Background

Diabetes mellitus, an increasing problem

The prevalence of diabetes mellitus is increasing worldwide [1]. The World Health Organization (WHO) calculates that there were over 177 million diabetics in 2003. Some researchers expect this number to have doubled by 2030 [2]. The huge prevalence of adiposity as well as increased life expectancy in western industrialized countries is why Type 2 diabetes in particular has become a more and more common disease. According to the International Diabetes Federation (IDF), about 5.5 % of the European population already lives with this chronic metabolic disease and is aware of it. The number of those who are unaware of their undiagnosed disease is almost as high [3]. One respective cause for this fact is the abstinence of symptoms during the early aetiopathogenesis of Type 2 diabetes. The American Diabetes Association defines Type 2 diabetes as a condition ranging from ‘predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretory defect with insulin resistance’ [4]. However the disease is a continuing process, which usually precedes a phase of Impaired Glucose Tolerance (IGT) and/or impaired fasting glucose (IFG).

A study of the German Diabetes Centre (GDC) together with the GSF-National Research Centre for Environment and Health has shown that more than 16% of 55-74 year olds have an impaired glucose tolerance [5]. Since the stadium of an IGT is already associated with an elevated risk of developing a macroangiopathy, the prevalence of an IGT can be classified as a disease rather than as a preliminary phase of a condition [6]. Thus, nearly every sixth European citizen lives with the still incurable metabolic syndrome or is at least in danger of getting diabetes mellitus.

The costs of Diabetes mellitus

The treatment of diabetes is expensive and an immense burden for health systems – not just in the European Union [7]. In the year 1998 the Code-2® study [8], which was conducted in eight European countries [9], revealed that the total costs of Type 2 diabetes – as a proportion of the overall healthcare expenditure – ranged between 3% and 6%. Apart from the fact that costs for Type 1 diabetes are excluded from this calculation, it is assumed that the real costs will be even higher since the estimated number of unknown cases was not part of this calculation. In the USA, direct costs of diabetes care alone were estimated to have amounted to 15% of the national overall healthcare expenditure in 2002 [10]. Moreover, the Code-2® study identified the distribution of costs. The governmental and private health insurance companies with 61% had to sustain the biggest part of total diabetes costs. The following figure shows a common distribution of costs covered by insurance companies in Germany.

Fig. 1: Total GMI costs of Type 2 diabetics in Germany – by category of costs. (Source: Liebl, A., Neiß, A., Spannheimer, A., Reitberger, U., Wagner, T. & Görtz, A., 2001, p. 587)

In particular, the costs of in-patient care resulting from complications in Type 2 diabetes are extremely high [11]. The study showed that the presence of micro and macro vascular complications increased the costs per patient more than threefold. Hospitalization accounted for between 30% and 65% of total costs. Thus, new strategies and interventions, which anticipate complications resulting from diabetes, are required.

It is assumed that the general risk of a type 2 diabetes patient to develop a major complication is:

  • 43% to develop a Cardiovascular Complication
  • 23% to develop a Diabetic Neuropathy
  • 11% to develop a Diabetic Retinopathy
  • 6% to develop a Sophisticated Nephropathy

Furthermore, late effects of diabetes are always associated with a higher mortality [12].

As described, the major part of the costs are not incurred by the necessity to treat and stabilise the metabolism of glucose and other risk parameters throughout a patients life but arise instead from the very high costs of intensive care of late effects resulting from the disease [13].

Diabetes mellitus, a challenge for doctors and patients

Thus, efficient interventions, which avoid typical after effects or at least delay the individual aetiopathology, are sensible from the medical and the economic point of view. Under these circumstances, three kinds of interventions can be differentiated:

  1. Primary prevention:
    Activities designed to prevent substance abuse before any signs of a problem appear.
  2. Measures for a more early diagnosis:
    Timely treatment of diabetes is very important for the prospective course of the disease and the prevention of complications [14]. Yet, quite often diabetes is not identified before typical after effects arise. Diabetes research showed that there are approximately as many diagnosed as undiagnosed diabetics in Europe [15].
  3. Secondary prevention measures:
    To reduce the risk of typical complications, optimal control of blood glucose and the consequent treatment of further risk factors such as hypertension or hyperlipoproteinemia are essential. To achieve this, the consequent co-operation and compliance of patients, is very important. The doctor-patient-relationship, confidence, and efficient teamwork are the basic requirements for successful long-term treatment.

As a medical tool for doctors and patients, computer-assisted diabetes management systems (CDMS) want to improve the health and quality of life of diabetes patients by supporting measures, which normalise the metabolism in the long term.

In recent years, many improvements have been made in the field of CDMS. On the one hand, software programmes have become more and more user-friendly. On the other hand, the scope of programmes has grown rapidly. Furthermore, growing telematic infrastructure with electronic and personal health records, standardised data coding and message transfer concepts (like HL7, UCUM, LOINC etc.) will enable electronic data documentation and exchange more efficiently.

In the context of Disease Management Programmes for diabetes and other chronic diseases, there are huge expectations in the ‘new technology’. Computer-assisted diabetes management systems (CDMS) are used in outpatient care to rationalise workflows, implement care guidelines, calculate and illustrate risks, improve doctor-patient-communication and increase patient compliance. Figure 2 shows a concept of a CDMS.

Fig. 2: Concept of a chronic care model in primary diabetes care (Chronic Care Model adopted from Wagner et al., Managed Care Quarterly, 1999;7(3):56–66. )

Computer-assisted management systems are tools − in the concept of national disease management programmes − aimed at creating the practical interface between doctor and patient. With the implementation of nationwide disease management programmes, especially in the European Union, a further reform of health systems is expected in the future [16]. In Germany, for example, the legal basis was provided in 2001 when the match of disease management programmes and the so-called ‘Risikostrukturausgleich’ (RSA) was legally established. It regulates payments within the German health insurance system.

Still, many questions persist which are or should be of general political, economic, public and thus also of scientific interest. Does the implementation of such instruments really result in positive effects on health outcomes, the doctor-patient-relationship or in improved compliance? Furthermore, new areas of applications for computer-assisted systems as part of disease management control are imaginable. For example, adapted systems could be used for the early recognition and prevention for high-risk populations.



[1] WHO, 2002, Diabetes mellitus, Fact sheet N°138, p. 1. [on-line] Available: http://www.who.int/entity/mediacentre/factsheets/en

[2] Wild, S., Roglic, G., Green, A., Sicree, R. & King, H., 2004, Global prevalence of diabetes. Diabetes Care (2004), 27 (5), 1047-1053, p. 1047.

[3] Rathmann, W., Haastert, B., Icks, A., Löwel, H., Meisinger, C., Holle, R. & Giani, G., 2003, High prevalence of undiagnosed diabetes mellitus in Southern Germany: Target populations for efficient screening. The KORA survey 2000. Diabetologia (2003), 46 (2), 182-189, pp. 185-189.

[4] American Diabetes Association, 2005, Diagnosis and Classification of Diabetes Mellitus, Diabetes Care (2005), 28 (1), 37-42, p. 38.

[5] Rathmann, W., Haastert, B., Icks, A., Löwel, H., Meisinger, C., Holle, R. & Giani, G., 2003, High prevalence of undiagnosed diabetes mellitus in Southern Germany: Target populations for efficient screening. The KORA survey 2000. Diabetologia (2003), 46 (2), 182-189, pp. 187-189.

[6] Kerner, W., 2003, Diabetische Makroangiopathie und Insulinresistenz. Journal für Kardiologie (2003), 10 (7-8), 321-324, p. 324. [on-line]. Available: http://www.kup.at/kup/pdf/3494.pdf

[7] O’Brien, J., Patrick, A. & Caro, J., 2003, Cost of managing complications resulting from Type 2 diabetes mellitus in Canada. BMC Health Services Research (2003), 7 (3), 1-11, pp. 1-2.

[8] The Code-2® study, Costs of Diabetes in Europe – Type 2.

[9] The study was conducted in the following eight countries: Belgium, France, Germany, Italy, the Netherlands, Spain, Sweden and the UK.

[10] WHO, 2002b, Diabetes: the cost of diabetes, Fact sheet N°236, p. 2. [on-line] Available: http://www.who.int/entity/mediacentre/factsheets/en

[11] Caro, J., Ward, A., & O’Brien, J., 2002, Lifetime costs of complications resulting from Type 2 diabetes in the U.S. Diabetes Care (2002), 25 (3), 476-481, pp. 476-479 and O’Brien, J., Patrick, A. & Caro, J., 2003, Cost of managing complications resulting from Type 2 diabetes mellitus in Canada. BMC Health Services Research (2003), 7 (3), 1-11, pp. 5-7 (Those studies refer to Type 2 diabetics; however more than 95% of all diabetics in Europe are down with Type 2 diabetes).

[12] Liebl, A., Neiß, A., Spannheimer, A., Reitberger, U., Wagner, T. & Görtz, A., 2001, Kosten des Typ-2-Diabetes in Deutschland – Ergebnisse der CODE-2®-Studie. Dtsch. Med. Wschr. (2001), 126, 585-589, p. 587.

[13] Brandle, M., Zhou, H., Smith, B., Marriott, D., Burke, R., Tabaei, B. & Herman, W., 2002, The direct medical cost of Type 2 diabetes. Diabetes Care (2003), 26 (8), 2300-2304, p. 2304.

[14] Benjamin, S., Valdez, R., Geiss, L., Bolka, D. & Narayan, V., 2003, Estimated number of adults with prediabetes in the US in 2000: Opportunities for prevention. Diabetes Care (2003), 26, 645-649, pp. 647-648.

[15] Rathmann, W., Haastert, B., Icks, A., Löwel, H., Meisinger, C., Holle, R. & Giani, G., 2003, High prevalence of undiagnosed diabetes mellitus in Southern Germany: Target populations for efficient screening. The KORA survey 2000. Diabetologia (2003), 46 (2), 182-189, pp. 185-189.

[16] On this also see Häussler, B., Glaeske, G. & Gothe, H. (2001) who describe in their article: ‘Durchführbare Konzepte erforderlich: Wie man Disease Management in Deutschland einführen sollte,’ a concept of how a Disease Management Program, e.g. for diabetes, could look like. [on-line] http://www.iges.de/e1788/e1818/e1833/DMP.pdf

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