Research Proposal: Nursing Interventions to Decrease complications of Diabetes

O R I G I N A L P A P E R

Costs of diabetes and its complications in Poland

Joanna Leśniowska • Agata Schubert •

Michał Wojna • Iwona Skrzekowska-Baran •

Marta Fedyna

Received: 3 August 2012 / Accepted: 12 June 2013 / Published online: 3 July 2013

� The Author(s) 2013. This article is published with open access at Springerlink.com

Abstract

Objective Diabetes mellitus (DM) is a major health

problem with severe complications and a significant impact

on quality of life. It constitutes an enormous burden of

disease due to high prevalence, severe co-morbidities and

high costs for society. This study is the first comprehensive

study on the direct and indirect costs of DM (type 1 and

type 2) and associated complications in Poland.

Methods In order to estimate the direct medical costs of

DM and its complications, including the costs of medical

consultation, hospitalisation, rehabilitation, drugs and med-

ical equipment, data from the National Health Fund were

used. Indirect costs on loss of productivity due to diabetes

and its complications were based on data obtained from the

ZUS (Social Insurance Institution) and from GUS (Poland’s

Central Statistical Office). Attributable risk methodology

was used to assess the burden of DM complications.

Results A continuous increase of the direct costs of dia-

betes has been observed since the year 2005. In the ana-

lysed time period (2005–2009) the direct costs of medical

services for both types of DM doubled. DM is a cause of

significant sickness absence and incapacity for work and

therefore is associated with a growing productivity decline

in Poland. The highest direct costs and indirect costs are

associated with treatment of diabetes-related complica-

tions. Direct costs of hospital complication treatment were

EUR 332 million, which exceeded by more than five times

the direct costs of hospital treatment of diabetes per se,

which in the same year amounted to EUR 58.5 million. The

indirect costs of diabetes-related complications were higher

by 41 % compared with indirect costs related to DM itself.

Total costs of health care services for DM and its com-

plications amounted to EUR 654 million, which constitutes

a 2.8 % of total health care costs in Poland. Total DM cost

in Poland in 2009 amounted EURO 1.5 billion.

Conclusions DM is causing a growing economic burden

on the health care system and on Polish society in terms of

health care and productivity losses. Most of the total cost of

diabetes are indirect costs caused by productivity losses.

Both direct and indirect costs are driven by the cost of

diabetes complications.

Keywords Diabetes type � Cost of disease � Complications � Indirect cost

JEL Classification H51 � I15 � I18

Introduction

Diabetes mellitus (DM) is a widespread clinical and public

health problem in many countries in the world, especially

when we take into account its high prevalence, increasing

morbidity and impact on health care systems in terms of

costs. An estimation of the influence of DM on health care

expenditures is complicated because of the many aspects of

the issue. Total costs can be divided into medical and non-

medical or direct and indirect costs. In addition to costs

associated with DM treatment (costs of insulin and

J. Leśniowska (&) � M. Wojna Koźminski University, 57/59 Jagiellońska St.,

03-301 Warsaw, Poland

e-mail: [email protected]

A. Schubert � I. Skrzekowska-Baran Novo Nordisk, 17 stycznia 45 St., 02-146 Warsaw,

Poland

M. Fedyna

Starowiślna 17/3 St., 31-038 Kraków, Poland

123

Eur J Health Econ (2014) 15:653–660

DOI 10.1007/s10198-013-0513-0

antidiabetic drugs, hypoglycaemia hospitalisation, etc.),

treatment of immediate and distant future complications

caused by DM should be taken into consideration. People

suffering from the disease are at high risk of serious cardio-

or cerebrovascular problems, neuropathy and/or micro-

vascular complications (nephropathy, retinopathy), which

lead to a rise in the total costs of the illness and signifi-

cantly lower the quality of life. Increased risk of disability,

inability to work or premature death is important as well.

Loss of productivity caused directly by DM as well as by

DM-related complications constitutes a substantial eco-

nomic burden.

The economic impact of DM on a health care system

depends, in particular, on the type of illness. According to the

classification recommended by the WHO, there are two main

types of DM: type 1 DM and type 2 DM. Although these

separate conditions have similar long-term consequences,

they affect different age groups and require different treat-

ment strategies. Type 1 DM, previously called insulin

dependent, usually develops in childhood and adolescence as

a result of impairment of pancreatic islets b-cells, whereas type 2 DM results from insulin resistance—an inappropriate

response of body tissue to insulin—and usually develops in

adulthood. It is estimated that more than 90 % of cases are

type 1 or 2 DM [1, 2]. It is estimated that in Poland

approximately 2.5 ml people have DM (6.54 % of the gen-

eral population), of whom 750,000 are yet to be diagnosed

[3]. This high prevalence will have devastating economic

and social effects over the medium and longer term.

A number of pharmacoeconomic or cost-of-illness

analyses related to DM have been performed recently.

However, reported costs vary significantly depending on

the data source used, type of assessment and scope of the

analysis. Some cost estimates are made on the basis of the

existing population data on health care use, disability and

mortality, while others are performed using the data of

patients with DM at an individual level. Methodologies

differ in terms of methods of calculating the direct and

indirect costs, costs attributable to DM, and in the way in

which the results are presented. Furthermore, a number of

investigations are concentrated on one type of DM only.

Therefore, the results of different studies either cannot be

compared or the comparison is problematic and unreliable.

An analysis performed in Spain [4], conducted in a

sample of 517 patients from endocrinology clinics, suf-

fering type 2 DM, showed an annual cost of EUR 4,278 per

patient. Direct costs, including, e.g., medication, specialist

consultations and hospitalisations, accounted for 58 % of

the total costs and were appreciably higher than indirect

costs, including temporary or permanent disability and

working hours lost. In the costs of DM study (CoDiM) [5],

data were collected by the local statutory health insurance

fund and the Association of Statutory Health Insurance

Physicians in the federal state of Hesse in Germany. It was

estimated that more than half of the medical costs per

patient with DM in Germany in 2001 (EUR 4,457) was

spent on the treatment of DM complications (EUR 2,380),

including microvascular complications, foot complications,

macrovascular complications and uncontrolled glucose

metabolism. In a recent article [6], it was shown that DM

costs approximately £23.7 billion in the UK and indirect

costs accounted for the majority of the costs (58 %). The

study used a top-down approach, estimated the direct and

indirect cost of type 1 and type 2 DM and provided cost

estimates for 2035/2036. A similar approach was used in a

study conducted in Sweden [7]. The study followed an

attributed risk methodology to estimate the share of costs

directly and indirectly attributed to DM. The estimated cost

for Sweden was 920 million euros in 2005 and DM per se

accounted for 50 % of the health care cost. Comparisons of

the above-mentioned studies have to be made very cau-

tiously because of methodological inconsistency.

So far, three studies of costs related to DM have been

conducted in Poland. In the cost of DM type 2 in Poland

study (CODIP) [8], direct and indirect costs of type 2 DM

were analysed. It has been estimated that the average direct

costs per patient with type 2 DM are EUR 539.88, whereas

indirect costs are at a level of EUR 1,510.50. This means

that in Poland in 2002, direct costs related to type 2 DM

accounted for 26 % of the total costs of the illness. It has

been shown that the direct costs of DM accounted for

8.08 % of total health care expenditures in Poland. CODIP

was designed as a multicentre, retrospective, bottom-up

study, based on health insurance data from Mazowieckie

province. According to another bottom-up study, the costs

of treatment of DM complications in Poland in 2002

exceeded 96.6 million euros [9]. In the third study [10],

only the indirect costs of DM were analysed. According to

this paper, the average indirect costs of treatment of one

patient with DM amount to 1,273 EUR. None of the

aforementioned studies provided a comprehensive view of

DM costs, which include direct and indirect costs of both

DM and its complications. Moreover, up to now there has

been no top-down study in Poland to provide estimates

based on aggregated data.

Severe criticism has been raised against cost of illness

studies [11], pointing out flaws in methodological

assumptions and questioning the utility of these analyses

for decision makers. Discussion on general methodological

issues of COI analyses is not the subject of this article.

Despite of all these controversies, the authors believe that

the results of this analysis can enhance the process of

health care priority setting and allocation of resources in

Poland. Furthermore, the results of the study can be a

source of cost comparison of different approaches to the

management of the disease. Common cost effectiveness

654 J. Leśniowska et al.

123

and budget impact analyses conducted in Poland do not

deliver essential information, as these are usually con-

ducted for a single intervention not a disease management

and focus only on the payer perspective.

The goal of this article is to present the results of the first

Polish top-down study that aimed to assess the total costs

of DM in Poland, including both direct and indirect costs of

DM and its complications.

There is a need of a comprehensive and systematic study

of the DM-related costs in Poland, as well as discussion on

proper DM prevention and management. The number of

people living with DM in Poland is expected to increase by

28 % by 2030 as a result of the obesity epidemic, the

ageing of the population and other factors such as lifestyle

changes and models of consumption. There is great public

concern about the obesity epidemic among children in

Poland. In the future, these children will face a substantial

risk of DM, and this will result in an increasing social and

economic burden. Another rationale for our study is to

estimate the structure of DM-related costs and to compare

them with the results of analyses conducted in other

countries. Our results can serve as a benchmark for future

studies on the effectiveness of DM management and effi-

ciency of health resources allocation in the health care

system and in the public finance sector.

Materials and methods

Method

This study is a prevalence-based top-down cost of illness study,

which analysed the direct and indirect costs of DM and DM-

related complications. We defined prevalence as all patients

suffering from DM and alive on 31 December 2009. The

resources used for DM per se were identified based on DM

being the first diagnosis for resource consumption. Addition-

ally, we estimated the costs of DM complications. DM-related

complications included in the analysis were identified based on

the ICD-10 codes of complications included in the German

CoDiM Study [9]. They are as follows:

• Ischaemic heart diseases: angina pectoris (I20), acute myocardial infarction (I21), chronic ischaemic heart

disease (I25)

• Other forms of heart disease: heart failure (I50) • Cerebrovascular diseases: intracerebral haemorrhage

(I61), cerebral infarction (I63), stroke, not specified as

haemorrhage or infarction (I64)

• Renal failure (N17–N19) • Retinal disorders in diseases classified elsewhere (H36) • Visual disturbances and blindness: visual impairment

including blindness (H54).

The research was based on the data acquired from the

National Health Fund (NFZ), ZUS (Social Insurance

Institution), and from GUS (Poland’s Central Statistical

Office).

Direct costs

The direct costs assessed in the research included: medical

care (i.e. outpatient consultations, hospitalisation) and drug

reimbursement calculated from the payer perspective. Due

to the marginal share of co-payments in the public health

care system the costs calculated from the payer perspective

are a good estimate of social cost.

Intangible costs have been omitted. The scope of the

analysis does not include the costs associated with indirect

costs of informal care, which can account for up to 30 % of

the indirect costs in DM treatment [6]. The cost of medical

care (i.e., medical consultations, hospitalisation) related to

type 1 and 2 DM was determined on the basis of the data

acquired from the NFZ. The costs of medical services

rendered within the system of Primary Health Care (PHC)

were calculated based on a report published by NFZ. Both

sources include expenditures incurred by health care pro-

viders. The cost analysis of drug reimbursement was based

on the data included in NFZ reports available on the Fund’s

homepage. The analysed costs of drug reimbursement

include the costs of oral antidiabetics and insulin.

A calculation of direct costs of DM-related complica-

tions was also carried out on the basis of the data acquired

from NFZ. These data cover complete information about

all patients treated in hospitals in 2009. The data were

extracted by NFZ in two stages. First, patients with a

diagnosis of primary and co-morbid DM (i.e. E10, E10.0–

E10.9, E11 and E11.0–E11.9) were selected. Then, epi-

sodes containing primary or DM-related co-morbidity were

identified in these patients. The direct costs of DM com-

plications were calculated using aetiological fractions (EF),

to estimate what share of co-morbidity costs is attributable

to DM. The EF is calculated based on the following:

EF ¼ P R � 1ð Þ

P R � 1ð Þþ 1

where P stands for the prevalence rate of DM among

hospital patients, and R is a relative risk of suffering from a

given chronic complication among people with DM [12].

The methodology applied is a source of possible sys-

tematic error in our estimates. When calculating relative

risks and prevalence rates values we used panel data of

hospital patients as a sample. This sample is not represen-

tative of the entire population with overrepresentation of

patients with severe DM; therefore there is a risk that the

estimated variables are overestimated. This possible bias can

thus lead to overestimation of the indirect costs share in the

Costs of diabetes and its complications in Poland 655

123

total costs. Moreover, because of this limitation in method-

ology, the calculated values of EFs are not easily comparable

with the results of other epidemiological studies.

Indirect costs

The indirect costs assessed in the research included the

costs of productivity loss due to work absence or inability

to work due to DM and DM complications. The indirect

costs were estimated using the data from ZUS to GUS. In

the case of the indirect costs of DM-related complications,

similarly to the approach applied in the direct cost esti-

mations, we used EF to estimate what share of the total

indirect cost of chosen co-morbidities can be attributed to

DM. ZUS reports the first diagnosis in the ICD-10 coding;

therefore it was impossible to directly identify patients who

were unable to work because of DM-related complications.

While estimating the indirect costs, the human capital

method was used. The costs of lost productivity due to

sickness absence were calculated with the use of the ZUS

data (i.e. the number of days taken off for sickness caused by

type 1 and 2 DM) and the average daily gross wage in the

economy (EUR 34.06 in 2009). The analysis of indirect costs

also involved lost productivity related to work incapacity.

These costs are incurred because of inactivity in the labour

market and the collection of social security benefits and were

calculated on the basis of the ZUS data concerning the vol-

ume of social security benefits transferred, along with the

GUS data on the average gross salary in the economy.

Lost productivity caused by premature death was not

included in the analysis of indirect costs because of the lack

of data.

Sensitivity analysis

In our study we applied point estimates of EF for DM com-

plications. The variables used to calculate EF are subject to

uncertainty; therefore we provided upper and lower limits of

the direct and indirect costs resulting from adjusting the

relative risks and prevalence rate. We applied sensitivity

analysis of ±10 % to relative risks. With regard to the

prevalence rate, we used the results of an epidemiological

study conducted in the Halemba district in Poland (6.54 %)

[3] and the data provided by the International DM Federation

(10.54 %) as the lower and upper bound respectively [13].

Results

Direct costs: hospitalisation and outpatient care

Figure 1 shows the costs of health care services provided in

2004–2009 related to type 1 and type 2 DM. In 2004–2009

a significant increase in the costs of health care services

provided in relation to type 1 and type 2 DM was observed.

In the case of type 1 DM the rate of increase in the costs

was 125 %, and for type 2 DM it was 129 %.

In the DM services analysis, care of patients treated

within the PHC network was not included because of the

method of reporting by the NFZ. Estimation of the PHC

costs was, however, possible for 2009. In 2009, care for

patients with DM was granted a higher financing level.

General practitioners treating DM patients receive a yearly

lump sum assigned to an individual patient that is three

times higher than that for a ‘regular’ patient. The data from

the performance of the contracts with the PHC doctors

show that the total number of patients with DM who were

treated in POZ in 2009 was 1,584,716. Thus, we can

estimate the PHC costs of DM treatment in 2009 to be EUR

70.4 million.

The total costs of health care services for type 1 and type

2 DM in 2009 amounted to EUR 163 million, and the

largest individual factors are the costs of PHC and hospital

treatment, which constitute 82.8 % of the total costs.

Direct costs: drug reimbursement

On the basis of the available data there is no possibility of

classifying the costs of drugs according to the type of DM.

Therefore, the costs were analysed for both DM types. The

total costs of drug reimbursement for DM in 2009

amounted to EUR 159 million. The distribution of the costs

for the years 2005–2009 demonstrated that the total

expenditures for drugs have increased by 25.7 % since

2005.

Total direct costs

The available data do not allow for a separate analysis of

the drug reimbursement and PHC costs for each type of

DM. Therefore the total direct costs were calculated

together for type 1 and type 2 DM (Table 1) and they

amounted to EUR 322 million. The largest shares of the

direct costs are drug reimbursement, PHC and hospital

treatment, which are respectively 49, 22 and 18 %.

Direct costs of complications

Since 2009, the NFZ database has made it possible to

extract the costs of hospital treatment for DM-related

complications. Calculated EFs for people diagnosed with

DM (in hospital treatment) are presented in Table 2.

In 2009, the direct costs of hospital complication treat-

ment were EUR 332 million, which exceeded by more than

five times the direct costs of hospital treatment of DM per

se, which in the same year amounted to EUR 58.5 million.

656 J. Leśniowska et al.

123

The biggest share in the costs of DM-related complications

goes to heart diseases (84.4 %).

Indirect costs of DM

The total indirect costs of type 1 and type 2 DM consist of

the following fractional costs: the costs of lost productivity

because of sickness absence and the costs of lost produc-

tivity due to work incapacity.

The costs of lost productivity because of sickness

absence in the case of type 1 DM were EUR 12.8 million

and in the case of type 2 DM were EUR 32.1 million. The

analysis of absenteeism revealed a growing trend of indi-

rect costs related to both types of DM in the period

2006–2009. A 74 % growth in the costs was observed for

both types of DM; however, a more rapid increase in the

costs was observed for type 2 DM patients (88.6 vs.

53.7 %). This correlated with an increase in the number of

sickness absence days by 23.2 % for type 1 DM and

51.2 % for type 2 DM (Fig. 2).

Lost productivity due to work incapacity in the case of

type 1 and type 2 DM was respectively EUR 223.6 million

and EUR 79.5 million.

In 2009, the total indirect costs of DM exceeded EUR

349 million, of which around 13 % was associated with

loss of productivity because of sickness absence, whereas

the remaining 87 % with lost productivity was attributed to

work incapacity.

Indirect costs of complications

The indirect costs of complications include the costs of lost

productivity caused by sickness absence and costs of lost

productivity related to work incapacity. These costs were

2004 2005 2006 2007 2008 2009

E10 (T1DM) 17.91 19.61 24.04 25.59 38.14 40.33

E11 (T2DM) 24.50 27.37 33.20 35.53 52.14 52.17

0.00

10.00

20.00

30.00

40.00

50.00

60.00Fig. 1 The costs DM services (without the costs of drugs and

PHC) in 2004–2009 (in million

euros)

Table 1 The values of total direct costs related to diabetes in Poland in 2009 (in EUR mln)

Type 1 DM ? type 2

DM

Total Per 100,000

Direct—total 322.03 0.84

Hospital treatment 58.51 0.15

Drugs reimbursement 159.08 0.41

GPs 70.43 0.18

Heath services—without drugs and GPs 92.51 0.24

Table 2 Calculated attributable risks for diabetes-related chronic complications in Poland in 2009 (in hospital treatment)

Diseases EF

Angina pectoris (I20) 0.41

Acute myocardial infarction (I21) 0.40

Chronic ischaemic heart disease (I25) 0.39

Heart failure (I50) 0.69

Intracerebral haemorrhage (I61) 0.21

Cerebral infarction (I63) 0.40

Stroke, not specified as haemorrhage or infarction (I64) 0.18

Acute renal failure (N17) 0.19

Chronic kidney disease (N18) 0.20

Unspecified kidney failure (N19) 0.19

Retinal disorders in diseases classified elsewhere (H36) 0.27

Visual impairment including blindness (H54) 0.14

306,6 301,3 351,8 377,7

448,4 458,2

559,6

677,9

0

100

200

300

400

500

600

700

800

2006 2007 2008 2009

T1DM

T2DM

Fig. 2 The number of sickness absence days due to type 1 DM (T1DM) and type 2 DM (T2DM) in thousands

Costs of diabetes and its complications in Poland 657

123

EUR 53.8 million and EUR 438.05 million respectively.

The structure of indirect costs related to DM-related

complications was then similar to the corresponding cost

structure of DM itself and demonstrated that 89 % of the

costs were associated with productivity losses due to

incapacity for work, while only 11 % with capacity lost

because of sickness absence days.

In both the costs of lost productivity due to sickness

absence and the costs of lost productivity related to work

incapacity, the prevalence of heart disease complications

was respectively 91.5 and 83.9 %.

Overall, the indirect costs of DM-related complications

were higher by 41 % compared with the indirect costs

related to DM itself.

Total costs of DM and complications in 2009

The total costs of DM in 2009 amounted to EUR 1.5 billion

(Table 3). In the structure of the total costs of DM and its

complications, there is a prevalence of indirect costs

(56 %). Figure 3 shows that in the structure of the total

costs of DM there is a slight prevalence of direct costs

(52 % of total costs). In the case of costs of complications

there is a domination of indirect costs (60 % of total costs).

Sensitivity analysis

A sensitivity analysis (Tables 4, 5) revealed low elasticity

of both direct and indirect costs with respect to relative

risks and prevalence rate. This is mainly attributed to the

very high absolute values of estimated EFs.

The analysis shows that a 10 % increase in relative risks

results in a 3 and 3.4 % increase in the direct and indirect

costs respectively. The values of the direct and indirect

costs calculated for lower limits of relative risks are 2.3 and

4.4 % lower in comparison with the model values. The

figures in Tables 5 and 6 also reveal low elasticity of the

direct and indirect costs with respect to the changes in the

prevalence rate values.

Conclusions

From a social perspective, the total annual cost of DM in

Poland is about EUR 1.5 billion. The total costs of health

care services for DM and its complications amount to EUR

654 million, which constitutes 2.8 % of the total health

care costs in Poland. Since 2005 a systematic increase in

direct costs of DM treatment has been observed. In the case

of type 1 DM such a substantial increase in the costs was

caused by a more than 90 % rise in the average cost of

medical services (Table 6). This was caused mainly by the

reimbursement of insulin pumps and related accessories for

children, which was first undertaken at that time. The

increase in the costs of type 2 DM was associated with an

increase of epidemiological indicators, because the average

cost of medical services in 2009 increased by 36 % as

compared to 2004. The highest costs are connected with

Table 3 The values of costs related to diabetes and its complications in Poland in 2009 (in million euros)

Type 1 DM ? type 2 DM Diabetes complications Total cost of diabetes

Total Per 100,000 Total Per 100,000 Total Per 100,000

Direct—total 322.03 0.84 332.24 0.87 654.27 1.71

Heath services—without drugs and GPs 92.51 0.24 332.24 0.87 424.75 1.11

Drugs reimbursement 159.08 0.41 NA NA 159.08 0.42

GPs 70.43 0.18 NA NA 70.43 0.18

Indirect—total 349.01 0.91 491.89 1.28 840.90 2.20

Loss productivity due to sickness absence 45.96 0.12 53.83 0.14 99.79 0.26

Loss productivity due to incapacity for work 303.05 0.79 438.05 1.14 741.11 1.94

Total without drugs reimbursement and GPs 441.53 1.15 824.13 2.16 1,265.66 3.31

Total 671.04 1.75 824.13 2.16 1,495.18 3.91

52%

40%

48%

60%

0%

10%

20%

30%

40%

50%

60%

70%

DM DM complications

direct costs

indirect costs

Fig. 3 Direct and indirect costs of diabetes and its complications related to the total costs

658 J. Leśniowska et al.

123

the treatment of DM-related complications, which are more

than five times greater than the costs of DM treatment

(including only hospital care); these results correspond to

the characteristics observed in other European studies. It

confirms that the treatment priorities adopted by the

European and Polish DM Associations, which recommend

treatments to target and result in a decreasing incidence of

DM-related complications, are reasonable not only from a

clinical point of view but can also generate cost savings.

Lower incidences of DM-related complications will have a

major impact on the total cost of DM, and this is a way to

halt the economic burden of DM. The study shows that a

significant share of the total costs (56 %) of DM and its

complications is constituted by indirect costs. The indirect

costs of DM are often overlooked in health care planning in

Poland; the results of this study show that indirect costs can

be higher than direct costs and therefore cannot be ignored

in health care decision-making processes. The usage of

health care resources should be planned not only to cut

direct costs of treatment but also to consider the social

impact of the disease, and through effective treatment to

minimise indirect costs. Sickness absence and work inca-

pacity can largely diminish productivity when the disease

is not managed correctly.

This is the first time that the attributable risk approach has

been used for estimating the direct and indirect cost of DM

complication in Poland. The Polish DM COI studies men-

tioned above have estimated the cost of DM complications

directly from the study sample without adjusting for attrib-

utable risk. Due to a major methodology discrepancy the

results are barely comparable with the previous studies

conducted in Poland, although it can be observed that indi-

rect costs constitute a high fraction of the total costs

regardless of the methodology used.

The fact that both the total health care cost and the cost

per person diagnosed with DM were found to be lower than

in the UK [6] is not surprising as the cost of resources and

the number of people with DM are much lower in Poland.

There is also a substantial difference in the cost compounds

proportion; in this characteristic Poland is more similar to

Sweden. Our estimate of the health care cost as a result of

DM per se was very similar to the estimate of Bolin et. al

[7]. DM per se in Poland accounted for 49 % of the health

care cost and 41 % of the productivity loss; the corre-

sponding figures in Sweden were 50 and 41 % respec-

tively. Despite these similarities DM in Poland seems to

constitute a more severe burden to the health care budget.

In Sweden DM-related health care costs accounted only for

approximately 1.4 % of the total health care cost; in Poland

this fraction was more than double (2.87 %). Polish DM

patients seem to be more severe cases; our study reported

almost twice as many hospitalisations per 100,000 inhab-

itants than in Sweden and hospital costs in Poland are more

than 50 % lower (Table 7). In comparison to the mentioned

Western European countries, our study results report sub-

stantially lower estimates for DM cost per capita. It would

be desirable to compare the Polish results to the estimates

from other Eastern European countries.

Most of the previous studies in Poland were based on

epidemiological data and surveys conducted on a repre-

sentative sample of the Polish population. This results from

low data availability, dispersion or a lack of data. Our top-

down study of DM costs is the first of its type in Poland. It

is based on reliable source data, and although some data

could not be obtained, the results provide an insight into

the structure of DM costs while demonstrating the scale of

the problem. Such measurements are the first step in the

proper DM control, and this study can be a starting point

for further research in this field in Poland to provide a full

picture of the DM burden. An improvement of data

availability and quality is needed to monitor the real costs

of the disease. We should indicate a number of difficulties

connected with conducting COI studies in Poland. These

are primarily low data availability, dispersion or lack of

data: difficulty in identification of costs related to the most

frequent complications, lack of legal regulations and un-

derdevelopment of the information infrastructure of the

health care system.

The study has certain limitations that should be men-

tioned. It is likely that the results underestimate the real

costs associated with DM and DM-related complications.

Table 4 Sensitivity analysis for DM direct costs

Variable Sensitivity:

lower value

Model value Sensitivity:

upper value

Relative risk 674,285,493.47 689,490,239.73 712,668,739.07

Prevalence rate 674,478,036.72 689,490,239.73 763,274,239.59

Table 5 Sensitivity analysis for DM indirect costs

Variable Sensitivity:

lower value

Model value Sensitivity:

upper value

Relative risk 795,148,021.56 830,909,121.87 859,814,374.69

Prevalence rate 796,725,482.51 830,909,121.87 943,988,689.14

Table 6 Average cost of medical services (without PHC and drug reimbursement) provided in relation to the type 1 DM and type 2 DM

in 2004-2009 (in EUR)

Years

2004 2005 2006 2007 2008 2009

Type 1 DM 112.69 128.53 126.99 148.12 209.25 214.49

Type 2 DM 70.28 77.33 71.33 81.48 103.58 95.74

Costs of diabetes and its complications in Poland 659

123

One reason is not including the loss of productivity asso-

ciated with mortality. This cost can account for a sub-

stantial part of the total DM cost. A recent DM COI study

reported that it can amount to as much as 46 % of the total

indirect DM burden [14]. The study does not include

information on direct costs of long-term care in formal care

centres or indirect costs of informal care provided to dis-

abled DM patients. It can be expected that the second

group of costs would constitute a significant share in

Poland. Informal care is the most common form of pro-

viding long-term care in Poland. There is also a limitation

connected with estimation of relative risks used for cal-

culation of costs of complications attributable to DM.

There is no DM registry in Poland; therefore calculations

were based on hospital data. DM patients treated in hos-

pitals tend to have more severe diseases in comparison to a

general sample of DM patients, as not all DM patients have

to be treated in the hospital. This inevitably leads to

problem with confounding variables and results in upward

bias in relative risks and prevalence rate values. However,

strikingly high values for some of the relative risks

potentially can also comprise some information about the

effectiveness of the management of chronic conditions in

the Polish Health Care System. This general issue is

beyond the scope of our analysis, but we believe it deserves

attention in future COI-related studies.

In conclusion, our study shows that DM imposes a major

economic burden in Poland. Therefore there is a need to

introduce an integrated system of DM management that

would enable containing future DM costs.

Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, dis-

tribution, and reproduction in any medium, provided the original

author(s) and the source are credited.

References

1. Lundman, B., Engström, L.: DM and its complications in a

Swedish county. DM. Res. Clin. Pr. 39(2), 157–164 (1998) 2. Andel, M., Grzeszczak, W., Michalek, J., Medvescek, M., Nor-

kus, A., Rasa, I., Niewada, M., Kamiski, B., Kraml, P., Madacsy,

L.: The DEPAC group: a multinational, multi-centre, observa-

tional, cross-sectional survey assessing DM secondary care in

Central and Eastern Europe (DEPAC survey). Diabet. Med.J.

British Diabet. Assoc. 25(10), 1195–1203 (2008) 3. Wittek, A., Sokalski, B., Grzeszczak, W., Strojek, K.: Prevalence

of DM and cardiovascular risk factors of industrial area in

southern Poland. Exp. Clin. Endocrinol. DM 117, 350–353 (2009)

4. Ballesta, M., Carral, F., Olveira, G., Giron, H.A., Aguilar, M.:

Economic costs associated with type II DM in Spanish patients.

Eur. J Health Econ. HEPAC Health Econ. Prev. care. 7(4), 270–275 (2006)

5. Ferber, L., Köster, I., Hauner, H.: Medical costs of diabetic

complications, total costs and excess costs by age and type of

treatment results of the German CoDiM study. Exp. Clin.

Endocrinol. DM Off. J. Ger. Soc. Endocrinol. Ger. DM Assoc.

115(2), 97–104 (2007) 6. Hex, N., Bartlett, C., Wright, D., Taylor, M., Varley, D.: Esti-

mating the current and future costs of Type 1 and Type 2 DM in

the UK, including direct health costs and indirect societal and

productivity costs. Diabet. Med. 29, 855–862 (2012) 7. Bolin, K., Gip, C., Mork, A.-C., Lindgren, B.: DM, healthcare

cost and loss of productivity in Sweden 1987 and 2005—a reg-

ister-based approach. Diabet. Med. 26, 928–934 (2009) 8. Kinalska, I., Niewada, M., Głogowski, C., Krzy _zanowska, A.,

Gierczyński, J., Łatek, M., Kamiński, B.: Koszty cukrzycy typu 2

w Polsce (Badanie CODIP). Diabetologia Praktyczna 5(1), 1–8 (2004)

9. Kawalec, P., Pilc, A.: Analiza kosztów leczenia powikłań cu-

krzycy poniesionych przez płatnika w Polsce w 2002 roku. Di-

abetologia Praktyczna 5(1), 9–14 (2004) 10. Kawalec, P., Pilc, A.: Koszty pośrednie cukrzycy w Polsce. Di-

abetologia Praktyczna 7(4), 211–215 (2006) 11. Tarricone, R.: Cost-of-illness analysis. What room in health

economics? Health Policy 77(1), 51–63 (2006) 12. American DM Association: Economic cost of DM in the US in

2002. DM Care 26, 917–932 (2003) 13. DM Atlas Update 2012: Regional and Country Fact Sheets, IDF

2012

14. American DM Association: Economic costs of DM in the U.S. In

2007. DM Care 31(3), 596–615 (2008)

Table 7 Hospital care costs of diabetes and diabetes-related chronic complications in Poland 2009, total and per 100,000 inhabitants (costs in EUR million)

DM DM complications DM and DM complications

Total Per 100,000 Total Per 100,000 Total Per 100,000

Hospital care

Number of hospital admissions 103,328 270.72 341,292 894.20 444,620 1,164.93

Costs 58.51 0.15 332.24 0.87 390.75 1.02

660 J. Leśniowska et al.

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