Under-treatment of migrants with diabetes in a universalistic health care system: the ARNO Observatory

Impact of migration on diabetes burden: audit in the metropolitan area of Bologna, Italy

PURPOSE

To investigate the impact of diabetes in immigrants on the Italian healthcare system, as well as their compliance with standard protocols of control and treatment.

METHODS

The prevalence of immigrants with diabetes living in the metropolitan area of Bologna (about 1 million inhabitants) in 2019 was investigated using a database containing all subjects in active follow-up for diabetes, based on antidiabetic drug use, disease-specific copayment exemption, ICD-9 codes, continuous care in diabetes units. Country of origin was derived from fiscal code.

RESULTS

The overall prevalence of diabetes (n = 53,941; 51.8% males, median age 64) was 6.1% in both Italy-born and immigrant cohorts. Immigrant prevalence was 12.4%, moderately higher than that observed in the total population (12.2%). Diabetes risk was increased in the whole immigrant cohort (odds ratio (OR) 1.74; 95% Confidence Interval (CI) 1.69-1.79). Among cases with incident diabetes, the proportion of immigrants (median age, 49 vs. 65 in Italy-born individuals) increased progressively from 11.7% to 26.5% from 2011 to 2019 (males, 8.9-21.0%; females, 14.9-32.8%) in all age groups, particularly in young adults, but also in older subjects. Metabolic control was lower in immigrants, as was adherence to shared diagnostic and therapeutic protocols, without systematic differences in antidiabetic drug use, but much lower use of drugs for comorbid conditions.

CONCLUSIONS

The population with diabetes in the metropolitan area of Bologna is rapidly changing. Quality improvement initiatives are needed to reduce the burden for the universalistic Italian health care system generated by the rapidly-growing high-risk immigrant population.

Glucose-lowering drug use in migrants and native Danes with type 2 diabetes: Disparities in combination therapy and drug types

AIM

To examine disparities in glucose-lowering drug (GLD) usage between migrants and native Danes with type 2 diabetes (T2D).

MATERIALS AND METHODS

In a nationwide, register-based cross-sectional study of 253 364 individuals with prevalent T2D on December 31, 2018, we examined user prevalence during 2019 of (i) GLD combination therapies and (ii) individual GLD types. Migrants were grouped by origin (Middle East, Europe, Turkey, Former Yugoslavia, Pakistan, Sri Lanka, Somalia, Vietnam), and relative risk (RR) versus native Danes was computed using robust Poisson regression to adjust for clinical and socioeconomic characteristics.

RESULTS

In 2019, 34.7% of native Danes received combination therapy, and prevalence was lower in most migrant groups (RR from 0.78, 95% confidence interval CI 0.71-0.85 [Somalia group] to 1.00, 95% CI 0.97-1.04 [former Yugoslavia group]). Among native Danes, the most widely used oral GLD was metformin (used by 62.1%), followed by dipeptidyl peptidase-4 inhibitors (13.3%), sodium-glucose cotransporter-2 inhibitors (11.9%) and sulphonylureas (5.2%), and user prevalence was higher in most migrant groups (RR for use of any oral GLD: 0.99, 95% CI 0.97-1.01 [Europe group] to 1.09, 95% CI 1.06-1.11 [Sri Lanka group]). Furthermore, 18.7% of native Danes used insulins and 13.3% used glucagon-like peptide-1 receptor agonists (GLP-1RAs), but use was less prevalent in migrants (RR for insulins: 0.66, 95% CI 0.62-0.71 [Sri Lanka group] to 0.94, 95% CI 0.89-0.99 [Europe group]; RR for GLP-1RAs: 0.29, 95% CI 0.22-0.39 [Somalia group] to 0.95, 95% CI 0.89-1.01 [Europe group]).

CONCLUSIONS

Disparities in GLD types and combination therapy were evident between migrants and native Danes. Migrants were more likely to use oral GLDs and less likely to use injection-based GLDs, particularly GLP-1RAs, which may contribute to complication risk and mortality among this group.

Guideline-level monitoring, biomarker levels and pharmacological treatment in migrants and native Danes with type 2 diabetes: Population-wide analyses

The prevalence of type 2 diabetes (T2D) is higher in migrants compared to native populations in many countries, but the evidence on disparities in T2D care in migrants is inconsistent. Therefore, this study aimed to examine this in Denmark. In a cross-sectional, register-based study on 254,097 individuals with T2D, 11 indicators of guideline-level care were analysed: a) monitoring: hemoglobin-A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), screening for diabetic nephropathy, retinopathy, and foot disease, b) biomarker control: HbA1c and LDL-C levels, and c) pharmacological treatment: glucose-lowering drugs (GLD), lipid-lowering drugs, angiotensin-converting enzyme-inhibitors/angiotensin receptor blockers, and antiplatelet therapy. Migrants were grouped by countries of origin: Middle East, Europe, Turkey, Former Yugoslavia, Pakistan, Sri Lanka, Somalia, Vietnam. In all migrant groups except the Europe-group, T2D was more prevalent than in native Danes (crude relative risk (RR) from 0.62 [0.61-0.64] (Europe) to 3.98 [3.82-4.14] (Sri Lanka)). In eight indicators, non-fulfillment was common (>25% among native Danes). Apart from monitoring in the Sri Lanka-group, migrants were at similar or higher risk of non-fulfillment than native Danes across all indicators of monitoring and biomarker control (RR from 0.64 [0.51-0.80] (HbA1c monitoring, Sri Lanka) to 1.78 [1.67-1.90] (LDL-C control, Somalia)), while no overall pattern was observed for pharmacological treatment (RR from 0.61 [0.46-0.80] (GLD, Sri Lanka) to 1.67 [1.34-2.09] (GLD, Somalia)). Care was poorest in migrants from Somalia, who had increased risk in all eleven indicators, and the highest risk in nine. Adjusted risks were elevated in some migrant groups, particularly in indicators of biomarker control (fully-adjusted RR from 0.84 [0.75-0.94] (LDL-C levels, Vietnam) to 1.44 [1.35-1.54] (LDL-C levels, Somalia)). In most migrant groups, T2D was more prevalent, and monitoring and biomarker control was inferior compared to native Danes. Migrants from Somalia received the poorest care overall, and had exceedingly high lipid levels.

The effect of diabetes on COVID-19 incidence and mortality: Differences between highly-developed-country and high-migratory-pressure-country populations

The objective of this study was to compare the effect of diabetes and pathologies potentially related to diabetes on the risk of infection and death from COVID-19 among people from Highly-Developed-Country (HDC), including Italians, and immigrants from the High-Migratory-Pressure-Countries (HMPC). Among the population with diabetes, whose prevalence is known to be higher among immigrants, we compared the effect of body mass index among HDC and HMPC populations. A population-based cohort study was conducted, using population registries and routinely collected surveillance data. The population was stratified into HDC and HMPC, according to the place of birth; moreover, a focus was set on the South Asiatic population. Analyses restricted to the population with type-2 diabetes were performed. We reported incidence (IRR) and mortality rate ratios (MRR) and hazard ratios (HR) with 95% confidence interval (CI) to estimate the effect of diabetes on SARS-CoV-2 infection and COVID-19 mortality. Overall, IRR of infection and MRR from COVID-19 comparing HMPC with HDC group were 0.84 (95% CI 0.82-0.87) and 0.67 (95% CI 0.46-0.99), respectively. The effect of diabetes on the risk of infection and death from COVID-19 was slightly higher in the HMPC population than in the HDC population (HRs for infection: 1.37 95% CI 1.22-1.53 vs. 1.20 95% CI 1.14-1.25; HRs for mortality: 3.96 95% CI 1.82-8.60 vs. 1.71 95% CI 1.50-1.95, respectively). No substantial difference in the strength of the association was observed between obesity or other comorbidities and SARS-CoV-2 infection. Similarly for COVID-19 mortality, HRs for obesity (HRs: 18.92 95% CI 4.48-79.87 vs. 3.91 95% CI 2.69-5.69) were larger in HMPC than in the HDC population, but differences could be due to chance. Among the population with diabetes, the HMPC group showed similar incidence (IRR: 0.99 95% CI: 0.88-1.12) and mortality (MRR: 0.89 95% CI: 0.49-1.61) to that of HDC individuals. The effect of obesity on incidence was similar in both HDC and HMPC populations (HRs: 1.73 95% CI 1.41-2.11 among HDC vs. 1.41 95% CI 0.63-3.17 among HMPC), although the estimates were very imprecise. Despite a higher prevalence of diabetes and a stronger effect of diabetes on COVID-19 mortality in HMPC than in the HDC population, our cohort did not show an overall excess risk of COVID-19 mortality in immigrants.

Healthcare Services for Undocumented Migrants: Organisation and Costs from the Italian NHS Perspective

Based on the principle of health equity, the Italian National Health Service is known worldwide for being a universalistic system that guarantees healthcare services for all its population, among which there are undocumented migrants. A commitment for their health needs is further motivated by their lower utilisation rates of healthcare services, which becomes even more crucial when considering chronic conditions such as diabetes that require adherence and continuity of care. However, the need for more official data has resulted in little research documenting these healthcare usage patterns. For this reason, our objective has been to deepen, from the Italian NHS perspective, the quantity, costs, type, preventability and organisation of healthcare services directed to undocumented migrants. We used official healthcare data from the Lombardy Region, which enable the identification of people receiving the STP code (undocumented migrants) and of people with foreign citizenship (documented migrants). After quantifying the average annual amount and expenditure for healthcare services grouped by Italian citizens, documented migrants and undocumented migrants for all clinical conditions (quantity and costs), we performed three primary investigations where we enlightened differences between the three mentioned groups focusing on the diagnosis of diabetes: (i) mapping the types of healthcare services used and their characteristics (type); (ii) quantifying the impact of preventable hospital admissions (preventability); (iii) examining the healthcare patterns linking pharmaceutical prescriptions with hospital accesses (organisation). Our results reveal significant differences among the three groups, such as more urgent hospital admissions, more preventable complications, and a higher recurrence in terms of access and costs to hospital services rather than pharmaceutical prescriptions for undocumented migrants. These findings can represent the leverage to raise awareness toward the emerging challenges of the migrant health burden.

Non-communicable diseases risk factors among the forcefully displaced Rohingya population in Bangladesh

Rohingya refugees of Ukhiya, Cox's bazar are an unaccounted group of people who form the largest cluster of refugees worldwide. Non-communicable disease (NCD) alone causes 70% of worldwide deaths every year therefore, the trend of NCD among Rohingya refugees demands proper evaluation and attention. The objective of this study was to measure the NCD risk factors among a convenient sample of Rohingya refugees. This cross-sectional study was conducted among 249 Rohingya refugees living in Balukhali and Kutupalang Rohinga Camps at Ukhiya, Cox's bazaar using a survey dataset adapted from the WHO Stepwise approach to NCD Risk Factor Surveillance (STEPS). Data was collected through face-to-face interviews with a structured questionnaire. Anthropometric and biochemical measurements were done by trained medical assistants. Descriptive analysis was applied as appropriate for categorical variables. A Chi-square test and a student t test were performed to compare the categories. In general, the findings of NCD risk factors as per STEPS survey was 53.4% for tobacco use including smokeless tobacco, 2.8% for alcohol consumption, 23.7% for inadequate vegetable and fruit intake, 34.5% for taking extra salt, 89.6% for insufficient physical activity, 44.5%for confirmed hypertension, 16.9% for overweight, 1.2% for obesity and 0.8% for high blood sugar. Some modifiable non-communicable disease risk factors such as physical inactivity, tobacco smoking, extra salt with food, and hypertension are present among the Rohinga refugees in Bangladesh. These findings were timely and essential to support the formulation and implementation of NCD-related policies among the Rohingya refugees as a priority sub-population.

Current Pharmacological Treatment of Type 2 Diabetes Mellitus in Undocumented Migrants: Is It Appropriate for the Phenotype of the Disease?

Type 2 diabetes is increasingly recognized as a spectrum of metabolic disorders sharing chronic hyperglycaemia. In Europe, the continually growing number of migrants from developing countries could affect diabetes phenotypes. We evaluated a population of 426 Italians and 412 undocumented migrants. Using 17 variables (with the exclusion of ethnic origin) we performed a multiple component analysis to detect potential clusters, independently from ethnicity. We also compared the two groups to evaluate potential ethnicity associated differences. We found five clusters of patients with different disease phenotypes. Comparing Italians with undocumented migrants, we noted that the first had more often cardiovascular risk factors and neurologic involvement, while the latter had a higher frequency of diabetic ulcers and renal involvement. Metformin was used in a comparable percentage of patients in all clusters, but other antidiabetic treatments showed some differences. Italians were more often on insulin, due to a larger use of long acting insulin, and received a larger number of oral antidiabetics in combination. Pharmacological treatment of comorbidities showed some differences too. We suggest that type 2 diabetes should be considered as a spectrum of diseases with different phenotypes also in heterogeneous populations, and that this is not due only to ethnic differences.

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.

Disparities in treatment of diabetes and hypertension among groups of foreign origin and the general Finnish population

BACKGROUND

Migrants from low-income countries are more predisposed to diabetes and cardiovascular risks than host European natives, but how treatment targets are met in migrant patients is unclear. We examined health service use and treatment of diabetes and hypertension among selected migrant groups and the general Finnish population and compared prevalence of cardiovascular risk factors between patients and non-patients.

METHODS

Cross-sectional data from randomly sampled 30- to 64-year-old participants (387 Russian, 198 Somali and 343 Kurdish origin migrants) of the Migrant Health and Wellbeing Survey (2010-2012) were used. Health 2011 survey data (n = 1086) were used as a comparison group.

RESULTS

Compared with the general population, diabetes-related doctor/nurse visits were more frequent among Russian and Somali, but not the Kurdish group. Use of prescribed antidiabetic and antihypertensive drugs were significantly lower among Russians (78%/56%) and Kurdish (68%/58%), but not in Somalis (85%/62%) compared with the general population (96%/78%). Obesity, elevated blood pressure and elevated glucose levels were more prevalent in patients than non-patients, and over 60% of patients and over 70% of non-patients had elevated plasma low density lipoprotein cholesterol. Differences in cardiovascular disease (CVD) risk profiles between patients and non-patients were not associated with socio-economic factors.

CONCLUSIONS

This study indicates disparities in prevalence and management of diabetes and hypertension and their associated risk factors among ethnic groups. Diabetes, CVD risks and treatment outcomes in patients were sub-optimal, especially among foreign origin groups. Comprehensive health promotion strategies are needed to improve cardiometabolic health in vulnerable populations.

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies

BACKGROUND AND AIMS

Italy has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy.

METHODS AND RESULTS

A multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013-14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16-2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65-1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk.

CONCLUSION

Adult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.

Will undocumented migrants contribute to change epidemiology, presentation and pharmacologic treatment of diabetes in Western countries?

AIMS

Migrants from countries in which health and social conditions are unsatisfactory, and their offspring, are becoming a growing component of the western population. Available health data show that their morbidity is at least comparable to that of the host country population, with a significant contribution of chronic diseases as diabetes. The possibility that diabetes shows different features in undocumented migrants is the hypothesis that we tried to investigate in this study.

METHODS

We retrospectively analysed the data of 413 patients with type 2 diabetes mellitus (T2DM): 222 patients followed in a diabetes clinic at a University Hospital and 191 undocumented migrants cared for by a Charity in Milan, Italy.

RESULTS

We found that the onset of the disease was earlier in migrants; they showed a significant lower body mass index (BMI) and had lower socioeconomic conditions. They had a worse glycaemic control. The pattern of complications was also different between the two groups, with cardiovascular complications more frequent in Italians. Finally, also pharmacologic treatment differed significantly.

CONCLUSIONS

Age of onset, clinical manifestations and complications of T2DM in undocumented migrants and natives may show significant differences. This is important for both epidemiological and clinical reasons. If these preliminary observations are confirmed by larger studies, we can conclude that undocumented migrants should be screened for T2DM earlier than natives, and that therapies should be tailored to the specific features of their disease.

Prevalence and management of diabetes in immigrants resident in the Lombardy Region: the importance of ethnicity and duration of stay

AIMS

To describe the prevalence and management of diabetes among immigrants according to ethnic group and duration of stay, compared to Italian citizens.

METHODS

Diabetic immigrant and Italian residents aged 20-69 years in the administrative database of the Lombardy Region. Immigrants were classified by region of origin and as long-term residents (LTR) and short-term residents (STR). Age- and sex-adjusted prevalence and indicators of diabetes management were calculated for immigrants by region of origin and by length of stay using Cox proportional models.

RESULTS

In 2010 19,992 immigrants (mean age 49.1 ± 10.8, 53.7% males) and 195,049 Italians (mean age 58.7 ± 9.3, 61.1 males) with diabetes were identified. Immigrants had a higher adjusted diabetes prevalence than Italians (OR 1.48; 95% CI 1.45-1.50). STR received significantly fewer recommended cardiovascular drugs (antiplatelets, statins and ACE-inhibitors/ARBs) than Italians, although prescription was higher among LTR from some ethnic groups. Immigrants were less likely to be seen by a diabetologist and to do at least one HbA1c test per year. Although the recommended tests/visits were more often done for the LTR than the STR, in the majority of ethnic groups these indicators were still far from optimal.

CONCLUSION

The prevalence and management of diabetes differ between immigrants and Italians, although some improvement can be seen among LTR.

Screening for gestational diabetes in Tuscany, Italy. A population study

AIMS

According to current Italian guidelines, only women at higher risk of gestational diabetes (GDM) are eligible for receiving a glucose tolerance test (OGTT) during pregnancy. This study evaluates the compliance to national guidelines, additionally proposing an algorithm able to identify women with GDM.

METHODS

The study included 23,270 pregnant women aged >15yr, resident in Tuscany, a region in central Italy, delivering in year 2015, identified by certificates of care at delivery. Eligibility to screening was evaluated by fulfillment to regional guidelines recommending a 2-h-75g-OGTT only in presence of risk factors. Additionally, a validated algorithm is proposed to diagnose GDM from regional administrative databases.

RESULTS

Glucose tolerance was tested in 79.2% of women. Eligibility criteria were fulfilled in 55.6% of OGTT performers and in 40.2% of those who didn't perform any OGTT. Performers' rate increased with age, body weight, higher education degree and in those followed by a well defined clinical setting. Housewives and students had a lower chance of receiving an OGTT. Algorithm identified GDM in 11% of women, ranging from 14% among eligible and 7% among non-eligible ones.

CONCLUSION

Selective screening for GDM is not being currently applied in Tuscany. Despite the percentage of eligible women by national guidelines was 55%, the rate of those who performed the screening was about 80%, with a 40% of low risk women continuing to be screened. Moreover, GDM rate, calculated by algorithm, was relatively large (7%) among non-eligible women, suggesting the need of universal glucose screening to adequately capture all GDM cases.

Lifestyle-tailored interventions for South Asians with type 2 diabetes living in high-income countries: a systematic review

AIM

To summarize evidence on the effectiveness of educational interventions for type 2 diabetes control in South Asians living in high-income countries.

METHODS

We systematically searched PubMed, EMBASE, Cinahl and the Cochrane Library, using Medical Subject Heading and free-text terms. The considered outcomes were: mortality, morbidity, glycaemic control, blood pressure, practice (diet, physical activity and self-care), attitudes/awareness and knowledge. Papers published up to July 2015 were considered. Two reviewers independently screened the title and abstract and then read the full text of selected papers.

RESULTS

Nine studies were included, four non-randomized studies of interventions and five randomized controlled trials. All studies except one were conducted in the UK. Target population ranged from 39 to 1486 individuals; the follow-up ranged from 1 to 24 months. The interventions were mostly based on a tailored educational package, individually or group administered, conducted by lay link workers, health professionals or both. No study measured mortality or morbidity. An effect on glycaemic control was observed only in before/after studies, while a randomized study showed a non-significant improvement (percentage of glycated haemoglobin -0.15, P = 0.11). Two randomized studies found a reduction in blood pressure. Changes in practice and attitudes showed heterogeneous results, mostly favouring intervention.

CONCLUSIONS

There was weak evidence that interventions using link workers and tailored education can modify attitudes, self-care skills and blood pressure in South Asian migrants to industrialized countries. Only one larger trial, with adequate follow-up, showed a small non-significant improvement of glycaemic control.

The global dynamics of diabetes and tuberculosis: the impact of migration and policy implications

The convergence between tuberculosis (TB) and diabetes mellitus (DM) will represent a major public health challenge in the near future. DM increases the risk of developing TB by two to three times and also increases the risk of TB treatment failure, relapse, and death. The global prevalence of DM is predicted to rise significantly in the next two decades, particularly in some of the low- and middle-income countries with the highest TB burden. Migration may add further complexity to the effort to control the impact on TB of the growing DM pandemic. Migration may increase the risk of DM, although the magnitude of this association varies according to country of origin and ethnic group, due to genetic factors and lifestyle differences. Migrants with TB may have an increased prevalence of DM compared to the native population, and the risk of TB among persons with DM may be higher in migrants than in autochthonous populations. Screening for DM among migrants, screening migrants with DM for active and latent TB, and improving access to DM care, could contribute to mitigate the effects of DM on TB.

A systematic review of the use of health services by immigrants and native populations

Background

Changes in migration patterns that have occurred in recent decades, both quantitative, with an increase in the number of immigrants, and qualitative, due to different causes of migration (work, family reunification, asylum seekers and refugees) require constant u pdating of the analysis of how immigrants access health services. Understanding of the existence of changes in use patterns is necessary to adapt health services to the new socio-demographic reality. The aim of this study is to describe the scientific evidence that assess the differences in the use of health services between immigrant and native populations.

Methods

A systematic review of the electronic database MEDLINE (PubMed) was conducted with a search of studies published between June 2013 and February 2016 that addressed the use of health services and compared immigrants with native populations. MeSH terms and key words comprised Health Services Needs and Demands/Accessibility/Disparities/Emigrants and Immigrants/Native/Ethnic Groups. The electronic search was supplemented by a manual search of grey literature. The following information was extracted from each publication: context of the study (place and year), characteristics of the included population (definition of immigrants and their sub-groups), methodological domains (design of the study, source of information, statistical analysis, variables of health care use assessed, measures of need, socio-economic indicators) and main results.

Results

Thirty-six publications were included, 28 from Europe and 8 from other countries. Twenty-four papers analysed the use of primary care, 17 the use of specialist services (including hospitalizations or emergency care), 18 considered several levels of care and 11 assessed mental health services. The characteristics of immigrants included country of origin, legal status, reasons for migration, length of stay, different generations and socio-demographic variables and need. In general, use of health services by the immigrants was less than or equal to the native population, although some differences between immigrants were also identified.

Conclusions

This review has identified that immigrants show a general tendency towards a lower use of health services than native populations and that there are significant differences within immigrant sub-groups in terms of their patterns of utilization. Further studies should include information categorizing and evaluating the diversity within the immigrant population.

Incidence, prevalence, costs and quality of care of type 1 diabetes in Italy, age 0-29 years: The population-based CINECA-SID ARNO Observatory, 2002-2012

BACKGROUND AND AIMS

To assess temporal trend in incidence (2003-12) and prevalence (2002-12) of type 1 diabetes in children and young adults, direct costs and selected indicators of quality of care under the coverage of the universalistic Italian National Health System (NHS).

METHODS AND RESULTS

The ARNO Observatory, a healthcare monitoring system based on administrative data, identified a population-based multiregional cohort of subjects aged 0-29 years. Type 1 diabetes was defined by at least two prescriptions of insulin over 12 months and continuous insulin-treatment in the following year. Indicators of quality of care and directs costs were assessed in persons with diabetes and in people without diabetes, individually matched for age, gender and health unit (1:4 ratio). We identified 2357 incident cases of type 1 diabetes aged 0-29 years (completeness of ascertainment, 99%). Incidence rates were similar in ages 0-14 (15.8, 95% CI 14.9-16.8) and 15-29 years (16.3, 15.4-17.2), with no significant trend. Prevalence increased from 137 to 166.9/100,000, particularly in the age 15-29 years. Direct costs accounted for € 2117 in persons with diabetes and € 292 in control individuals. A statistically significant decreasing trend in hospitalization for acute complications was evident (p < 0.001), which was almost completely due to ketoacidosis. People with at least one HbA1c measurement over the year were 48.5%.

CONCLUSION

We showed high incidence and increasing prevalence of type 1 diabetes in young adults in Italy, which impact on direct costs under the universalistic coverage of the NHS.

The relative burden of diabetes complications on healthcare costs: The population-based CINECA-SID ARNO Diabetes Observatory

BACKGROUND AND AIMS

In the present population-based study, we aimed to describe the per patient annual healthcare cost of people with diabetes in 2007-2012, to assess the relative burden of diabetes complications and other potential determinants on healthcare costs in the 2012 cohort, and to describe and analyse the determinants of the cost of incident cases diagnosed in 2012.

METHODS AND RESULTS

We analysed data from a retrospective cohort of residents in four Italian areas that were served by Local Health Units participating in the ARNO Observatory. Per patient annual healthcare costs (Euros) were estimated as the sum of all the resources supplied during that year (drugs, outpatient care, and hospitalisations). The mean per patient annual healthcare cost increased from €2752 in 2007 to €3191 in 2010, before decreasing to €2791 in 2012. The largest component of these costs was represented by hospitalisations (around €1550, on average; 51.7% of total cost), followed by outpatient care (€422; 14.6%) and drugs (€973; 33.7%). In 2012, the most relevant cost determinants were chronic diabetes complications, with an additional cost due to nephropathy/end stage renal disease (€4683), amputations (€5042), lower extremity revascularization (€4808), and cerebrovascular diseases (€3861). Costs associated with incidence cases were higher than those associated with prevalent.

CONCLUSION

The present study provides evidence on the excess of healthcare costs due to diabetes complications in both prevalent and incident cases.

The burden of chronic noncommunicable diseases in undocumented migrants: a 1-year survey of drugs dispensation by a non-governmental organization in Italy

OBJECTIVES

This study was carried out with two objectives. The first one was to have an insight into the prevalence of chronic noncommunicable diseases (CNCD) in undocumented migrants, and the second one was to evaluate if differences existed among different ethnic groups.

STUDY DESIGN

The study is based on the collection of data on drug dispensation by a non-governmental organization (NGO) providing free medical assistance to undocumented migrants in Milan, Italy. All the prescriptions to adult subjects from January 1 to December 31 2014 (total 8438) were recorded and analyzed. All the data available for the patients receiving prescriptions (age, gender and country of birth) were also collected in anonymous form. Ethical approval for the study was given by the Ethics Committee of the NGO.

METHODS

Drugs were grouped according to the anatomical therapeutic chemical (ATC) classification and their quantities expressed as daily defined doses (DDDs)/1000 patients/day. The 56 ATC levels were divided into three groups according to their use for acute, chronic, or both acute and chronic diseases. The statistical analysis of drug dispensation was performed for the whole population and for the five ethnic groups into which it had been divided.

RESULTS

Prescription of medicines for chronic conditions was significantly greater than for acute (154.2 ± 45.9 vs 51.3 ± 18.4 DDD/1000 patients/day, P < 0.02) and for both acute and chronic conditions (57.9 ± 12.8 DDD/1000 patients/day, P < 0.02). Five ATC classes accounted for 60% of all chronic prescriptions. They were differently distributed among the five ethnic groups (e.g., Asians required more antihypertensives and antidiabetics, East Europeans required more lipid modifying drugs, antihypertensives and antithrombotics).

CONCLUSIONS

Our data show an important use of medicines for chronic diseases in a population of undocumented migrants. Though with some limitations, this could be an indicator of a high prevalence of CNCD in this population, with significant differences among different ethnic groups. This situation should be considered when planning health interventions, also in consideration of the fact that it could have an impact on European Health Services in a short time.

Focus on migrants with type 2 diabetes mellitus in European Countries

The prevalence of type 2 diabetes mellitus, one of the major causes of morbility and mortality in Europe, is increasing in all European countries. Diabetes is not distributed equally among all population groups, as higher incidence, appearance of complications, and different mortality rates have been observed among migrants and the native population. These differences may be due to genetic profiles, lifestyle, and utilization of the health care system in different ways. Taking into account that the quantity of migrants is nowadays increasing, mainly in the southern part of Europe, the knowledge of diabetes in migrants through a better collection of data is necessary, considering that few limited epidemiological studies have evaluated the importance of this problem in EU countries. A special effort in developing a comprehensive management for native and immigrant populations in order to prevent and cure diabetes should be mandatory. This activity could be helpful to limit the incidence of future diabetes complications and to avoid the consequent burden of the health care system along with a control on its costs. It is clear that diabetes complication prevention is essential for long-term sustainability of the health care system.

Hospital incidental diagnosis of diabetes: A population study

AIMS

To identify incidental previously unrecognized diabetes (IPUD) among hospitalized patients and corresponding mortality risk in comparison with individuals with known diabetes (KDM).

METHODS

Out of 214,991 individuals discharged in year 2011 from all hospitals of Tuscany, Italy we retrospectively identified IPUD as individuals with no known diabetes and/or previous antidiabetic medication, receiving at least two prescriptions of glucose-lowering-drugs over the next 6months after discharge. Two-year (2012-2013) adjusted mortality risk was tested by a Cox-regression-analysis, comparing IPUD and KDM patients with at least one hospital admission in 2011.

RESULTS

974 patients with IPUD (375.6×100,000 hospitalized people) have been identified. IPUD risk was associated with aging, male gender and greater burden of co-morbidities, was higher in migrants of non-Italian ancestry and was reduced among patients of family physicians adhering to guidelines resulting in a proactive model of care delivery. In IPUD patients alive at 1st January 2012, (n=865) the adjusted risk of two-year mortality was similar to that of KDM subjects (HR=1.08; 95% CI: 0.92-1.26; p=NS).

CONCLUSIONS

IPUD occurs more commonly in older male subjects, migrants of non-Italian ancestry, and among patients of physicians non-adhering to a shared diabetes care model. People with IPUD have similar two-year-mortality risk compared with KDM individuals.

Diabetes in migrants and ethnic minorities in a changing World

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases (NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a PubMed search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.

Prevalence of diabetes across different immigrant groups in North-eastern Italy

BACKGROUND AND AIMS

Type 2 diabetes, one of the most important non-communicable diseases, represents a major health problem worldwide. Immigrants may contribute relevantly to the increase in diabetes. The aim of the study was to investigate variability in diabetes prevalence across different immigrant groups in the Veneto Region (northeastern Italy).

METHODS AND RESULTS

Diabetic subjects on January 2013 were identified by record linkage of hospital discharge records, drug prescriptions, and exemptions from medical charges for diabetes. Immigrant groups were identified based on citizenship. Age-standardized prevalence rates were obtained for residents aged 20-59 years by the direct method, taking the whole regional population as reference. Prevalence rate ratios (RR) with 95% Confidence Intervals (CI) were computed with respect to Italian citizens. Among residents aged 20-59 years, 45280 Italian and 7782 foreign subjects affected by diabetes were identified. Prevalence rates were highest among immigrants from South-East Asia, RR 4.9 (CI 4.7-5.1) among males, and 7.6 (7.2-8.1) among females, followed by residents from both North and Sub-Saharan Africa. Citizens from Eastern Europe (the largest immigrant group) showed rates similar to Italians. Most South-Asian patients aged 20-39 years were not insulin-treated, suggesting a very high risk of early onset type 2 diabetes in this ethnic group.

CONCLUSION

Large variations in diabetes prevalence by ethnicity should prompt tailored strategies for primary prevention, diabetes screening, and disease control. An increased demand for prevention and health care in selected population groups should guide appropriate resource allocation.