Kurt Neeser

Prevention of diabetic ketoacidosis and self-monitoring of ketone bodies: an overview

ABSTRACT Objective: Diabetic ketoacidosis (DKA) is associated with significant morbidity and mortality. Self-monitoring of ketone bodies by diabetes patients can be done using blood or urine. We compared the two self-monitoring methods and summarized recent developments in the epidemiology and management of DKA. Methods: MEDLINE and EMBASE were searched for relevant publications addressing the epidemiology, management and prevention of DKA up to 2009. The current, relevant publications, along with the authors’ clinical and professional experience, were used to synthesize this narrative review. Findings: Despite considerable advances in diabetes therapy, key epidemiological figures related to DKA remained nearly unchanged during the last decades at a global level. Prevention of DKA – especially in sick day management – relies on intensive self-monitoring of blood glucose and subsequent, appropriate therapy adjustments. Self-monitoring of ketone bodies during hyperglycemia can provide important, complementary information on the metabolic state. Both methods for self-monitoring of ketone bodies at home are clinically reliable and there is no published evidence favoring one method with respect to DKA prevention. Conclusions: DKA is still a severe complication potentially arising during prolonged hyperglycemic episodes with possibly fatal consequences. Education of patients and their social environment to promote frequent testing – especially during sick days – and to lower their glucose levels, as well as to recognize the early symptoms of hyperglycemia and DKA is of paramount importance in preventing the development of severe DKA. Both methods for self-monitoring of ketone bodies are safe and clinically reliable.

Cost Impact of Self-Measurement of Blood Glucose on Complications of Type 2 Diabetes: The Spanish Perspective

BACKGROUND Despite the increasing prevalence of type 2 diabetes, its financial burden on the Spanish healthcare system remains unclear. This study was conducted to determine the cost share of self-measurement of blood glucose (SMBG) by comparing the direct costs of reduced complications of diabetes in SMBG users versus nonusers in the Spanish statutory health insurance system. METHODS Matched-pair analysis was done of the average annual total direct cost of diabetes monitoring, treatment-related services, complications, and follow-up in the RetrOlective Study Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes (ROSSO) study cohort, updated to 2008 from the year of occurrence or diagnosis of diabetes. RESULTS In patients treated with oral antidiabetes drugs (OADs) only, total annual costs were euro1,934 in SMBG users and euro1,982 in nonusers. In those treated with OADs plus insulin, total annual costs were euro3,451 and euro4,167, respectively. By increasing the number of patients using SMBG, the Spanish statutory health insurance system might save several million Euros annually. CONCLUSIONS The analysis showed that the promotion of SMBG in patients with type 2 diabetes is associated with considerable cost savings for the Spanish healthcare system.

An Electrical Plasma Surgery Tool for Device Replacement—Retrospective Evaluation of Complications and Economic Evaluation of Costs and Resource Use

Device replacements bear many potential risks for patients. Electrocautery should be used cautiously because of heating of the cautery tip which may lead to insulation melting. The PEAK PlasmaBlade™ (Medtronic Inc., Minneapolis, MN, USA) uses a novel technology to cut tissue. The objective of this study was to evaluate if this instrument is less destructive and can decrease complications and shorten procedure times.

Impact of self-measurement of blood glucose on complications of type 2 diabetes: economic analysis from a Czech perspective

Abstract Objective: A growing body of evidence indicates that self-measurement of blood glucose (SMBG) also has beneficial effects in people with type 2 diabetes, irrespective of the type of therapy. The objective of this analysis was to determine the economic impact of SMBG by comparing the cost share of self-monitoring and the direct costs of diabetes-related complications in users and non-users. Research design and methods: A matched-pair analysis based on the cohorts of a large retrospective study of patients with type 2 diabetes (ROSSO) was conducted. The average annual direct costs of diabetes monitoring, treatment-related services, complications and follow-up costs of the disease for SMBG users versus non-users were calculated from the perspective of the Czech statutory health insurance system. Univariate sensitivity analysis was performed to determine the main cost drivers. Limitations of this study are: (1) differences in medical facilities/practice between Germany and the Czech Republic, (2) causal relationship between SMBG and health outcomes is missing, (3) ROSSO underestimated the number of test strips used, (4) Czech cost data are scarce. Results: In patients treated with oral antidiabetic drugs (OAD) only, total annual costs in Czech koruna (CZK) were CZK 16 476 for SMBG users and CZK 19 440 for non-users. In patients treated with OAD + insulin, total annual costs were CZK 32 590 and CZK 48 600, respectively. The main cost drivers were stroke and myocardial infarction in patients treated with OAD only, and stroke, dialysis and myocardial infarction in patients treated with OAD + insulin. Conclusion: Cost analysis indicated that SMBG provides a rapid return on initial investment. By increasing the number of patients using SMBG, the statutory health insurance system in the Czech Republic may save several million CZK annually.

Glucose Information for Tight Glycemic Control: Different Methods with Different Challenges

Rigorous glucose control is essential for prevention of diabetes-related complications in diabetes patients. Even without diabetes, tight glucose control is beneficial in hospitalized, critically ill patients. Actually, three different glucose measurement methods are used: (1) hand held devices, (2) blood-gas analyzers, and (3) laboratory analyzers in core laboratories. Each method is subject to specific challenges and limitations that can affect the overall system performance. In this article, we aim to demonstrate that even glucose measurement results from core laboratories (professional laboratory systems) do not necessarily reflect the absolute “true” glucose level of a patient.

Description of a New Predictive Modeling Approach That Correlates the Risk and Associated Cost of Well-Defined Diabetes-Related Complications With Changes in Glycated Hemoglobin (HbA1c)

The modeling approach described here is designed to support the development of spreadsheet-based simple predictive models. It is based on 3 pillars: association of the complications with HbA1c changes, incidence of the complications, and average cost per event of the complication. For each pillar, the goal of the analysis was (1) to find results for a large diversity of populations with a focus on countries/regions, diabetes type, age, diabetes duration, baseline HbA1c value, and gender; (2) to assess the range of incidences and associations previously reported. Unlike simple predictive models, which mostly are based on only 1 source of information for each of the pillars, we conducted a comprehensive, systematic literature review. Each source found was thoroughly reviewed and only sources meeting quality expectations were considered. The approach allows avoidance of unintended use of extreme data. The user can utilize (1) one of the found sources, (2) the found range as validation for the found figures, or (3) the average of all found publications for an expedited estimate. The modeling approach is intended for use in average insulin-treated diabetes populations in which the baseline HbA1c values are within an average range (6.5% to 11.5%); it is not intended for use in individuals or unique diabetes populations (eg, gestational diabetes). Because the modeling approach only considers diabetes-related complications that are positively associated with HbA1c decreases, the costs of negatively associated complications (eg, severe hypoglycemic events) must be calculated separately.

Economic assessment of traditional surgical intervention versus use of a new innovative radiofrequency based surgical system in device replacements

Introduction Intra-operative complications like mechanical damages to the leads, infections and hematomas during generator replacements of implantable pacemakers and defibrillators contribute to additional costs for hospitals. The aim of this study was to evaluate operation room use, costs and budget impact of generator replacements using either a traditional surgical intervention (TSI) with scissors, scalpel and electrocautery vs. a new radiofrequency energy based surgical system, called PEAK PlasmaBladeTM (PPB). Materials and methods We conducted a retrospective analysis of a population including 508 patients with TSI and 254 patients with PPB who underwent generator replacement at the Kepler University Hospital in Linz or the St. Josef Hospital in Braunau, Austria. The economic analysis included costs of resources used for intra-operative complications (lead damages) and of procedure time for TSI vs. PPB. Results Proportion of males, mean age and type of generator replaced were similar between the two groups. Lead damages occurred significantly more frequent with TSI than with PPB (5.3% and 0.4%; p< 0.001) and the procedure time was significantly longer with TSI than with PPB (47.9±24.9 and 34.1±18.1 minutes; p<0.001). Shorter procedure time and a lower rate of lead damages with PPB resulted in per patient cost savings of €81. Based on estimated 2,700 patients annually undergoing generator replacement in Austria, the use of PPB may translate into cost savings of €219,600 and 621 saved operating facility hours. Conclusion PPB has the potential to minimize the risk of lead damage with more efficient utilization of the operating room. Along with cost savings and improved quality of care, hospitals may use the saved operating room hours to increase the number of daily surgeries.

PDB30 CSII COMPARED TO MDI: A HEALTH ECONOMIC ANALYSIS IN THE GERMAN HEALTH CARE SETTING

patients with type 2 diabetes and nephropathy over 3.4 years. The clinical outcome data were based on the results from the RENAAL trial. Direct medical costs referred to the purchase costs of losartan and the cost of National Health Service (NHS) hospitalization. The costs were discounted back at an annual rate of 3%. Also sensitivity analysis was performed. RESULTS: RENAAL study establishes that losartan, along with conventional antihypertensive treatment as needed, confers strong renal protection in patients with type-2 diabetes and nephropathy. Globally, the total cost over 42 months of follow-up was estimated at 9.802,49 a in the losartan and a13,405,47 in the placebo group, resulting into a cost saving of a3602.98 per patient. Results were robust to both clinical and economic variables. CONCLUSIONS: In addition to the medical benefit, this analysis demonstrated the economic relevance of treatment with losartan in type 2 diabetic patients with nephropathy.