up of 1729 people (54.4% women, mean age 68.9 years), of whom 1500 (86.8%) did not undergo surgery while in hospital. Hospital mortality, recorded only for the over-65 age class, averaged 1.2%; for patients not receiving surgery during the initial hospitalization it was 0.5%, reaching 5.2% in patients undergoing surgery. The percentage of patients with one or more readmissions for diverticulitis within a year of the first was on average 7.8% and in 48% of cases this resulted in surgery.

CONCLUSIONS

Our study is the first analysis in Italy to use real-world data to measure the financial impact of diverticular disease. Assuming that the diagnostic and therapeutic behaviour identified in the Marche region could be representative of the situation nationwide, the estimated annual number of hospitalizations in Italy for acute episodes of diverticulitis is 19,000. The total amount of economic resources needed to treat patients suffering from acute episodes of diverticulitis is estimated at €63.5 million a year.

Long-term Cost-effectiveness of Two GLP-1 Receptor Agonists for the Treatment of Type 2 Diabetes Mellitus in the Italian Setting: Liraglutide Versus Lixisenatide

PURPOSE

Maintaining glycemic control is the key treatment target for patients with type 2 diabetes mellitus. In addition, the glucagon-like peptide-1 (GLP-1) receptor agonists may be associated with other favorable treatment characteristics, such as reduction in body weight and reduced risk of hypoglycemia compared with traditional diabetes interventions. The aim of the present analysis was to compare the long-term cost-effectiveness of 2 GLP-1 receptor agonists, liraglutide 1.8 mg and lixisenatide 20 μg (both administered once daily), in the treatment of patients with type 2 diabetes failing to achieve glycemic control with metformin monotherapy in the Italian setting.

METHODS

The IMS CORE Diabetes Model was used to project long-term clinical outcomes and subsequent costs (in 2015 Euros [€]) associated with liraglutide 1.8 mg versus lixisenatide 20 μg treatment in a cohort with baseline characteristics derived from the open-label LIRA-LIXI trial (Efficacy and Safety of Liraglutide Versus Lixisenatide as Add-on to Metformin in Subjects With Type 2 Diabetes; NCT01973231) over patient lifetimes from the perspective of a health care payer. Efficacy data were taken from the 26-week end points of the same trial, including changes in glycated hemoglobin, body mass index, serum lipid levels, and hypoglycemic event rates. Outcomes projected included life expectancy, quality-adjusted life expectancy, cumulative incidence and time to onset of diabetes-related complications, and direct medical costs. Outcomes were discounted at 3% annually, and sensitivity analyses were performed.

FINDINGS

Liraglutide 1.8 mg was associated with improved discounted life expectancy (14.07 vs 13.96 years) and quality-adjusted life expectancy (9.18 vs 9.06 quality-adjusted life years [QALYs]) compared with lixisenatide 20 μg. These improvements were mostly attributable to a greater reduction in glycated hemoglobin level with liraglutide 1.8 mg versus lixisenatide 20 μg, leading to reduced incidence and increased time to onset of diabetes-related complications. Compared with lixisenatide 20 μg, liraglutide 1.8 mg was associated with increased total costs over patient lifetimes (€41,623 vs €41,380), but this was offset by lower costs of treating diabetes-related complications (€26,682 vs €27,476). Liraglutide 1.8 mg was associated with an incremental cost-effectiveness ratio of €2001 per QALY gained versus lixisenatide 20 μg. At a willingness-to-pay threshold of €30,000 per QALY gained, liraglutide 1.8 mg had a probability of 77.2% of being cost-effective.

IMPLICATIONS

Based on long-term projections, liraglutide 1.8 mg is likely to be considered cost-effective compared with lixisenatide 20 μg for the treatment of patients with type 2 diabetes in Italy.

Economic Burden of Rheumatoid Arthritis in Italy: Possible Consequences on Anti-Citrullinated Protein Antibody-Positive Patients

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disease with a substantial medical and economic burden. In Italy, it affects approximately 280,000 people, therefore representing the musculoskeletal disease with the highest economic impact in terms of costs for the National Health Service and the social security system.

OBJECTIVE

The aim of this study was to estimate the annual economic burden of RA in Italy and determine the potential cost reduction considering the most effective biologic treatment for early rapidly progressing RA (ERPRA) patients.

METHODS

The model developed considers both direct costs that are mainly due to the pharmacological treatments, and indirect costs, which also include the productivity lost because of the disease. A systematic literature review provided the epidemiological and economic data used to inform the model. A one-way probabilistic sensitivity analysis based on 5000 Monte Carlo simulations was performed. Furthermore, specific scenario analyses were developed for those patients presenting an ERPRA, with the aim of evaluating the effectiveness of different biologic treatments for this subgroup of patients and estimating potential cost reduction.

RESULTS

The total economic burden associated with RA was estimated to be €2.0 billion per year (95% confidence interval [CI] €1.8-2.3 billion). Forty-five percent of the expenditure was due to indirect costs (95% CI €0.8-1.0 billion); 45% depended on direct medical costs (95% CI €0.7-1.1 billion), and the residual 10% was determined by direct non-medical costs (95% CI €0.16-0.25 billion). In particular, the costs estimated for ERPRA patients totalled €76,171,181, of which approximately €18 million was associated with patients with a high level of anti-citrullinated protein antibodies (ACPA). The results of the analysis outline how it is possible to obtain a cost reduction for ERPRA patients of between €1 and €3 million by varying the number of patients with a high level of immunoglobulin G treated with the most effective biologic drug. In fact, the latter may determine higher efficacy outcomes, especially for poor prognostic ERPRA patients, ensuing higher levels of productivity.

CONCLUSIONS

This study presents a pioneering approach to estimate the direct and indirect costs of RA. The model developed is a useful tool for policy makers as it allows to understand the economic implications of RA treatment in Italy, identify the most effective allocation of resources, and select the most appropriate treatment for ERPRA patients.

Economic aspects in the management of diabetes in Italy

BACKGROUND

Diabetes mellitus (DM) is a chronic-degenerative disease associated with a high risk of chronic complications and comorbidities. The aim of this study is to estimate the average annual cost incurred by the Italian National Health Service (NHS) for the treatment of DM stratified by patients' comorbidities. Moreover, the model estimates the economic impact of implementing good clinical practice for the management of patients with DM.

METHODS

Data were extrapolated from administrative database of the Marche Region and specific inclusion and exclusion criteria were developed from a clinical board in order to estimate patients with DM only, DM+1, DM+2, DM+3 and DM+4 comorbidities (cardiovascular disease, neuropathy, nephropathy and retinopathy). Regional data were considered a good proxy for implementing a previously developed cost-of-illness (COI) model from Italian NHS perspective already published. A scenario analysis was considered to estimate the economic impact of good clinical practice implementation in the treatment of DM and its comorbidities in Italy.

RESULTS

The model estimated an average number of patients with DM per year in the Marche region of 85.909 (5.5% of population) from 2008 to 2011. The mean costs per patients with DM only, DM+1, DM+2, DM+3 and DM+4 comorbidities were €341, €1,335, €2,287, €5,231 and €7,085 respectively. From the Italian NHS perspective, the total economic burden of DM in Italy amounted to €8.1. billion/year (22% for drugs, 74% for hospitalization and 4% for visits). Scenario analysis demonstrates that the implementation of good clinical practice could save over €700 million per year.

CONCLUSIONS

This model is the first study that considers real world data and COI model to estimate the economic burden of DM and its comorbidities from the Italian NHS perspective. Integrated management of the patients with DM could be a good driver for the reduction of the costs of this disease in Italy.