Improved quality of diabetes control reduces complication costs in Bulgaria

Figures & data

Table 1. Reduction of relative risk of diabetes-related complications upon achieving 1% reduction in HbA1c, according to UKPDS35 [11, 12].

Diabetes-related complications	Relative risk (RR) reduction for 1% reduction in HbA1c level	95% CI for RR
Any diabetes-related endpoint	21	17	24
Diabetes-related mortality	21	15	27
All-cause mortality	14
Fatal or non-fatal myocardial infarction	14	8	21
Fatal or non-fatal stroke	12
Microvascular endpoints	37	33	41
Cataracts extraction	19
Amputation or death due to peripheral vascular disease	43
Heart failure	16

Table 2. Costs of healthcare services offered by hospitals and reimbursed through clinical pathways.

Diabetes-related complications	Hospital treatment cost (BGN)	Yearly costs of ambulatory treatment^a (BGN)
Any diabetes-related endpoint	600	427.92
Diabetes related death	600	0
All-cause mortality	2134	0
Fatal and non-fatal myocardial infarction^b	200	51.22
Fatal and non-fatal stroke^b	650.56	43.13
Microvascular endpoints^c	744	36,38
Cataract extraction	360	10.08
Amputation or death from peripheral vascular disease	2050	20.68
Heart failure	420	112.72

a Ostrowska et al. [13].

b Average weighed costs obtained by multiplying expected number of patients by the corresponding clinical pathways.

c Arithmetic mean costs for a singular patient according to the designated clinical pathways.

Table 3. Prevalence and incidence of diabetes recorded in the national diabetes register.

Description	2012	2013	2014	2015	2016
Total number of DM cases	431,197	446,881	461,645	473,192	483,836
Patients with type-1 DM	28,108	27,886	27,193	26,259	25,426
Patients with type-2 DM	397,154	413,331	428,972	441,199	452,490
New cases of type-1 DM	1474	1982	1722	1613	1538
New Cases of type-2 DM	72,973	75,120	75,447	71,948	713,31

Table 4. Percentage of patients with body mass index above 30.

BMI (as per available data)	2013	2014	2015	2016	2017
>30	23.79	24.01	24.06	23.76	24.05
>35	11.22	11.32	11.58	11.85	12.39

Table 5. Percentage of patients with HgA1c below 7%.

Indicator	2012	2013	2014	2015	2016
Patients with HgA1c below 7% with type 1 DM (%)	24.6	23.89	27.69	33.88	32.44
Patients with HgA1c below 7% with type 2 DM (%)	41.68	40.05	42.52	44.13	43.91

Table 6. Characteristics of the cohort of patients with two measures of HgA1c.

Demographics	Year
	2012	2013	2014	2015	2016
Total number of diabetics with at least two measurements of HbA1c	92,748	103,592	107,477	127,916	155,288
Men	41,882	46,913	48,490	58,219	10,430
Women	50,866	56,679	58,987	69,697	144,858
Average age (SD)	63 (13.06)	63 (13.08)	63.02 (13.02)	63 (9.6)	64 (9.5)
Type of diabetes
Type 1 diabetes (ICD code е10)	10,784	11,133	10,390	10,056	10,430
Type 2 diabetes (ICD code е11)	81,669	92,110	96,703	117,417	144,048
Malnutrition diabetes (ICD code е12)	3	3	2	3	3
Other identified diabetes (ICD code е13)	6	15	9	8	18
Other unidentified diabetes (ICD code е14)	286	331	373	432	790
HbA1c-1 (SD)	7.63 (1.88)	7.6 (1.82)	7.501(1.81)	7.5 (1.34)	7.4 (1.35)
HbA1c-2 (SD)	7.59 (1.85)	7.5 (1.77)	7.45(1.75)	7.4 (1.32)	7.3 (1.32)
HBA1c-average diff. (SD)	0.05 (1.11)	0.08 (1.23)	0.048 (1.2)	0.06 (0.59)	0.07 (0.46)
Number of patients with increases in HbA1c	15,509	26,863	25,135	33,154	32,135
Number of patients with decreases in HbA1c	17,869	22,364	26,812	29,071	26,360
Number of patients with no change	59,370	54,365	55,530	65,691	96,793
Average increase (SD)	1.24 (0.35)	1.3 (1.33)	1.26 (0.81)	1.2 (0.87)	1,19 (0.89)
Average decrease (SD)	1.33 (0.88)	0.08 (1.23)	1.14 (0.93)	1.1 (0.8)	1.04 (0.77)

Table 7. Reduction in relative risk (RR) of various diabetes-related complications.

Diabetes-related complications	2012	2013	2014	2015	2016	Total mean reduction in RR (%) for the whole period
Any diabetes-related endpoint	28	2	24	23	22	19.8
Diabetes related death	28	2	24	23	22	19.8
All-cause mortality	19	1	16	15	15	13.2
Fatal and non-fatal myocardial infarction	19	1	16	15	15	13.2
Fatal and non-fatal stroke	16	1	14	13	13	11.4
Microvascular endpoints	49	3	42	40	39	34.6
Cataract extraction	25	2	22	21	20	18
Amputation or death from peripheral vascular disease	57	3	49	47	45	40.2
Heart failure	21	1	18	18	17	15
Total mean reduction	29.1	1.8	25.0	23.9	23.1	20.6

Table 8. Mean number of prevented complications for the observed period.

Diabetes-related complications	2012	2013	2014	2015	2016	Total mean number of prevented diabetes incidents for all years
Any diabetes-related endpoint	224	281	337	365	331	1538
Diabetes related death	83	104	125	136	123	572
All-cause mortality	77	96	115	125	113	526
Fatal and non-fatal myocardial infarction	75	93	112	121	110	512
Fatal and non-fatal stroke	17	21	25	27	25	114
Microvascular endpoints	179	224	268	291	264	1225
Cataract extraction	24	30	36	39	35	164
Amputation or death from peripheral vascular disease	44	56	67	72	65	304
Heart failure	16	20	24	26	23	109
Total mean number of prevented incidents for the whole period	739	925	1109	1202	1090	5065

Table 9. Cost of prevented complications.

Diabetes-related complications	Costs for hospital treatment (BGN)	Costs for ambulatory treatment (BGN)	Total mean number of prevented incidents for the period	Total costs (BGN)
Any diabetes-related endpoint	600	427.92	1538	158,0941
Diabetes-related death	600	0	572	343,200
All-cause mortality	2134	0	526	1,122,484
Fatal and non-fatal myocardial infarction	200	51.22	512	128,624.6
Fatal and non-fatal stroke	650.56	43.13	114	79,080.66
Microvascular endpoints	744	36.38	1225	955,965.5
Cataract extraction	360	10.08	164	60,693.12
Amputation or death from peripheral vascular disease	2050	20.68	304	629,486.7
Heart failure	420	112.72	109	58,066.48
Total mean number of prevented incidents for the whole period			5065	4,958,542

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