The burden of hospitalization related to diabetes mellitus: A population-based study

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Abstract

Background and aims

To estimate the impact of diabetes and its complications, overall and in different age classes, on the likelihood of hospital admission for specific causes.

Methods and results

We carried out a record-linkage analysis of administrative registers including data on 8,940,420 citizens in 21 Local Health Authorities in Italy. Individuals with pharmacologically treated diabetes (≥2 prescriptions of antidiabetic agents during the year 2008) were paired in a 1:1 proportion with those who did not receive such drugs (controls) based on propensity-score matching. Odds Ratios (ORs) of hospitalization for macro and microvascular conditions in individuals with diabetes as compared to controls were estimated. The system identified 498,825 individuals with diabetes pharmacologically treated (prevalence of 5.6%). Prevalence of diabetes in people aged <14 years, 14–39 years, 40–65 years, and ≥65 years was 0.1%, 0.6%, 6.4%, and 18.2%, respectively. Overall, 23.9% of subjects with diabetes and 11.5% of controls had had at least a hospital admission during 12 months for the causes considered. Diabetes increased the likelihood of hospitalization by two to six times for the different causes examined. In absolute terms, diabetes was responsible for an excess of over 12,000 hospital admissions per 100,000 individuals/year.

Conclusion

Despite the availability of effective treatments to prevent or delay major complications, diabetes still places an enormous burden on both patients and the health care system. Given the continuous rise in diabetes prevalence both in middle-aged and elderly individuals, we can expect an additional, hardly sustainable increase in the demand for health care in the near future.

Introduction

The prevalence of type 1 and type 2 diabetes mellitus is quickly and alarmingly increasing worldwide, and it is progressively assuming the of a global epidemic, in both developed and developing countries [1], [2]. Based on International Diabetes Federation population projections, in Italy the prevalence of diabetes could reach 10.4% in the age range 20–79 years in 2030 [2], [3], being more than double the percentage identified in an Italian study conducted in 2003 [4]. The number of people with diagnosed diabetes could thus increase to 4 million by a few years. The burden of the disease is increasing both for the progressive aging of population and for the worsening of lifestyle [5], [6]. Along with the increase in the prevalence of the disease, a parallel, dramatic escalation of the clinical, social and economic burden of diabetes and its complications, particularly those of the cardiovascular system, is expected [7], [8]. Care of individuals with diabetes generate a consistent use of hospital resources, the greatest impact on hospital stay and expense is from hospitalizations being attributable to chronic complications, especially cardiovascular complications. The prevention of diabetes and the control of its complications therefore became one of the most important challenges of the XXI century, aimed at the substantial reduction of diabetes-related morbidity, mortality, and overall health care expenditure. Fortunately, several pharmacological and nonpharmacological interventions for the reduction of the risk of diabetes complications have been proved to be effective in randomized clinical trials and are currently available [9], [10], [11]. Nevertheless, a gap persists between recommendations and clinical practice, as recently documented by an Italian quality improvement program report [12]. The persistence of sub-optimal care can be responsible for an increased risk of complications [13], which in turns determines an increased demand for hospital care. The use of administrative databases represents an efficient instrument, complementary to ad hoc studies, for the continuous monitoring of morbidity and resource consumption related to diabetes mellitus. Diabetes presents, in fact, a feasible detection by the use of a highly specific pharmacologic treatment.

The aim of this study was to estimate in different age classes the impact of diabetes and its complications on the likelihood of hospital admission for specific causes, using a record-linkage analysis of administrative databases.

Section snippets

Methods

We carried out a record-linkage analysis of hospital discharge records, prescription databases, and the civil registry, including data on 8,940,420 citizens in 21 local Health authorities (LHAs) in different Italian regions, in the last available year (2007 or 2008).

Record-linkage analysis is increasingly recognized as a reliable research tool to assess the interplay between different clinical conditions to evaluate outcomes in large, unselected populations which better represent the real

Results

The ReClust Record Linkage System allowed the identification of 498,825 diabetic patients over 8,940,420 inhabitants (prevalence of 5.6%) according to antidiabetic agents prescriptions, and of a random group of 2,494,125 patients without diabetes (1:5 ratio) balanced for age, gender, and LHAs. Pre-matching characteristics are presented in Online Appendix Table A3. The propensity score-based greedy matching algorithm successfully matched 492,146 diabetic patients. Adequacy of covariate balance

Discussion

This study provides a useful model to describe the burden of the disease in terms of diabetic complications, health services utilization, and health outcome. From prescription data, the prevalence of pharmacologically treated diabetes is estimated to be 5.6%. This is a conservative estimate, based on at least two prescriptions during the year, and does not take into account individuals with diabetes treated only with lifestyle interventions. Therefore, considering that about 10% of diabetic

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