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We would like to congratulate de Groot et al. for having performed this cost of illness study regarding hypoglycaemic events in insulin-treated diabetic patients in the Netherlands, which is a great step forward to a broader perspective on the hypoglycaemic burden specifically for the Netherlands . In this study, Groot et al. use data from self-assessment questionnaires in type 1 (T1DM) and type 2 diabetes mellitus (T2DM) patients in the Netherlands during a 4-week follow up period, to assess the costs of hypoglycaemic events. The article sheds light on the substantial impact which direct and indirect costs related to hypoglycaemia have on the total economic burden of diabetes. Accordingly, the study suggests that preventing hypoglycaemia can lead to an increase in quality of life, but also lead to a reduction in DM-related health care costs. We would like to elaborate on the results of this study to stimulate debate, and encourage further research.
Using self-reported data on hypoglycaemic events due to insulin treatment, de Groot et al. estimated that the total annual costs of hypoglycaemia, lies between a range of €112.5 million to €590.8 million in the Netherlands. Further research could support the conclusions reached in this study, for example, using alternative sources and methods to estimate costs. In addition, further research could be conducted on the incidence and frequency of hypoglycaemia and its potential consequences. To furthe...
Using self-reported data on hypoglycaemic events due to insulin treatment, de Groot et al. estimated that the total annual costs of hypoglycaemia, lies between a range of €112.5 million to €590.8 million in the Netherlands. Further research could support the conclusions reached in this study, for example, using alternative sources and methods to estimate costs. In addition, further research could be conducted on the incidence and frequency of hypoglycaemia and its potential consequences. To further elucidate the total burden of hypoglycaemia in diabetic patients, additional data during an extended follow-up period could be collected to provide a more comprehensive view of hypoglycaemia related costs. Additional data could include hypoglycaemia related adverse events, such as: falls, fractures, and corresponding hospitalisations.
Hypoglycaemia may cause dizziness, visual disturbances, confusion or even loss of consciousness in severe cases, which can lead to falls, and associated fractures, other injuries and hospitalizations [2–5]. To further elucidate the total burden of hypoglycaemia in diabetic patients, additional data during an extended follow-up period could be collected to provide a more comprehensive view of hypoglycaemia related costs. Furthermore, it is important to consider that 74% of T2DM patients in the Netherlands is 65-years or older . Elderly T2DM patients often have multiple comorbidities and therefore polypharmacy, resulting in a higher rate of frailty. As such, fractures due to hypoglycaemia in T2DM patients may be frequent, and represent a significant adverse outcome with associated costs, in T2DM patients.
A disadvantage of self-reported assessments used in the study by de Groot et al. is that these reports can only be completed by patients in an outpatient care setting. This means that ill, frail or non-ambulatory diabetes patients would be excluded from the self-report assessment, which eventually leads to partial mapping of the hypoglycaemia burden. Further research focussing on complications and hospitalizations due to hypoglycaemic events, would support the identification of additional consequences and costs that are part of the total burden of hypoglycaemia.
The study by De Groot et al. focuses on insulin-treated T1DM and T2DM patients. The outcome of the study reflects the total burden of disease in T1DM patients in the Netherlands, as these patients are treated with insulin upon diagnosis. Nevertheless, only a proportion of patients with T2DM are actually treated with insulin. In the Netherlands insulin will only be prescribed to T2DM patients once oral treatment is insufficient, which means that prior to insulin, they have often already been treated with other drugs for years. Whereas many oral drugs are not related to hypoglycaemic risks, some oral treatments, like sulphonylurea derivatives, do have such risk . Further research could evaluate the impact of these oral drugs on the economic burden of hypoglycaemia. As patients that use oral treatments are on average younger than patients on insulin, costs related to productivity losses could be measured alongside healthcare costs.
De Groot et al. based the costs of hypoglycaemia on a subanalysis of the Global Hypoglycaemia Assessment Tool (HAT) study . This subanalysis indicates that 15% of Dutch patients had a severe event, which is considered reasonably high compared to other international studies and guidelines . For example, the Dutch primary care guideline for T2DM refers to Schopman et al., which mentions a lower incidence of severe hypoglycaemic events in T2DM [7,9]. Varying definitions for hypoglycaemia and severe hypoglycaemia could partially explain this difference. Notably, De Groot et al. defined a severe event as “hypoglycaemia requiring assistance from another person to administer carbohydrate and/or glucagon”(p.2), whereas Schopman et al. refer to a severe event as hypoglycaemia requiring help of a third party or medical assistance [1,9]. Consensus on the definition of a hypoglycaemic event, and a consistent application of this definition, can facilitate the identification of hypoglycaemia at a higher level of granularity and consistency. Furthermore, we would suggest to make a distinction between mild, moderate and severe events, following the definitions of the AACE/ACE guidelines . These guidelines provide a clear definition of severity states, and are commonly used in international health economic studies.
Considering our review and suggestions on the article of de Groot et al., we recommend that further research is conducted to help identify, broaden and complete the knowledge on the economic burden of hypoglycaemia in the Netherlands. This will require research that includes a longer follow-up period, the inclusion of T2DM patients that are not using insulin, and the application of a common definition and categorization of hypoglycaemia. Throughout the next four years, a recently launched EU project Hypo-RESOLVE aims to identify the burden of hypoglycaemia in Europe, including the Netherlands . The start of this project underlines the critical need for more data and knowledge in this area, and the importance of the study published by de Groot et al. In the meantime, we would recommend performing additional analyses to assess the incidence of hypoglycaemic events and its consequences in terms of falls, fractures and hospitalizations as reported in different (Western) countries in T2DM patients, to complement the study of de Groot et al. This knowledge will further broaden the perspective and strengthen the evidence base of the total burden of hypoglycaemia for T2DM population in the Netherlands.
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