The economic costs of diabetes: a population-based study in Tehran, Iran

Aim/hypothesis  The aim of the study was to determine the annual healthcare expenditures of an individual with diabetes in Tehran, between March 2004 and March 2005. Methods  This prevalence-based ‘cost-of-illness’ study was conducted in two phases. In the first phase, 23,707 randomly selected individuals were interviewed to gather a cohort of participants with diabetes. In the second phase, 710 diabetic patients and 904 age- and sex-matched controls were followed up for 1 year at intervals of 3 months and the direct (physician services, medications and devices, hospitalisation, laboratory, paraclinical and transport) and indirect (loss of productivity) expenditures were recorded. The excess costs of a person with diabetes were estimated through comparison with matched controls. The estimates were also extrapolated to the total population of Tehran and Iran. The costs were converted from the Iranian rial to the US dollar (exchange rate September 2004). Results  Total annual direct costs of diabetic and control participants were $152.3 ± 14.5 and $52.0 ± 5.8, respectively, which is indicative of 2.92 times higher costs in diabetic patients. The most expensive components of direct costs were medications and devices, and hospitalisation in diabetic patients (28.7% and 28.6%, respectively). Total indirect costs were $39.6 ± 2.4 and $16.7 ± 1.1 in diabetic and non-diabetic individuals. The aggregate annual direct costs of diabetes were estimated to be $112.424 ± 10.732 million and $590.676 ± 65.985 million in Tehran and Iran, respectively. Diabetes complications contributed 53% of the aggregate excess direct costs of diabetes. Conclusions/interpretation  Diabetes is an expensive medical problem in Iran and planning of national programmes for its control and prevention is necessary.     

Albumin dialysis in cirrhosis with superimposed acute liver injury: possible impact of albumin dialysis on hospitalization costs

Abstract Albumin dialysis using the Molecular Adsorbents Recirculating System (MARS) has been found to be beneficial in the treatment of cirrhotic patients with acute decompensation to improve survival as well as reduce associated complications. The present study attempts to analyze the costs involved, and compare it to the benefit as a result of the MARS therapy, thus evaluating its cost‐effectiveness. Using the results of a study by Kim et al. (Hepatology 2001) describing the effects of complications on the cost of hospitalization in alcoholic liver disease patients, the expenditure incurred in a group of 11 patients treated with standard medical therapy (five survivors) and a group of 12 patients treated with MARS in addition (11 survivors) (Heemann et al., Hepatology 2002) were analyzed. MARS resulted in a reduction of in‐hospital deaths, as well as liver disease‐related complications. Both these factors led to a substantial reduction of costs in the MARS group, which was enough to counterbalance the extra costs associated with extra‐corporeal therapy. In the control group, the total hospitalization cost per survivor were calculated to be at $35 904. In the MARS group, the overall expenditure per survivor including standard medical therapy plus additional MARS liver support therapy were $32 036 – a saving of nearly $4000 compared to the control group. Therefore, it appears that the benefits of MARS therapy are enough to justify the cost of treatment and safe hospital costs, at least in the described population. However, further studies are needed to confirm these results.     

Neuropsychiatric disorders in HIV infection: impact of diagnosis on economic costs of care

BACKGROUND: HAART is associated with a growing prevalence of HIV-associated neuropsychiatric disorders (NPD) despite improved overall survival. OBJECTIVE: To investigate the added direct costs of medical care for patients with and without NPD. METHODS: Nine dimensions of patient-specific costs [as costs per patient per month (CPM)] were followed prospectively between 1997 and 2003 in a community-based HIV/AIDS clinic for HIV-1-seropositive patients with a diagnosis of NPD (n = 188) and without (n = 153). Patients with NPD were stratified into subgroups of cognitive impairment (CI), peripheral neuropathies (PN), or other neuropsychiatric disorders (OND). RESULTS: Compared with the non-NPD group ($916), patients in the NPD group showed an increased mean CPM during the 12-month intervals immediately preceding and subsequently following NPD diagnosis [$1371 (P < 0.001) and 1463 US dollars (P < 0.001), respectively], but not at 18 months prior to diagnosis (1061 US dollars; P > 0.05). Intragroup comparisons between 12 month post-diagnosis and 18 month pre-diagnosis showed a mean CPM increased of 67% (1613 US dollars; P < 0.001) with CI, 31% (1490 US dollars; P < 0.01) with PN, and 33% (1362 US dollars; P < 0.01) with OND. Increased numbers of clinic and physician visits, non-antiretroviral drugs and home care accounted for the higher mean CPM (P < 0.05) both pre-and post-diagnosis within the NPD group. CONCLUSIONS: Neuropsychiatric disorders in patients with HIV/AIDS increase medical costs both before and after diagnosis, primarily owing to the management of the neuropsychiatric illness. Cost analyses offer useful measures of evolving patient needs, and provide a basis for allocation of healthcare resources.     

Management of diabetes in dialysis patients

Diabetes mellitus is the most common cause of kidney disease worldwide, and of end-stage renal disease (ESRD) in the United States and elsewhere. Mortality rates of patients with diabetes mellitus (DM) on chronic dialysis exceed those of non-DM patients. ESRD and dialysis add to the complexity of glycemic management in this population. Abnormal glucoregulation includes reduced insulin sensitivity and renal clearance of the hormone. Implementation of dialysis affects glucose and insulin levels, while increasing insulin sensitivity. Tight glycemic control carries an increased risk of hypoglycemia in ESRD. Monitoring glycemic control with hemoglobin A_1c (HbA_1c) levels may be suboptimal because of analytical and clinical variability of the test. Recent studies on HbA_1c and clinical outcomes in this population present complementary results on the role of glycemic control in patients with DM with ESRD.     

Tuberculous peritonitis in different dialysis patients in Southern Taiwan

Eleven cases of tuberculous peritonitis (TBP) in hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients at the Kaohsiung Veterans General Hospital in Kaohsiung, Taiwan between 1991 and 2000 were studied retrospectively (six cases in the HD group and five cases in the CAPD group) The diagnosis of TBP was established by either positive ascite tuberculosis (TB) culture or biopsy-proven chronic granulomatous inflammation. Fever and abdominal pain were the most common symptoms, while leukocytosis and unexplained hypercalcemia were the most common laboratory findings. Ascite analysis showed a lymphocyte predominance in all HD patients, but in only 40% of the CAPD patients. The mean duration of a diagnosis by ascite TB cultures was six weeks, while a diagnosis confirmed by laparascopic biopsy took one week. All four fatal cases were diagnosed by TB cultures. Laparoscopic biopsy provided a rapid diagnosis and resulted in low morbidity and mortality in our patients. Based on our review of all possible abstracts found in a Medline search from 1966 to 2002 using the keywords tuberculosis, peritonitis, uremia, and dialysis, this may be the first study of TBP in different dialysis patients.     

Predicting factors associated with costs of diabetic patients in Taiwan

This study examined healthcare costs for medication-using diabetic patients in Taiwan and predicted which factors were associated with costs. We analyzed claims data from the National Health Insurance (NHI) program in Taiwan from 1998 to 1999. The approach included estimates of costs attributable to diabetes, diabetes-related complications, comorbidity incurred by diabetic patients. A multiple regression model was used to assess the contribution of patients' characteristics in 1998 on outpatient, inpatient, and total costs in 1998 and 1999. The prevalence of medication-using patients with diabetes was 2.6% in 1998 and 2.8% in 1999. Costs of healthcare were 13.3% of total costs of NHI in 1998 versus 13.0% in 1999. Health services delivered near the end of life consumed large portions of medical dollars. The three most prevalent clinical associations of diabetes were congestive heart failure, neuropathy, and ischemic heart disease. Adjusted for demographic and clinical characteristics in 1998, this model could explain 8.0, 9.3, and 12.5%, respectively, of the cost variation in outpatient, inpatient, and total costs in 1999.     

Management of diabetes mellitus in dialysis patients: Obstacles and challenges

Background and aimsDiabetic kidney disease (DKD) is a major health issue that is associated with an increased risk of morbidity and mortality. The treatment of DKD is challenging given changes in blood glucose homeostasis, unclear accuracy of glucose metrics, and altered kinetics of the blood glucose-lowering medications. There is uncertainty surrounding the optimal glycemic target in this population although recent epidemiologic data suggest that HbA1c ranges of 6–8%, as well as 7–9%, are associated with increased survival rates among diabetic dialysis patients. Furthermore, the treatment of diabetes in patients maintained on dialysis is challenging, and many blood glucose-lowering medications are renally metabolized and excreted hence requiring dose adjustment or avoidance in dialysis patients.Methodology: PubMed, Google Scholar, and Medline were searched for all literature discussing the management of diabetes in dialysis patients.ResultsThe literature was discussed under many subheadings providing the latest evidence in the treatment of diabetes in dialysis patients.ConclusionThe management of diabetes in dialysis is very complex requiring a multi-disciplinary team involving endocrinologists and nephrologists to achieve targets and reduce morbidity and mortality.     

The importance of delirium: economic and societal costs

Although a number of studies have documented the negative clinical and economic consequences of delirium, interventions to prevent and treat delirium are infrequently implemented. The importance of delirium may continue to be underestimated until its societal and economic effects are documented. The current article outlines the existing literature related to long-term sequelae and costs associated with delirium and stresses the importance of such research in prompting recognition, prevention, and treatment efforts that could reduce the effect of delirium and improve quality of life for older adults and their caregivers.     

The impact of hepatitis C virus infection on survival in dialysis patients: meta-analysis of observational studies

The impact of hepatitis C virus (HCV) infection on mortality of patients receiving regular dialysis remains unclear. The assessment of the natural history of HCV in dialysis population is difficult because of the low progression of HCV-related liver disease over time and the reduced life expectancy in patients with end-stage renal disease. The aim of the study was to conduct a systematic review of the published medical literature concerning the impact of HCV infection on the survival of patients undergoing maintenance dialysis. The relative risk of mortality was regarded as the most reliable outcome end-point. Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates for mortality with HCV across the published studies. We identified seven studies involving 11 589 unique patients on maintenance dialysis; two (29%) were case-control studies. Pooling of study results demonstrated that presence of anti-HCV antibody was an independent and significant risk factor for death in patients on maintenance dialysis. The summary estimate for adjusted relative risk (aRR) (all-cause mortality) was 1.34 with a 95% confidence interval (CI) of 1.13-1.59. Heterogeneity statistics, R(i) = 0.48 (P-value by Q-test = 0.13). In a sensitivity analysis including only (n = 5) cohort studies, the pooled aRR was 1.38 (95% CI, 1.20-1.59); heterogeneity statistics R(i) = 0.46. As a cause of death, hepatocellular carcinoma and liver cirrhosis were significantly more frequent among anti-HCV-positive than -negative dialysis patients. Our meta-analysis indicates that anti-HCV-positive patients on dialysis have an increased risk of mortality compared with HCV-negative patients. The excess risk of death in HCV-positive patients may be at least partially attributed to chronic liver disease with its attendant complications.     

Assessing the impact of complications on the costs of Type II diabetes

AIMS/HYPOTHESIS: 'The Cost of Diabetes in Europe - Type II (CODE-2) study' provides the first coordinated attempt to assess the total costs of managing people with Type II (non-insulin-dependent) diabetes mellitus in Europe. Type II diabetes is associated with a number of serious long-term complications, which are a major cause of morbidity, hospitalisation and mortality in diabetic patients. METHODS: Patients were divided into four broad categories defining their complication status in terms of no complications, one or more microvascular complications, one or more macrovascular complications or one or more of each microvascular and macrovascular complication. The prevalence of complications and associated costs were assessed retrospectively for 6 months. RESULTS: In total, 72% of patients in the CODE-2 study had at least one complication, with 19% having microvascular only, 10% having macrovascular only and 24% of the total having both microvascular and macrovascular complications. Of patients with microvascular complications, 28% had neuropathy, 20% renal damage, 20% retinopathy and 6.5% required treatment for eye complications. Among the patients with macrovascular complications, 18% had peripheral vascular disease, 17% angina, 12% heart failure and 9% had myocardial infarction. Percutaneous transluminal coronary angioplasty, coronary artery bypass graft or stroke occurred in 3%, 4% and 5% of the patients, respectively. In patients with both microvascular and macrovascular complications, the total cost of management was increased by up to 250% compared to those without complications. CONCLUSION/INTERPRETATION: Complications have a substantial impact on the costs of managing Type II diabetes. This study has confirmed that the prevention of diabetic complications will not only benefit patients, but potentially reduce overall healthcare expenditure.     

The impact of new comorbidities on nutritional status in continuous ambulatory peritoneal dialysis patients

OBJECTIVE: To study the prevalence and risk factors for malnutrition in a peritoneal dialysis (PD) center with an active PD program. METHODS: We assessed the nutritional status in 205 continuous ambulatory peritoneal dialysis (CAPD) patients, including stable and unstable patients, by subjective global assessment (SGA), dietary diaries and biochemistry index. Serum C-reactive protein (CRP) levels were examined as inflammatory marker. Fluid status including extracellular water (ECW), intracellular water, and total body water (TBW) was evaluated by multiple-frequency bioelectrical impedance analysis and brachial blood pressure was measured. New comorbidities included systemic infection, congestive heart failure and trauma that occurred within 1 month or less. Cardiovascular disease (CVD) was recorded too. Dialysis adequacy and residual renal function were calculated by a standard technique. RESULTS: Based on SGA, 15.6% of our CAPD patients were malnourished. The malnourished patients had advanced age, higher CRP and ECW/TBW levels than normally nourished patients (age: 68.78 +/- 11.92 vs. 59.26 +/- 13.46 years, p = 0.001; CRP: 11.98 +/- 20.22 vs. 5.56 +/- 8.30 mg/l, p = 0.004; ECW/TBW: 0.55 +/- 0.16 vs. 0.52 +/- 0.04, p = 0.049). Patients with malnutrition were more prone to have CVD (53.13 vs. 31.79%, p = 0.004) and new comorbidities (65.62 vs. 4.62%, p = 0.023). Multivariate analysis showed new comorbidities, mostly systemic infection, which were associated with nutritional status (p < 0.001). Both ECW/TBW and new comorbidities were associated with serum CRP, CVD and malnutrition (p < 0.001-0.05). In contrast, some traditional factors which were recognized as contributing to malnutrition such as residual renal function, dialysis adequacy, metabolic acidosis, total protein loss, diabetes and Charlson indexes were not different between normally nourished and malnourished patients in the present study. CONCLUSIONS: Our results suggest that only 15.6% of patients were malnourished in our PD program. Old age, inflammation, CVD, fluid overload and new comorbidities were all associated with malnutrition, with new comorbidities, mostly systemic infections, being the most significant risk factor. However, many traditional factors such as residual renal function, dialysis adequacy and diabetes were not.