Diabet Med. 2015 Nov;32(11):1520-6. doi: 10.1111/dme.12843.

Incidence and care-related costs of severe hypoglycaemia requiring emergency treatment in Andalusia (Spain): the PAUEPAD project.

Barranco RJ1,2, Gomez-Peralta F3, Abreu C3, Delgado M4,5, Palomares R6, Romero F1, Morales C7, de la Cal MA1, Garcia-Almeida JM8, Pasquel F9, Umpierrez GE9.
  • 1Public Company for Health Emergencies of Andalucıa (EPES), Sevilla, Spain.
  • 2Department Health Sciences, University of Jaen, Segovia, Spain.
  • 3Endocrinology and Nutrition Unit, Segovia General Hospital, Segovia, Spain.
  • 4Division of Preventive Medicine and Public Health, Department Health Sciences, University of Jaen, Jaen, Spain.
  • 5Center for Biomedical Research in Epidemiology and Public Health (CIBERESP), ISCIII, Ministry of Health, Madrid, Spain.
  • 6Endocrinology and Nutrition Unit, Reina Sofia Hospital, Cordoba, Spain.
  • 7Endocrinology and Nutrition Unit, Virgen Macarena Hospital, Sevilla, Spain.
  • 8Endocrinology and Clinical Nutrition Unit, Virgen de la Victoria Hospital, Malaga, Spain.
  • 9Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.



Aims Hypoglycaemia is a serious medical emergency. The need for emergency medical service care and the costs of hypoglycaemic emergencies are not completely known.

Methods This was a retrospective observational study using Public Company for Health Emergencies (EPES) data for hypoglycaemia in 2012. The EPES provides emergency medical services to the entire population of Andalusia, Spain (8.5 million people). Data on event type, onsite treatments, emergency room visits or hospitalization were collected. Medical costs were estimated using the public rates for healthcare services.

Results From a total of 1 137 738 emergency calls that requested medical assistance, 8683 had a primary diagnosis of hypoglycaemia (10.34 per 10 000 person-years). The incidence of severe hypoglycaemic episodes requiring emergency treatment in the estimated population with diabetes was 810 episodes per 10 000 person-years. A total of 7479 episodes (86%) required an emergency team to visit the patient’s residence. The majority of cases (64%) were addressed in the residence, although 1784 (21%) cases were transferred to hospital. A total of 5564 events (65%) involved patients aged > 65 years. Overall mortality was 0.32% (28 cases). The total annual cost of attending a hypoglycaemic episode was €6 093 507, leading to an estimated mean direct cost per episode of €702 _ 565. Episodes that required hospital treatment accounted for 49% of the total costs.

Conclusions Hypoglycaemia is a common medical emergency that is associated with high emergency medical service utilization, resulting in a significant economic impact on the health system.



This study is a retrospective study of all registered hypoglycaemic calls attended during 2012 by the Emergency Medical Services in Andalusia, Spain. It is a very broad population-based analysis of about 8.5 million residents from a large geographic area in Spain. We illustrate the incidence, severity and costs associated with this serious acute complication of diabetes.  The costs of emergency care and resource utilization due to hypoglycaemia treatment outside the hospital are usually absent in the health care economics studies.

In our opinion, the information provided by this study is particularly relevant. It has not been previously published European information about incidence and costs of severe hypoglycaemia requiring emergency treatment on the entire population of such a large size (8.5 million inhabitants) European region.

Understanding the incidence of hypoglycaemic emergencies (10.34 per 10,000 person/years among the total population, 80 per 10,000 person-years among people with diabetes) may be valuable for clinical and epidemiological purposes. 54.6% of affected patients were women.

Taking in consideration the figure of 300 per 10,000 patients-years as a reference of incidence of SHEs in adults with diabetes (1), our data suggest that the percentage of patients with SHEs who require assistance from an emergency care service would be about 30% of the total. Structured training in self-management could reduce both the rate of SHEs requiring emergency treatment, and their associated costs (2).

The frequency of calls was lower during the night, but the average urgency was higher than during the remainder of the day. (Figure 1) The time distribution analysis of hypoglycaemia provides novel information from a clinical perspective. We found that the frequency of telephone calls is lower during the night period (26.45% of the total) and higher between 9 and 11h in the morning. On the other hand, the nocturnal assistance calls had an average category of urgency higher than during the rest of the day. These results are consistent with those of Chico et al. (3), who observed unrecognized hypoglycaemias in 47% to 62% of diabetic patients with 73.7% of all events occurring at night. These data underline the unmet need of improving prevention and detection of nocturnal hypoglycaemia.



fig1Figure 1. Incidence of severe hypoglycaemic episodes (SHEs) (n = 8683) and average category of urgency per hour.


Seasonal distribution of SHEs is also interesting because, unexpectedly, the frequency is lower during summer time (when more physical activity is done). (Figure 2) On the other hand, the average of urgency priority is higher during this season.

Our results indicate the high cost of treating hypoglycaemia as emergency care (€702 per episode). The episodes that require referral to a hospital (21%) represented half of the total expenditure.

In summary, hypoglycaemia requiring emergency treatment is common and is associated with a significant utilization of health care resources and financial impact. More efforts are needed to reduce this serious complication mainly related to diabetes treatment. In addition, our study indicates the need for well-structured treatment and hospital transfer protocols that might improve outcome and reduce hospitalization cost of patients with hypoglycaemia.



fig2Figure 2. Seasonal incidence of severe hypoglycaemic episodes (SHEs) requiring emergency care (n = 8683) and average category of urgency.



  1. Bloomfield HE, Greer N, Newman D, MacDonald R, Carlyle M, Fitzgerald P, Rutks I, Wilt TJ (2012) Predictors and Consequences of Severe Hypoglycemia in Adults with Diabetes – A Systematic Review of the Evidence . Department of Veterans Affairs, Washington (DC)
  2. Elliott J, Jacques RM, Kruger J et al (2014) Substantial reductions in the number of diabetic ketoacidosis and severe hypoglycaemia episodes requiring emergency treatment lead to reduced costs after structured education in adults with Type 1 diabetes. Diabet Med 31(7):847-853
  3. Chico A, Vidal-Rios P, Subirà M, Novials A (2003) The Continuous Glucose Monitoring System Is Useful for Detecting Unrecognized Hypoglycemias in Patients With Type 1 and Type 2 Diabetes but Is Not Better Than Frequent Capillary Glucose Measurements for Improving Metabolic Control. Diabetes Care 26(4):1153-1157


Correspondence to:

Fernando Gomez-Peralta.

Endocrinology and Nutrition Unit

Hospital General de Segovia, Spain

E-mail: fgomezperalta@gmail.com



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