Severe hypoglycaemia in adults with insulin-treated diabetes: impact on healthcare resources.

AIMS: To assess resource utilization associated with severe hypoglycaemia across three insulin regimens in a large phase 3a clinical programme involving people with Type 1 diabetes treated with basal-bolus insulin, people with Type 2 diabetes treated with multiple daily injections and people with Type 2 diabetes treated with basal-oral therapy. METHODS: Data relating to severe hypoglycaemia events (defined as episodes requiring external assistance) from the insulin degludec and insulin degludec/insulin aspart programme (15 trials) were analysed using descriptive statistics. Comparators included insulin glargine, biphasic insulin aspart, insulin detemir and sitagliptin. Mealtime insulin aspart was used in some regimens. This analysis used the serious adverse events records, which documented the use of ambulance/emergency teams, a hospital/emergency room visit ≤ 24 h, or a hospital visit > 24 h. RESULTS: In total, 536 severe hypoglycaemia events were analysed, of which 157 (29.3%) involved an ambulance/emergency team, 64 (11.9%) led to hospital/emergency room attendance of ≤ 24 h and 36 (6.7%) required hospital admission (> 24 h). Although there were fewer events in people with Type 2 diabetes compared with Type 1 diabetes, once a severe episode occurred, the tendency to utilize healthcare resources was higher in Type 2 diabetes vs. Type 1 diabetes. A higher proportion (47.6%) in the basal-oral therapy group required hospital treatment for > 24 h versus the Type 1 diabetes (5.0%) and Type 2 diabetes multiple daily injections (5.3%) groups. CONCLUSION: This analysis suggests that severe hypoglycaemia events often result in emergency/ambulance calls and hospital treatment, incurring a substantial health economic burden, and were associated with all insulin regimens.

Hypoglycaemia and accident risk in people with type 2 diabetes mellitus treated with non-insulin antidiabetes drugs.

AIMS: To assess associations between hypoglycaemia and risk of accidents resulting in hospital visits among people with type 2 diabetes receiving antidiabetes drugs without insulin. METHODS: People with type 2 diabetes who were not treated with insulin were identified from a US-based employer claims database (1998-2010). Following initiation of an antidiabetes drug, the occurrence of accidents resulting in hospital visits was compared between people with, and without, claims for hypoglycaemia using multivariable Cox proportional hazard models adjusted for demographics, comorbidities, prior treatments and prior medical service use. Additional analyses were stratified by age 65 years or older. RESULTS: A total of N = 5582 people with claims for hypoglycaemia and N = 27,910 with no such claims were included. Accidents resulting in hospital visits occurred in 5.5 and 2.8% of people with, and without, hypoglycaemia, respectively. After adjusting for baseline characteristics, hypoglycaemia was associated with significantly increased hazards for any accident [hazard ratio (HR) 1.39, 95% CI 1.21-1.59, p < 0.001], accidental falls (HR 1.36, 95% CI 1.13-1.65, p < 0.001) and motor vehicle accidents (HR 1.82, 95% CI 1.18-2.80, p = 0.007). In age-stratified analyses, hypoglycaemia was associated with greater hazards of driving-related accidents in people younger than age 65 and falls in people aged 65 or older. CONCLUSIONS: In people with type 2 diabetes receiving antidiabetes drugs without insulin, hypoglycaemia was associated with a significantly higher risk of accidents resulting in hospital visits, including accidents related to driving and falls.

Management of severe hypoglycaemia: cultural similarities, differences and resource consumption in three European countries.

BACKGROUND: To investigate the characteristics of people with insulin-treated diabetes, who have experienced severe hypoglycaemic events (SHEs), in Germany, Spain or UK. METHODS: Patients with type 1 (n=319) or insulin-treated type 2 diabetes (n=320) who had experienced ≥ 1 SHE in the preceding year were enrolled. Their median age was 53 years (range, 16-94 years). Data were collected using a questionnaire administered by an experienced interviewer. RESULTS: The median number of reported SHEs was 2-3 in 12 months. Most events (69%) occurred at home, usually during the day or evening (74%) and most commonly due to insufficient food consumption (45%). In patients whose hypoglycaemia awareness was tested, 68% had normal awareness. Patients requiring emergency healthcare treatment frequently had impaired hypoglycaemia awareness, and developed hypoglycaemic coma more often. Hospital treatment was usually provided in an emergency department (72-94%). The duration of stay was longest in Germany. Following a SHE, patients receiving professional treatment were more likely to: consult their physician, test their blood glucose more often, adjust insulin dose and receive self-management training. CONCLUSIONS: This survey of diabetes patients aged 16-94 years showed that SHEs represent a substantial burden on national healthcare systems in Germany, UK and Spain. The pattern of occurrence and treatment was similar in all three countries, despite differences in cultures and healthcare systems.

Hypoglycaemia and driving in people with insulin-treated diabetes: adherence to recommendations for avoidance.

BACKGROUND: Hypoglycaemia impairs driving performance, so drivers with insulin-treated diabetes should try to avoid hypoglycaemia when driving, and treat it effectively if it occurs. It is not known how many insulin-treated drivers are familiar with, or adhere to, recommended safe practice. METHODS: We surveyed a representative sample of 202 current drivers with insulin-treated diabetes (115 with Type 1 diabetes), using a structured questionnaire. Data were obtained on driving history, estimated frequency of hypoglycaemia, and measures taken to avoid and treat hypoglycaemia when driving. RESULTS: The licensing authority (DVLA) and motor insurance company had been informed by almost all participants. Sixty-four participants (31.7%) had experienced hypoglycaemia while driving, and 27 (13.4%) reported that this had occurred within the preceding year. A minimum blood glucose level of 4.0 mmol/l or higher was considered necessary for driving by 151 drivers (74.8%), and 176 (87.1%) reported always keeping carbohydrate in their vehicle. However, 77 (38.1%) reported never carrying a glucose meter when driving, and 121 (59.9%) that they never test blood glucose before driving, or test only if symptomatic of hypoglycaemia. Most participants (89%) would stop driving to treat hypoglycaemia and would not resume driving immediately, although only 28 (13.9%) would wait longer than 30 min. Almost half of participants were failing to observe at least one essential aspect of safe driving. CONCLUSIONS: Compliance with statutory requirements to inform the licensing authority and motor insurer is good, and drivers' perceptions of the minimum safe blood glucose level for driving are encouraging. However, most drivers rely on symptoms to detect hypoglycaemia while driving, and seldom test blood glucose before driving. Patient education should emphasize the role of blood glucose monitoring in relation to driving, and highlight the potential deterioration in driving performance when blood glucose falls below 4.0 mmol/l.

Causes, management and morbidity of acute hypoglycaemia in adults requiring hospital admission.

In the community, acute hypoglycaemia is commonly caused by therapies for diabetes mellitus or the excessive consumption of alcohol. Although most episodes do not require admission to hospital, little information is available on the causes and outcome of those that do. We retrospectively surveyed adult patients admitted to a large urban teaching hospital with acute hypoglycaemia in a 12-month period, identifying 56 admissions of 51 patients. Forty-one had diabetes mellitus, 33 (80%) of whom were receiving treatment with insulin. The others had hypoglycaemia induced by excessive consumption of alcohol or by deliberate self-poisoning with insulin. A history of psychiatric illness and/or chronic alcoholism was common. Neurological manifestations of hypoglycaemia were the principal reason for admission, observed on 50 occasions (89%), and 11 events (20%) had precipitated convulsions. Although many patients (59%) had received treatment for hypoglycaemia before admission, hypoglycaemia recurred in 16% of patients in hospital. Four patients (7%) died following admission, but in only one case was this the direct result of hypoglycaemia. However, within 15 months of the index hypoglycaemia event, a further six patients (11%) had died, mostly of causes unrelated to hypoglycaemia. Patients who require hospital admission for treatment of hypoglycaemia have a high incidence of neurological manifestations, a high rate of mental illness and other medical disorders, and may represent a high-risk subgroup with a poor long-term prognosis.

Type 1 diabetes mellitus and Down's syndrome: prevalence, management and diabetic complications.

Type 1 insulin-dependent, diabetes mellitus (Type 1 DM) is thought to be more prevalent in individuals with Down's syndrome. To ascertain the local prevalence of Type 1 DM in patients with Down's syndrome in a geographically defined area, the four diabetes clinics in Lothian were surveyed and 13 patients with Down's syndrome and Type 1 DM were identified. Using data from previous epidemiological surveys which determined the prevalence of Down's syndrome in the general population, the prevalence rate of Type 1 DM in patients with Down's syndrome was calculated to be between 1.4 and 10.6%, a prevalence considerably higher than in the general population. Although 7 (54%) of the Down's syndrome patients were treated with once daily administration of insulin, the mean HbA1c value of the group was similar to that observed in a control group of 39 age-, sex- and duration-matched Type 1 patients, all of whom were taking two or more injections of insulin daily. Glycaemic control was therefore of similar quality to matched Type 1 patients without Down's syndrome, despite the frequent use of simple insulin regimens, which may relate to the more stable lifestyle of these patients.

Medical assessment for licensing of taxi drivers by Scottish local authorities.

In the UK, licensing of taxi drivers is dealt with by local government authorities. In Scotland, before the recent reorganization of local government, taxi licensing was under the jurisdiction of District Councils, so a telephone survey was conducted of all 52 mainland Scottish District Councils to ascertain the procedures which were being employed in assessing medical fitness to drive a taxi, for which there is no national standard. Medical enquiries relevant to fitness to drive were being made by 41 (79%) of local authorities, but in 38 (73%) this was limited to a single question about health. No enquiry regarding health status was being made by 11 (21%) District Councils (all serving < 100,000 population size). Only three Scottish District Councils conducted a routine medical examination of all applicants. Thirteen of the 15 large (> 100,000 population size), and 20 of the 21 medium-sized (50,000-100,000) Scottish District Councils carried out medical examinations either when a relevant medical disorder was declared by the applicant, or when the applicant was above a defined age (which varied between local authorities). The small local authorities (population < 50,000) examined only those applicants who declared medical disorders. This survey has shown considerable variation and limitations in the approach of the previously existing Scottish District Councils to the assessment of medical fitness to drive of applicants for taxi licences. It is suggested that national standards and guidelines are required for medical fitness to drive in relation to taxi licensing.

Psychological and demographic correlates of glycaemic control in adult patients with type 1 diabetes.

The relationship between an objective measure of glycaemic control (glycated haemoglobin (HbA1)) and personality variables was examined in two separate groups of adult Type 1 (insulin-dependent) diabetic patients. Study 1 included 121 patients, all of whom also had subjective self-reporting of treatment compliance assessed, while the first 57 patients had individual differences in intelligence, major dimensions of personality and forgetfulness documented. Study 2 examined 303 patients, all of whom had their major dimensions of personality assessed using a shortened and updated version of the original personality questionnaire. Demographic indices (age, onset-age, duration of diabetes) were assessed in both groups. No significant correlation was found between HbA1 and self-report compliance suggesting that self-reporting may be invalid as a measure of glycaemic control. In study 1 personality and intelligence variables did not correlate significantly with HbA1 values. Older patients with shorter duration of diabetes had significantly better glycaemic control (p < 0.05). A significant correlation was observed between HbA1 concentration and onset-age of diabetes (p < 0.001); the patients who had developed diabetes later in life were achieving better control of their blood glucose. In the larger number of subjects in study 2 no significant correlations were evident between HbA1 and personality variables. It is concluded that the predictors of glycaemic control indexed by HbA1 may be distinct from predictors of self-report compliance and that the latter have limited or no value in providing an assessment of quality of glycaemic control. There is no evidence of an effect of personality on glycaemic control as measured by HbA1.

Type 1 diabetes and driving experience: an eight-year cohort study.

The driving habits of 250 drivers with Type 1 diabetes were reviewed 8 years after a previous assessment. At least 45 patients had died and 18 patients could not be traced. A postal questionnaire of the 187 survivors elicited a response from 89%. Fifty-six patients (34%) still held an unrestricted driving licence, demonstrating that a significant proportion of diabetic drivers had not declared diabetes to the licensing authority and/or their motor insurer and continued to ignore the statutory regulations. Fewer patients held Heavy Goods Vehicle licences than 8 years previously. Twenty-four patients had ceased driving as their driving skills had diminished with advancing age and ill health. This was a voluntary decision by all but two patients whose driving licences had been revoked. Thirty-nine patients admitted to a total of 55 road traffic accidents since 1979; 9 accidents (16%) were attributed to hypoglycaemia. Although dependent on patients' honesty and the accuracy of recall, the disclosed accident rates of 4.9 per million miles driven for male drivers and 6.3 per million miles for female drivers are comparable to the accident rate of a non-diabetic driving population of similar age.

Diabetes and insurance: a survey of patient experience.

A survey of 186 diabetic patients examined their collective experience of life and motor insurance. Some form of life insurance policy had been obtained by 150 patients, with a combined total of 204 policies, 107 of which had been agreed before the diagnosis of diabetes. Most patients had declared diabetes to the insurer but 12 patients had been refused acceptance. Only 15 patients sought alternative quotations. The premium had been loaded by 10-40% for 36 patients because of diabetes, and 48 required a medical report. Of 147 diabetic drivers, 95 (65%) had declared diabetes either to the Licensing authority, or to the motor insurer, but only 62 (42%) had informed both. Fourteen patients had been refused motor insurance cover by individual companies, and 36 patients were aware of having had their premium increased, but only 16 patients had sought alternative quotations. Major differences in attitude with regard to diabetes as a risk factor for insurance are evident, and patients should be advised to approach several companies when seeking insurance cover.