Cost of hospitalisation and length of stay due to hypoglycaemia in patients with diabetes mellitus: a cross-sectional study
Objective: This study aims to estimate the length of stay and hospitalisation cost of hypoglycaemia, and to identify determinants of variation in the length of stay and hospitalisation cost among individual patients with type 1 or 2 diabetes mellitus.
Methods: A cross-sectional study was conducted using inpatients records for patients with diabetes mellitus who had been hospitalised due to hypoglycaemic events in two private hospitals in Amman, Jordan between January 2009 and May 2017. All hospitalisation costs were inflated to the equivalent costs in 2017. Hospitalisation cost was estimated from the patient’s perspective in Jordanian dinars (JOD). Descriptive analyses and correlation between sociodemographic or clinical characteristics with the cost and length of stay were explored. Predictors of hypoglycaemic hospitalisation cost and length of stay were determined using logistic regression.
Results: During the study period a total of 126 patients with diabetes mellitus were hospitalised due to an incident of hypoglycaemia. The mean patient age was 64.2 (SD=19.6) years; half were male. Patients admitted for hypoglycaemia stayed in hospital for a median duration of two days (IQR=2 days). The median cost of hospitalisation for hypoglycaemia was 163.2 JOD (USD 230.1) (IQR=216.3 JOD). We found that the Glasgow coma score was positively associated with length of stay (0.345, p=0.008), and older age was correlated with higher hospitalisation cost (0.207, p=0.02). Patients with a family history of diabetes had higher hospitalisation costs and longer duration of stay (0.306 and 0.275, p<0.05). In addition, being a male patient (0.394, p<0.05) and with an absence of smoking history was associated with longer duration of stay (0.456, p<0.01), but not with higher hospitalisation cost.
Conclusions: Costs associated with the incidence of hypoglycaemic events are not low and constitute a large cost component of managing and treating diabetes mellitus. Male patients and patients having a family history of diabetes should receive extra care and education on the prevention of hypoglycaemic events, and a treatment de-intensification approach should be considered if necessary, so we can prevent its associated hospitalisation costs and length of stay.
Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature. 2001;414(6865):782‐787. https://doi.org/10.1038/414782a
International Diabetes Federation, IDF Diabetes Atlas. Available at: https://www.diabetesatlas.org/en/ (accessed Feb 17, 2020).
Rathmann W, Giani G. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(10):2568‐2569. https://doi.org/10.2337/diacare.27.10.2568
Ng CS, Lee JY, Toh MP, Ko Y. Cost-of-illness studies of diabetes mellitus: a systematic review. Diabetes Res Clin Pract. 2014;105(2):151‐163. https://doi.org/10.1016/j.diabres.2014.03.020
Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, Goff DC Jr, Bigger JT, Buse JB, Cushman WC, Genuth S, Ismail-Beigi F, Grimm RH Jr, Probstfield JL, Simons-Morton DG, Friedewald WT. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545‐2559. https://doi.org/10.1056/nejmoa0802743
Umpierrez G, Korytkowski M. Diabetic emergencies - ketoacidosis, hyperglycaemic hyperosmolar state and hypoglycaemia. Nat Rev Endocrinol. 2016;12(4):222‐232. https://doi.org/10.1038/nrendo.2016.15
Naser AY, Wong ICK, Whittlesea C, Beykloo MY, Man KKC, Lau WCY, Hyassat DA, Wei L. Use of multiple antidiabetic medications in patients with diabetes and its association with hypoglycaemic events: a case-crossover study in Jordan. BMJ Open. 2018;8(11):e024909. https://doi.org/10.1136/bmjopen-2018-024909
Chan SP, Ji LN, Nitiyanant W, Baik SH, Sheu WH. Hypoglycemic symptoms in patients with type 2 diabetes in Asia-Pacific-Real-life effectiveness and care patterns of diabetes management: the RECAP-DM study. Diabetes Res Clin Pract. 2010;89(2):e30‐e32. https://doi.org/10.1016/j.diabres.2010.05.008
Miller CD, Phillips LS, Ziemer DC, Gallina DL, Cook CB, El-Kebbi IM. Hypoglycemia in patients with type 2 diabetes mellitus. Arch Intern Med. 2001;161(13):1653‐1659. https://doi.org/10.1001/archinte.161.13.1653
Edridge CL, Dunkley AJ, Bodicoat DH, Rose TC, Gray LJ, Davies MJ, Khunti K. Prevalence and Incidence of Hypoglycaemia in 532,542 People with Type 2 Diabetes on Oral Therapies and Insulin: A Systematic Review and Meta-Analysis of Population Based Studies. PLoS One. 2015;10(6):e0126427. https://doi.org/10.1371/journal.pone.0126427
Heller SR, Frier BM, Hersløv ML, Gundgaard J, Gough SC. Severe hypoglycaemia in adults with insulin-treated diabetes: impact on healthcare resources. Diabet Med. 2016;33(4):471‐477. https://doi.org/10.1111/dme.12844
Liu S, Zhao Y, Hempe JM, Fonseca V, Shi L. Economic burden of hypoglycemia in patients with Type 2 diabetes. Expert Rev Pharmacoecon Outcomes Res. 2012;12(1):47‐51. https://doi.org/10.1586/erp.11.87
McEwan P, Larsen Thorsted B, Wolden M, Jacobsen J, Evans M. Healthcare resource implications of hypoglycemia-related hospital admissions and inpatient hypoglycemia: retrospective record-linked cohort studies in England. BMJ Open Diabetes Res Care. 2015;3(1):e000057. https://doi.org/10.1136/bmjdrc-2014-000057
Harris SB, Leiter LA, Yale JF, Chiasson JL, Kleinstiver P, Saurio L, Out-of-pocket costs of managing hyperglycemia and hypoglycemia in patients with type 1 diabetes and insulin-treated type 2 diabetes. Can J Diabetes. 2007;31(1):25-33. https://doi.org/10.1016/S1499-2671(07)11008-X
Kim G, Lee YH, Han MH, Lee EK, Kim CH, Kwon HS, Jeong IK, Kang ES, Kim DJ. Economic Burden of Hypoglycemia in Patients with Type 2 Diabetes Mellitus from Korea. PLoS One. 2016;11(3):e0151282. https://doi.org/10.1371/journal.pone.0151282
Foos V, Varol N, Curtis BH, Boye KS, Grant D, Palmer JL, McEwan P. Economic impact of severe and non-severe hypoglycemia in patients with Type 1 and Type 2 diabetes in the United States. J Med Econ. 2015;18(6):420‐432. https://doi.org/10.3111/13696998.2015.1006730
Jönsson L, Bolinder B, Lundkvist J. Cost of hypoglycemia in patients with Type 2 diabetes in Sweden. Value Health. 2006;9(3):193‐198. https://doi.org/10.1111/j.1524-4733.2006.00100.x
Hanan Hospital. About us. Available at: http://www.hananhospital.com/about/vision.html (accessed Mar 14, 2017).
The Speciality Hospital. About us. Available at: https://www.specialty-hospital.com/ar/home/ (accessed Mar 14, 2017).
Veronese G, Marchesini G, Forlani G, Saragoni S, Degli Esposti L, Centis E, Fabbri A; Italian Society of Emergency Medicine (SIMEU). Costs associated with emergency care and hospitalization for severe hypoglycemia. Nutr Metab Cardiovasc Dis. 2016;26(4):345‐351. https://doi.org/10.1016/j.numecd.2016.01.007
Central Bank of Jordan. Currency prices. Available at: http://www.cbj.gov.jo/ (accessed Apr 12, 2017).
Trading economics. Jordan Inflation Rate. Available at: https://tradingeconomics.com/jordan/inflation-cpi (accessed Mar 14, 2017).
World Health Organization. Global Health Expenditure Database. Available at: http://apps.who.int/nha/database/Select/Indicators/en (accessed Jan 25, 2018).
Laires PA, Conceição J, Araújo F, Dores J, Silva C, Radican L, Nogueira A. The cost of managing severe hypoglycemic episodes in Type 2 diabetic patients. Expert Rev Pharmacoecon Outcomes Res. 2016;16(2):315‐325. https://doi.org/10.1586/14737167.2015.1084230
Nicholson G, Gandra SR, Halbert RJ, Richhariya A, Nordyke RJ. Patient-level costs of major cardiovascular conditions: a review of the international literature. Clinicoecon Outcomes Res. 2016;8:495‐506. https://doi.org/10.2147/ceor.s89331
Parekh W, Hoskins N, Baker-Knight J, Ramirez de Arellano A, Mezquita Raya P. The Economic Burden of Insulin-Related Hypoglycemia in Spain. Diabetes Ther. 2017;8(4):899‐913. https://doi.org/10.1007/s13300-017-0285-0
Giorda CB, Rossi MC, Ozzello O, Gentile S, Aglialoro A, Chiambretti A, Baccetti F, Gentile FM, Romeo F, Lucisano G, Nicolucci A; HYPOS-1 Study Group of AMD. Healthcare resource use, direct and indirect costs of hypoglycemia in type 1 and type 2 diabetes, and nationwide projections. Results of the HYPOS-1 study. Nutr Metab Cardiovasc Dis. 2017;27(3):209‐216. https://doi.org/10.1016/j.numecd.2016.10.005
de Groot S, Enters-Weijnen CF, Geelhoed-Duijvestijn PH, Kanters TA. A cost of illness study of hypoglycaemic events in insulin-treated diabetes in the Netherlands. BMJ Open. 2018;8(3):e019864. https://doi.org/10.1136/bmjopen-2017-019864
Hammer M, Lammert M, Mejías SM, Kern W, Frier BM. Costs of managing severe hypoglycaemia in three European countries. J Med Econ. 2009;12(4):281‐290. https://doi.org/10.3111/13696990903336597
World Health Organization. Global Health Expenditure Database. Available at: https://apps.who.int/nha/database/Select/Indicators/en (accessed May 14, 2020).
Conceição J, Dores J, Araújo F, Brodovicz K, Radican L, Nogueira AM. Hipos-ER (Hypoglycemia in Portugal Observational Study - Emergency Room): Clinical Outcomes in Admitted Patients. Value Health. 2014;17(7):A332. https://doi.org/10.1016/j.jval.2014.08.628
Zapatero A, Gómez-Huelgas R, González N, Canora J, Asenjo A, Hinojosa J, Plaza S, Marco J, Barba R. Frequency of hypoglycemia and its impact on length of stay, mortality, and short-term readmission in patients with diabetes hospitalized in internal medicine wards. Endocr Pract. 2014;20(9):870‐875. https://doi.org/10.4158/ep14006.or
Rezaei S, Akbari Sari A, Arab M, Majdzadeh R, Shaahmadi F, Mohammadpoorasl A. The association between smoking status and hospital length of stay: evidence from a hospital-based cohort. Hosp Pract (1995). 2016;44(3):129‐132. https://doi.org/10.1080/21548331.2016.1178579
Hayes RM, Carter PR, Gollop ND, Uppal H, Sarma J, Chandran S, Potluri R. The impact of marital status on mortality and length of stay in patients admitted with acute coronary syndrome. Int J Cardiol. 2016;212:142‐144. https://doi.org/10.1016/j.ijcard.2016.03.066
Gordon HS, Rosenthal GE. Impact of marital status on outcomes in hospitalized patients. Evidence from an academic medical center. Arch Intern Med. 1995;155(22):2465‐2471. https://doi.org/10.1001/archinte.1995.00430220129014
Poirier P, Giles TD, Bray GA, Hong Y, Stern JS, Pi-Sunyer FX, Eckel RH; American Heart Association; Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113(6):898‐918. https://doi.org/10.1161/circulationaha.106.171016
Vyas V, Lambiase P. Obesity and Atrial Fibrillation: Epidemiology, Pathophysiology and Novel Therapeutic Opportunities. Arrhythm Electrophysiol Rev. 2019;8(1):28‐36. https://doi.org/10.15420/aer.2018.76.2
Frier BM, Schernthaner G, Heller SR. Hypoglycemia and cardiovascular risks. Diabetes Care. 2011;34(Suppl 2):S132‐S137. https://doi.org/10.2337/dc11-s220
Chow E, Bernjak A, Williams S, Fawdry RA, Hibbert S, Freeman J, Sheridan PJ, Heller SR. Risk of cardiac arrhythmias during hypoglycemia in patients with type 2 diabetes and cardiovascular risk. Diabetes. 2014;63(5):1738‐1747. https://doi.org/10.2337/db13-0468
Zizza C, Herring AH, Stevens J, Popkin BM. Length of hospital stays among obese individuals. Am J Public Health. 2004;94(9):1587‐1591. https://doi.org/10.2105/ajph.94.9.1587
Naser AY, Wong ICK, Whittlesea C, Alwafi H, Abuirmeileh A, Alsairafi ZK, Turkistani FM, Bokhari NS, Beykloo MY, Al-Taweel D, Almane MB, Wei L. Attitudes and perceptions towards hypoglycaemia in patients with diabetes mellitus: A multinational cross-sectional study. PLoS One. 2019;14(10):e0222275. https://doi.org/10.1371/journal.pone.0222275
Evans Kreider K, Pereira K, Padilla BI. Practical Approaches to Diagnosing, Treating and Preventing Hypoglycemia in Diabetes. Diabetes Ther. 2017;8(6):1427‐1435. https://doi.org/10.1007/s13300-017-0325-9
Alumran A, Almutawa H, Alzain Z, Althumairi A, Khalid N. Comparing public and private hospitals’ service quality. J Public Health (Berl). 2020 [Ahead of print]. https://doi.org/10.1007/s10389-019-01188-9
Health Information Act Advisory Committee. What is Health Care Cost? Health Information Act Advisory Committee Meeting. 2016.
Glick HA, Doshi JA, Sonnad SS, Polsky D. Economic evaluation in clinical trials. Oxford university press: New York; 2007. ISBN: 978-0198529972
Copyright (c) 2020 Pharmacy Practice and the Authors
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors hereby transfer, assign or otherwise convey to Pharmacy Practice (1) the right to grant permission to republish or reprint the stated material, in whole or in part, without a fee; (2) the right to print or epublish copies for free distribution or sale; and (3) the right to republish the stated material in any format (electronic or printed). In addition, the undersigned affirms that the article described above has not previously been published, in whole or part, is not subject to copyright or other rights except by the author(s), and has not been submitted for publication elsewhere, except as communicated in writing to Pharmacy Practice with this document.
Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License (CC-BY-NC-ND) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
Author Self-Archiving Policy
Pharmacy Practice permits and encourages authors to post and archive the final PDFs of their respective articles submitted to the journal on personal websites or institutional repositories after publication, while providing bibliographic details that credit its publication in this journal.