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«Diabetes expenditure, burden of disease and management in 5 EU countries Panos Kanavos, Stacey van den Aardweg and Willemien Schurer LSE Health, ...»

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Diabetes expenditure, burden of

disease and management in 5 EU


Panos Kanavos, Stacey van den Aardweg and

Willemien Schurer

LSE Health, London School of Economics

January 2012


Table of Contents


List of Tables

List of Figures

List of Boxes

List of Abbreviations


Executive summary

1. Background and Objectives

1.1 Background

1.2 Objectives

2. Methodology

2.1 Data sources and caveats

2.2.1 Precision of Prevalence

2.2.2 Direct costs

2.2.3 Cost of complications

2.2.4 Indirect costs

2.2.5 Process and outcome indicators

3. Diabetes Burden and Policies in Europe

3.1 Incidence

3.2 Diabetes prevalence

3.3 National Diabetes Programmes

3.3.1 France

3.3.2 Germany

3.3.3 Italy

3.3.4 Spain

3.3.5 United Kingdom

3.3.6 Overall

–  –  –

4.1 Diabetes Guidelines

4.2 Diagnosis

4.2.1 Patient testing and screening

4.2.2 Physician involvement

4.2.3 Treatment processes, timelines and patient education

4.2.4 Patient monitoring

Routine visits

Home blood glucose monitoring, continuous glucose monitoring & insulin pumps.. 41

4.3 Diabetes care delivery

4.4 Conclusion

5. Cost burden of diabetes and its complications

5.1 Total health expenditure in EU5

5.2 Direct cost burden of diabetes

5.2.1 Costs in In- and Out-patient Care Settings





United Kingdom

5.2.2 Costs by Diabetes Type





United Kingdom

5.2.3 Direct Costs: Diabetes Medications





United Kingdom

5.3 Complications related to diabetes and associated costs

5.4 Selected complications related to diabetes and associated costs

–  –  –

5.4.2 Foot disease

5.4.3 Cardiovascular disease

5.4.5 Renal disease

5.4.6 Erectile dysfunction

5.4.7 Neurological complaints

5.5 Indirect cost burden of diabetes

5.5.1 Historical evidence

5.5.2 Estimates of indirect cost in 2010

5.6 Summary and discussion

6. Outcomes

6.1 Recommendations for monitoring patients with diabetes

6.2 Available evidence on diabetes outcomes

6.2.1 France

6.2.2 Germany

6.2.3 Italy

6.2.4 Spain

6.2.5 United Kingdom

6.3 Conclusions

The Challenges of Diabetes – Outlook for the future


7.1 Current and future trends in prevalence and the impact of aging

7.2 The challenge of poor data: prevalence, costs and complications

7.2.1 Scarce prevalence statistics

7.2.2 Incomplete direct cost data

7.2.3 Direct diabetes cost burden

7.2.4 Cost of diabetes-related complications

7.2.5 Insufficient outcomes data

7.2.6 Indirect diabetes cost burden

7.3 Lack of effective prevention strategies

–  –  –

7.5 Variations in access and quality of care

7.6 Incomplete outcomes data

8. Policy options

8.1 Understand the effects of diabetes through data

8.2 Enhance and expand prevention strategies for diabetes

8.3 Evidence-based guidelines

8.4 Multi-disciplinary diabetes care

8.5 Monitoring, evaluating and learning from each other

Appendix 1 LSE survey of diabetes and diabetes costs in 5 EU countries: Experts interviewed, by country

Appendix 2 Availability of cost and prevalence of diabetes-related complications data........ 95 Appendix 3: Diabetes databases and information sources in EU5 countries

Appendix 4: Diabetes databases and information on health outcomes

Appendix 5 Direct diabetes costs based on International Diabetes Federation estimates (2007, €)

Appendix 6: Total direct diabetes costs: estimates from regional studies extrapolated nationally (France, Germany, Italy, Spain) or from government data (UK) (2001-2010)...... 99 Appendix 7: Diabetes complications and their cost: data collected through the LSE survey 100 Appendix 7A: Diabetic retinopathy - Screening, diagnostic and treatment costs............. 100 Appendix 7B: Diabetic foot: Costs of monitoring and treatment

Appendix 7C: Cardiovascular disease resulting from diabetes - Costs of testing and treatment

Appendix 7D: Renal disease resulting from diabetes - Costs of testing and treatment..... 103 Appendix 8: Quality and Outcomes Framework (QOF)


–  –  –

We are also indebted to a large number of clinicians, academics and decision-makers in the study countries who have contributed to the survey and the report itself. Without their help, the report would not have been written.

This study was funded by an unrestricted educational grant from Novo Nordisk.

–  –  –

Table 2.1: Absenteeism due to diabetes and its complications (days/year), early retirement and social benefits (% of diabetes patients).

Table 3.1: Diabetes prevalence and attributable mortality (20-79 years)

Table 3.2: Compilation of all national diabetes policies, and their goals and evaluations.

..... 31 Table 4.1: Aspects of treatment addressed by national diabetes guidelines

Table 4.2: Patient groups tested and screened for diabetes by family physician

Table 4.3: Diabetes treatment practices across EU5 (2010)

Table 4.4: Problems in delivering diabetes care α

Table 5.1: Total health expenditure in EU5, 2000-2008 (€, million)

Table 5.2: Total direct diabetes cost burden: Medicines, In- and Outpatient care (estimates in € million)1

Table 5.3: Per patient direct diabetes cost burden: Medicines, In- and Outpatient care (estimates in €) 1

Table 5.4: Estimated total cost of absenteeism, early retirement, and social benefit among diabetes patients in EU countries, 2010.

Table 6.1: Recommended frequency and cost of diabetes biomarker monitoring.

................. 68 Table 6.2: Diabetes monitoring: Proportion of patients testing annually and their results (yellow shaded figures show recommended biological ranges)

Table 6.3: Key outcome indicators results from a German DMP (2003)

vii List of Figures

Figure 3.1: Diabetes Type 1 incidence (0-14 years)

Figure 3.2: Comparison of benchmark national diabetes prevalence versus IDF prevalence.

23 Figure 3.3: National diabetes prevalence, extrapolation from benchmark

Figure 3.4: Diabetes stratification by BMI category in Scotland (2003, 2009) (Scottish Diabetes Survey Monitoring Group 2004, 2010)

Figure 3.5: Population estimates by age, EU5 average (2000 - 2050)

Figure 5.1: Total health expenditure per capita in EU5, 2000-2008 (in €)α

Figure 5.2: Total direct diabetes cost burden (A), and proportional comparison of in- and outpatient costs, and diabetes medicines (B) (2010 estimates, € million).


Figure 5.3: Direct and indirect cost burden of diabetes in EU5 (2010 estimates, € million).

. 61 Figure 6.1: Diabetes outcomes: Italy AMD data 2004 – 20091,α, β

Figure 6.2: Adherence to patient monitoring (A) and results of monitoring outcomes (B) in Spain (1996-2007).

Figure 6.3: Diabetes outcomes National Diabetes Audit (2003/04-2009/10).

Figure 6.4: Diabetes outcomes Scottish Diabetes Survey (2003-2010).

Figure 6.5: QOF indicators (DM12 (blood pressure), DM17 (cholesterol), DM23 (HbA1C)) in individual SHAs (2009/10)*

viii List of Boxes

Box 2.1: Diabetes prevalence benchmarks

Box 2.2: Diabetes direct cost benchmarks

Box 3.1: Burden of disease - Key takeaways

Box 4.1: Patient education & monitoring pilot programme in France (Sophia)

Box 4.2: Diabetes guidelines, diagnosis and treatment - Key takeaways

Box 5.1: Cost burden of diabetes - Key takeaways

Box 6.1: Outcomes - Key takeaways

Box 8: Policy options - Key takeaways

ix List of Abbreviations AFD Association Française des Diabetiques AFSSAPS Agence française de sécurité sanitaire des produits de santé ALD Affection de Longue Durée Association de langue française pour l‘étude du diabète et des maladies metaboliques ALFEDIAM AMD Italian Association of Diabetologists (Associazione Medici Diabetologi) Agence Nationale d’Accréditation et d’Evaluation des Soins ANAES APHO Association of Public Health Observatories (UK) BAK Bundesärztekammer Body Mass Index (kg/m2) BMI BP Blood Pressure CGM Continuous Glucose Monitoring CHD Coronary Heart Disease Caisse Nationale d‘Assurance Maladie (National Health Insurance Fund – France) CNAM CP Cumulative Prevalence CVD Cardiovascular Disease DDG Deutsche Diabetes Gesellschaft (Germany) DMP Disease Management Programme (Germany) DR Diabetic Retinopathy DRG Diagnosis Related Group DSN Diabetes Specialist Nurse ECB European Central Bank ENTRED Echantillon National Representative des Diabétiques ESRD End Stage Renal Disease HAS Haute Autorité de Santé HbA1C Glycosylated Haemoglobin HBGM Home Blood Glucose Monitoring HDL High Density Lipoprotein Cholesterol IDF International Diabetes Federation IGT Impaired Glucose Tolerance IDDM Insulin Dependent Diabetes Mellitus LDL Low Density Lipoprotein Cholesterol LOS Length of Stay MI Myocardial Infarction NHP National Healthcare Plan (Italy) NICE National Institute for Health and Clinical Excellence NIDDM Non-Insulin Dependent Diabetes Mellitus NPP National Prevention Plan (Italy) NSF-D National Service Framework for Diabetes (UK) OGGT Oral Glucose Tolerance Test OOP Out-of-Pocket PAD Peripheral Arterial Disease PAOD Peripheral Arterial Occlusive Disease PCT Primary Care Trust (UK) PMSI Diagnosis Related Group system (France) QOF Quality and Outcomes Framework SBGM Self Blood Glucose Monitoring SDS Scottish Diabetes Survey SHA Strategic Health Authority (UK) SHI Social Health Insurance SID Italian Society for Diabetologists SIMG Italian Society of General Medicine SIGN Scottish Intercollegiate Guidelines Network TG Triglycerides

–  –  –

Our aims are to identify and compare the diabetes burden of disease, costs (direct and indirect) and diabetes outcomes, focusing on complications across France, Germany, Italy, Spain, and the UK (EU5). We will then have an understanding of the state of diabetes management in EU5 from which to make informed policy options.

Materials and methods: A survey was designed and sent to health economists in the EU5 countries. In turn, key diabetes clinicians, decision makers and health officials were interviewed in order to answer the survey. In addition, secondary data was collected from PubMed, diabetes association publications and health government publications and websites, including national statistics.

Results: Diabetes record keeping in all EU5 countries is poor for prevalence, direct diabetes costs, cost of complications, indirect costs and diabetes outcomes. No diabetes registers exist in any of the EU5 countries. Diabetes prevalence ranges between 4.8% (Italy) to 8.9% (Germany), and has increased over time. Although none of the EU5 countries record diabetes costs directly, including complications, estimates for 2010 suggest that the total direct annual cost ranges from €5.45bn (Spain) to €43.2bn (Germany); across EU5 the total direct cost burden of people with diabetes was €90 billion; this figure includes the cost of complications or medical conditions some of which may not necessarily be caused by diabetes, but can be exacerbated by it. Incremental costs are reported in Germany only and stand at €19.7 billion in 2010. Per patient direct medical costs are more comparable across countries, with some variation (€1,708 (Spain) to €5,899 (Germany) in 2010), suggesting a key driver behind total diabetes costs is prevalence. Inpatient costs are consistently higher than outpatient costs in all countries, due to increased medical care required with diabetes-related complications.

Outpatient costs on the other hand, as well as diabetes medications, can be less than half of inpatient costs due to the relatively low costs of maintaining good glycaemic control via medication and regular monitoring. Expenditure on insulin and oral anti-diabetic medicines ranges between 6.2% and 10.5% of total direct cost. A significant majority of inpatient direct costs account for treatment of diabetes related complications, affecting approximately 18.3 million diabetic patients each year across the five study countries. Indirect costs, relate to reduced productivity, absenteeism, early retirement, social benefits and carer costs; these costs are significant and, having quantified part of these costs for the first time in Europe (relating to absenteeism, early retirement and social benefits), it appears that they stand at €98.4 billion and can exceed direct costs by at least a factor of 2- or even 3- to-1 depending on the country. Significant variations exist between countries in the availability of outcomes data and the quality of the relevant indicators. In some cases, improvements in quality of care for diabetic patients are shown over time (Italy, UK), whereas in others discrepancies exist between the quality of care in metropolitan versus rural areas (France, Spain).

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