Cost-effectiveness of biphasic insulin aspart versus insulin glargine in patients with type 2 diabetes in China

BACKGROUND

The OnceMix and INITIATE studies have indicated that biphasic insulin aspart 30 (BIAsp 30) is more effective than insulin glargine (IGlarg), in terms of glycohemoglobin reductions, in patients with type 2 diabetes initiating insulin therapy. The cost-effectiveness of BIAsp 30 versus IGlarg in the Chinese setting is estimated here.

METHODS

The validated and peer-reviewed CORE Diabetes Model was used. The nephropathy, retinopathy, and stroke submodels were modified to incorporate available Chinese clinical data. Diabetes complication costs were derived from hospital surveys in Beijing and Chengdu. Simulated cohorts and insulin treatment effects were based on the OnceMix study for once-daily BIAsp 30 versus IGlarg and on the INITIATE study for twice-daily BIAsp 30 versus IGlarg. Life expectancy and direct medical costs were calculated. Projections were made over 30-year time horizons, with costs and life years discounted at 3% annually. Extensive sensitivity analyses were performed, including adjustments to cardiovascular risk for Chinese ethnicity.

RESULTS

Once-daily BIAsp 30 increased life expectancy by 0.04 years (12.37 vs. 12.33 years) and reduced direct medical costs by Chinese Yuan (CNY) 59,710 per patient (CNY 229,911 vs. CNY 289,621 per patient) compared with IGlarg in the OnceMix-based analysis. Twice-daily BIAsp 30 increased life expectancy by 0.08 years (12.99 vs. 12.91 years) and reduced direct medical costs by CNY 107,349 per patient (CNY 303,142 vs. CNY 410,491 per patient) compared with IGlarg in the INITIATE-based analysis. Improvements in life expectancy were driven by reduced incidences of most diabetes-related complications. Cost savings were attributable to lower lifetime insulin costs for BIAsp 30 compared with IGlarg in China. Lowered cardiovascular risk for Chinese ethnicity reduced the projected clinical improvements for BIAsp 30 but increased treatment-related lifetime cost savings.

CONCLUSIONS

BIAsp 30, either once- or twice-daily, improved projected life expectancy and reduced projected costs compared with IGlarg in the Chinese setting.

The impact of health insurance coverage on pediatric diabetes management

AIMS

To examine the association between health insurance coverage, insulin management plans, and their impact on diabetes control in a pediatric type 1 diabetes mellitus clinic population.

METHODS

Retrospective cohort design drawn from the medical records of the Pediatric Endocrinology Clinic at the University of Louisville, Kentucky.

RESULTS

Out of 701 patients, 223 had public insurance, and 478 had private insurance. 77% of publically insured used two or three injections per day vs. 40% private. Conversely, 58% of privately insured used a multiple daily injection (MDI) plan or insulin pump (vs. 21%). 84% of MDI patients had private insurance with 93% using insulin pens compared with 38% of publically insured. Mean HbA1c was 8.6% for privately insured vs. 9.8% public, p<0.0001. Privately insured MDI and pump patients had the lowest HbA1cs.

CONCLUSIONS

Insurance type had a significant effect on the insulin management plan used and was the most significant factor in overall diabetes control. Limitations on insulin pen use and number of glucose test strips may play a role in the decreased use of MDI/insulin pumps by publicly insured patients. Addressing factors related to insurance type, including availability of resources, could substantially improve diabetes control in those with public insurance.

Direct healthcare costs of patients with type 2 diabetes using long-acting insulin analogues or NPH insulin in a basal insulin-only regimen

AIMS

To compare direct healthcare costs incurred by patients with type 2 diabetes in Denmark prescribed long-acting insulin analogues (LAIA) or intermediate-acting human insulin (NPH) in a basal-only regimen.

METHODS

Demographic and socio-economic patient characteristics, hospital utilisation data, primary care visits, specialist physician visits and prescription data were extracted from registers covering the Danish population. Patients receiving basal insulin were identified during a 1-year inclusion period (2005) and allocated to a LAIA (n=303) or NPH group (n=8523). LAIA patients were then matched with NPH patients using propensity scores based on observable covariates. Annual direct healthcare costs were determined during a <2-year analysis period (2005-2006).

RESULTS

Direct healthcare costs, including prescription costs, were equivalent between groups. However, while most cost items were similar between groups, ambulatory visit costs were significantly lower in LAIA-treated patients (p=0.03), whereas insulin pharmacy costs were significantly lower in NPH-treated patients (p<0.001).

CONCLUSION

There was no difference in direct healthcare costs between patients using LAIAs or NPH insulin.

A randomized study comparing IGL-1 to the University of Wisconsin preservation solution in liver transplantation

BACKGROUND

Institut Georges Lopez-1 (IGL-1) is a new preservation solution with lower potassium and lower viscosity than University Wisconsin solution (UW). These characteristics which improve liver preservation lead us to evaluate clinical effects of IGL-1 in a randomized controlled study with UW.

MATERIAL/METHODS

From June 2007 to July 2009, after exclusion of partial graft, combined transplantation and fulminant hepatic failure, 140 deceased donor allografts were randomly assigned to IGL-1 (n=48) or UW (n=92) solution. Variables concerning donors and recipients were collected including liver tests (total serum bilirubin, prothrombin time and transaminases) were analyzed until postoperative day 30. Incidences of hepatic artery thrombosis (HAT), primary non function (PNF) and biliary non anastomotic strictures (NAS) were analyzed. The comparative analysis of costs was realized.

RESULTS

Donor and recipients characteristics were similar in both groups. Volume of preservation solution utilized for harvesting was identical. Duration of cold ischemia (472±142 vs. 477±122 min), surgery (427±97 vs. 437±94 min) and proportion of extended criteria donor was similar. Postoperative kinetic and level liver tests were similar. Rate of PNF (2% vs. 4%), early retransplantation (6% vs. 7%), incidence of biliary NAS (2% vs. 3%) and HAT (6% vs. 4%) were similar. Mean intensive care unit (ICU) stay was similar (5.6 vs. 6.1 days). However costs related to preservation solution for one liver procurement were 992.0 for IGL-1 vs. 1609.0 Euros for UW.

CONCLUSIONS

Results of this randomized study shows that the efficacy and safety of IGL-1 are comparable to those of the reference UW with a lower cost.

A clinical and health economic review of a prefilled insulin pen

OBJECTIVE

Several different durable or disposable insulin pen delivery devices are currently available, and newer, improved devices are being introduced. One prefilled insulin device, FlexPen (FP), has recently been improved (known as the Next Generation FlexPen (NGFP) in Europe or the improved FlexPen in the United States). The aim of this review is to summarize the clinical and health economic data of FP and its modified version.

METHODS

Relevant clinical and health economic terms relating to insulin pens were used to search Medline for studies and other publications involving FP and NGFP.

RESULTS

Sixteen publications investigating FP and/or the NGFP were identified. Patients prefer FP and are more confident with its use in comparison to vial/syringe insulin administration: in a study of 105 patients with type 1 or type 2 diabetes, 85% of patients found FP to be more discreet for use in public than a syringe, 74% of patients found FP to be easier to use overall and 82% of patients had more confidence with setting the correct dose with FP. Four publications investigated the dosing accuracy of FP or NGFP: all studies found the study doses for both were within ISO-specified limits. Pharmacoeconomic issues with insulin pen devices were identified in four papers, and switching to FP from vial/syringe was found to increase treatment adherence from 59% to 68% (p < 0.01), as measured by medication possession ratio. Switching to FP is also a cost-effective option for patients. Mean all-cause annual treatment (-$1748/patient, p < 0.01), hypoglycaemia-attributable costs (-$908/patient, p < 0.01), and other diabetes-attributable costs (-$643/patient, p < 0.01) were reduced following the switch from vial/syringe.

CONCLUSIONS

Some limitations of traditional insulin administration devices can be overcome with insulin pen devices. FP is a prefilled disposable pen that has been modified to further improve characteristics beneficial to patient insulin administration.

Cost comparison of insulin glargine with insulin detemir in a basal-bolus regime with mealtime insulin aspart in type 2 diabetes in Germany

OBJECTIVE

To compare the treatment costs of insulin glargine (IG; Lantus) to detemir (ID; Levemir), both combined with bolus insulin aspart (NovoRapid) in type 2 diabetes (T2D) in Germany.

METHODS

Cost comparison was based on data of a 1-year randomised controlled trial. IG was administered once daily and ID once (57% of patients) or twice daily (43%) according to treatment response. At the end of the trial, mean daily basal insulin doses were 0.59 U/kg (IG) and 0.82 U/kg (ID). Aspart doses were 0.32 U/kg (IG) and 0.36 U/kg (ID). Costs were calculated from the German statutory health insurance (SHI) perspective using official 2008 prices. Sensitivity analyses were performed to test robustness of the results.

RESULTS

Annual basal and bolus insulin costs per patient were euro 1,473 (IG) and euro 1,940 (ID). The cost of lancets and blood glucose test strips were euro 1,125 (IG) and euro 1,286 (ID). Annual costs for needles were euro 393 (IG) and euro 449 (ID). The total annual cost per patient of administering IG was euro 2,991 compared with euro 3,675 for ID, translating into a 19% annual cost difference of euro 684/patient. Base case results were robust to varying assumptions for insulin dose, insulin price, change in weight and proportion of ID once daily administrations.

CONCLUSION

IG and ID basal-bolus regimes have comparative safety and efficacy, based on the Hollander study, IG however may represent a significantly more cost saving option for T2D patients in Germany requiring basal-bolus insulin analogue therapy with potential annual cost savings of euro 684/patient compared to ID.

Health economics and compliance of vials/syringes versus pen devices: a review of the evidence

BACKGROUND

The goal of this review was to assess the state of the published literature on health economics and compliance of vials/syringes versus pen devices.

METHODS

A literature search was performed using the Embase search engine for publications that linked drug terms (insulin and insulin lispro) to disease terms (insulin-dependent diabetes mellitus, non-insulin-dependent diabetes mellitus) and other terms (accuracy, article, clinical trial, controlled clinical trial, controlled study, cost benefit analysis, drug delivery system, drug dosage form, drug dosage form comparison, drug dose comparison, drug preference, equipment design, force, glycemic control, healthcare cost, human, insulin treatment, needle, patient attitude, patient compliance, patient safety, torque) along with author keywords (Diabetes, Dose accuracy, FlexPen [Novo Nordisk, Bagsvaerd, Denmark], Insulin, Next Generation FlexPen).

RESULTS

The search yielded 39 articles, of which five articles met our study criteria. The focus of the critical outcomes was patient adherence to insulin pen devices versus insulin vials (syringes), hypoglycemic events, emergency department visits due to hypoglycemic events, and costs associated with diabetes and health care. The observation period, mean age of patients, and data sources differed across the studies. The studies indicated that there was an improved adherence with insulin pen devices as opposed to insulin vials (syringes) and that the associated healthcare resource utilization and costs associated with them were found to decrease with the use of pen devices, compared to vials.

CONCLUSIONS

The use of pen devices improves the health economics benefits and adherence to insulin therapy.

Analysis of health utility data when some subjects attain the upper bound of 1: are Tobit and CLAD models appropriate?

BACKGROUND

Health utility data often show an apparent truncation effect, where a proportion of individuals achieve the upper bound of 1. The Tobit model and censored least absolute deviations (CLAD) have both been used as analytic solutions to this apparent truncation effect. These models assume that the observed utilities are censored at 1, and hence that the true utility can be greater than 1.We aimed to examine whether the Tobit and CLAD models yielded acceptable results when this censoring assumption was not appropriate.

METHODS

Using health utility (captured through EQ5D) data from a diabetes study, we conducted a simulation to compare the performance of the Tobit, CLAD, ordinary least squares (OLS), two-part and latent class estimators in terms of their bias and estimated confidence intervals. We also illustrate the performance of semiparametric and nonparametric bootstrap methods.

RESULTS

When the true utility was conceptually bounded above at 1, the Tobit and CLAD estimators were both biased. The OLS estimator was asymptotically unbiased and, while the model-based and semiparametric bootstrap confidence intervals were too narrow, confidence intervals based on the robust standard errors or the nonparametric bootstrap were acceptable for sample sizes of 100 and larger. Two-part and latent class models also yielded unbiased estimates.

CONCLUSIONS

When the intention of the analysis is to inform an economic evaluation, and the utilities should be bounded above at 1, CLAD, and Tobit methods were biased. OLS coupled with robust standard errors or the nonparametric bootstrap is recommended as a simple and valid approach.

Systematic review of the cost-effectiveness of biphasic insulin aspart 30 in type 2 diabetes

OBJECTIVES

To review the cost-effectiveness of biphasic insulin aspart (BIAsp 30) compared to other insulin regimens in the treatment of type 2 diabetes based on published literature.

METHODS

The electronic databases MEDLINE, EMBASE, the Cochrane Library and EconLit and a selection of congress/meeting databases were systematically searched using combinations of search terms designed to identify publications describing cost-effectiveness analyses of BIAsp 30 in patients with type 2 diabetes. Searches were limited to studies in humans, and published in the English language between January 1999 and July 2009. All records were screened for inclusion in the review.

RESULTS

Seven published cost-effectiveness analyses and ten abstracts were identified. One was a health technology assessment from the UK, which evaluated cost-effectiveness using the UKPDS Outcomes Model and meta-analysis of published clinical trials and concluded that premixed insulin analogs were unlikely to be cost-effective versus insulin glargine or biphasic human insulin. In all other studies the cost-effectiveness of BIAsp 30 versus other insulin regimens was assessed using the validated CORE Diabetes Model and outcomes from either the INITIATE randomized controlled trial, or the PRESENT or IMPROVE observational studies. However, notable limitations include the fact that all cost-effectiveness analyses to date have been performed using a single model and that a number of these are based on data from observational studies rather than randomized controlled trials. Nevertheless, long-term clinical and economic outcomes were reported for several countries: UK, US, Sweden, Saudi Arabia, Poland, South Africa, South Korea and China. BIAsp 30 was associated with improvements in quality-adjusted life expectancy in all countries. Estimates of direct costs varied according to country and comparator, but incremental cost-effectiveness ratios for the US and UK were USD 46 533 and GBP 6951 per quality-adjusted life year gained for BIAsp 30 versus insulin glargine.

CONCLUSIONS

Although cost-effectiveness data on BIAsp 30 are scarce the majority of the analyses identified in this review suggest that BIAsp 30 is likely to be cost-effective compared to insulin glargine and biphasic human insulin across a wide range of settings, and under certain circumstances would be a dominant treatment option.

Reusable and disposable insulin pens for the treatment of diabetes: understanding the global differences in user preference and an evaluation of inpatient insulin pen use

Insulin is essential for the management of type 1 diabetes and is more commonly being used for the treatment of type 2 diabetes. Insulin pen devices were first introduced over 20 years ago and have evolved to provide significant practical advantages compared with the vial and syringe. Pen devices are now used by patients with diabetes worldwide, but there are marked geographical variations in the use of reusable and disposable pens. In some countries the vial and syringe is still the most popular method of administering insulin, whereas in other countries the use of reusable or disposable pens is more prevalent. Therefore, the aim of this review is to discuss the factors that seem to be involved in these differences, which include patient access to insulin, cost, and physician/patient awareness and preference. Inpatient use of insulin is also common, and the use of insulin pens could offer substantial benefits in this patient population, not only during the admission period but also after discharge from the hospital. However, the evidence base for inpatient use is still weak, and more studies are needed to investigate the use of insulin pens in this patient population.

Evolution of diabetes insulin delivery devices

The first manufactured insulin pump was introduced in the 1970s and the first insulin pens in 1985; since then, many improvements have been made to both devices. The advantages of pens over syringes have been confirmed in numerous studies and include greater accuracy, ease of use, patient satisfaction, quality of life, and adherence. United States claims database analyses indicate that the improved adherence made possible by use of an insulin pen has the potential to reduce diabetes care costs when compared with using a vial and syringe. Features of certain advanced pump models include the ability to connect wirelessly to a blood glucose meter or to a subcutaneous interstitial glucose sensor for semicontinuous glucose-driven insulin rate adjustment. A new trend in the design of insulin pumps is the tubing-free patch pump that adheres directly to the skin. The low rate of insulin pen usage in the United States compared with European countries and the fact that many patients report that they are not offered the option of an insulin pen by their physician suggest that there is a need to increase patient and provider awareness of the currently available devices for insulin administration.

Healthcare utilization changes in relation to treatment intensification with insulin aspart in patients with type 2 diabetes. Data from a large US managed-care organization

OBJECTIVE

Most patients with type 2 diabetes eventually require exogenous insulin therapy to achieve good glycemic control due to the progressive nature of the disease. Insulin aspart is a rapid-acting insulin analog developed for prandial use. This study aimed to illustrate the implications on healthcare costs of adding insulin aspart to basal therapy in a real-world setting.

METHODS

Patients with type 2 diabetes who intensified previous basal therapy with insulin aspart were identified from a large commercial US healthcare data source between April 2007 and September 2008. Patients were required to have received basal insulin treatment with or without concomitant oral antidiabetic (OAD) therapy for at least 90 days pre- and post-initiation of insulin aspart. Wilcoxon signed-rank test and McNemar's test were used for continuous and categorical variables, respectively, to analyze the difference of self-comparison between pre- and post insulin aspart add-on.

RESULTS

In total, 1,739 patients with an average age of 56 years were identified, of whom 55% were male. After initiation of insulin aspart, a significant improvement in glycemic control was observed (change in HbA(1c): -0.5%, p=0.0013). Similarly, a reduction of 0.4% in HbA(1c) was observed for the subpopulation of 151 patients, who had both pre-and post-index HbA(1c) data (p=0.0085). Also, significantly fewer patients used OADs after insulin aspart initiation (56 vs. 64%, p< 0.0001). Overall and diabetes-related healthcare costs also significantly decreased by $2,283 and $2,028, respectively (p≤ 0.0001). Diabetes-related inpatient visits appear to be the main contributor to total cost (46%); however, after initiation of insulin aspart the number of inpatient visits decreased by 0.50 visits/patient/year (p< 0.05). This decrease was reflected in a large reduction in cost related to inpatient visits ($3,019/patient).

LIMITATIONS

A regression to the mean effect may be associated with this pre-post comparison. The ability to make conclusions regarding cause and effect may be limited due to the retrospective design of this study.

CONCLUSIONS

Patients with type 2 diabetes achieved better glycemic control and needed less OAD treatment after adding insulin aspart to previous basal therapy. Furthermore, patients experienced on average reduced healthcare utilization after initiation of insulin aspart, which resulted in significant cost savings.

Cost effectiveness of insulin glargine plus oral antidiabetes drugs compared with premixed insulin alone in patients with type 2 diabetes mellitus in Canada

BACKGROUND

Several treatment options are available for patients with type 2 diabetes mellitus who are making the transition from oral antidiabetes drugs (OADs) to insulin. Two options currently recommended by the Canadian Diabetes Association for initiating insulin therapy in patients with type 2 diabetes who are no longer responsive to OADs alone are insulin glargine plus OADs, and premixed insulin therapy only. Because of differences in efficacy, adverse events (such as hypoglycaemia) and acquisition costs, these two treatment options may lead to different long-term clinical and economic outcomes.

OBJECTIVE

To determine the cost effectiveness of insulin glargine plus OADs compared with premixed insulin without OADs in insulin-naive patients with type 2 diabetes in Canada.

METHODS

Using treatment effects taken from a published clinical trial, the validated IMS-CORE Diabetes Model was used to simulate the long-term cost effectiveness of insulin glargine with OADs, versus premixed insulin. Input treatment effects for the two therapeutic approaches were based on changes in glycosylated haemoglobin A(1c) (HbA(1c)) at clinical trial endpoint, and hypoglycaemia rates. The analysis was conducted from the perspective of the Canadian Provincial payer. Direct treatment and complication costs were obtained from published sources (primarily from Ontario) and reported in $Can, year 2008 values. All base-case costs and outcomes were discounted at 5% per year. Sensitivity analyses were conducted around key parameters and assumptions used in the study. Outcomes included direct medical costs associated with both treatment and diabetes-related complications. Cost-effectiveness outcomes included total average lifetime (35 years) costs, life expectancy (LE), QALYs and incremental cost-effectiveness ratios (ICERs).

RESULTS

Base-case analyses showed that, compared with premixed insulin only, insulin glargine in combination with OADs was associated with a 0.051-year increase in LE and a 0.043 increase in QALYs. Insulin glargine plus OADs showed a very slight increase in total direct costs ($Can 343 +/- 2572), resulting in ICERs of $Can 6750 per life-year gained (LYG) and $Can 7923 per QALY gained. However, considerable uncertainty around the ICERs was demonstrated by insulin glargine having a 50% probability of being cost effective at a willingness-to-pay threshold of $Can 10,000 per QALY, and a 54% probability at a $Can 20,000 threshold. Base-case results were most sensitive to assumed disutilities for hypoglycaemic events, to the assumed effect of insulin glargine plus OADs on HbA(1c), and to its assumed acquisition costs.

CONCLUSIONS

These findings should be interpreted within the context of a large degree of uncertainty and of several study limitations that include a single clinical trial as the source for primary treatment assumptions and a single province as the source for most cost inputs. Under current study assumptions and limitations, insulin glargine plus OADs was projected to be a cost-effective option, compared with premixed insulin only, for the treatment of insulin-naive patients with type 2 diabetes unresponsive to OADs. Additional work is needed to examine the generalizability of the findings to individual jurisdictions of the Canadian healthcare system.

Resource utilization with insulin pump therapy for type 2 diabetes mellitus

OBJECTIVES

To evaluate the effects of switching from multiple daily injection (MDI) therapy to insulin pump therapy, also called continuous subcutaneous insulin infusion (CSII), on antidiabetic drug and healthcare resource utilization.

STUDY DESIGN

This study was a retrospective analysis of administrative claims data from a large geographically diverse health plan in the United States from January 1, 2005, through April 30, 2008.

METHODS

Changes in antidiabetic drug use, antidiabetic drug switching and augmentation, and healthcare utilization during the baseline period and after CSII initiation were assessed using paired t test.

RESULTS

There were 3649 possible subjects, of whom 943 met the criteria for analysis. The mean number of antidiabetic drugs used decreased by 46% after CSII initiation, and the mean reduction in antidiabetic drug utilization was 0.67; both were statistically significant. More than one-third of subjects who were taking antidiabetic drugs before CSII initiation discontinued oral therapy after CSII initiation. The number of subjects using multiple antidiabetic drugs significantly decreased after CSII initiation by 58%, and rates of switching or augmenting significantly decreased from 42% at baseline to 25% after CSII initiation.The rates of emergency department visits and inpatient admissions significantly decreased, and the rate of ambulatory visits significantly increased.

CONCLUSIONS

CSII was associated with significant decreases in antidiabetic drug and healthcare resource utilization, contributing to stability of care. The evidence from this study indicates that CSII should be considered as an option for patients with type 2 diabetes mellitus who are using MDI and are experiencing a high degree of antidiabetic drug and healthcare resource utilization.

Direct costs associated with initiating NPH insulin versus glargine in patients with type 2 diabetes: a retrospective database analysis

AIMS

To compare total costs and risk of hypoglycemia in patients with type 2 diabetes (T2D) initiated on NPH insulin versus glargine in a real-world setting.

METHODS

This study used claims data (10/2001 to 06/2005) from a privately insured U.S. population of adult T2D patients who were initiated on NPH or glargine following a 6-month insulin-free period. A sample of 1698 glargine-treated and 400 NPH-treated patients met the inclusion criteria. Total and diabetes-related costs (inflation-adjusted to 2006) were calculated for 6-month pre- and post-index periods and compared between 400 patient pairs matched by a propensity score method.

RESULTS

In the post-index 6-month period, glargine patients incurred higher diabetes-related drug costs than NPH patients ($785 versus $632, p<0.0001) but there were no significant differences in diabetes-related medical or total costs, or all other total cost categories. Compared to the pre-index period, glargine patient costs declined by $2420 (p=0.058) whereas NPH patient costs declined by $4200 (p=0.046), with no statistically significant group differences (p=0.469). Among patients with hypoglycemia-related claims (0.75% in both groups), mean hypoglycemia-related costs were $85 and $202 for NPH and glargine patients, respectively (p=0.564).

CONCLUSION

Initiation of either NPH or glargine was associated with major cost reductions and infrequent hypoglycemia-related claims.

An economic evaluation of colesevelam when added to metformin-, insulin- or sulfonylurea-based therapies in patients with uncontrolled type 2 diabetes mellitus

BACKGROUND

Several early studies demonstrated that bile acid sequestrants were useful for lowering lipid levels in patients with hypercholesterolaemia and may also be useful for lowering glucose levels in patients with type 2 diabetes mellitus (T2DM) uncontrolled on existing treatment (metformin-, insulin- or sulfonylurea-based therapies).

OBJECTIVE

This study modelled efficacy and safety data from the three clinical trials to evaluate the cost effectiveness to US Managed Care Organizations of add-on treatment with colesevelam for reducing diabetes-related complications.

METHODS

Three randomized controlled trials in patients with T2DM and one in hyperlipidaemia established that colesevelam lowered both glycaemic and lipid parameters in adult patients participating in the studies. The validated 'diabetic risk equation' (DRE) and the 'LIPID cardiovascular risk equation' (LCRE) were used to translate the observed clinical benefits (surrogate markers related to T2DM [glycosylated haemoglobin {HbA(1c)} and fasting plasma glucose] and cardiovascular disease [low-density lipoprotein cholesterol {LDL-C}]). Performing an appropriate economic evaluation required the use of both the DRE and the LCRE. These equations parameterize the clinical efficacy measures as continuous, facilitating their application to clinical trial results as well as the replication of other well established epidemiological data. Tobit regressions were applied to a large commercially available managed care administrative claims database (2000-6), Integrated Health Care Services (IHCS), to evaluate the incremental costs associated with each type of diabetic complication. Costs were inflated to 2010 values using the Healthcare Consumer Price Index, while second- and third-year cost savings were discounted at 5% to the current year. Bootstrap sampling with 5000 samples of 100 patients per cohort was conducted, varying the number of events avoided as well as their associated cost.

RESULTS

With established metformin-, insulin- or sulfonylurea-based therapies, the addition of colesevelam significantly reduced HbA(1c) by approximately 0.5% (p < 0.001) in all three studies. In addition, colesevelam reduced placebo-adjusted LDL-C by 12.8-16.7% (p < 0.001). Using the DRE and LCRE equations, the total savings from reductions in diabetes-related and cardiovascular events were $US3543, $US4074 and $US3855 for colesevelam added to metformin-, insulin- and sulfonylurea-based regimens in patients with normal lipid levels. After subtracting the cost of colesevelam, first-year savings were $US1326, $US1852 and $US1629 in the metformin, insulin and sulfonylurea studies, respectively, for patients with raised lipid levels.

CONCLUSIONS

In adult patients with T2DM, the addition of colesevelam to metformin-, insulin- or sulfonylurea-based therapies significantly improves glycaemic control while also reducing LDL-C, and these improvements could translate into substantial cost reductions due to reductions in the rates of diabetes-related and cardiovascular complications.

Cost-effectiveness of switching to biphasic insulin aspart from human premix insulin in a US setting

OBJECTIVES

To evaluate the cost-effectiveness of switching to biphasic insulin aspart (BIAsp 30) from human premix insulin for type 2 diabetes patients in the United States (US) setting.

METHODS

The previously published and validated IMS Core Diabetes Model was used to project life expectancy, quality-adjusted life expectancy (QALE) and costs over 30 years. Patient characteristics and treatment effects were based on Canadian patients included the IMPROVE observational study (n = 311). Mean glycohaemoglobin (HbA(1c)) was 8.4%, duration of diabetes 16 years and prevalence of complications high at baseline. Simulations were conducted from the perspective of a third-party payer, with costs accounted in 2008 US dollars ($).

RESULTS

BIAsp 30 was projected to improve life expectancy by 0.202 years and QALE by 0.301 quality-adjusted life-years (QALYs), due to a reduced incidence of most diabetes-related complications. BIAsp 30 was associated with increased lifetime direct medical costs ($76,517 vs. 67,518) and an incremental cost-effectiveness ratio of $29,870 per QALY gained. Long-term outcomes were sensitive to the impact of BIAsp 30 on hypoglycaemia and changes in HbA(1c).

CONCLUSIONS

BIAsp 30 may represent a cost-effective treatment option in the US setting for advanced type 2 diabetes patients experiencing poor glycaemic control or hypoglycaemia on human premix insulin.

LIMITATIONS

The application of treatment effect data derived from a Canadian cohort to the US setting was a limitation of the cost-effectiveness analysis. The findings of this cost-effectiveness analysis are not applicable to insulin-naïve diabetes patients.

Part D coverage gap and adherence to diabetes medications

OBJECTIVE

To evaluate the impact of Medicare Part D coverage gap (donut hole) on adherence to diabetes medications.

STUDY DESIGN

Retrospective cohort analysis based on pharmacy claims data.

METHODS

The sample included 12,881 Medicare Part D beneficiaries with diabetes who entered the coverage gap in 2008. Sample patients had 3 different levels of coverage in the donut hole: no coverage, generic drug coverage only, and both generic and brand-name drug coverage. Adherence was measured by the proportion of days covered. We used a difference-in-difference model to evaluate the effect of coverage gap on adherence.

RESULTS

In the donut hole, the average copayment for diabetes medications increased substantially for beneficiaries with no coverage and beneficiaries with generic drug coverage only, whereas the average copayment for beneficiaries with both generic and brand-name medication coverage declined slightly. Compared with beneficiaries with full coverage of both generic and brand-name drugs, beneficiaries with no coverage (odds ratio[OR] = 0.617, P <.0001, 95% confidence interval [CI] = 0.523, 0.728) and beneficiaries with generic drug coverage only (OR = 0.702, P <.0001, 95% CI = 0.604, 0.816) were significantly less likely to be adherent after entering the donut hole. The difference between having generic coverage and no coverage was not significant (P = .1586).

CONCLUSIONS

The coverage gap in the Medicare Part D program has a significant negative impact on medication adherence among beneficiaries with diabetes. Availability of brand-name drug coverage in the donut hole is critical to adherence to diabetes medications.

Evaluation of exenatide vs. insulin glargine in type 2 diabetes: cost-effectiveness analysis in the German setting

OBJECTIVES

The objective of this analysis was to determine the cost-effectiveness of exenatide vs. insulin glargine in patients with type 2 diabetes failing to achieve glycaemic control with oral antidiabetic agents, in the German setting, from a third-party payer perspective.

METHODS

Data from a published randomized controlled trial were used in combination with a published, validated computer simulation model of type 2 diabetes to project clinical and cost outcomes over a time horizon of 10 years. Cost data were obtained from published literature and expert opinion. Clinical and cost outcomes were discounted at 5% per annum. Sensitivity analyses were performed to establish key drivers and parameters.

RESULTS

Treatment with exenatide compared with insulin glargine was projected to be associated with improvements in life expectancy of 0.016 years and quality-adjusted life expectancy of 0.280 quality-adjusted life years (QALYs), increased lifetime direct medical costs of euro 3854 (euro 22 095 vs. euro 18 242) and an incremental cost-effectiveness ratio (ICER) of euro 13 746 per QALY. If quality of life was not taken into account, exenatide was associated with an ICER of euro 238 201 per life year gained vs. insulin glargine. Sensitivity analyses revealed that outcomes were most sensitive to changes in assumptions for (dis)utility values relating to weight change and the rate of self-monitored blood glucose testing.

CONCLUSIONS

Exenatide was projected to be associated with similar clinical outcomes and increased costs compared with insulin glargine. Analysis of cost-effectiveness from a third-party perspective suggests that exenatide is likely to represent good value for money in the German setting.

Treatment satisfaction and quality of life for an integrated continuous glucose monitoring/insulin pump system compared to self-monitoring plus an insulin pump

BACKGROUND

Little is known about how the most advanced technology affects treatment satisfaction and health-related quality of life (HRQOL) in adults with diabetes. This study was designed to assess treatment satisfaction and HRQOL among users of an integrated real-time (RT) continuous glucose monitoring (CGM)/continuous subcutaneous insulin infusion (CSII) system compared with those using self-monitoring of blood glucose (SMBG) with CSII.

METHODS

Participants were 311 adult respondents to an Internet survey, 162 using RT-CGM/CSII, 149 using SMBG + CSII (median age 43 years; type 1 diabetes 94%; diabetes duration >15 years 61%; median insulin use 15 years). Respondents completed instruments assessing glucose monitoring system and insulin delivery system convenience, interference, burden, glucose control efficacy, cost satisfaction, overall satisfaction, and treatment preference, as well as quality of life (diabetes-related worries, social burden, and psychological well-being). Real-time CGM/CSII users also assessed specific elements of the RT-CGM/CSII system. Group differences were assessed using analysis of covariance controlling for respondent characteristics.

RESULTS

The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their glucose monitoring system's glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend, and significantly worse ratings for interference with daily activities. The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their insulin delivery system's convenience and glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend. Real-time CGM/CSII users gave positive ratings of all system features.

CONCLUSIONS

Users of the integrated RT-CGM/CSII system reported more benefits of treatment, higher treatment satisfaction and quality of life, and greater preference for this system than SMBG + CSII users.

The business of intensive insulin therapy for type 2 diabetes patients: where it all began for me

Ideally, it would be easy for physicians with Diabetes Control and Complications Trial data in hand to convince type 2 diabetes mellitus (T2DM) patients on insulin to move toward intensive insulin therapy (IIT), but in actuality, patient compliance remains a significant issue. One of the statistics that best illustrates this point is that 89% of T2DM patients on insulin do not inject themselves outside of the home (according to the National Health and Nutrition Examination Survey). The market has responded to poor compliance by developing insulin pens and different insulin formulations to improve compliance. But the fact remains that most T2DM patients on insulin are out of control. I would suggest that, in addition to better education, an opportunity exists for a medical device approach to better facilitate an easy-to-use, discreet approach to moving from conventional to IIT.

Cost-effectiveness of switching to biphasic insulin aspart 30 from human insulin in patients with poorly controlled type 2 diabetes in South Korea

OBJECTIVES

To estimate the cost-effectiveness of switching patients with poorly controlled type 2 diabetes mellitus from human insulin (HI) to biphasic insulin aspart 30 (BIAsp 30) in South Korea.

METHODS

A published and validated diabetes computer simulation model (the IMS CORE Diabetes Model) was used to evaluate the long-term clinical and economic outcomes associated with switching to BIAsp 30, using treatment effects from the South Korean subgroup of the Physician's Routine Evaluation of Safety and Efficacy of NovoMix 30 Therapy study and cost data collected through primary research. Outcomes included life expectancy, quality-adjusted life expectancy, incidence of complications, direct medical costs, and cost-effectiveness. Analyses were performed from a third-party payer perspective over a 30-year time horizon. Future costs and clinical benefits were discounted at 5% per annum. Extensive sensitivity analyses were performed.

RESULTS

Switching patients uncontrolled on HI to BIAsp 30 was projected to increase discounted mean life expectancy by 0.15 +/- 0.18 years per patient (8.62 +/- 0.13 years vs. 8.47 +/- 0.13 years) and improve discounted mean quality-adjusted life expectancy by 0.30 +/- 0.12 quality-adjusted life-years (QALYs) per patient (5.68 +/- 0.09 QALYs vs. 5.38 +/- 0.09 QALYs). Conversion to BIAsp 30 was associated with a mean increase in direct costs of South Korean Won (KRW) 1,777,323 +/- 359,209 over patient lifetimes. BIAsp 30 was associated with an incremental cost-effectiveness ratio of KRW5,916,758 per QALY gained versus HI.

CONCLUSION

Switching patients uncontrolled on HI to BIAsp 30 was projected to improve life expectancy and quality-adjusted life expectancy. This analysis suggests that BIAsp 30 could be a cost-effective treatment option in type 2 diabetes patients poorly controlled on HI in South Korea.

Glycemic control in the medical intensive care unit

Hyperglycemia in the critically ill is a well-known phenomenon, even in those without known diabetes. The stress response is due to a complex interplay between counter-regulatory hormones, cytokines, and changes in insulin sensitivity. Illness/infection, overfeeding, medications (e.g., corticosteroids), insufficient insulin, and/or volume depletion can be additional contributors. Acute hyperglycemia can adversely affect fluid balance (through glycosuria and dehydration), immune and endothelial function, inflammation, and outcome. While there are several insulin infusion protocols that are able to safely and effectively treat hyperglycemia, the bulk of accumulated evidence does not support a causal relationship between acute hyperglycemia and adverse outcomes in the medical intensive care unit. Meta-analysis of randomized controlled trials suggests there is no benefit to tightening glucose control to normal levels compared to a reasonable and achievable goal of 140 to 180 mg/dl. There is a significantly increased risk of hypoglycemia. Although there is some evidence that patients without known diabetes have worse outcomes than those with known diabetes, more recent evidence is conflicting. Glycemic control in critically ill patients should not be neglected, as studies have not tested tight versus no/poor control, but tight versus good control. A moderate approach to managing critical illness hyperglycemia seems most prudent at this juncture. Future research should ascertain whether there are certain subgroups of patients that would benefit from tighter glycemic goals. It also remains to be seen if tight glucose control is beneficial once hypoglycemia is minimized with technological advances such as continuous glucose monitoring systems.

Large impact of antidiabetic drug treatment and hospitalizations on economic burden of diabetes mellitus in The Netherlands during 2000 to 2004

OBJECTIVE

To estimate the burden of diabetes mellitus (DM) and its complications in The Netherlands.

METHODS

The PHARMO Record Linkage System comprised among others linked drug dispensing, hospital and clinical laboratory data from approximately 2.5 million individuals in The Netherlands. Patients with DM (type 1 and type 2) were included in the study cohort from 2000 to 2004 if they used antidiabetic drugs or had HbA1c >or= 6.5 mmol/L or had a hospitalization for DM or a diabetic complication in the measurement year or in the preceding year. Controls, defined as subjects without a diagnosis of DM and/or subjects not prescribed glucose-lowering medication, were 1:1 matched to patients with diabetes, on birth year, zip code, and gender. Complications (hospitalizations and dispensings for cardiovascular disease/eye problems/amputations) were classified into stages. Complications attributed to DM were estimated as complication stages 1 and 2 among patients minus those among controls. Drug costs were extrapolated to The Netherlands by direct standardization.

RESULTS

Among the total population in The Netherlands, the prevalence of DM increased from 2.8% in 2000 to 4.0% in 2004. Severe cardiovascular complications attributed to DM increased from 18,000 to 39,000 patients. Per DM patient the cost of direct treatment attributed to DM increased from Euro 974 in 2000 to Euro 1283 in 2004. Per 100 members of the total population, this increase was from Euro 2764 in 2000 to Euro 5140 in 2004. Most of these costs (65% in 2004) were because of hospitalizations.

CONCLUSION

Drug treatment, hospitalizations, and cost attributed to diabetes mellitus have almost doubled between 2000 and 2004, but so did the "background" costs in the general population, perhaps because of preventive efforts.