Economic impact of severe and non-severe hypoglycemia in patients with Type 1 and Type 2 diabetes in the United States

Figures & data

Figure 1. Direct cost calculation model. R₁ to R_N = resource 1 to resoure N; frq R1 to frq R_N = frequency of resource utilization 1 to N.

Table 1. Unit costs for medical resources included in the hypoglycemia model.

Resource type	Costs	Comment	Source
Secondary care
ER visit	$43.67	For physician – 99283 – emergency department visit – medium intensity	Medicare 2012 Physician Fee Schedule
	$139.14	For the hospital – Ambulatory Payment Classification (APC) 614	Addendum B Medicare Outpatient Prospective Payment System for hospital outpatient services
	$182.81	Total fee from payer perspective for ER visit (sum of two costs above)
Ambulance	$214.47	Base rate for an ambulance (Basic Life Support) averaged across state localities	Medicare ambulance fee schedule
Inpatient	$7354.00	Diabetes with MCC	Medicare inpatient Prospective Payment System, FY2012 FR, Table 5 Weights
	$4171.00	Diabetes with CC
	$2811.00	Diabetes withoutCC/MCC
Inpatient with ER	See inpatient	Inpatient with ER is equal to inpatient (from a payer perspective). The ER visit would be folded into the subsequent inpatient admission.
Outpatient	$324.81	US insurance claims data	Curkendall et al.14; $285 inflated to 2012
Primary care
Visit to GP	$76.23	99203 – physician visit for a medium, new patient	Medicare 2012 Physician Fee Schedule
	$51.07	99213 – physician visit for medium, established patient
Home visit from GP	$93.26	99343 – physician visit at home for medium, new patient
	$59.46	99348 – physician visit at home for a medium, established patient
Nurse	$43.41	It is assumed that Nurse Practitioners or Clinical Nurse Specialists are providing these services. They are reimbursed at 85% of the physician fee	Medicare 2012 Physician Fee Schedule (85% of 99213 – physician visit for medium, established patient)
Telephone contact with medical care	$9.87	99441 Phone e/m by phys 5–10 min – $9.87	Medicare 2012 Physician Fee Schedule
	$19.00	99442 Phone e/m by phys 11–20 min – $19.00
	$28.13	99443 Phone e/m by phys 21–30 min – $28.13
Other
SMBG	$1.05	Average cost per testing strip	Yeaw et al.34; $0.98 inflated to 2012
Non HCP treatment (third-party assitance)	$55.02	Costs for intramuscular glucagon injection	US net effective sales price of replacement vials
Non HCP treatment (self-treatment)	$9.23	Extra/special groceries, food and drink and glucose products required following NSHE	Brod et al.6

ER, emergency room; GP, general practitioner; HCP, healthcare practitioner; SMBG, self-monitoring of blood glucose; MCC, major complications and comorbidities; CC, complications and comorbidities; e/m, evaluation and management; NSHE, non-severe hypoglycemic event.

Table 2. Outline of the direct medical cost calculations for NSEH, SHE1, and SHE2 (T1DM and T2DM).

Procedures/medical interventions	Resource frequency						Resource cost		Resource cost weights
	SHE2		SHE1		NSHE				SHE2	SHE1	NSHE
	%	Reference	%	Reference	%	Reference	Cost	Reference
Secondary care
ER visit	17.00%	Bullano et al.12	0.00%		0.00%		$139	Medicare 2012 Physician Fee Schedule +  Addendum B of OPPS	$24	$0	$0
Ambulance	21.32%	Leese et al.13	0.00%		0.00%		$214	2012 Medicare ambulance fee schedule	$48	$0	$0
Inpatient	0.00%		0.00%		0.00%		$4171	IPPS	$0	$0	$0
Inpatient with ER	24.00%	Bullano et al.12	0.00%		0.00%		$4171	IPPS	$1001	$0	$0
Outpatient	20.00%	Bullano et al.12	0.00%		0.00%		$325	Curkendall et al.14	$65	$0	$0
Primary care
Visit to GP	26.00%	Bullano et al.12	13.70%	Brod et al.6	13.70%	Brod et al.6	$51	US Medicare 2012 Physician Fee Schedule	$13	$7	$7
Home visit from GP	0.00%		0.00%		0.00%		$59		$0	$0	$0
Nurse	13.00%	Bullano et al.12	0.00%		0.00%		$43	85% of the physician visit based on US Medicare 2012 Physician Fee Schedule	$6	$0	$0
Telephone contact with medical care	0.00%		0.00%		0.00%		$19		$0	$0	$0
Other treatment
I.M. glucose injection	0.00%		100.00%	Jönsson et al.10	0.00%		$55	Average price of a Glucagon Emergency Kit replacement vial	$0	$55	$0
Number of extra  SMBG tests  post episode	3.90*	Brod et al.6	3.90*	Brod et al.6	3.90*	Brod et al.6	$1.05	Yeaw et al.34	$4	$4	$4
OOP per episode	0%		0%		%		$9.23	Brod et al.6	$0	$0	$0
Total direct costs*									$1161	$66	$11

ER, emergency room; GP, general practitioner; HCP, healthcare practitioner; SMBG, self-monitoring of blood glucose; OOP, out-of-pocket; OPPS, Medicare Outpatient Prospective Payment System; IPPS, Medicare Inpatient Prospective Payment System; I.M, Intramuscular.

*Number of extra SMBG tests per event.

*Total direct event costs = Σ (resource frequency (i) × resource cost (i)).

Figure 2. Indirect cost calculation model. P₁ to P₄ = four day and night time periods; frq P₁ to P₄ = frequency during which events occur across periods; PL = productivity loss; WPL = weighted productivity loss; PL/event = total productivity loss per event.

Table 3. Indirect cost calculation.

	PSF (NSHE) Brod et al.6	NSHE (T1DM & T2DM) Brod et al.6		PSF (SHE) Gold et al.22	SHE1 T1DM Davis et al.21		SHE1 T2DM Davis et al.21		SHE2 T1DM Davis et al.21		SHE2 T2DM Davis et al.21
		PSPL	WPL		PSPL	WPL	PSPL	WPL	PSPL	WPL	PSPL	WPL
08:00–13:00	17.59%	0.14	0.024	16.0%	2.9	0.464	2.70	0.432	3.6	0.576	8.6	1.376
13:00–18:00	17.59%	0.14	0.024	9.0%	2.9	0.261	2.70	0.243	3.6	0.324	8.6	0.774
18:00–00:00	38.86%	0.12	0.046	35.0%	2.9	1.015	2.70	0.945	3.6	1.260	8.6	3.010
00:00–08:00	25.95%	0.25	0.066	40.0%	1.6	0.640	2.50	1.000	3.6	1.440	8.6	3.440
Productivity loss/event (days)*			0.16			2.38		2.62		3.60		8.60
Indirect costs/event (USD)			$11			$160		$176		$242		$579

PSF, period-specific frequency; PSPL, period-specific productivity loss; WPL, weighted productivity loss; WPL = PSF * PSPL; NSHE, non-severe hypoglycemic event; SHE1, severe hypoglycemic event requiring non-medical assistance; SHE2, severe hypoglycemic event requiring medical assistance; SHE, severe hypoglycemic event requiring (any) assistance; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

*Productivity loss/event = Σ WPL.

Table 4. Direct, indirect, and total annualized costs of hypoglycemic episodes in T2DM individuals ($US).

	Direct costs	Indirect costs	Combined costs
Per event costs
NSHE	$11	$11	$22
SHE1	$66	$176	$242
SHE2	$1161	$579	$1740
Per patient annual costs
T2DM with diabetes duration <2 years
NSHE	$45	$44	$89
SHE1	$6	$16	$22
SHE2	$14	$7	$21
T2DM with diabetes duration >5 years
NSHE	$113	$110	$223
SHE1	$41	$109	$150
SHE2	$96	$48	$144

NSHE, non-severe hypoglycemic event; SHE1, severe hypoglycemic event requiring non-medical assistance; SHE2, severe hypoglycemic event requiring medical assistance; SHE, severe hypoglycemic event requiring (any) assistance; T2DM, type 2 diabetes mellitus.

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