Estimation of the direct health and indirect societal costs of diabetes in the UK using a cost of illness model.

AIMS: The direct cost of diabetes to the UK health system was estimated at around £10 billion in 2012. This analysis updates that estimate using more recent and accurate data sources. METHODS: A pragmatic review of relevant data sources for UK nations was conducted, including population-level data sets and published literature, to generate estimates of costs separately for Type 1, Type 2 and gestational diabetes. A comprehensive cost framework, developed in collaboration with experts, was used to create a population-based cost of illness model. The key driver of the analysis was prevalence of diabetes and its complications. Estimates were made of the excess costs of diagnosis, treatment and diabetes-related complications compared with the general UK population. Estimates of the indirect costs of diabetes focused on productivity losses due to absenteeism and premature mortality. RESULTS: The direct costs of diabetes in 2021/22 for the UK were estimated at £10.7 billion, of which just over 40% related to diagnosis and treatment, with the rest relating to the excess costs of complications. Indirect costs were estimated at £3.3 billion. CONCLUSIONS: Diabetes remains a considerable cost burden in the UK, and the majority of those costs are still spent on potentially preventable complications. Although rates of some complications are reducing, prevalence continues to increase and effective approaches to primary and secondary prevention continue to be needed. Improvements in data capture, data quality and reporting, and further research on the human and financial implications of increasing incidence of Type 2 diabetes in younger people are recommended.

Impact of MidMed, a general practitioner-led modified comprehensive geriatric assessment for patients with frailty.

INTRODUCTION: the identification and management of frailty occurs mostly in primary care. Several different models of care exist. This study aimed to assess the impact of a new General Practitioner (GP)-led modified Comprehensive Geriatric Assessment (CGA) on service delivery, healthcare utilisation and patient outcomes. METHOD: patients with moderate-severe frailty (electronic Frailty Index score > 0.24) in Newbattle Medical Practice, Scotland, were eligible for a novel intervention (MidMed) in which an additional GP performed a modified CGA and was directly accessible for appointments. The recruits to the intervention (MidMed) group were compared with those waiting to be enrolled (non-MidMed). Outcomes included unscheduled hospital admissions, primary care consultations, continuity of care (Usual Provider of Care (UPC) index), outpatient attendances and mortality. Adjusted rate ratios (aRR), for MidMed compared to non-MidMed, were estimated using regression models adjusting for demographics and healthcare utilisation histories. RESULTS: 510 patients were included: 290 MidMed (mean(SD) age 80.1(7.6)years; 59.6% female) and 220 non-MidMed (75.4(8.6)years; 57.7% female). Median follow-up was 396 days. aRR(95%CI) was 0.46(0.30-0.71) for >1 admission, 0.62(0.41-0.95) >1 Emergency Department (ED) attendance and 1.52(1.30-1.75) for use of primary care, with no difference in outpatient appointments or mortality. Continuity of care was better for the MidMed group (MidMed UPC 0.77(SD 0.19), non-MidMed 0.41(0.18), P < 0.001). CONCLUSION: this GP-led service for frail patients was associated with lower risk of hospital readmission/ED reattendance, greater use of primary care and improved continuity of care. More detailed evaluation of novel primary care frailty services, over longer time-periods, including robust randomised controlled trials, are needed.

Cost-Utility of an Online Education Platform and Diabetes Personal Health Record: Analysis Over Ten Years.

BACKGROUND AND AIMS: My Diabetes My Way (MDMW) is Scotland's interactive website and mobile app for people with diabetes and their caregivers. It contains multimedia resources for diabetes education and offers access to electronic personal health records. This study aims to assess the cost-utility of MDMW compared with routine diabetes care in people with type 2 diabetes who do not use insulin. MATERIALS AND METHODS: Analysis used the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model 2. Clinical parameters of MDMW users (n = 2576) were compared with a matched cohort of individuals receiving routine care alone (n = 11 628). Matching criteria: age, diabetes duration, sex, and socioeconomic status. Impact on life expectancy, quality-adjusted life years (QALYs), and costs of treatment and complications were simulated over ten years, including a 10% sensitivity analysis. RESULTS: MDMW cohort: 1670 (64.8%) men; average age 64.3 years; duration of diabetes 5.5 years. 906 (35.2%) women: average age 61.6 years; duration 4.7 years. The cumulative mean QALY (95% CI) gain: 0.054 (0.044-0.062) years. Mean difference in cost: -£118.72 (-£150.16 to -£54.16) over ten years. Increasing MDMW costs (10%): -£50.49 (-£82.24-£14.14). Decreasing MDMW costs (10%): -£186.95 (-£218.53 to -£122.51). CONCLUSIONS: MDMW is "dominant" over usual care (cost-saving and life improving) in supporting self-management in people with type 2 diabetes not treated with insulin. Wider use may result in significant cost savings through delay or reduction of long-term complications and improved QALYs in Scotland and other countries. MDMW may be among the most cost-effective interventions currently available to support diabetes.

Breast cancer incidence and survival in Scotland by socio-economic deprivation and tumour subtype.

BACKGROUND: Women from socio-economically deprived areas are less likely to develop and then to survive breast cancer (BC). Whether associations between deprivation and BC incidence and survival differ by tumour molecular subtypes and mode of detection in Scotland are unknown. METHODS: Data consisted of 62,378 women diagnosed with invasive BC between 2000 and 2016 in Scotland. Incidence rates and time trends were calculated for oestrogen receptor positive (ER+) and negative (ER-) tumours and stratified by the Scottish Index of Multiple Deprivation (SIMD) quintiles and screening status. SIMD is an area-based measure derived across seven domains: income, employment, education, health, access to services, crime and housing. We calculated adjusted hazard ratios (aHR [95% confidence intervals]) for BC death by immunohistochemical surrogates of molecular subtypes for the most versus the least deprived quintile. We adjusted for mode of detection and other confounders. RESULTS: In Scotland, screen-detected ER+tumour incidence increased over time, particularly in the least deprived quintile [Average Annual Percentage Change (AAPC) = 2.9% with 95% CI from 1.2 to 4.7]. No marked differences were observed for non-screen-detected ER+tumours or ER- tumours by deprivation. BC mortality was higher in the most compared to the least deprived quintile irrespective of ER status (aHR = 1.29 [1.18, 1.41] for ER+ and 1.27 [1.09, 1.47] for ER- tumours). However, deprivation was associated with significantly higher mortality for luminal A and HER2-enriched tumours (aHR = 1.46 [1.13, 1.88] and 2.10 [1.23, 3.59] respectively) but weaker associations for luminal B and TNBC tumours that were not statistically significant. CONCLUSIONS: Deprivation is associated with differential BC incidence trends for screen-detected ER+tumours and with higher mortality for select tumour subtypes. Future efforts should evaluate factors that might be associated with reduced survival in deprived populations and monitor progress stratified by tumour subtypes and mode of detection.

IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045.

AIMS: To provide global, regional, and country-level estimates of diabetes prevalence and health expenditures for 2021 and projections for 2045. METHODS: A total of 219 data sources meeting pre-established quality criteria reporting research conducted between 2005 and 2020 and representing 215 countries and territories were identified. For countries without data meeting quality criteria, estimates were extrapolated from countries with similar economies, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates. Diabetes-related health expenditures were estimated using an attributable fraction method. The 2021 diabetes prevalence estimates were applied to population estimates for 2045 to project future prevalence. RESULTS: The global diabetes prevalence in 20-79 year olds in 2021 was estimated to be 10.5% (536.6 million people), rising to 12.2% (783.2 million) in 2045. Diabetes prevalence was similar in men and women and was highest in those aged 75-79 years. Prevalence (in 2021) was estimated to be higher in urban (12.1%) than rural (8.3%) areas, and in high-income (11.1%) compared to low-income countries (5.5%). The greatest relative increase in the prevalence of diabetes between 2021 and 2045 is expected to occur in middle-income countries (21.1%) compared to high- (12.2%) and low-income (11.9%) countries. Global diabetes-related health expenditures were estimated at 966 billion USD in 2021, and are projected to reach 1,054 billion USD by 2045. CONCLUSIONS: Just over half a billion people are living with diabetes worldwide which means that over 10.5% of the world's adult population now have this condition.

Marked and widening socioeconomic inequalities in type 2 diabetes prevalence in Scotland.

BACKGROUND: This study investigated the association between socioeconomic status and type 2 diabetes (T2D) prevalence in Scotland in 2021 and tested the null hypothesis that inequalities had not changed since they were last described for 2001-2007. METHODS: Data from a national population-based diabetes database for 35-to-84-year-olds in Scotland for 2021 and mid-year population estimates for 2019 stratified by sex and fifths of the Scottish Index of Multiple Deprivation were used to calculate age-specific prevalence of T2D. Age-standardised prevalence was estimated using the European Standard Population with relative risks (RRs) compared between the most (Q1) and least (Q5) deprived fifths for each sex, and compared against similar estimates from 2001 to 2007. RESULTS: Complete data were available for 255 764 people (98.9%) with T2D. Age-standardised prevalence was lowest for women in Q5 (3.4%) and highest for men in Q1 (11.6%). RRs have increased from 2.00 (95% CI 1.52 to 2.62) in 2001-2007 to 2.48 (95% CI 2.43 to 2.53) in 2021 for women and from 1.58 (95% CI 1.20 to 2.07) in 2007 to 1.89 (95% CI 1.86 to 1.92) in 2021 for men. CONCLUSIONS: Socioeconomic inequalities in T2D prevalence have widened between 2001-2007 and 2021. Further research is required to investigate potential medium-term effects of the COVID-19 pandemic.

Socio-demographic and clinical characteristics of diabetes mellitus in rural Rwanda: time to contextualize the interventions? A cross-sectional study.

BACKGROUND: Existing prevention and treatment strategies target the classic types of diabetes yet this approach might not always be appropriate in some settings where atypical phenotypes exist. This study aims to assess the socio-demographic and clinical characteristics of people with diabetes in rural Rwanda compared to those of urban dwellers. METHODS: A cross-sectional, clinic-based study was conducted in which individuals with diabetes mellitus were consecutively recruited from April 2015 to April 2016. Demographic and clinical data were collected from patient interviews, medical files and physical examinations. Chi-square tests and T-tests were used to compare proportions and means between rural and urban residents. RESULTS: A total of 472 participants were recruited (mean age 40.2 ± 19.1 years), including 295 women and 315 rural residents. Compared to urban residents, rural residents had lower levels of education, were more likely to be employed in low-income work and to have limited access to running water and electricity. Diabetes was diagnosed at a younger age in rural residents (mean ± SD 32 ± 18 vs 41 ± 17 years; p < 0.001). Physical inactivity, family history of diabetes and obesity were significantly less prevalent in rural than in urban individuals (44% vs 66, 14.9% vs 28.7 and 27.6% vs 54.1%, respectively; p < 0.001). The frequency of fruit and vegetable consumption was lower in rural than in urban participants. High waist circumference was more prevalent in urban than in rural women and men (75.3% vs 45.5 and 30% vs 6%, respectively; p < 0.001). History of childhood under-nutrition was more frequent in rural than in urban individuals (22.5% vs 6.4%; p < 0.001). CONCLUSIONS: Characteristics of people with diabetes in rural Rwanda appear to differ from those of individuals with diabetes in urban settings, suggesting that sub-types of diabetes exist in Rwanda. Generic guidelines for diabetes prevention and management may not be appropriate in different populations.

Use of personalised risk-based screening schedules to optimise workload and sojourn time in screening programmes for diabetic retinopathy: A retrospective cohort study.

BACKGROUND: National guidelines in most countries set screening intervals for diabetic retinopathy (DR) that are insufficiently informed by contemporary incidence rates. This has unspecified implications for interval disease risks (IDs) of referable DR, disparities in ID between groups or individuals, time spent in referable state before screening (sojourn time), and workload. We explored the effect of various screening schedules on these outcomes and developed an open-access interactive policy tool informed by contemporary DR incidence rates. METHODS AND FINDINGS: Scottish Diabetic Retinopathy Screening Programme data from 1 January 2007 to 31 December 2016 were linked to diabetes registry data. This yielded 128,606 screening examinations in people with type 1 diabetes (T1D) and 1,384,360 examinations in people with type 2 diabetes (T2D). Among those with T1D, 47% of those without and 44% of those with referable DR were female, mean diabetes duration was 21 and 23 years, respectively, and mean age was 26 and 24 years, respectively. Among those with T2D, 44% of those without and 42% of those with referable DR were female, mean diabetes duration was 9 and 14 years, respectively, and mean age was 58 and 52 years, respectively. Individual probability of developing referable DR was estimated using a generalised linear model and was used to calculate the intervals needed to achieve various IDs across prior grade strata, or at the individual level, and the resultant workload and sojourn time. The current policy in Scotland-screening people with no or mild disease annually and moderate disease every 6 months-yielded large differences in ID by prior grade (13.2%, 3.6%, and 0.6% annually for moderate, mild, and no prior DR strata, respectively, in T1D) and diabetes type (2.4% in T1D and 0.6% in T2D overall). Maintaining these overall risks but equalising risk across prior grade strata would require extremely short intervals in those with moderate DR (1-2 months) and very long intervals in those with no prior DR (35-47 months), with little change in workload or average sojourn time. Changing to intervals of 12, 9, and 3 months in T1D and to 24, 9, and 3 months in T2D for no, mild, and moderate DR strata, respectively, would substantially reduce disparity in ID across strata and between diabetes types whilst reducing workload by 26% and increasing sojourn time by 2.3 months. Including clinical risk factor data gave a small but significant increment in prediction of referable DR beyond grade (increase in C-statistic of 0.013 in T1D and 0.016 in T2D, both p < 0.001). However, using this model to derive personalised intervals did not have substantial workload or sojourn time benefits over stratum-specific intervals. The main limitation is that the results are pertinent only to countries that share broadly similar rates of retinal disease and risk factor distributions to Scotland. CONCLUSIONS: Changing current policies could reduce disparities in ID and achieve substantial reductions in workload within the range of IDs likely to be deemed acceptable. Our tool should facilitate more rational policy setting for screening.

Incidence of Type 2 Diabetes in People With a History of Hospitalization for Major Mental Illness in Scotland, 2001-2015: A Retrospective Cohort Study.

OBJECTIVE: To determine the incidence of type 2 diabetes in people with a history of hospitalization for major mental illness versus no mental illness in Scotland by time period and sociodemographics. RESEARCH DESIGN AND METHODS: We used national Scottish population-based records to create cohorts with a hospital record of schizophrenia, bipolar disorder, or depression or no mental illness and to ascertain diabetes incidence. We used quasi-Poisson regression models including age, sex, time period, and area-based deprivation to estimate incidence and relative risks (RRs) of diabetes by mental illness status. Estimates are illustrated for people aged 60 years and in the middle deprivation quintile in 2015. RESULTS: We identified 254,136 diabetes cases during 2001-2015. Diabetes incidence in 2015 was 1.5- to 2.5-fold higher in people with versus without a major mental disorder, with the gap having slightly increased over time. RRs of diabetes incidence were greater among women than men for schizophrenia (RR 2.40 [95% CI 2.01, 2.85] and 1.63 [1.38, 1.94]), respectively) and depression (RR 2.10 [1.86, 2.36] and 1.62 [1.43, 1.82]) but similar for bipolar disorder (RR 1.65 [1.35, 2.02] and 1.50 [1.22, 1.84]). Absolute and relative differences in diabetes incidence associated with mental illness increased with increasing deprivation. CONCLUSIONS: Disparities in diabetes incidence between people with and without major mental illness appear to be widening. Major mental illness has a greater effect on diabetes risk in women and people living in more deprived areas, which has implications for intervention strategies to reduce diabetes risk in this vulnerable population.

Sex differences in the association between socioeconomic status and diabetes prevalence and incidence in China: cross-sectional and prospective studies of 0.5 million adults.

AIMS/HYPOTHESIS: China has undergone rapid socioeconomic transition accompanied by lifestyle changes that are expected to have a profound impact on the health of its population. However, there is limited evidence from large nationwide studies about the relevance of socioeconomic status (SES) to risk of diabetes. We describe the associations of two key measures of SES with prevalent and incident diabetes in Chinese men and women. METHODS: The China Kadoorie Biobank study included 0.5 million adults aged 30-79 years recruited from ten diverse areas in China during 2004-2008. SES was assessed using the highest educational level attained and annual household income. Prevalent diabetes was identified from self-report and plasma glucose measurements. Incident diabetes was identified from linkage to disease and death registries and national health insurance claim databases. We estimated adjusted ORs and HRs for prevalent and incident diabetes associated with SES using logistic and Cox regression models, respectively. RESULTS: At baseline, 30,066 (5.9%) participants had previously diagnosed (3.1%) or screen-detected (2.8%) diabetes among 510,219 participants included for cross-sectional analyses. There were 480,153 people without prevalent diabetes at baseline, of whom 9544 (2.0%) had new-onset diabetes during follow-up (median 7 years). Adjusted ORs (95% CIs) for prevalent diabetes, comparing highest vs lowest educational level, were 1.21 (1.09, 1.35) in men and 0.69 (0.63, 0.76) in women; for incident diabetes, the corresponding HRs were 1.27 (1.07, 1.51) and 0.80 (0.67, 0.95), respectively. For household income, the adjusted ORs for prevalent diabetes, comparing highest vs lowest categories, were 1.45 (1.34, 1.56) in men and 1.26 (1.19, 1.34) in women; for incident diabetes, the HRs were 1.36 (1.19, 1.55) and 1.06 (0.95, 1.17), respectively. CONCLUSIONS/INTERPRETATION: Among Chinese adults, the associations between education and diabetes prevalence and incidence differed qualitatively between men and women, whereas higher household income was positively associated with diabetes prevalence and incidence in both sexes, with a stronger relationship in men than in women.

Estimation of global insulin use for type 2 diabetes, 2018-30: a microsimulation analysis.

BACKGROUND: The amount of insulin needed to effectively treat type 2 diabetes worldwide is unknown. It also remains unclear how alternative treatment algorithms would affect insulin use and disability-adjusted life-years (DALYs) averted by insulin use, given that current access to insulin (availability and affordability) in many areas is low. The aim of this study was to compare alternative projections for and consequences of insulin use worldwide under varying treatment algorithms and degrees of insulin access. METHODS: We developed a microsimulation of type 2 diabetes burden from 2018 to 2030 across 221 countries using data from the International Diabetes Federation for prevalence projections and from 14 cohort studies representing more than 60% of the global type 2 diabetes population for HbA1c, treatment, and bodyweight data. We estimated the number of people with type 2 diabetes expected to use insulin, international units (IU) required, and DALYs averted per year under alternative treatment algorithms targeting HbA1c from 6·5% to 8%, lower microvascular risk, or higher HbA1c for those aged 75 years and older. FINDINGS: The number of people with type 2 diabetes worldwide was estimated to increase from 405·6 million (95% CI 315·3 million-533·7 million) in 2018 to 510·8 million (395·9 million-674·3 million) in 2030. On this basis, insulin use is estimated to increase from 516·1 million 1000 IU vials (95% CI 409·0 million-658·6 million) per year in 2018 to 633·7 million (500·5 million-806·7 million) per year in 2030. Without improved insulin access, 7·4% (95% CI 5·8-9·4) of people with type 2 diabetes in 2030 would use insulin, increasing to 15·5% (12·0-20·3) if insulin were widely accessible and prescribed to achieve an HbA1c of 7% (53 mmol/mol) or lower. If HbA1c of 7% or lower was universally achieved, insulin would avert 331 101 DALYs per year by 2030 (95% CI 256 601-437 053). DALYs averted would increase by 14·9% with access to newer oral antihyperglycaemic drugs. DALYs averted would increase by 44·2% if an HbA1c of 8% (64 mmol/mol) were used as a target among people aged 75 years and older because of reduced hypoglycaemia. INTERPRETATION: The insulin required to treat type 2 diabetes is expected to increase by more than 20% from 2018 to 2030. More DALYs might be averted if HbA1c targets are higher for older adults. FUNDING: The Leona M and Harry B Helmsley Charitable Trust.

Socioeconomic status and self-reported, screen-detected and total diabetes prevalence in Chinese men and women in 2011-2012: a nationwide cross-sectional study.

BACKGROUND: A rapid epidemiological transition is taking place in China and the association between socioeconomic status (SES) and diabetes prevalence is not clear and may vary by population characteristics and geography within the country. We describe the associations between educational level, annual household living expenditure (AHLE) and diabetes prevalence in a large middle-aged and elderly Chinese population using data from a nationwide cross-sectional study. METHODS: We used data from the China Health and Retirement Longitudinal Study, which collected information from interviews and blood tests from a nationwide sample of people over 44 years of age in 2011-2012. We used multivariable logistic regression to describe the association between highest levels of education (high school or above compared to illiterate) or AHLE (top vs bottom quartile) and self-reported, screen-detected or total diabetes prevalence. We stratified by sex and adjusted for age, education or AHLE (as appropriate), urban, rural or migrant residence status and geographical area. RESULTS: Complete data were available for 10 100 participants of whom 10.5% and 28.9% had the highest and the lowest levels of education respectively. Overall prevalence of self-reported diabetes was 6.0% and of screen-detected diabetes was 9.8%. Higher education level was associated with both self-reported diabetes (odds ratio (OR) = 2.41, 95% confidence interval CI = 1.36-4.46) and total diabetes (OR = 1.53 95%, CI = 1.10-2.15) only in men. AHLE was associated with self-reported diabetes in men (OR = 1.87, 95% CI = 1.26-2.84) and women (OR = 2.31, 95% CI = 1.62-3.34). There was no association between SES and screen-detected diabetes for men or women. CONCLUSIONS: SES inequalities exist in prevalence of diabetes in China and can be used to inform approaches to prevention. Identification and appropriate intervention for people with undiagnosed diabetes is required for all SES groups.

Socioeconomic status and prevalence of type 2 diabetes in mainland China, Hong Kong and Taiwan: a systematic review.

BACKGROUND: China is estimated to have had the largest number of people with diabetes in the world in 2015, with extrapolation of existing data suggesting that this situation will continue until at least 2030. Type 2 diabetes has been reported to be more prevalent among people with low socioeconomic status (SES) in high-income countries, whereas the opposite pattern has been found in studies from low- and middle-income countries. We conducted a systematic review to describe the cross-sectional association between SES and prevalence of type 2 diabetes in Chinese in mainland China, Hong Kong and Taiwan. METHODS: We conducted a systematic literature search in Medline, Embase and Global Health electronic databases for English language studies reporting prevalence or odds ratio for type 2 diabetes in a Chinese population for different SES groups measured by education, income and occupation. We appraised the quality of included studies using a modified Newcastle-Ottawa Scale. Heterogeneity of studies precluded meta-analyses, therefore we summarized study results using a narrative synthesis. RESULTS: Thirty-three studies met the inclusion criteria and were included in the systematic review. The association between education, income and occupation and type 2 diabetes was reported by 27, 19 and 12 studies, respectively. Most, but not all, studies reported an inverse association between education and type 2 diabetes, with odds ratios (OR) and 95% confidence interval (CI) ranging from 0.39 (CI not reported) to 1.52 (95% CI 0.91 - 2.54) for the highest compared to the lowest education level. The association between income and type 2 diabetes was inconsistent between studies. Only a small number of studies identified a significant association between occupation and type 2 diabetes. Retired people and people working in white collar jobs were reported to have a higher risk of type 2 diabetes than other occupational groups even after adjusting for age. CONCLUSIONS: This first systematic review of the association between individual SES and prevalence of type 2 diabetes in China found that low education is probably associated with an increased prevalence of type 2 diabetes, while the association between income and occupation and type 2 diabetes is unclear.

Five-Year Mortality and Hospital Costs Associated with Surviving Intensive Care.

RATIONALE: Survivors of critical illness experience significant morbidity, but the impact of surviving the intensive care unit (ICU) has not been quantified comprehensively at a population level. OBJECTIVES: To identify factors associated with increased hospital resource use and to ascertain whether ICU admission was associated with increased mortality and resource use. METHODS: Matched cohort study and pre/post-analysis using national linked data registries with complete population coverage. The population consisted of patients admitted to all adult general ICUs during 2005 and surviving to hospital discharge, identified from the Scottish Intensive Care Society Audit Group registry, matched (1:1) with similar hospital control subjects. Five-year outcomes included mortality and hospital resource use. Confounder adjustment was based on multivariable regression and pre/post within-individual analyses. MEASUREMENTS AND MAIN RESULTS: Of 7,656 ICU patients, 5,259 survived to hospital discharge (5,215 [99.2%] matched to hospital control subjects). Factors present before ICU admission (comorbidities/pre-ICU hospitalizations) were stronger predictors of hospital resource use than acute illness factors. In the 5 years after the initial hospital discharge, compared with hospital control subjects, the ICU cohort had higher mortality (32.3% vs. 22.7%; hazard ratio, 1.33; 95% confidence interval, 1.22-1.46; P < 0.001), used more hospital resources (mean hospital admission rate, 4.8 vs. 3.3/person/5 yr), and had 51% higher mean 5-year hospital costs ($25,608 vs. $16,913/patient). Increased resource use persisted after confounder adjustment (P < 0.001) and using pre/post-analyses (P < 0.001). Excess resource use and mortality were greatest for younger patients without significant comorbidity. CONCLUSIONS: This complete, national study demonstrates that ICU survivorship is associated with higher 5-year mortality and hospital resource use than hospital control subjects, representing a substantial burden on individuals, caregivers, and society.

Socioeconomic status, comorbidity and mortality in patients with type 2 diabetes mellitus in Scotland 2004-2011: a cohort study.

BACKGROUND: Mortality in people with and without diabetes often exhibits marked social patterning, risk of death being greater in deprived groups. This may reflect deprivation-related differences in comorbid disease (conditions additional to diabetes itself). This study sought to determine whether the social patterning of mortality in a population with type 2 diabetes mellitus (T2DM) is explained by differential comorbidity. METHODS: Hospital records for 70 197 men and 56 451 women diagnosed with T2DM at 25 years of age and above in Scotland during the period 2004-2011 were used to construct comorbidity histories. Sex-specific logistic models were fitted to predict mortality at 1 year after diagnosis with T2DM, predicted initially by age and socioeconomic status (SES) then extended to incorporate in turn 5 representations of comorbidity (including the Charlson Index). The capacity of comorbidity to explain social mortality gradients was assessed by observing the change in regression coefficients for SES following the addition of comorbidity. RESULTS: After adjustment for age and Charlson Index, the OR for the contrast between the least deprived and most deprived quintiles of SES for men was 0.79 (95% CI 0.67 to 0.94). For women, the OR was 0.81 (0.67 to 0.97). Similar results were obtained for the 4 other comorbidity measures used. CONCLUSIONS: The social patterning of mortality in people with T2DM is not fully explained by differing levels of comorbid disease additional to T2DM itself. Other dimensions of deprivation are implicated in the elevated death rates observed in deprived groups of people with T2DM.

Socioeconomic deprivation increases the effect of winter on admissions to hospital with COPD: retrospective analysis of 10 years of national hospitalisation data.

BACKGROUND: Admission to hospital with chronic obstructive pulmonary disease (COPD) is associated with deprivation and season. However, it is not known whether deprivation and seasonality act synergistically to influence the risk of hospital admission with COPD. AIMS: To investigate whether the relationship between season/temperature and admission to hospital with COPD differs with deprivation. METHODS: All COPD admissions (ICD10 codes J40-J44 and J47) were obtained for the decade 2001-2010 for all Scottish residents by month of admission and 2009 Scottish Index of Multiple Deprivation (SIMD) quintile. Confidence intervals for rates and absolute differences in rates were calculated and the proportion of risk during winter attributable to main effects and interactions were estimated. Monthly rates of admission by average daily minimum temperatures were plotted for each quintile of SIMD. RESULTS: Absolute differences in admission rates between winter and summer increased with greater deprivation. In the most deprived quintile, in winter 19.4% (95% CI 17.3% to 21.4%) of admissions were attributable to season/deprivation interaction, 61.2% (95% CI 59.5% to 63.0%) to deprivation alone, and 5.2% (95% CI 4.3% to 6.0%) to winter alone. Lower average daily minimum temperatures over a month were associated with higher admission rates, with stronger associations evident in the more deprived quintiles. CONCLUSIONS: Winter and socioeconomic deprivation-related factors appear to act synergistically, increasing the rate of COPD admissions to hospital more among deprived people than among affluent people in winter than in the summer months. Similar associations were observed for admission rates and temperatures. Interventions effective at reducing winter admissions for COPD may have potential for greater benefit if delivered to more deprived groups.

Surviving intensive care: a systematic review of healthcare resource use after hospital discharge*.

OBJECTIVES: Intensive care survivors continue to experience significant morbidity following acute hospital discharge, but healthcare costs associated with this ongoing morbidity are poorly described. As the demand for intensive care increases, understanding the magnitude of postacute hospital healthcare costs is of increasing relevance to clinicians and healthcare planners. We undertook a systematic review of the literature reporting major healthcare resource use by intensive care survivors following discharge from the hospital and identified factors associated with increased resource use. DATA SOURCES: Seven electronic databases (1990 to August 2012), conference proceedings, and reference lists were searched. STUDY SELECTION: Studies published in English were included that reported postacute hospital discharge healthcare resource use at the individual level for survivors of intensive care. DATA EXTRACTION: Two reviewers screened abstracts and one abstracted data using standardized templates. Study quality was assessed using recognized appraisal methods specific to economic evaluation, epidemiological studies, and randomized trials. DATA SYNTHESIS: From 4,909 articles, 18 articles representing 14 cohorts fulfilled inclusion criteria. There was substantial variation in methodology, especially the resource categories included in the studies. Following standardization to a common currency and year, variation in cost of resource use was evident (range 2011 US $18,847-$148,454 for year 1 postdischarge). Studies undertaken within the United States reported the highest costs; those in the United Kingdom reported substantially lower costs. Factors associated with increased resource use included increasing age, comorbidities, organ dysfunction score, and previous resource use. CONCLUSIONS: Wide variation in methodological approaches limited study comparability and external validity of findings. We found substantial variation in the cost of resource use, especially among countries. Careful description of patient cohorts and healthcare systems is required to maximize generalizability. We give recommendations for a more standardized approach to improve design and reporting of future studies.

Effect of socioeconomic status on mortality among people with type 2 diabetes: a study from the Scottish Diabetes Research Network Epidemiology Group.

OBJECTIVE: The study objective was to describe the effect of socioeconomic status (SES) on mortality among people with type 2 diabetes. RESEARCH DESIGN AND METHODS: We used a population-based national electronic diabetes database for 35- to 84-year-olds in Scotland for 2001-2007 linked to mortality records. SES was derived from an area-based measure with Q5 and Q1 representing the most deprived and affluent quintiles, respectively. Poisson regression was used to estimate relative risks (RRs) for mortality among people with type 2 diabetes compared with the population without diabetes stratified by age (35-64 and 65-84 years), sex, duration of diabetes (< 2 and ≥ 2 years), and SES. RESULTS: Complete data were available for 210,994 eligible individuals (99.4%), and there were 33,842 deaths. Absolute mortality from all causes among people with type 2 diabetes increased with increasing age and socioeconomic deprivation and was higher for men than women. RR for mortality associated with type 2 diabetes was highest for women aged 35-64 years in Q1 with diabetes duration < 2 years at 4.83 (95% CI 3.15-7.40) and lowest for men aged 65-84 years in Q5 with diabetes duration ≥ 2 years at 1.13 (1.03-1.24). CONCLUSIONS: SES modifies the association between type 2 diabetes and mortality so that RR for mortality is lower among more deprived populations. Age, sex, and duration of diabetes also interact with type 2 diabetes to influence RR of mortality. Differences in prevalence of comorbidities may explain these findings.

Socioeconomic status and diabetes-related hospital admissions: a cross-sectional study of people with diagnosed diabetes.

BACKGROUND: Low socioeconomic status (SES) is associated with adverse cardiovascular risk factor patterns and poorer outcomes for people with diabetes. METHODS: A cross-sectional study was performed using data for 35,925 people with diagnosed diabetes in Scotland and an area-based measure of SES using linked hospital and population-based diabetes register records. Comparisons by quintile of SES were made before (with p values presented for trend across quintiles given below) and after adjusting for other factors using multivariable logistic regression. RESULTS: People in the most deprived quintile were more likely than people in the most affluent quintile to have hospital records for diabetic kidney disease (2.4% vs 2.0%, p=0.049), diabetic ketoacidosis (3.5% vs 3.0%, p=0.11), hypoglycaemia (1.8% vs 1.4%, p=0.008), ischaemic heart disease (22% vs 17%, p<0.0001), stroke (6.8% vs 5.1%, p<0.0001) and peripheral arterial disease (4.1% vs 2.1%, p<0.0001). An independent effect of SES persisted for cardiovascular disease outcomes after adjusting for age and sex. There were minimal differences in disease management measures by SES. CONCLUSION: Managing current risk factors equitably is unlikely to remove socioeconomic inequalities in diabetes-related outcomes. Measures of SES may be valuable in risk scores and in making valid comparisons of the quality of diabetes care.