Dossier n. 267/2019 [Abstract] Epidemiology and clinical, economic and organizational impact of diabetes in Emilia-Romagna. Summary of research activities 2016-2018

Diabetes management is a challenge for current health systems due to the spread of the disease, its evolution and prognosis, the need to develop dedicated clinical care pathways and the relevant resource consumption. This report collects objectives/methodologies and results of some research activities carried out by the Regional Agency for Health and Social Care of Emilia-Romagna Region in collaboration with the High School for Health Policies of the University of Bologna and with the Local Health Authorities of Bologna, Modena, Parma, Piacenza and Romagna, in the three-year period 2016-2018.

• Prevalence estimation, evaluation of the clinical impact in terms of mortality and complications and analysis of the consumption of health services in the diabetic population aged 18 years and over resident in Emilia-Romagna over the period 2010-2016. The study was conducted by analyzing the current administrative databases related to hospital discharge, prescribed drugs, outpatient specialist services and the mortality registry.
• Evaluation of direct medical costs in 2015 for patients with diabetes in the Local Health Authorities of Parma, Modena and Bologna, calculated by analyzing information contained in current administrative databases and Local Health Authority registries for diabetes. A classification and regression tree (CART) model was used to stratify patients into homogeneous subgroups of costs based on demographic and clinical characteristics.
• Estimation of the costs attributable to the regional guidelines recommendations  for the integrated management type 2 diabetes mellitus. To identify the hypothetical theoretical cost to refer to this integrated clinical pathway, an incremental approach was taken, first analysing the diagnostic-therapeutic pathway and subsequently proceeding with the quantification of the hypothetical theoretical cost.
• Quali-quantitative study aimed at identifying the causes of non-compliance with the diagnostic-therapeutic pathway of diabetes recommended by the regional guidelines, in the Local Health Authorities of Piacenza, Modena and Romagna. In the first phase, the determinants of non-compliance with the guidelines inferable from the current administrative databases were analyzed; in the second phase some in-depth focus groups were conducted with healthcare professionals and patients.
• Evaluation study of the clinical impact of adherence to regional guidelines for diabetes integrated management in 2015, in patients with diabetes belonging to the Local Health Authority of Parma, Modena and Bologna, through current administrative databases  and Local Health Authority diabetes registries analysis.

Key messages

• Between 2010 and 2016 in Emilia-Romagna diabetes prevalence increased by 4.2%. In 2010 there were 240,779 diabetic subjects aged 18 years or older, in 2016 they were 265.470. The percentage of diabetics grew from 6.29% in 2010 to 6.9% in 2016, probably as a result of the early identification of people at risk and/or sick.
• Standardized rates for mortality (-2.2%), diabetic coma (-41.1%), acute and chronic ischemic heart disease (-23.7%), acute myocardial infarction (-13.3%), stroke (-21.9%) decreased, as well as ocular complications (-38.2%), retinopathies (-31.9%), interventions for peripheral revascularization (-7.1%) and lower limb amputations (-19.2%), dialysis procedures (-9.5%). Conversely, renal complications (+7.5%) and cataract operations (+17%) increased.
• In absolute terms, the total health expenditure of the diabetic population of Emilia-Romagna increased from 753 million Euros in 2010 to 806 million Euros in 2016, probably due to the increase in the number of diabetic subjects. On the contrary, the average expenditure per assisted (-2.8%) as well as the average expenditure per assisted in hospital (-11.1%) decreased, while the average expenditure per assisted for drugs (+9.9 %) and for specialist outpatient care (+5.9%) increased.
• In diabetic patients, hospitalizations, drugs and specialist services respectively account for about 50%, 30% and 20% of the costs. The median annual cost per capita was 1,012.60 Euros, with no significant differences among the Local Health Authorities considered (Parma, Modena and Bologna). The classification and regression tree model allowed to stratify patients into subgroups characterized by homogeneous costs based on 6 variables (age, disease duration, renal complications, ischemic heart disease, ocular complications and stroke) and to identify 10 patient subgroups with different costs, ranging from a median of 483 Euros to a median of 39,578 Euros.
• The "theoretical" cost of the integrated clinical pathway - calculated on the basis of the regional guidelines according to Local Health Authorities’ perspective, including specialist outpatient services and additional fixed financial rewards for general practitioners - was around 275 Euros, while the corresponding "theoretical" rate is about 306 Euros.
• The analyses carried out in current administrative databases have mostly shown a significant non-adherence to regional diabetes follow-up guidelines by younger patients (in particular between 18 and 40 years) and foreigners; on the other hand, there was a significantly greater compliance of older patients over 60, insulin-dependent and with associated comorbidities. At the same time, focus groups allowed to outline the points of view of users and health professionals on three dimensions that were always influential on adherence to the clinical pathways arranged by the Local Health Authority: the relationship between operators and patients; the patient empowerment; structural and organizational aspects of the clinical pathway.
• The estimates showed that, compared to patients who do not follow the recommendations, those who carry out regular monitoring of some laboratory parameters show better health results in terms of lower probability of new complications and limited use of hospital services (hospitalizations for all causes and for ambulatory care sensitive conditions). Furthermore, participation in the integrated diabetes management program increases the likelihood of compliance with the standards established by regional guidelines.