Diabetes in Norway : costs, health-related quality of life and cost-effectiveness of life-style interventions
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AbstractDiabetes mellitus places a considerable burden on patients in terms of morbidity and mortality and on society in terms of costs. The number of individuals with diabetes is estimated at 160 000 in Norway, 170 mill globally. These numbers are expected to increase considerably in the future. The objective of this thesis was to increase knowledge about the costs and cost-effectiveness of diabetes interventions. The first sub-study explored the economic costs of diabetes in Norway, the second analyzed HRQoL in patients with diabetes and the third explored the cost-effectiveness of a lifestyle intervention.
Costs of diabetes
Using the prevalence approach, we included costs of in-patient hospital services, outpatient clinic visits, physician services, drugs, medical equipment, nutrition guidance, physiotherapy, acupuncture, foot therapy and indirect costs. Data were collected from national registers and responses to a survey of 584 individuals with diabetes. The total estimated cost of diabetes in Norway in the year 2005 was NOK4.2 billion, which represents 2.4% of total national health care expenditure. The largest contributors to the costs were drugs, medical devices and hospital admissions. When hospital stays with diabetes as a secondary diagnosis were excluded, total costs were NOK2.49 billion. Pharmaceuticals accounted for NOK808 million (32%), disability pensions NOK408 million (16%), medical devices NOK340 million (14%) and hospital admissions NOK179 million (7%). Patient expenditures for acupuncture, physiotherapy and foot therapy were many times greater than those of nutritional guidance. Finally, the total costs of lost production from job absenteeism and premature mortality amounted to NOK596 million.
Health-related quality of life in diabetes
The aim of this study was to explore the impact of diabetes complications on health-related quality of life (HRQoL). We used the responses from a mail survey performed in Norway and asked about demographics, diabetes related complications and HRQoL using the EQ- 5D descriptive system. The EQ-5D is a standardised instrument for use as a measure for health outcome. It is widely used, and by many governments a recommended instrument for measuring HRQoL. We explored the EQ-5D’s ability to capture and represent typical complications related to diabetes. Individuals without any self-reported diabetes complications had HRQoL in the range 0.85-0.90 on a scale from 0 (death) to 1.0 (prefect health). HRQoL was largely dependent on the presence of major diabetes related complications. Complications with the most severe impact were stroke, ischemic heart disease and neuropathy.
Cost-effectiveness of a diabetes intervention
We estimated costs and health outcomes of lifestyle interventions by means of the British UKPDS Outcomes Model. Data on the impact of diet and exercise on diabetes risk factors (HbA1c, blood-pressure, cholesterol, and body weight) were taken from a Norwegian trial on individuals with poorly controlled type 2 diabetes. Cost and HRQoL data were taken from paper I and II. With immediate switch to insulin the estimated discounted life expectancy was 9.44 years (7.67 Quality Adjusted Life Expectancy (QALE)), while it was 9.48 (7.71 QALE), 9.53 (7.75 QALE) and 9.64 years (7.86 QALE) for two years, five years and lifelong lifestyle intervention. The discounted lifetime total costs including indirect costs of the four programmes were NOK283,637, NOK512,540, NOK799,245 and NOK1,417,004, respectively. Compared with immediate switch to insulin, the costs per additional life-year were NOK6,053,073, NOK6,209,362 and NOK5,832,427 for two-year, five-year and lifelong lifestyle intervention, respectively. When the cost of time related to travel and participation in the diet and exercise sessions were disregarded, the costs per incremental QALY for the respective treatment courses were NOK40,656, NOK55,277 and NOK33,649. The results indicate that lifestyle interventions are not cost-effective unless society disregards indirect costs.
List of papers. Paper III is removed from the thesis due to copyright restrictions.
Paper I Solli O, Jensen T, Kristiansen IS. Diabetes: cost-of illness in Norway. BMC Endocrine Disorders 2010, 10:15 doi:10.1186/1472-6823-10-15 Published under the Creative Commons Attribution License
Paper II Solli O, Stavem K, Kristiansen IS. Health-related quality of life in diabetes: The associations of complications with EQ-5D scores. Health and Quality of Life Outcomes 2010, 8:18 doi:10.1186/1477-7525-8-18 Published under the Creative Commons Attribution License
Paper III Solli O, Birkeland K, Aas AM, Kristiansen IS. Cost-effectiveness of intensive lifestyle intervention in patients with poorly controlled type 2 diabetes. Manuscript submitted