Diabetes Care in Ireland

In this article, Dr Jonathan Briody, a health economist with the Royal College of Surgeons in Ireland, discusses a new project in which pioneering microsimulation models adapted from international programmes and validated for the first time in the Irish setting will be used to estimate the health economic consequences of incremental improvements in the quality of diabetic and pre-diabetic care in Ireland.

Diabetes mellitus is a metabolic disorder that occurs when the body cannot produce or properly use insulin, a hormone produced by the pancreas. Insulin is essential for regulating the amount of glucose (sugar) in the blood, as it helps the body to convert glucose into energy. When the body is unable to produce insulin, or when the insulin it produces is ineffective, glucose builds up in the blood, leading to high blood sugar levels or hyperglycemia, which damages the blood vessels and nerves in the body. Such uncontrolled diabetes has been associated with heart disease, stroke, blindness, kidney failure and amputation.

As a growing global public health threat, diabetes is placing an enormous burden on individuals, families, health systems, and national economies. Ireland is sharing this burden, as prevalence has doubled over the last two decades to 7%. There are an estimated 225,000 people living with the disease nationally.

An additional 17-19% of the population have pre-diabetes or undiagnosed diabetes, putting one-quarter of the Irish adult population at high risk for the morbidity stemming from chronic hyperglycemia.

Fortunately, randomised controlled trials have provided a diverse range of options to prevent diabetes and its complications. Multi-component lifestyle interventions for adults with pre-diabetes can reduce the incidence of diabetes by 50% or more. Where diabetes has not been prevented, achieving strict glycemic control reduces the risk of microvascular complications while lowering blood pressure and lipid levels significantly reduce myocardial infarction and stroke. These have been shown to be cost-effective, with blood pressure management, glycemic management, lipid management, and screening for complications all demonstrating favourable cost-effectiveness ratios. Likewise, structured lifestyle interventions have also been highly cost-effective, particularly when stratification approaches are applied to identify high-risk individuals.

Unfortunately, the direction of the diabetes epidemic in Ireland is less encouraging. Recent estimates indicate a significantly increased trend in the prevalence of type 1 diabetes with increasing age. Similarly, the number of type 2 diabetes patients is predicted to double to almost half a million in the next 15 years unless population-wide prevention policies are instituted, according to HSE research. If unaddressed, the incremental national cost associated with this trend is anticipated to be greater than ¤100 million annually.

Of late, the HSE, the Diabetes National Clinical Programme and the National Framework for the Integrated Prevention and Management of Chronic Disease have prioritised enhancing integrated care to achieve comprehensive risk factor management and avoid complications while also launching regional pilot programmes in diabetes prevention. However, such efforts are hampered by a lack of evidence to support optimal investment in the prevention and management of diabetes in Ireland.

This no longer needs to present a missed opportunity to reduce Ireland’s disease burden. The Irish Research Council (IRC) has awarded researchers at the Royal College of Surgeons in Ireland University of Medicine and Health Sciences (RCSI) funds to collaborate with enterprise partner Diabetes Ireland on a research project of mutual interest via the Enterprise Partnership Scheme (EPS).

Professor Ed Gregg, Chair and Head of the School of Population Health at RCSI, and Professor Kathleen Bennett, Deputy Head of School – Research at the School of Population Health and Head of the Data Science Centre at RCSI, provide internationally established disease experience. Dr Jonathan Briody brings healtheconomic expertise at RCSI as the project awardee. Dr Kate Gajewska completes the team as Research and Advocacy Manager at Diabetes Ireland, the preeminent charity and advocacy organisation in Ireland dedicated to supporting people with diabetes.

Through strong collaboration with world-class experts in diabetes epidemiology, care, prevention, and economics nationally and internationally, this partnership will meet the objective of this project.

That is, to draw on advances in health impact modelling pioneered globally to develop a state-of-theart simulation model to prioritise interventions for Ireland that costeffectively stem the health burden of diabetes.

Particularly, a health economic model is being adapted to the Irish setting. This model will estimate the long-term health effects of diabetes in Ireland and determine the health consequences and cost-effectiveness of implementing new approaches to screen, manage, and prevent diabetes and its complications. The partnership will also provide Diabetes Ireland with critical estimates while adding significantly to the national infrastructure for evaluating healthcare policies for diabetes. This work consists of several primary aims, developing an innovative and sustainable Irish diabetes model, using this model to estimate the health impact and cost-effectiveness that could be achieved with optimal management in the Irish population with diabetes and evaluating early action to prevent diabetes. Central to all of this is the fundamental research question to be answered by this undertaking, the financial and population health consequences of applying advanced health economic modelling of diabetes to the Irish setting.

In sum, numerous evidencebased options exist to prevent diabetes and its complications. However, the potential health and economic consequences of appropriate implementation of these interventions have yet to be quantified for Ireland. This project is under development to produce some of the first evidence on the expected health benefit and cost-effectiveness of successfully integrated population-level care and prevention programmes in Ireland. The provision of this evidence in a manner that is actionable when planning prevention and treatment policies at a national level presents a critical opportunity to prioritise interventions that cost-effectively reduce the long-term health burdens of diabetes for all.