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This retrospective, non-interventional study aimed to quantify the resource use associated
with a severe hypoglycemic event (SHE), using the Maccabi Healthcare Service (MHS)
database to compare overall healthcare utilization per patient in the month pre vs post
SHE. MHS, a large health maintenance organization in Israel, maintains a comprehensive
database of health services used by its 2 million members. Patients with diabetes were
included if they had at least 1 SHE, identified by diagnosis codes in the database from
2005–2014. A total of 4376 patients were included: 6.4% T1D, 75.2% T2D and 18.4%
diabetes type unknown. Mean characteristics of the study population: age 64.5 yrs, A1c
7.4%, BMI 29.5 kg/m2, 47.9% male and 42.9% insulin-treated. Diabetes duration (yrs)
was <5 in 20.4%, 5–9 in 45.2% and 10+ in 34.4% of cases. Hospital admissions increased
significantly (p<0.001) in the month following a SHE. Of those admitted to hospital (n=1418),
the mean duration of stay was significantly (p<0.001) longer the month post (5.59 d) vs pre
SHE (4.37 d). In this period outpatient visits increased 46% (12557 to 18441, p<0.001). The
greatest increases were visits to endocrinologists (+169%), nurses (+70%) and dieticians
(+66%). This real-world analysis indicates increased use of healthcare services, including
more frequent and prolonged hospital admissions and outpatient visits after a SHE.
Statistics
Duration of hospital stay was compared using paired Student’s t-test.
Chi-square was used to compare the number of hospitalizations.
Wilcoxon signed rank test was used to compare the number of
hospitalizations per patient, the days of hospitalization and the cost of
treatment.
McNemar test was used for the visits comparison.
Statistical significance was set at p<0.05.
Results
Introduction
Hypoglycemia is a common side effect associated with anti-hyperglycemic
therapy and is a burden for the patient and payer alike.
Severe hypoglycemia may require hospitalization and inpatient care,
leading to significant resource use and economic costs.1,2
The Maccabi Healthcare Services (MHS) is the second-largest Health
Management Organization (HMO) in Israel, serving 25% of the country’s
total population (~2 million members). Data from this HMO have been
used previously to investigate chronic diseases.3,4
The aim of this study was to quantify the resource use associated with
a severe hypoglycemic event (SHE) in patients with diabetes, using the
MHS database registry.
Out of more than 100,000 patients with diabetes in the MHS registry,
4376 patients were eligible for study inclusion: their characteristics at
baseline (time of SHE) are summarized in Table 1.
Overall, 6.4% had type 1 diabetes (T1D), 75.2% had type 2 diabetes
(T2D) and in 18.4% the diabetes type was undefined.
n
280
Age, years
Methods
This observational, retrospective, non-interventional study analyzed
anonymized patients’ electronic medical record (EMR) data to compare
resource use 1 month pre and post SHE.
The registry included any patient with one or more of the following
criteria: HbA1c ≥7.25%, blood glucose (BG) ≥200 mg/dL, a preceding
diagnosis of diabetes together with a measurement of HbA1c ≥6.5% or
BG >125 mg/ dL, and those who purchased ≥2 monthly packs of antihyperglycemic medication during a 6-month period.
Patients were included if they were identified as having at least one SHE.
SHE were identified by International Classification of Diseases version 9
(ICD-9) codes in the MHS registry from 2005–2014.
T1D
Males, %
29.6 ± 6.6
52.5
Duration of diabetes, years:
<5
5–9
10+
BMI (kg/m )
2
HbA1c, % (most recent prior to SHE)
34.6%
46.1%
19.3%
25.5 ± 4.6
7.9 ± 1.8
Table 2 Number of hospitalization episodes.
Total no.
of episodes
1 month
pre SHE
1 month
post SHE
Change (%)
p-value
Total
1861
557
1304
134.1
<0.001
Non-surgical
1710
494
1216
146.2
<0.001
Surgical
151
63
88
39.7
0.060
T1D
67
23
44
91.3
NS
T2D
1407
433
974
124.9
<0.001
Diabetes type unknown
387
101
286
183.2
<0.001
Analysis conducted using a Chi square test. NS, not significant; T1D, type 1 diabetes; T2D, type 2 diabetes; SHE, severe
hypoglycemic event.
Figure 1 Proportion of patients who had hospital admissions pre and
post SHE.
Table 1 Study population characteristics.
Characteristic
At baseline, 42.9% of patients were insulin-treated, 60.5% were
treated with oral drugs that may cause hypoglycemia (sulfonylureas
or meglitinides) and 67.6% used oral drugs not known to cause
hypoglycemia (metformin, gliptins, glitazones and acarbose).
The number of hospital admissions increased significantly (by 134%,
p<0.001) in the month following a SHE (Table 2) and the proportion of
patients with 1, 2 or 3+ hospital admissions also increased significantly
(Figure 1).
The proportion of patients with T1D hospitalized once increased 1 month
post SHE but there was no increase in the number of patients requiring
2 or 3 hospitalizations.
T2D
3289
67.5 ± 11.7
47.8
25.6%
49.6%
24.8%
29.9 ± 5.5
7.2 ± 1.4
Diabetes type
unknown
807
63.8 ± 12.1
46.8
25.3%
47.5%
27.3%
29.2 ± 5.9
7.9 ±1.4
All
90
4376
64.5 ± 14.7
47.9
20.4%
45.2%
34.4%
29.5 ± 5.6
7.4 ± 1.5
Cardiac comorbidity – yes
5.0%
44.6%
45.2%
42.2%
Hypertension comorbidity – yes
8.6%
79.4%
70.5%
73.3%
Data are mean ± standard deviation, unless otherwise specified. BMI, body mass index; T1D, type 1 diabetes; T2D, type 2
diabetes; SHE, severe hypoglycemic event.
*
100
Proportion of patients (%)
Abstract
Patients were excluded if they were <18 years, were diagnosed with
diabetes for <12 months or had <12 months follow-up after their SHE.
Data collected by the MHS included overall as well as detailed health
utilization data per patient.
Costs were assessed for different healthcare services according to The
Israeli Ministry of Health price list in New Israeli Shekel and have been
converted to $US.
80
1 month post SHE
74.5
70
60
50
40
*
30
22.1
20
9.8
10
0
*
1.1
0
*
2.7
1
2
Number of hospital admissions
Table 3 Number of hospitalization episodes.
N
Pre SHE
Post SHE
Change (%)
p-value
Total
1418
4.37 ± 4.38
5.59 ± 9.74
27.91
0.002
T1D
58
3.94 ± 3.65
3.95 ± 3.88
0.25
0.996
T2D
1082
5.03 ± 4.15
6.09 ± 8.46
21.07
0.021
Diabetes type unknown
278
4.89 ± 3.58
7.31 ± 11.50
49.48
0.053
Data are mean ± standard deviation for hospitalized patients only. p-values are based on an unpaired t-test which assumes
independence between groups. T1D, type 1 diabetes; T2D, type 2 diabetes; SHE, severe hypoglycemic event.
A limitation of this study is that the registry did not record the reason
why patients were hospitalized, so the primary reason for hospitalization
may not have been related to diabetes or hypoglycemia.
In the month following a SHE, outpatient visits increased significantly
(p<0.001). The greatest increases were in visits to endocrinologists, nurses
and dieticians (Table 4).
Table 4 Outpatient visits pre and post SHE.
1 month pre SHE
88.8
In patients with T2D or undefined diabetes, there was an increase in the
proportion of patients with 1, 2 and 3+ hospitalizations post versus pre
SHE, possibly due to the higher rate of comorbidities and higher age in
these populations.
Of those admitted to hospital (n=1418), the overall mean duration of
stay was significantly longer (p<0.001) during the month post (5.59 days)
versus pre SHE (4.37 days) (Table 3). The increase in hospital stay was
greater in patients with T2D or undefined diabetes compared with those
with T1D.
0.2
0.7
3+
Analysis conducted using a Wilcoxon signed rank test. *p<0.001 for 1 month pre SHE versus 1 month post SHE.
SHE, severe hypoglycemic event
Visit category
Pre SHE
Post SHE
Change (%)
p-value
Endocrinology
474
1277
169.4
<0.001
Nursing care
899
1527
69.85
<0.001
Dietician
414
688
66.18
<0.001
Mental care
237
369
55.69
<0.001
General medicine
7108
10838
52.47
<0.001
Physiotherapy
666
830
24.62
<0.001
Cardiology
172
210
22.09
0.058
Internal medicine
1007
1148
14.00
0.003
Ophthalmology
621
654
5.31
0.370
Surgery
402
402
0
1.000
Orthopedics
557
498
–10.59
0.074
12557
18441
46.85
<0.001
Total
4. Brian L Thorsted
Novo Nordisk A/S,
Søborg, Denmark
2. Gabriel Chodick
Maccabitech, Maccabi
Healthcare Services, Israel
5. Lisa Elliott
Novo Nordisk A/S,
Søborg, Denmark
3. Varda Shalev
Maccabitech, Maccabi
Healthcare Services, Israel
6. Avraham Karasik
Sheba Medical Center,
Hashomer, Israel
In total, there was a 174% increase in hospitalization costs from US$1.1
to 3.0 million for pre versus post SHE.
Additionally, there was a 21% increase in outpatient costs during the
month following index SHE versus pre SHE (Figure 2).
Figure 2 Outpatient costs 1 month pre and post SHE.
2000
1800
Other (NS)
Lab tests (p=0.05)
1600
Costs $US (thousands)
Increased hospital admissions, length of stay and
outpatient visits in diabetes patients following
severe hypoglycemia
1. Dalit Goldstein
Maccabitech, Maccabi
Healthcare Services, Israel
1400
Outpatient visits
(p<0.001)
1200
1000
800
Medicine
purchases
(p<0.001)
600
400
Emergency
department visit
(p<0.001)
200
0
1 month pre SHE
1 month post SHE
Costs are for all patients. SHE, severe hypoglycemic event. p-values for 1 month pre SHE versus 1 month post SHE.
References
1.Hammer et al. J Med Econ 2009;12:281–90.
2.Leese et al. Diabetes Care 2003;26:1176–80.
3.Shalev et al. Int J Cardiol 2011;152:345–9.
4.Chodick et al. Eur J Epidemiol 2003;18:1143–6.
Conclusions
In this real-world, non-interventional analysis of data
from a large-scale diabetes registry, severe hypoglycemia
was associated with increased use of healthcare services.
These results indicate that in the month following a SHE
patients have significantly more frequent and prolonged
hospital admissions and outpatient visits.
Visits comparison was conducted using a McNemar test. SHE, severe hypoglycemic event.
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of this poster.
This study was sponsored by Novo Nordisk.
The authors take full responsibility for the content of the poster but are grateful to Watermeadow Medical (supported by Novo Nordisk) for writing assistance.
Presented at the American Diabetes Association, 75th Annual Scientific Sessions, 5–9 June 2015, Boston, MA, USA.