In the 2019-2022 period the average annual expenditure on diabetes amounted to 174 million euros.

More than half of the annual direct expenditure of the Health Insurance Institute of Slovenia (ZZZS) intended for diabetes is spent on managing the consequences of diabetes complications, such as hospitalizations due to cardiovascular complications, kidney complications, diabetic foot, and others.

A team of researchers led by Prof. Dr. Petra Došenović Bonča from Ljubljana’s Faculty of Economics -the research team also included Karmen Janša, a diabetologist and expert associate of the ZZZS -collected, classified and analyzed data from the ZZZS database for the period between August 2019 and 2022 for seven groups of diseases. The result is the first comprehensive and in-depth collection of data on how much of the compulsory health insurance funds and co-payments are spent on average each year on the treatment of diabetes. A paper presenting the results of the study has also been published in a reputable international health economics journal and the results were presented by Ms. Došenović Bonča and Ms. Janša at a press conference.

Diabetes is a metabolic disease characterized by fluctuations in blood sugar or glycemia which, if not properly controlled, eventually causes damage to other organs and organ systems. It is a very common disease, affecting 10% of the world's population between the ages of 20 and 79 according to the latest figures from the International Diabetes Federation (IDF). As such, and particularly due to its complications, it is a major economic burden for individuals, healthcare systems, and societies.

"There were no major surprises because we have been monitoring certain results or costs even before the study. Prof. Dr. Petra Došenović Bonča and I made our first assessment a few years ago when we received data from a European study. However, at that time we could not access the data available today," said Dr. Janša. "I expected the percentage of late complications to be higher than 53, but I am happy to see that it is not."

Prof. Dr. Došenović Bonča also presented details of the paper, explaining that in addition to direct expenditures, the researchers added age-sex profiles of expenditures. The average annual growth rate of direct spending on diabetes and its complications was 12.5 percent over the period studied. "We disaggregated spending by sex and age to predict future trends. Looking at demographic changes and taking into account projections, they show that if we do not change the way we treat and prevent diabetes, 7.5 percent of the total increase in costs in Slovenia will be due to diabetes," says Prof. Došenović Bonča."The Institute for Health Insurance has a very well-developed database, and we wanted to use this data. Studies like this are very important for new decisions, such as whether it is appropriate to introduce a new medicine or technology. They allow us to better and more easily plan the health care basket and respond to the needs of society. I would like to see this kind of monitoring become a regular feature and established for other diseases as well so that we can make decisions based on real data."

Complications are relentlessly increasing expenditure

The average annual expenditure per person with diabetes without complications is €520, and many times more for a person with complications. During the period under review, for example, it was calculated that the average expenditure for a diabetic patient with kidney complications was an additional €4,385 per year. And there are other complications to consider. Dr. Karmen Janša explained that the researchers calculated the total direct expenditure by taking the direct expenditure for diabetes itself and adding the expenditure for the treatment of groups of known diabetes complications: complications of the heart, kidneys, eyes, legs, nerves, as well as acute complications (with frequent hospitalizations for specific acute conditions such as hypoglycemia). When the data are disaggregated, it is clear that complications account for more than half of the direct costs of diabetes.

The high cost of complications is also reflected in the number of hospitalizations, which account for up to 33% of all direct diabetes spending. "Diabetes is not just high blood glucose, it is a chronic metabolic disease that has many late complications, not just acute ones," explained Dr. Janša. Late complications are divided into microvascular and macrovascular, so patients need to be monitored for blood pressure, elevated blood fats, etc. "That is why the management of a diabetic patient is one of the most complex tasks," says Dr. Janša.

"For me as a diabetologist, the key message is that significant resources are spent on treating the chronic complications of diabetes, so it would make sense to redirect as much of this money as possible to preventing these complications so that money can be spent on people who are still healthy and maintaining their health," commented Prof. Dr. Tadej Battelino, pediatric endocrinologist and head of the Department of Endocrinology, Diabetes and Metabolic Diseases at the Ljubljana Children's Hospital. "These data will be crucial for Slovenia to finally get on the road to prevention, early access to technologies, and modern medicines for the treatment of diabetes."

Just under a quarter of direct expenditure (24%) is spent on diabetes drugs, where Slovenia is one of the best performers in the EU in terms of accessibility. All advanced therapies are available. "Ten years ago, the share was almost half of what it is today, and I hope that the increase will slow down," commented Prim. Dr. Jurij Furst, Head of the Pharmaceuticals Department at the National Health Insurance Institute (ZZZS), on drug spending. He highlighted the problem that people with diabetes take three or four medications a day. "It would be better to prescribe fewer medicines, but reducing medicines is an art, it is much easier to add them."

For this reason, Ms. Došenović Bonča also pointed out that over the period under review, the cost of treatment has been rising by about 12 percent per year due to the increase in the number of patients, which naturally has an impact on the increased consumption of medicines. "Data is important, but we are all aware of the importance of a healthy lifestyle, so we are educated, but achieving lifestyle changes is very different than education," added the professor from Ljubljana’s Faculty of Economics.

More attention to human resources and the patient
According to Urška Kšela, diabetologist and head of the Department of Endocrinology and Diabetology at the University Medical Center Maribor, modern medicines and other tools for disease management, to which we have excellent access, are not enough. We need a strategy to coordinate teams working with people with diabetes and ensure more equal access across Slovenia.

"The comprehensive management of people with diabetes is the responsibility of the extended health care team, which is defined and organized differently at different health system levels. In this respect, Slovenia is unfortunately at the bottom of the ranking of developed countries," says Dr. Kšela. "The shortage of doctors and healthcare professionals at all levels of the healthcare system, the primary, secondary, and tertiary, means that people with diabetes receive less quality care. Health teams are distributed in a highly unequal way across regions and we do not have a strategy in place at the national level to address these problems and begin to solve them constructively."

Dr. Katarina Skubec Moćić, a general practice physician from the Celje Municipal Healthcare Centre, agrees. "It is important for all stakeholders in healthcare and government to speak the same language. In the family medicine team, the tasks of prevention and treatment are defined and divided clearly. We all share the goal of an empowered patient."

The Slovenian Diabetes Association, of which Samo Fakin is vice president, also works to empower patients. "The key issue is the motivation of the person with diabetes. Type 1 diabetics are highly motivated to learn to eat right because the punishment is immediate. Type 2 diabetics, especially those over 75, find it harder to get them to be physically active every day and to start eating," he added.

The results show us where we are. Where do we want to go
In the three years of the study alone, the average annual growth rate of diabetes spending was 12.5%. According to official data, only 15% of people with diabetes can control their disease with non pharmacological measures and a healthy lifestyle. An aging population, multiple risk factors and a sedentary society with unhealthy eating habits will be the main drivers of spending growth in the coming years. "Given the large amount of money spent on treating the complications of diabetes, more intensive implementation of measures to prevent and optimally manage the disease could significantly reduce its impact on the healthcare system," the researchers said, explaining the practical value of such research for healthcare decision-makers.

The results are very important for the Slovenian context, as the numbers and evidence can be used to make a much more robust assessment of the situation and to plan for the future, says Mojca Gobec from the Ministry of Health. "We are aware of the complexity of the disease and its complications. We have guidelines that have been updated several times, and drafted by different experts, not just physicians, so they cover everything from early diagnosis to treatment and prevention of complications. Education must always be an integral part of treatment, but it is not enough, patient motivation is essential," says Ms. Gobec.

Finally, the researchers suggested some guidelines for decision-makers to reduce the burden of diabetes. Many of the risk factors that contribute significantly to the development of diabetes can be reduced, and primary prevention and healthy lifestyle programs should be strengthened, they said. By improving early detection and treatment of diabetes with optimal management and control, we can slow its progression and the onset of costly complications.

"The Slovenian Diabetes Association looks forward to such research because it confirms our belief that prevention is an essential aspect of managing diabetes and other non-communicable chronic diseases. It is also about empowering the patient, who needs to be involved in the management of diabetes and not simply rely on healthcare professionals," says Robert Gratton, President of the Slovenian Diabetes Association.

In conclusion, Prof. Dr. Došenović Bonča added that "the patient can reduce their burden on the healthcare system through his or her behavior and self-management."

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