Hypoglycemia: An overview of fear of hypoglycemia,quality-of-life,and impact on costs

Abstract

Background:

The clinical goal in the treatment of diabetes is to achieve good glycemic control. Tight glycemic control achieved with intensive glucose lowering treatment reduces the risk of long-term micro- and macro-vascular complications of diabetes, resulting in an improvement in quality-of-life for the patient and decreased healthcare costs. The positive impact of good glycemic control is, however, counterbalanced by the negative impact of an increased incidence of hypoglycemia.

Methods:

A search of PubMed was conducted to identify published literature on the impact of hypoglycemia, both on patient quality-of-life and associated costs to the healthcare system and society.

Results:

In people with type 1 or type 2 diabetes, hypoglycemia is associated with a reduction in quality-of-life, increased fear and anxiety, reduced productivity, and increased healthcare costs. Fear of hypoglycemia may promote compensatory behaviors in order to avoid hypoglycemia, such as decreased insulin doses, resulting in poor glycemic control and an increased risk of serious health consequences. Every non-severe event may be associated with a utility loss in the range of 0.0033–0.0052 over 1 year, further contributing to the negative impact.

Limitations:

This review is intended to provide an overview of hypoglycemia in diabetes and its impact on patients and society, and consequently it is not a comprehensive evaluation of all studies reporting hypoglycemic episodes.

Conclusion:

To provide the best possible care for patients and a cost-effective treatment strategy for healthcare decision-makers, a treatment that provides good glycemic control with a limited risk of hypoglycemia would be a welcome addition to diabetes management options.     

Effects of patient-reported non-severe hypoglycemia on healthcare resource use,work-time loss,and wellbeing in insulin-treated patients with diabetes in seven European countries

Abstract

Purpose:

Hypoglycemia is a frequent side effect induced by insulin treatment of type 1 (T1DM) and type 2 diabetes (T2DM). Limited data exist on the associated healthcare resource use and patient impact of hypoglycemia, particularly at a country-specific level. This study investigated the effects of self-reported non-severe hypoglycemic events (NSHE) on use of healthcare resources and patient wellbeing.

Methods:

Patients with T1DM or insulin-treated T2DM diabetes from seven European countries were invited to complete four weekly questionnaires. Data were collected on patient demographics, NSHE occurrence in the last 7 days, hypoglycemia-related resource use, and patient impact. NSHE were defined as events with hypoglycemia symptoms, with or without blood glucose measurement, or low blood glucose measurement without symptoms, which the patient could manage without third-party assistance.

Results:

Three thousand, nine hundred and fifty-nine respondents completed at least one wave of the survey, with 57% completing all four questionnaires; 3827 respondents were used for data analyses. Overall, 2.3% and 8.9% of NSHE in patients with T1DM and T2DM, respectively, resulted in healthcare professional contact. Across countries, there was a mean increase in blood glucose test use of 3.0 tests in the week following a NSHE. Among respondents who were employed (48%), loss of work-time after the last hypoglycemic event was reported for 9.7% of NSHE. Overall, 10.2% (daytime) and 8.0% (nocturnal) NSHE led to work-time loss, with a mean loss of 84.3 (daytime) and 169.6 (nocturnal) minutes among patients reporting work-time loss. Additionally, patients reported feeling tired, irritable, and having negative feelings following hypoglycemia.

Limitations:

Direct comparisons between studies must be interpreted with caution because of different definitions of hypoglycemia severity, duration of the studies, and methods of data collection.

Conclusions:

NSHE were associated with use of extra healthcare resources and work-time loss in all countries studied, suggesting that NSHE have considerable impact on patients/society.     

Development and Psychometric validation of the Diabetes Therapy-Related QOL (DTR-QOL) Questionnaire

Abstract

Objective:

We developed and evaluated the psychometric properties of the Diabetes Therapy-Related QOL (DTR-QOL) as a disease-specific, self-administered questionnaire to assess the influence of diabetes treatment on patient QOL, regardless of treatment method.

Methods:

This new questionnaire was developed and validated in a standardized manner: Item development, pilot-testing and psychometric validation. A survey was conducted using the provisional version of the questionnaire, and reliability and validity were evaluated with psychometric testing.

Results:

The provisional version of the questionnaire was generated with 29 items through literature review and pilot testing. For psychometric assessment, analyses were performed on the responses of 284 adult Japanese patients with diabetes. Factor analysis by the principal factor method with promax rotation revealed 4 factors; “burden on social activities and daily activities” (13 items), “anxiety and dissatisfaction with treatment” (8 items), “hypoglycemia” (4 items), and “satisfaction with treatment” (4 items). For reliability, the intraclass correlation was 0.92, and Cronbach’s alpha coefficient was 0.94, indicating adequate test-retest reliability and internal consistency. For known-group validity, there were significant differences in scores for following variables: age, diabetes type, HbA1c, treatment method, glycemic control, hypoglycemia, nocturnal hypoglycemia, concern about weight gain, health status (patient assessment), and degree of communication with physician.

Conclusions:

The DTR-QOL, with good reliability and validity, can assess the influence of diabetes treatment on patient QOL. The DTR-QOL can be used regardless of treatment method that patients receive, and this characteristic enables to detect a difference on patients QOL between treatment methods before and after a switch of treatment. Limitations of this study include representativeness of the patient sample. The relatively small number of patients with type 1 diabetes should be noted. Also, responsiveness of the DTR-QOL has not yet been examined.     

中国国内地方保护问题的调查与分析

本文通过对地方保护主义调查问卷的分析 ,回答了当前国内地方保护的状况、政府致力于减弱地方保护的政策和努力是否有效、现阶段地方保护的方法和手段所呈现的特征以及今后政策的着力点等问题。同时 ,在重点行业管理、劳动力流动、司法公正、财税制度等方面提出了削减地区间贸易和要素流动壁垒、抑制地方保护行为的政策建议。     

亚洲健康相关生命质量工具概况及其发展建议

目的:介绍健康相关生命质量(HR-QOL)的概念,并对在亚洲国家应用HR-QOL工具提供帮助和建议。方法:在回顾国内外相关文献的基础上,总结亚洲国家可获得的HR-QOL测量量表,并举例说明HR-QOL在亚洲应用过程中存在的问题。结果与结论:HR-QOL工具在亚洲国家的应用绝大部分属于翻译和修改现存的工具,翻译的质量、版权等问题影响着翻译后的量表效度,另外量表管理模式以及亚洲各国的文化特点等都影响着HR-QOL工具在亚洲国家的发展。     

Estimating worldwide life satisfaction

Whilst studies of life satisfaction are becoming more common-place, their global coverage is far from complete. This paper develops a new database of life satisfaction scores for 178 countries, bringing together subjective well-being data from four surveys and using stepwise regression to estimate scores for nations where no subjective data are available. In doing so, we explore various factors that predict between-nation variation in subjective life satisfaction, building on Vemuri and Costanza's (Vemuri, A.W., & Costanza, R., 2006. The role of human, social, built, and natural capital in explaining life satisfaction at the country level: toward a National Well-Being Index (NWI). Ecological Economics, 58:119-133.) four capitals model. The main regression model explains 76% of variation in existing subjective scores; importantly, this includes poorer nations that had proven problematic in Vemuri and Costanza's (Vemuri, A.W., & Costanza, R., 2006. The role of human, social, built, and natural capital in explaining life satisfaction at the country level: toward a National Well-Being Index (NWI). Ecological Economics, 58:119-133.) study. Natural, human and socio-political capitals are all found to be strong predictors of life satisfaction. Built capital, operationalised as GDP, did not enter our regression model, being overshadowed by the human capital and socio-political capital factors that it inter-correlates with. The final database presents a stop-gap resource that, until robust surveys are carried out worldwide, allows comparisons of subjective life satisfaction between nations to be made with reasonable confidence.     

How do experts forecast sovereign spreads?

This paper assesses how forecasting experts form their expectations about future government bond spreads. Using monthly survey forecasts for France, Italy and the United Kingdom between January 1993 and October 2014, we test whether respondents consider the expected evolution of the fiscal balance—and other economic fundamentals—to be significant drivers of the expected bond yield differential over a benchmark German 10-year bond. Our main result is that a projected improvement of the fiscal outlook significantly reduces expected sovereign spreads. This suggests that credible fiscal plans affect market experts’ expectations and reduce the pressure on sovereign bond markets. In addition, we show that expected fundamentals generally play a more important role in explaining forecasted spreads compared to realized spreads.     

论当代科学论的经济学转向

哲学家借助经济分析来应对科学相对主义和经济学家寻求扩展经济学解释范围等诸多动因,促成了当代科学论的经济学转向。科学经济学和科学知识经济学是科学论应用经济学分析工具的两种理论形式。科学知识经济学对科学知识生产和传播机制的阐述有助于削弱科学相对主义的威胁,并且对制定科学政策有重要的启发意义。     

新制度经济学的边界——三种代表性观点及其比较

在新制度经济学的边界问题上,新制度经济学家(威廉姆森和芮切特)、旧制度经济学家(霍奇森)以及经济思想史家(卢瑟福)不仅边界刻画依据不完全相同,而且他们对新制度经济学智力成果的描述也存在着很大的差异。新制度经济学家认为,某种制度分析是否属于新制度经济学关键是看该理论是否假定环境存在着不确定性、人是否具有有限理性,是否明确地或隐含地以交易费用为正为前提。而新制度经济学的边界在旧制度经济学家和经济思想史家那里被进一步放宽。他们深入到本体论层面,认为某种制度分析只要坚持方法论个人主义,那么它就属于新制度经济学的内容。而新制度经济学家的边界刻画更能准确、客观地反映新制度经济学的智力成果。     

健康教育对血液透析患者生存质量的影响

目的探讨健康教育对血液透析患者生存质量的影响。方法抽取本中心新加入规律血液透析患者共52例,随机分成两组,观察组和对照组各26例。对照组进行常规护理;观察组在对照组基础上实施健康教育护理干预,随访观察12个月后,对比两组患者的营养状况、心理情绪、社会角色、运动等生活质量相关指标的变化。结果观察组接受系统的健康教育后营养状况、心理健康、社会角色等各项相关生存质量有明显改善,差异均有统计学意义（均P〈0.05）。结论全面系统的健康教育,可明显提高规律血液透析患者的生存质量。     

Cost of severe hypoglycaemia in nine European countries

Objective: Complications contribute largely to the economic gravity of diabetes mellitus (DM). How they arise and are treated differs substantially between countries. This paper assesses the total annual, direct, and indirect cost of severe hypoglycemia events (SHEs) in nine European countries: Bulgaria, Croatia, the Czech Republic, Greece, Hungary, Macedonia/the former Yugoslav Republic of Macedonia (MK), Poland, Slovenia, and Spain.

Methods: Data was collected on epidemiology, treatment structure, SHE-driven resource consumption, and unit costs. Two systematic reviews—on the SHE rates and the resources used for treatment—and data on the days-of-work lost due to SHE along with salaries and employment rates were used. The total SHE cost in each country was calculated and how the differences are driven by individual parameters was analysed.

Results: The annual costs of SHEs varied in absolute terms from €379,951.25 in MK up to €58,429,684.40 in Spain, or—when expressed per one drug-treated DM patient—from €5.47 in Bulgaria up to €17.74 in Spain. Indirect cost constituted between 6.01% (MK) and 26.49% (Hungary) of the total cost. The differences between countries are driven mostly by the cost of treating a single event, and this is related to general differences in prices.

Limitations: The main limitation is the lack of good quality data in some parts, and the necessity to use mean-value imputations, experts’ opinions, etc. Additionally, we only considered DM treatment as the SHE driver, while other elements, e.g. style of living, may contribute substantially.

Conclusions: A common framework can be applied to estimate the economic burden of SHE in various countries, allowing one to identify the drivers of differences in cost. Treating DM is complex, and so no resolute conclusions ought to be drawn as to whether SHE management is better in one country than another.     

Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems

Abstract

Objective:

Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI?+?S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI?+?S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI?+?S vs NEB.

Methods:

A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1–18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded.

Results:

Three hundred and four patients were analyzed: 94 in the MDI?+?S group and 209 in the NEB group. Mean age in years for the MDI?+?S group was 9.57 vs 5.07 for the NEB group (p?<?0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI?+?S group vs 61.7% in the NEB group (p?<?0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI?+?S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p?<?0.001; 95% CI?=?3.8–31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of $213,532 annually using MDI?+?S vs NEB.

Conclusion:

In mild asthma exacerbations, administering albuterol via MDI?+?S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput.

Limitations:

The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.     

Variations in care: a retrospective database analysis of healthcare utilization patterns for patients with inflammatory bowel disease

Abstract

Background:

Biologic therapy has been shown to be effective in achieving and maintaining remission in the treatment of inflammatory bowel disease (IBD). However, their impact on healthcare resource utilization is not well understood. This study explored the impact of biologic use on IBD-related hospital admissions and emergency room visits and healthcare expenditures.

Methods:

This study used a retrospective cohort design to analyze data from the MarketScan Commercial and Medicare databases (Truven Health Analytics Inc.) for the years 2006–2010. Patients were identified using ICD-9 diagnosis codes for IBD and age 18 or older at time of initial diagnosis. Linear models were used to predict the probability of an IBD-related hospitalization or ER visit and healthcare expenditures with binary variables indicating use of biologics in the current year and in the previous 2 years, as well as patient- and area-level control variables.

Results:

Patients using biologics in the current year were 14.1–17.6% more likely to be hospitalized for IBD. However, biologic use in the previous year was associated with a 3.8–5.6% reduction in hospitalizations, and biologic use 2 years prior was associated with a 1–2.8% reduction in hospitalizations in the current year. Similar results are found for ER visits. All indicators for biologic use were associated with increased expenditures.

Conclusions:

There was a negative association between lagged use of biologics and the proportion of patients with IBD-related hospitalizations and ER visits. This finding may suggest that increased use of biologics over time is associated with a decrease in IBD-related healthcare utilization.     

A broad utilitarian theory of value and moral value

Never before has the American business community been challenged to justify and support its ethical standards as today. Hearings before government agencies, attacks by public interest groups, and emphasis on consumer interests have raised serious questions concerning the moral code of industry, the social responsibility of the business community, and what lies ahead for the business firm as it behaved in the past. Somehow much of the public believes that corporate responsibility has been compromised, and that regard for profits has become a way of life that overlooks humane and societal considerations. Management must recognize that it is invested with a definite ethical and moral, as well as legal, responsibility to demonstrate the highest traits of business leadership in its stewardship role. Anything short of such a standard may be catastrophic for the future of the American enterprise system.     

Pain,health related quality of life and healthcare resource utilization in Spain

Objectives:

The aim of this paper is to consider the relationship between the experience of pain, health related quality of life (HRQoL) and healthcare resource utilization in Spain.

Methods:

The analysis contrasts the contribution of pain severity and frequency of pain reported against respondents reporting no pain in the previous month. Data are from the 2010 National Health and Wellness Survey (NHWS) for Spain. Single equation generalized linear regression models are used to evaluate the association of pain with the physical and mental component scores of the SF-12 questionnaire as well as health utilities generated from the SF-6D. In addition, the role of pain is assessed in its association with self-reported healthcare provider visits, emergency room visits and hospitalizations in the previous 6 months.

Results:

The results indicate that the experience of pain, notably severe and frequent pain, is substantial and is significantly associated with the SF-12 physical component scores, health utilities and all aspects of healthcare resource utilization, which far outweighs the role of demographic and socioeconomic variables, health risk factors (in particular body mass index) and the presence of comorbidities. In the case of severe daily pain, the marginal contribution of the SF-12 physical component score is a deficit of ?17.86 compared to those reporting no pain (population average score 46.49), while persons who are morbidly obese report a deficit of only ?6.63 compared to those who are normal weight. The corresponding association with health utilities is equally dramatic with a severe daily pain deficit of ?0.186 compared to those reporting no pain (average population utility 0.71). The impact of pain on healthcare resource utilization is marked. Severe daily pain increases traditional provider visits by 208.8%, emergency room visits by 373.0% and hospitalizations by 348.5%.

Limitations:

As an internet-based survey there is the possibility of bias towards those with internet access, although telephone sampling is used to supplement responses. Respondents are asked to describe their experience of pain; there is no independent check on the accuracy of responses. Finally, while certain acute pain categories are omitted, the study focuses on pain in the last month and not on pain chronicity.

Conclusions:

The societal burden of severe and frequent pain in Spain is substantial. Although not reported on before, at a national level, the deficit impact of the experience of pain far outweighs the contribution of more traditional explanations of HRQoL deficits as well as being the primary factor associated with increased provider visits, emergency room visits and hospitalizations.     

Comparing Interpersonal Comparisons in Utility Theory and Happiness Research

Social scientists are reluctant to make explicit interpersonal comparisons of well-being. However, implicit comparisons are made on a surprisingly regular basis. These comparisons are based on the wealth and the Kaldor–Hicks concept in utility theory and on self-reported well-being in happiness research. Taking a utilitarian stance, this paper tests the ethical foundations of both principles. While self-reported well-being serves as an acceptable proxy for utilitarian decision-making, the Kaldor–Hicks concept does not appear so. Implications for evaluating policies are outlined.

Complementarity and the Measurement of Individual Risk Tradeoffs: Accounting for Quantity and Quality of Life Effects

This paper considers the factors responsible for differences with age in estimates of the wage compensation an individual requires to accept increased occupational fatality risk. We derive a relationship between the value of a statistical life (VSL) and the degree of complementarity between consumption and labor supplied when health status serves as a potential source of variation in this relationship. Our empirical analysis finds that variations in an individual’s health status or quality of life and anticipated longevity threats lead to significant differences in the estimated wage/risk tradeoffs. We describe how extensions to the specification of hedonic wage models, including measures for quality of life and anticipated longevity threats, help to explain the diversity in past studies examining how the estimated wage–risk tradeoff changes with age.