Cost of severe hypoglycaemia in nine European countries

Figures & data

Figure 1. General modeling framework.

Table 1. Number of diagnosed and treated type 1 and type 2 diabetes mellitus patients.

	Bulgaria^27–29	Croatia^30–32	The Czech Republic^33–35	MK	Greece^34^,^35	Hungary	Poland^36^,^37	Slovenia	Spain^38
Total number of treated	435,911	217,431	829,099	67,695	491,933	539,085	1,813,255	96,290	3,293,794
Type 1 DM (%)	5.63	6.21	6.82	4.07	5.00	11.60	6.30	5.50	4.35
Below 20	12.32	18.69	3.10	9.98	12.76*	8.00	11.21	10.03	12.76*
20–64	63.62	75.38	79.05*	62.25	71.18*	59.00†	72.44*	83.46	71.18*
Above 65	24.06	5.93	17.85*	27.77	16.07*	33.00†	16.35*	6.51	16.07*
Type 2 DM (%)	94.37	93.79	93.18	95.93	95.00	88.40	93.70	94.50	95.65
Below 20	0.19	3.80	1.13*	0.07	1.00	0.10	0.43	0.47	4.07
20–64	39.10	47.20	43.60*	45.33	60.00	56.60†	46.84	42.77	33.78
Above 65	60.71	49.00	55.27*	54.60	39.00	43.30†	52.73	56.76	62.15

* Missing data on epidemiology were replaced with mean values of four other countries complete data, and scaled to sum up to 100%, where necessary.

† Calculated by adding or reducing by a half of range value of age 20–70 to receive proper age groups.

DM, diabetes mellitus; MK, Macedonia/the Former Yugoslav Republic of Macedonia.

Table 2. Market share of pre-defined drug regimens (%) and annual SHE rate for every treatment pattern (episode per pt.).

	Annual SHE rate	Bulgaria^39	Croatia	The Czech Republic	MK	Greece	Hungary	Poland	Slovenia	Spain
Type 1 DM
BB (basal insulin analog)	0.472	14.00	90.00	69.00	55.86	83.00	30.00	27.23	50.55	66.59
BB (basal insulin human)	1.084	24.00	8.00	23.00	5.30	5.00	48.89	28.90	28.57	9.95
insulin pump	0.168	0.10	1.50	1.00	7.26	8.00	3.33	31.61	18.88	8.06*
pre-mix insulin analog	1.084	35.30	0.00	3.99	31.58	2.50	4.44	5.68	1.00	9.50*
pre-mix insulin human	1.628	26.60	0.50	3.01	0.00	1.50	13.33	6.58	1.00	5.91*
Type 2 DM
BOT analog (±OADs)	0.113	1.21	1.00	3.89	9.79	6.50	1.14	0.70	3.27	12.21
BOT human (±OADs)	0.173	2.42	1.00	1.16	4.43	1.20	1.37	4.18	1.85	1.83
BB (basal insulin analog) (±OADs)	0.080	3.62	10.00	5.11	5.23	10.00	7.40	0.69	4.12	5.96
BB (basal insulin human) (±OADs)	0.554	3.62	0.50	6.00	0.40	2.00	10.59	3.37	2.33	0.89
Pre-mix insulin analog (±OADs)	0.092	7.25	21.00	3.88	20.96	11.00	1.82	9.58	15.40	8.93*
Pre-mix insulin human (±OADs)	0.299	7.03	0.50	4.20	3.50	2.30	2.96	14.44	1.30	5.86*
Sulfonylureas (±OADs)	0.045	24.15	26.00	34.09	17.84	28.50	43.39	30.71	47.62	29.36*
OADs (excl. SU, no insulin)	0.0035	50.71	40.00	41.67	37.85	38.50	31.32	36.33	24.10	34.96*

* Missing data on market share were replaced with means of nine other countries complete data, scaled to sum up to 100%, where necessary.

BB, basal-bolus; BOT, basal therapy combined with oral anti-diabetic medication; DM, diabetes mellitus; MK, Macedonia/the Former Yugoslav Republic of Macedonia; OADs, other anti-diabetic drugs; SHE, severe hypoglycemia event; SU, sulfonylurea.

Table 3. Resources usage and quantity of units used per hospital, medical professional, and family treated SHE (% of cases, number of units used per patient).

	Bulgaria^41	Croatia	The Czech Republic^5	MK	Greece	Hungary	Poland	Slovenia	Spain
Hospital treated SHEs
Hospital stay [stay]	100%, 1	100%, 1	100%, 1	100%, 1	100%, 1	100%, 1	100%, 1	100%, 1	100%, 1
Ambulance [trip]	100%, 1	45%, 1	100%, 1	50%, 1	90%, 1	28%, 1	34%, 1	nd	90%, 1
Glucose in blood serum [test]			100%, 2		HC	28%, 1			HC
Glucose injection [inj.]	HC
Glucagon [inj.]	HC
Haemoglobin A1c in serum [sample]			100%, 2		HC	27%, 1			HC
SMBG [strip]	100%, 2	LS	LS		HC	28%, 1		HC	HC
GP [visit]					HC	28%			HC
Emergency room [visit]					HC	28%		nd	HC
Medical professional treated SHEs
Emergency room [visit]	70%, 1	55%, 1		80%, 1	45%, 1	50%, 1	33%, 1	15%, 1	45%, 1
GP [visit]	30%, 1	35%, LS	5%, 1	10%, 1	20%, 1	50%, 1	17%, 1		20%, 1
GP home [visit]		3%, 1	2%, 1	5%, 1	0%, 1		17%, 1		0%, 1
GP call [call]				30%, 1
Specialist [visit]		7%, 1	30%, 1	60%, 1	35%, 1				35%, 1
Ambulance [trip]		30%, 1	63%, 1	5%, 1	0%, 1	27%, 1	30%, 1	85%, 1	0%, 1
SMBG [strip]	100%, 2				90%, 1	28%, 1			90%, 1
Blood glucose in serum [sample]			13%, 2	100%, 2	40%, 1	27%, 1			40%, 1
Glucose injection [inj.]	HC			90%, 7
Glucagon [inj.]	50%, 1			10%, 1
Haemoglobin A1c in serum [sample]			13%, 2		0%, 1	27%, 1			0%, 1
Family treated SHEs
SMBG [strip]	100%, 2	LS	LS	100%, 2	100%, 1	37%, 1	100%, 1		100%, 1
Glucagon [inj.]	20%, 1	1%, 1	5%, 1	15%, 1	1%, 1		30%, 1		1%, 1

GP, general practitioner; HC, included in the hospital costs; inj., injection; LS, lump sum; MK, Macedonia/the Former Yugoslav Republic of Macedonia; nd, no data; SHEs, severe hypoglycemic events; SMBG, Self-Monitoring of Blood Glucose.

Table 4. Resource unit prices for public payer (€).

	Bulgaria	Croatia^40^,^41	The Czech Republic^42^,^43	MK	Greece	Hungary	Poland^44	Slovenia	Spain^45–48
GP visit [visit]	10.00	2.64	6.22	Capitation system	10.00	Capitation system	4.84		27.76
Emergency room visit [visit]	25.00	76.55	34.93	12.85 (1.32*)	50.00	0.87	7.80	100.81†	550.56
GP home visit [visit]		8.88	2.23	Capitation system (1.65*)	30.00	Capitation system	16.26		36.93
Specialist visit [visit]		12.29	12.22	7.91 (0.66*)	50.00				104.47
Ambulance [trip]	25.00	15.87	43.85	18.12	50.00	81.74	150.40	175.40‡	460.04
Hospital stay [stay]	254.00	702.12	583.88	476.86 (44.49*)	731.00	274.88$	514.00	1175.78¶	662.01
Glucose injection [inj.]	4.00			0.52
SMBG [strip]	0.00		0.00	0.06	0.64	0.17	0.24		0.25
Glucose in blood serum [test]			1.49	0.12	1.40	0.18			0.47
Glucagon [inj.]	15.70		23.90	0.12	16.80		15.06		21.46
Haemoglobin A1c in serum [sample]		14.65	4.97	12.57	5.70	4.45			8.02

* price for patient.

† weighted average cost of one visit to Emergency room at primary level, calculated from the very wide range of data (24 centers reported costs from 0–140 EUR/visit, 75 visits in total), average =61.63 EUR, median =50 EUR⁵¹.

‡ weighted average cost of one intervention in the filed which includes transportation, medication, and medical team, etc. Calculated from the very wide range of data (24 centers reported costs from 60–547.40 €/intervention, 420 interventions in total), average =177.79, median =129.60⁵¹.

$ regarding there is no possibility to distinguish costs due to age, the average value of all cost was used, the cost of hospitalization under age of 14 was only skipped because of less frequent SHE prevalence in this group.

¶ database of hospitalizations in 2011 at the National Institute of Public Health of Republic of Slovenia (NIPHRS) was searched. The most conservative approach when only cases of hospitalizations due to hypoglycemia and attributed to diabetes are taken into account. In the less conservative approach, taking into account cases that might be attributed to diabetes, the weighted mean is 1609.89 EUR⁵².

GP, general practitioner; inj., injection; MK, Macedonia/the Former Yugoslav Republic of Macedonia; SMBG, Self-Monitoring of Blood Glucose.

Table 5. Direct and overall societal costs per single SHE (€).

	Bulgaria	Croatia	The Czech Republic	MK	Greece	Hungary	Poland	Slovenia	Spain
HT SHE cost	279.00	709.26	640.65	530.41	776.00	300.28	565.81	1175.78	1076.05
PT SHE cost	30.35	47.99	33.37	22.25	43.14	23.97	56.21	164.21	209.28
FT SHE cost	3.14	0.15	1.20	2.00	0.81	0.06	4.76	0.00	0.46
Direct cost	36.71	81.52	72.12	59.20	87.53	35.33	72.17	153.84	172.33
Overall societal cost	42.36	91.89	85.39	62.99	106.96	48.05	85.74	178.94	193.83

FT, family treated; HT, hospital treated; MK, Macedonia/the Former Yugoslav Republic of Macedonia; PT, medical professional treated; SHE, severe hypoglycemia episode.

Table 6. Total costs of SHEs treatment in all countries (€).

	Bulgaria	Croatia	The Czech Republic	MK	Greece	Hungary	Poland	Slovenia	Spain
HT SHEs direct cost	1566,808.77	1184,188.22	6197,455.90	319,000.57	3129,744.17	3182,788.12	13,287,748.74	1053,427.13	32,339,530.58
PT SHEs direct cost	381,223.96	179,224.10	721,975.38	29,930.17	389,131.77	568,366.27	2952,394.18	329,072.59	19,513,354.64
FT SHEs direct cost	119,791.87	1,661.85	78,542.88	8181.26	22,138.31	4511.18	759,421.96	0.00	94,856.70
Total direct cost	2067,824.60	1365,074.17	6997,974.16	357,112.00	3541,014.25	3755,665.57	16,999,564.87	1382,499.72	51,947,741.91
HT SHEs indirect cost	236,823.85	129,401.77	958,770.49	17,012.25	585,213.86	1007,908.73	2380,870.39	167,998.81	4828,198.89
PT SHEs indirect cost	27,488.55	15,019.88	111,286.12	1974.64	67,926.77	116,989.68	276,351.67	19,499.91	560,417.25
FT SHEs indirect cost	53,627.81	29,302.51	217,109.75	3852.36	132,519.31	228,236.91	539,138.59	38,042.66	1093,326.35
Total indirect cost	317,940.21	173,724.17	1287,166.36	22,839.25	785,659.97	1353,135.32	3196,360.65	225,541.38	6,481,942.49
Overall societal cost	2385,764.81	1538,798.34	8285,140.52	379,951.25	4326,674.21	5108,800.89	20,195,925.52	1608,041.10	58,429,684.40
Total direct cost per diabetic patient	4.74	6.28	8.44	5.28	7.20	6.97	9.38	14.36	15.77
Total overall societal cost per diabetic patient	5.47	7.08	9.99	5.61	8.80	9.48	11.14	16.70	17.74

FT, family treated; HT, hospital treated; MK, Macedonia/the Former Yugoslav Republic of Macedonia; PT, medical professional treated; SHEs, severe hypoglycaemia episodes.

Figure 2. Between-country comparison of costs and its components (BG = Bulgaria, CR = Croatia, CZ = the Czech Republic, MK = Macedonia/the former Yugoslav Republic of Macedonia, GR = Greece, HU = Hungary, PL = Poland, SI = Slovenia, ES = Spain).

Jankowski M, Bała MM, Płaczkiewicz-Jankowska E, et al. Specialty outpatient care of diabetic patients in Poland-are we far from treatment targets? Rationale, design, and preliminary results of the OPTIMO study. Pol Arch Med Wewn 2011;121:375-8

 PubMed Web of Science ®Google Scholar

Wittek A, Sokalski B, Grzeszczak W, et al. Prevalence of diabetes and cardiovascular risk factors of industrial area in southern Poland. Exp Clin Endocrinol Diabetes 2009;117:350-3

 PubMed Web of Science ®Google Scholar

Soriguer F, Goday A, Bosch-Comas A, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Diabetes Study. Diabetologia 2012;55:88-93.

 PubMed Web of Science ®Google Scholar

Doneva M, Valov V, Borisova AM, et al. Comparative analysis of the cost of insulin treated patients in Bulgaria. Biotechnol Biotec Eq 2013;27:3748-52

 Web of Science ®Google Scholar

Croatian Health Insurance Fund. Health services price list and codebook. http://www.hzzo-net.hr/04_01_08.php. Accessed October 2012

 Google Scholar

Business Report of Croatian Health Insurance Fund for 2011. Zagreb: Croatian Health Insurance Fund, 2012

 Google Scholar

“Public Note of the Czech Ministry of Health no.134/1998, Coll.ofActs,” and “Public Note of the Czech Ministry of Health no.396/2010, Coll. Of Acts,” Ministerstvo Zdravotnictví České Republiky (Ministry of Health of the Czech Republic). http://www.mzcr.cz. Accessed November 2013

 Google Scholar

Ahrén B. Avoiding hypoglycemia: a key to success for glucose-lowering therapy in type 2 diabetes. Vasc Health Risk Manag 2013;9:155-63

 PubMedGoogle Scholar

Státni ústav pro kontrolu léčiv (State Institute for Drug Control). http://www.sukl.eu. Accessed November 2013

 Google Scholar

National Health Found. 2013 Contract Guide. http://www.nfz.gov.pl/new/index.php. Accessed January 2013

 Google Scholar

Antoñanzas F, Brenes F, Molero JM, et al. Cost-effectiveness of the combination therapy of dutasteride and tamsulosin in the treatment of benign prostatic hyperlasia in Spain. Actas Urol Esp 2011;35:65-71

 PubMed Web of Science ®Google Scholar

Hammer M, Lammert M, Mejías SM, et al. Costs of managing severe hypoglycaemia in three European countries. J Med Econ 2009;12:281-90

 PubMedGoogle Scholar

Český Statistický Úřad (Czech Statistical Office). http://www.czso.cz. Accessed October 2012

 Google Scholar

Hungarian Central Statistical Office (HCSO). https://www.ksh.hu/docs/hun/xftp/gyor/let/let21412.pdf. Accessed October 2012

 Google Scholar