The number of patients with type 2 diabetes mellitus (DM2) is constantly increasing and is one of the main world health problems, due to its high prevalence, its high economic cost and the number of premature deaths it causes, particularly in the most socially and materially deprived sectors, among other reasons.
The World Health Organisation (WHO) predictions for the year 2030 are 366 million diabetics in the world, of true epidemic proportions with a proven existence of an inverse socioeconomic gradient in the mortality of patients with DM2, which means that at the lowest social level it is double that of the highest social level.1
Currently it is calculated that the population with diabetes consume 4%-14% of total health spending and that a diabetic patient consumes 2-6 times more resources than individuals of similar age and sex with other chronic diseases.2 In Spain, according to the likelihood estimates, the total mean costs per patient per year varies between €758 and €43483-5 and with the presence of macrovascular complications they increase between 5-12 times that of patients without complications,6,7 with a chosen prevalence of DM2 that is one of the main determining factors of the annual mean cost per patient. The indirect costs are unknon, such as days lost at work or permanently incapacitated.
Its association with high blood pressure, in 40%-70% of cases, increases cardiovascular mortality and speeds up microangiopathy, particularly nephropathy. Although suitable blood pressure control achieves more significant effects than good glucose control2 on the morbidity and mortality due to diabetes by reducing the incidence of acute myocardial infarction (↓ 63%), cardiovascular complications (↓ 51%), and all the causes of mortality (↓62%), the evidence available shows that diabetic patients do not receive the cost effective care available,8 since around 29% of the hypertensive diabetics do not know they have a high blood pressure and only 43% have adequate levels of control.9 To achieve the objective of controlling blood pressure in diabetic patients appears to require a higher number of visits, but the economic benefit due to the decrease in cardiovascular complications seems to compensate for the additional costs.10 There are no relevant studies on this association in the Spanish setting.
The original article published on the care costs of the hypertensive diabetic patient shows 2 deficiencies, normal in these types of results: firstly, a non-validated basic methodology for cost calculation is used that would enable results to be compared and, secondly, it does not describe a minimum standard of care as a reference of the care provided to the individual diabetic patient. On the other hand, it does provide new data on the cost of a very common association and risk that should enable it to be compared with the possible benefits of the investment in interventions that might reduce the associated morbidity and mortality. The calculation of costs in this environment reduces its value, mainly in regard to the development of quality care and, as regards the significance of chronic complications, it is reasonable to think that cost studies based exclusively on demand may be strongly biased downward in that it does not allow the costs associated with the prevention of the complications of DM2 to be identified or the use of resources in the treatment of these.
In any case, homogeneous data bases must be made available to be able to obtain information on the efficiency of the health services in modifying the causes of mortality associated with DM2 and make them comparable, as well as being able to use the total costs as a measure of the benefits of prevention and treatment programmes capable of altering the increase in cases and reduce the effects of the diabetes on the patient, the health system, and society in general.11
Finally, we will consider the known distribution of the costs3,4,11: hospitalisation uses up 32%-60%, pharmacy costs are 12%-42%, and 8%-26% to primary care clinics. Hospital costs and spending on drugs are the highest weighted areas. Must we continue like this? Perhaps there is too much interest in continuing to use hospitals to treat conditions with a high variability of use. Patients, health services and society must accept the challenge to change chronic conditions by interventions of proven preventive effectiveness. It would be reasonable to believe that the efforts of the professionals in the practice of cost effective medicine can correct these deficiencies.
Key Points
* In the combination of DM2 and high blood pressure, adequate control of the blood pressure achieves more important effects on morbidity and mortality for the diabetic than good glucose control, but around 29% of diabetic-hypertensive patients are unaware they have high blood pressure and only 43% are adequately controlled.
* In Spain the annual cost per patient varies between €758 and €4348 and the presence of macrovascular complications is the factor that increases the associated costs even more (5-12 times).
* Homogeneous data bases need to be available to be able to obtain information on the efficiency of the health services in modifying the causes of death associated to DM2 so that they can be compared, as well as being able to use the total costs as a measure of the benefits.
* Hospital costs and drug spending are the most weighted areas. Patients, the health system, and society must accept the challenge to change chronic complications by of proven preventive effectiveness.
