[Costs of intensive insulin therapy in type 1 diabetes mellitus. Experiences from the DCCT study]

Diabetes mellitus is one of the most common metabolic diseases in many countries of the world. Its prevalence in Germany has increased 7- to 8-fold over the past 30 years. The clinical and economical importance of diabetes is determined by the frequent occurrences of such serious complications as neuropathy, retinopathy and nephropathy. Intensive insulin therapy with regular monitoring of blood glucose (up to 4 measurements daily) and adjustment of the insulin dose accordingly may achieve virtually normal levels of blood glucose and thus decrease the risk of these complications. The present cost-effectiveness-study shows that the higher costs of invasive insulin therapy are offset by savings of 8.114 German marks per patient resulting from the reduction in morbidity and mortality. On the basis of an estimated 5% to 10% type 1 diabetes among the total diabetic population (prevalence 4.9%), potential saving of 1.62 to 3.24 billion marks are calculated for Germany.

Impact of pharmacist consultations provided to patients with diabetes on healthcare costs in a health maintenance organization

We conducted a study to assess the impact on healthcare utilization and costs of pharmacist consultations provided to patients with diabetes. Data for this study were derived from a larger study conducted by Kaiser Permanente and the University of Southern California that evaluated three alternative models of pharmacist consultations (control, state, and Kaiser). Computerized data were available for patient demographic characteristics and healthcare utilization. We used medication data to classify patient cohorts as insulin only or oral antidiabetics +/- insulin. We estimated hospitalization costs based on diagnostic related group and medication costs based on average wholesale price; office visits were estimated at $70 each. In the insulin only cohort, total costs for patients who had their prescriptions filled at a state model pharmacy were 7.8% less than those for patients filling prescriptions at a control model pharmacy (P = 0.008). In the oral +/- insulin cohort, total costs for patients filling new prescriptions at a Kaiser model pharmacy were 21.9% less than those for patients using a control model pharmacy (P = 0.0001). The state model also was negatively correlated (beta coefficient, -0.0997) with total costs (P = 0.0001). These data suggest that pharmacist consultations provided to patients with diabetes can decrease total healthcare costs in a health maintenance organization.

Insulin lispro, a new insulin analog

Insulin lispro is a rapid-acting insulin analog to regular insulin. Inversion of the proline-lysine amino acid sequence at positions 28 and 29 on the B chain is responsible for its more rapid absorption, faster onset, and shorter duration of action compared with regular insulin. The fast onset of action allows for greater flexibility in dosing and mealtime scheduling. Insulin lispro provides equivalent or slightly improved glycemic control in patients with types I and II diabetes mellitus compared with regular insulin, without subsequent increases in hypoglycemic episodes. It also results in greater reduction in postprandial blood glucose excursion than regular insulin. Compared with other insulins, insulin lispro represents a more physiologic approach to exogenous insulin therapy.

Economic evaluation of insulin lispro versus neutral (regular) insulin therapy using a willingness-to-pay approach

This willingness-to-pay (WTP) analysis is the first study of its kind undertaken in Australia to support an application for listing of a new drug on the Australian national formulary. The technique offers the advantage of being able to summarise diverse outcomes of therapy in a single unit of measure. Willingness to pay is used to value benefits in cost-benefit analysis (CBA), and CBA represents an absolute decision rule. An open-ended question with a bid-up approach was used to minimise bias and elicit the maximum amount patients would be willing to pay for insulin lispro. The WTP study incorporated scenarios describing the outcomes from insulin lispro and neutral (regular) insulin, the results from a formal metaanalysis and a description of the injection characteristics of the therapies. A sample of 83 patients with type I or II diabetes mellitus were surveyed using an open questionnaire to determine their maximum willingness to pay for the therapy they preferred. Overall, 92% of patients preferred insulin lispro (referred to as insulin A) and 8% preferred neutral insulin (referred to as insulin B). The incremental benefit per patient was calculated as 452.16 Australian dollars ($A) per year. Insulin lispro was listed on the Australian national formulary at a 36% premium over neutral insulin, so the additional cost per patient would be $A70.32 per year. Therefore, costs were exceeded by the benefits and insulin lispro was deemed to offer a net benefit. A multivariate analysis indicated that those patients who were middle-aged had the strongest preference for insulin lispro.

A short term cost-effectiveness model for oral antidiabetic medicines in Europe

A short term (6-month) cost-effectiveness model has been developed to simulate current medical practice and disease progression in patients with type 2 (non-insulin-dependent) diabetes mellitus uncontrolled by diet and exercise. The model is based on decision-analytical techniques and includes probabilities of switching between treatments, the reason for the switch and the most common switch options. Effectiveness and economic measures are the 2 main outcomes. In order to assess effectiveness, we use symptom-free days with acceptable control (SFDACs), which represent each day of treatment without adverse events or symptoms, and with acceptable control of glucose and lipids. For the economic evaluation, only incremental costs incurred directly by a health insurance system are considered. This model should prove useful in the evaluation of new oral antidiabetic agents, since the short term aim of antidiabetic therapy is to provide adequate control in the absence of adverse effects and symptoms (a prerequisite for successful long term treatment). Furthermore, short term analysis provides data for comparing initial investment in drug therapy with potential savings over a longer treatment period.

Patient mixed biphasic insulin in a diabetic clinic

INTRODUCTION

Improved glycaemic control is possible with the use of multiple injections of premixed insulin. These are expensive, and not available in state hospitals.

OBJECTIVES

To study the cost, patient acceptance and efficacy of a patient mixed and administered combination of soluble and lente (biphasic) insulin administered twice a day.

PATIENTS

A cohort of 25 patients with poor glycaemic control on a single dose of 100 units or more of lente insulin. 25 patients matched for age and glycaemic control were used as a control.

SETTING

The diabetic clinic of the National Hospital Sri Lanka.

METHOD

A prospective study of a cohort of patients.

RESULTS

Mean fasting blood glucose decreased from 8.3 mmol/l (SD 3.1) to 6.9 mmol/l (SD 2.3, p < 0.01) and mean blood glucose levels declined from 12.3 mmol/l (SD 4.1) to 10.1 mmol/l (SD 4.7, p < 0.01) in the biphasic group. Total mean insulin dose fell from 80 units (SD 12) to 61 units (SD 11) in the biphasic group, but increased in the control group from 82 units (SD 16) to 91 units (SD 13.1). The diabetes well-being score in the biphasic group was 91.5 (SD 35.3), while the control group had a score of 63.7 (SD 21.3 p < 0.01). Mean glycosylated haemoglobin (HbA1c %) was 8.1 (SD 2.7) in the biphasic group compared to 9.2 (SD 3.3) in the control group.

CONCLUSION

Patient mixed and administered biphasic insulin on a twice daily basis is feasible, acceptable to patients, results in better glycaemic control and affords better patient satisfaction.

Comparison of different insulin regimens in elderly patients with NIDDM

OBJECTIVE

To compare the metabolic effects of three different frequently used regimens of insulin administration on blood glucose control and serum lipids, and the costs associated with this treatment, in subjects with NIDDM, who were poorly controlled with oral antihyperglycemic agents.

RESEARCH DESIGN AND METHODS

We studied 95 elderly patients with NIDDM (age 68 +/- 9 years, BMI 26.0 +/- 4.6 kg/m2, and median time since diagnosis of diabetes 9 years [range 1-37]; 37 men, 58 women), who were poorly controlled, despite diet and maximal doses of oral antihyperglycemic agents. Three insulin administration regimens were compared during a 6-month period: patients were randomized for treatment with a two-injection scheme (regimen A) or a combination of glibenclamide with one injection of NPH insulin, administered either at bedtime (regimen B) or before breakfast (regimen C), and insulin treatment was mainly instituted in an outpatient setting.

RESULTS

After 6 months of insulin treatment, fasting blood glucose of the total patient population had decreased from an average of 14.1 +/- 2.2 to 8.3 +/- 2.0 mmol/L (P < 0.001), and HbA1c fell from 11.0 +/- 1.3 to 8.3 +/- 1.2% (P < 0.001); 34 patients reached HbA1c levels below 8.0%, 25 of them even below 7.5%. With two insulin injections daily, HbA1c decreased from 11.2 +/- 1.3 to 8.2 +/- 1.2%, while during combined treatment, HbA1c fell from 10.5 +/- 1.2 to 8.1 +/- 1.1% (regimen B) and from 11.1 +/- 1.3 to 8.5 +/- 1.1% (regimen C). Comparable improvement of the other measures of glycemic control, lipids and lipoproteins, was observed in the different treatment regimens. Body weight increase was moderate (mean +/- 4.0 kg) and similar in all patient groups. One-third of patients starting with one insulin injection daily needed a second injection to control glycemia. One episode of severe hypoglycemia was observed. Combined insulin-sulfonylurea treatment was almost 20% more expensive than twice-daily administration of insulin alone.

CONCLUSIONS

Insulin treatment can safely be instituted in elderly patients with NIDDM. However, it is difficult to obtain optimal glycemic control. Insulin has moderate beneficial effects on serum lipoproteins. Although on the basis of glycemic control and weight gain, no preference for any treatment regimen can be discerned, twice-daily insulin administration is the most simple and cost-effective regimen.

Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial. The Diabetes Control and Complications Trial Research Group

OBJECTIVE

To examine the cost-effectiveness of alternative approaches to the management of insulin-dependent diabetes mellitus (IDDM).

DESIGN

A Monte Carlo simulation model was developed to estimate the lifetime benefits and costs of conventional and intensive insulin therapy. Data were collected as part of the Diabetes Control and Complications Trial (DCCT) and supplemented with data from other clinical trials and epidemiologic studies.

SETTING

Twenty-nine academic medical centers.

PATIENTS

Persons with IDDM in the United States who meet demographic and clinical eligibility criteria for enrollment in the DCCT.

INTERVENTIONS

Conventional vs intensive diabetes management.

RESULTS

Approximately 120 000 persons with IDDM in the United States meet DCCT eligibility criteria. Implementing intensive rather than conventional therapy in this population would result in a gain of 920 000 years of sight, 691 000 years free from end-stage renal disease, 678 000 years free from lower extremity amputation, and 611 000 years of life at an additional cost of $4.0 billion over the lifetime of the population. The incremental cost per year of life gained is $28 661.

CONCLUSIONS

Over a lifetime, DCCT-defined intensive therapy reduces complications, improves quality of life, and can be expected to increase length of life. From a health care system perspective, intensive therapy is well within the range of cost-effectiveness considered to represent a good value.

[Cost effectiveness and evaluation of a structured therapy and education program for insulin-treated type II diabetic patients in Bradenburg]

The aim of the study was to evaluate the practicability and efficacy of a structured treatment and teaching programme (STTP) for Type II diabetic outpatients on conventional insulin treatment after introducing a remuneration for physicians. Reimbursement policy was introduced in the state of Brandenburg, Germany, in July 1993. Between August 1993 and February 1994, 108 practices in Brandenburg participated in a postgraduate seminar, which is a prerequisite for remuneration. Within the first year 10% of the target group of physicians participated in the seminars. A standardised interview was performed with 103 physicians. Twenty of the practices who had performed STTP were visited in order to collect data on all the patients who had participated in the programme. The seminar and the programme were well accepted. An improvement of HbA1c levels was observed in patients (n = 54) who had started insulin treatment (9.7 +/- 1.6% of total Hb before, 8.2 +/- 1.3% of total Hb after the programme) and in those (n = 189) who were already being treated with insulin before the STTP (9.6 +/- 2.5% of total Hb before, 8.1 +/- 1.4% of total Hb after the programme). The results of the study demonstrate the efficacy and practicability of an STTP for Type II diabetic patients on conventional insulin therapy in ambulatory health care.

Pharmacologic treatment options for non-insulin-dependent diabetes mellitus

Non-insulin-dependent diabetes mellitus (NIDDM) is a major health concern for clinicians who are responsible for the care of an aging population. The relationship between hyperglycemia and the chronic complications of retinopathy, nephropathy, and neuropathy has been established in patients with insulin-dependent diabetes mellitus, and it is extremely likely that such a relationship exists in patients with NIDDM as well. Diet and exercise are the cornerstone for the management of NIDDM. The assessment of glycemic control should determine which patients with NIDDM need more aggressive intervention to control hyperglycemia. Pharmacologic treatment options include oral administration of the sulfonylureas, a biguanide, and an alpha-glucosidase inhibitor and subcutaneous administration of insulin. Extensive education about diabetes and self-monitoring of blood glucose levels are important components in maximizing glycemic control. Additional pharmacologic treatment options are necessary when adequate individualized treatment goals are not attained. The goal of therapy is to prevent the onset or progression of long-term microvascular and macrovascular complications. In this review, we present the therapeutic options and outline our approach to the pharmacologic treatment of NIDDM. Relevant medical literature on each treatment modality is reviewed, and the cost of therapy with use of each medication is provided.

[Drug consumption in diabetes mellitus (V). Pharmacoeconomics and the acceptance of the hospital changeover to insulin U100. Group for the Study of Diabetes in Tarragona]

BACKGROUND

The U100 insulin (100 units [U]/ml) in only used in a minority of Spanish hospitals and is not ordinarily evaluated. To study the convenience of converting from U40 (40 U/ml) to U100 insulin in a first level hospital, the procedure, costs and professional acceptance were analyzed after one year of experience.

SUBJECTS AND METHODS

The chronology and the transfer method are described making an interannual pharmacoeconomical comparison of costs U40/U100 based on insulin intake and injection material. The primary source of information was the computerized base of admission, pharmacy and supply. The secondary source included the obligatory registries of daily medicine sheets. Nursing staff acceptance of the new system (preloaded U100 syringes) was analyzed with a predesigned quantitative scale questionnaire.

RESULTS

In the U40 phase, 69,600 U and 8,260 syringes were used to satisfy 136 diabetics at a mean prescription of 21 U/day for 10.9 days. In the U100 phase, 92,100 U and 1,682 syringes were used for 132 admissions with a mean dose of 20 U during 8.6 days. The insulin prescribed and injected was 45.5% and 24.7%, respectively with the consumption of non injected insulin in the center being 20.8%. On taking only the fraction injected into consideration, the mean daily cost per complete treatment was lower in U100 (116/84 and 1,368/809 pesetas; p < 0.0001) representing 0.53% (U40) and 0.36% (U100) of hospital stay costs. The total cost increased by 44 ptas./patient/day during the first year of conversion. Each section of the 67 questionnaires evaluated scored from 4 (greatest acceptance) to 20 (lowest acceptance). The general mean was 6.8 +/- 1.6 with no significant differences between the section of management/manipulation of U100 devices (6.7 +/- 2.1), learning and protocol (7.3 +/- 2.6) and patient education (6.5 +/- 1.8; p = 0.07, NS).

CONCLUSIONS

Current hospital conversion to U100 insulin requires the use of mechanized injection systems which represent a slight extra cost of scarce social relevance and are greatly accepted by users if adequate transfer procedures are applied.

Analysis of direct cost of standard compared with intensive insulin treatment of insulin-dependent diabetes mellitus and cost of complications

Insulin-dependent diabetes mellitus (type 1) is accompanied by long-term complications: retinopathy, nephropathy, neuropathy, as well as macrovascular complications. We compared the direct cost of standard insulin treatment in type 1 patients with that of intensified treatment as well as the direct cost of their complications during the two treatment modes for 35 years' duration of disease. According to our model calculations, the direct cost of basic intensified insulin treatment is $3300 per year, about three times more than that of the standard insulin treatment. However, for the period of 35 years, the cost of complications associated with intensified insulin treatment is lower, while the total cost of intensified treatment, over 35 years, is higher than that of the standard treatment. Thus, looking from the health provider point of view and relating only to economic analysis, intensified insulin treatment encompassing all type 1 patients is not cost-beneficial. Therefore, the decision to adopt this type of therapy should be based on the combination of medical, ethical, political, and economical principles, and applied to selected, well motivated, and prepared patient groups, in whom compliance to intensified treatment would be expected to prevent or delay the onset of complications. According to cost analysis, nephropathy is the most common and severest complication, and intensive treatment promises to be most effective in this group of patients.

Resource utilization and costs of care in the diabetes control and complications trial

OBJECTIVE

To describe in detail the resources used and costs incurred in the clinical management of patients with insulin-dependent diabetes mellitus (IDDM) in the Diabetes Control and Complications Trial (DCCT).

RESEARCH DESIGN AND METHODS

The resources used for intensive and conventional therapy and to deal with the side effects of therapy were assessed at each of the 29 DCCT clinics and summarized. Unit costs were derived from the DCCT, manufacturers, and Medicare and chosen to reflect what an item would cost to a single-payer national health system. Costs were calculated as the product of resources used and unit costs. The costs of the research component of the DCCT were not included.

RESULTS

In the DCCT, the annual cost of intensive therapy ($4,000 and $5,800/year for multiple daily injections and continuous subcutaneous insulin infusion, respectively) was approximately three times the cost of conventional therapy ($1,700/year). A large portion of the difference in cost was related to the greater frequency of outpatient visits and the greater resources used in self-care.

CONCLUSIONS

DCCT intensive therapy is more expensive than conventional therapy, but it offers the hope of cost savings as a result of averted complications.

[Diabetes and pharmacoeconomics. Efficiency of insulin injection methods available in Spain]

OBJECTIVES

In Spain today there are three ways of injecting insulin, the traditional syringe (TS) and two automatic methods: injector pens (IP) and preloaded syringes (PS). The main aim of the study was to compare their efficiency in normal use; and the second, to compare their effectiveness in terms of how they suited the clinical profile and needs of the users.

DESIGN

A pharmacoeconomical study to minimise costs.

SETTING

Two Primary Care clinics, one specialising in diabetes and the other not, and a third clinic, part of hospital out-patients.

PATIENTS AND OTHER PARTICIPANTS

Systematic examination of the insulin packages and the material used by 108 diabetics (3 groups of 36, divided by the method of injection) over an average period of 51 days.

MEASUREMENTS AND MAIN RESULTS

The average dose prescribed was 34.7 units (U) per day, supplied in 2.2 injections per day. The real average dose consumed was 41.4 U per day with an average daily loss of 3.1 U per injection and average re-use of needles at 7.1 times per patient. Type 11 diabetics, older patients and those with worse eye sight used TS more often. Younger and Type 1 diabetics and those who needed more injections generally used an automatic method, in particular IP. PS seemed to be used by both types of diabetic indifferently. There were significant differences found between users of TS, IP and PS regarding the doses taken (44.6, 45.1 and 34.5 U; p < 0.03), the daily loss per injection (4.5, 3.2 and 1.4 U; (p < 0.0004) and in the re-use of needles (4.1, 7.7 and 8.1 times; p < 0.02).

CONCLUSION

If we suppose similar efficacy, automatic systems are more efficient in reality than traditional syringes and insulin vials.