Painful Diabetic Peripheral Neuropathy in a Managed Care Setting: Patient Identification, Prevalence Estimates, and Pharmacy Utilization Patterns

Gabapentin and Opioids Utilization in Patients With Diabetic Neuropathy Enrolled in Medicare (2012-2016): A Cohort Study

This retrospective cohort study describes the utilization of opioids and gabapentin among patients with diabetic neuropathy who were gabapentin and opioid naïve, and assesses predictors of concomitant use of opioids and gabapentin. Using Medicare claims data (2012-2016), 22 037 patients were identified, of whom 23.42% (N = 5161) initiated opioids without concomitant gabapentin, 4.56% (N = 1004) initiated gabapentin without concomitant opioids, and 3.87% (N = 852) had concomitant use of gabapentin and opioids 12 months following their index date (date of earliest diagnosis). Concomitant gabapentin and opioid use were more common for lower doses of both drugs and for 15 days or more cumulatively. Compared to individuals aged 65-74, those aged 75-84 (OR: .759; 95% CI: 0.653-.882) or ≥ 85 years (OR: .586, 95% CI: 0.462-.743) had lower odds of concomitant use. People residing in the Northeast had lower odds of concomitant use, compared to those residing in the South (OR: .646 95% CI: 0.535-.779). Females compared to males (OR: 1.185, 95% CI: 1.027-1.367), people with higher Charlson's Comorbidity Index (CCI) scores (OR: 1.085, 95% CI: 1.037-1.135) or those having anxiety (OR: 1.462, 95% CI: 1.131-1.889) had higher odds of concomitant use. Concomitant prescriptions of opioids and gabapentin were more common for longer durations, indicating the need for interventions aimed at minimizing this prescribing practice.

A clinical tool to predict severe pain during wound dressing changes

ABSTRACT

Dressing changes cause severe pain (ie, 8-10 on a 10-point scale) for approximately one-third (36%) of patients with open skin wounds. No tool exists that allows nurses to predict which patients are likely to experience severe pain during dressing changes. The aim of this study was to develop a clinical tool to predict severe pain during dressing changes using clinically accessible wound and pain predictors and to evaluate the diagnostic validity of this model. Using a cross-sectional design, a one-time study dressing change was conducted by the same wound care nurse on 445 subjects while concurrently measuring patient and wound predictors and pain intensity during the dressing change. Three predictors came out of the study as most useful for a clinical prediction tool: type of dressing, resting wound pain, and expected pain. Algorithms based on these predictors are presented, which can be applied in other settings to predict patients likely to experience severe pain during a dressing change. This is the first study to systematically examine a comprehensive set of wound and patient predictors for their individual and collective associations with pain during dressing changes using precisely defined and rigorously measured study variables. The ability to predict which patients are likely to have severe pain during dressing changes is critically needed so that they can be targeted for preventive pain control strategies.

Statins and renal disease progression, ophthalmic manifestations, and neurological manifestations in veterans with diabetes: A retrospective cohort study

Background

Statins increase insulin resistance, which may increase risk of diabetic microvascular complications. Little is known about the impact of statins on renal, ophthalmologic, and neurologic complications of diabetes in practice. The objective of this study was to examine the association of statins with renal disease progression, ophthalmic manifestations, and neurological manifestations in diabetes.

Methods

This is a retrospective cohort study, new-user active comparator design, that included a national Veterans Health Administration (VA) patients with diabetes from 2003 to 2015. Patients were age 30 years or older and were regular users of the VA with data encompassing clinical encounters, demographics, vital signs, laboratory tests, and medications. Patients were divided into statin users or nonusers (active comparators). Statin users initiated statins and nonusers initiated H2-blockers or proton pump-inhibitors (H2-PPI) as an active comparator. Study outcomes were: 1) Composite renal disease progression outcome; 2) Incident diabetes with ophthalmic manifestations; and 3) Incident diabetes with neurological manifestations.

Results

Out of 705,774 eligible patients, we propensity score matched 81,146 pairs of statin users and active comparators. Over a mean (standard deviation) of follow up duration of 4.8 (3) years, renal disease progression occurred in 9.5% of statin users vs 8.3% of nonusers (odds ratio [OR]: 1.16; 95% confidence interval [95%CI]: 1.12–1.20), incident ophthalmic manifestations in 2.7% of statin users vs 2.0% of nonusers (OR: 1.35, 95%CI:1.27–1.44), and incident neurological manifestations in 6.7% of statin users vs 5.7% of nonusers (OR: 1.19, 95%CI:1.15–1.25). Secondary, sensitivity, and post-hoc analyses were consistent and demonstrated highest risks among the healthier subgroup and those with intensive lowering of LDL-cholesterol.

Conclusions

Statin use in patients with diabetes was associated with modestly higher risk of renal disease progression, incident ophthalmic, and neurological manifestations. More research is needed to assess the overall harm/benefit balance for statins in the lower risk populations with diabetes and those who receive intensive statin therapy.

Gene therapy for diabetic peripheral neuropathy: A randomized, placebo-controlled phase III study of VM202, a plasmid DNA encoding human hepatocyte growth factor

VM202 is a plasmid DNA encoding two isoforms of hepatocyte growth factor (HGF). A previous phase II study in subjects with painful diabetic peripheral neuropathy (DPN) showed significant reductions in pain. A phase III study was conducted to evaluate the safety and efficacy of VM202 in DPN. The trial was conducted in two parts, one for 9 months (DPN 3-1) with 500 subjects (VM202: 336 subjects; and placebo: 164) and a preplanned subset of 101 subjects (VM202: 65 subjects; and placebo: 36) with a noninterventional extension to 12 months (DPN 3-1b). VM202 or placebo was administered to calf muscles on days 0 and 14, and on days 90 and 104. The primary end point in DPN 3-1 was change from baseline in the mean 24-h Numerical Rating Scale (NRS) pain score. In DPN 3-1b, the primary end point was safety, whereas the secondary efficacy end point was change in the mean pain score. VM202 was well-tolerated in both studies without significant adverse events. VM202 failed to meet its efficacy end points in DPN 3-1. In DPN 3-1b, however, VM202 showed significant and clinically meaningful pain reduction versus placebo. Pain reduction in DPN 3-1b was even greater in subjects not receiving gabapentin or pregabalin, confirming an observation noted in the phase II study. In DPN 3-1b, symptomatic relief was maintained for 8 months after the last injection suggesting that VM202 treatment might change disease progression. Despite the perplexing discrepancy between the two studies, the safety and long-lasting pain-relieving effects of VM202 observed in DPN 3-1b warrant another rigorous phase III study. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? Current therapies for painful diabetic peripheral neuropathy (DPN) are palliative and do not target the underlying mechanisms. Moreover, symptomatic relief is often limited with existing neuropathic pain drugs. Thus, there is a great medical need for safer and effective treatments for DPN. WHAT QUESTION DID THIS STUDY ADDRESS? Can nonviral gene delivery of hepatocyte growth factor reduce pain in patients with DPN and potentially modify progression of the disorder? WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? Nonviral gene therapy can be used safely and practically to treat DPN. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? As the first gene medicine to enter advanced clinical trials for the treatment of DPN, this study provides the proof of concept of an entirely new potential approach to the disorder.

Validity of Algorithms for Identification of Individuals Suffering from Chronic Noncancer Pain in Administrative Databases: A Systematic Review

BACKGROUND

Secondary analysis of health administrative databases is indispensable to enriching our understanding of health trajectories, health care utilization, and real-world risks and benefits of drugs among large populations.

OBJECTIVES

This systematic review aimed at assessing evidence about the validity of algorithms for the identification of individuals suffering from nonarthritic chronic noncancer pain (CNCP) in administrative databases.

METHODS

Studies reporting measures of diagnostic accuracy of such algorithms and published in English or French were searched in the Medline, Embase, CINAHL, AgeLine, PsycINFO, and Abstracts in Social Gerontology electronic databases without any dates of coverage restrictions up to March 1, 2018. Reference lists of included studies were also screened for additional publications.

RESULTS

Only six studies focused on commonly studied CNCP conditions and were included in the review. Some algorithms showed a ≥60% combination of sensitivity and specificity values (back pain disorders in general, fibromyalgia, low back pain, migraine, neck/back problems studied together). Only algorithms designed to identify fibromyalgia cases reached a ≥80% combination (without replication of findings in other studies/databases).

CONCLUSIONS

In summary, the present investigation informs us about the limited amount of literature available to guide and support the use of administrative databases as valid sources of data for research on CNCP. Considering the added value of such data sources, the important research gaps identified in this innovative review provide important directions for future research. The review protocol was registered with PROSPERO (CRD42018086402).

Can diabetic polyneuropathy and foot ulcers in patients with type 2 diabetes be accurately identified based on ICD-10 hospital diagnoses and drug prescriptions?

Purpose: We examined whether diabetic polyneuropathy (DPN) and diabetic foot ulcers in type 2 diabetes can be accurately identified using International Classification of Diseases, 10th revision discharge diagnosis codes, surgery codes, and drug prescription codes.

Methods: We identified all type 2 diabetes patients in the Central Denmark region, 2009–2016, who had ≥1 primary/secondary diagnosis code of “diabetes with neurological complication” (E10.4-E14.4), “diabetic polyneuropathy” (G63.2), or “polyneuropathy, unspecified” (G62.9). Patients with potential painful DPN and non-painful DPN were identified based on prescription history for serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants, or gabapentinoids. Likewise, type 2 diabetes patients with potential foot ulcers were identified based on diagnosis or surgery codes. We used medical record review as the reference standard and calculated positive predictive values (PPVs).

Results: Of 53 randomly selected patients with potential painful DPN, 38 were classified as having DPN when validated against medical records; of these, 18 also had neuropathic pain, yielding a PPV of 72% (95% CI: 58–83%) for DPN and 34% (95% CI: 22–48%) for painful DPN. Likewise, among 54 randomly selected patients with potential non-painful DPN, 30 had DPN based on medical record data; of these, 27 had non-painful DPN, yielding PPVs of 56% (95% CI: 41–69%) and 50% (95% CI: 36–64%), respectively. Secondary E-chapter codes often denoted stroke or mononeuropathies, rather than DPN. Excluding secondary E-chapter codes from the algorithm increased the PPV for DPN to 78% (95% CI: 63–89%) for the painful DPN cohort and to 74% (95% CI: 56–87%) for the non-painful DPN cohort. Of 53 randomly selected patients with potential diabetic foot ulcer, only 18 diagnoses were confirmed; PPV=34% (95% CI: 22–48%).

Conclusion: G-chapter and primary E-chapter diagnosis codes can detect type 2 diabetes patients with hospital-diagnosed DPN, and may be useful in epidemiological research. In contrast, our diabetic foot ulcer algorithm did not perform well.

Text Messaging to Improve Disease Management in Patients With Painful Diabetic Peripheral Neuropathy

Purpose The purpose of the study was to determine the impact of educational text messages on diabetes self-management activities and outcomes in patients with painful diabetic peripheral neuropathy (pDPN). Methods Patients with pDPN identified from a large integrated health system who agreed to participate were randomized to 6 months of usual care (UC) or UC plus twice-daily diabetes self-management text messages (UC+TxtM). Outcomes included the Pain Numerical Rating Scale, Summary of Diabetes Self-Care Activities (SDSCA), questions on diabetes health beliefs, and glycated hemoglobin (A1C). Changes from baseline were evaluated at 6 months and compared between groups. Results Demographic characteristics were balanced between groups (N = 62; 53% female, mean age = 63 years, 94% type 2 diabetes), as were baseline measures. After 6 months, pain decreased with UC+TxtM from 6.3 to 5.5 and with UC from 6.5 to 6.0, with no difference between groups. UC+TxtM but not UC was associated with significant improvements from baseline on all SDSCA subscales. On diabetes health beliefs, UC+TxtM patients reported significantly increased benefits and reduced barriers and susceptibility relative to UC at 6 months. A1C declined in both groups, but neither change was significant relative to baseline. Conclusions Patients with pDPN who receive twice-daily text messages regarding diabetes management reported reduced pain relative to baseline, although this change was not significant compared with usual care. In addition, text messaging was associated with increased self-management activities and improved diabetes health beliefs and total self-care. These results warrant further investigation.

Identification, prevalence, and treatment of painful diabetic neuropathy in patients from a rural area in South Carolina

Diabetic peripheral neuropathy (DPN) represents significant burdens to many patients and the public health-care system. Patients with diabetes in rural areas have higher risk of developing complications and having less access to proper treatment. We studied a rural population of patients with diabetes who attended a pharmacist-led free clinic for a diabetic education program. Our objectives were to 1) determine the prevalence of DPN and painful diabetic neuropathy (p-DN) in patients with type 2 diabetes; 2) assess the proportion of patients with DPN and p-DN left undocumented upon physician referral to a pharmacist-led free clinic; and 3) determine the appropriateness of pain medication regimen. We performed a retrospective analysis of clinical records of patients from the Presbyterian College School of Pharmacy (PCSP) Wellness Center located in Clinton, SC. Diagnoses of DPN and/or p-DN were obtained from referral notes in the clinical records and compared with results from foot examinations performed in the free clinic and clinical features. Medication regimens were also obtained and compared using American Academy of Neurology (AAN) treatment guidelines. Within our study population (n=111), the prevalence of DPN was 62.2% (national average of 28%–45%) and that of p-DN was 23.4% (national average of 11%–24%). In p-DN patients (n=26), 53.8% (n=14) had a documented diagnosis of p-DN by the referring physician, and 46.2% (n=12) were identified by the pharmacists. A total of 95% (19 of 20) of the patients treated for p-DN received adequate pharmacological agents, though suboptimal as per clinical guidelines. More than 50% of the patients used subtherapeutic doses of their medications. Gabapentin was the most frequently used medication in our population (65.4%). Patients in rural South Carolina had a higher prevalence of DPN and p-DN with >60% undocumented cases of p-DN. More than 95% of treated patients did not receive optimum therapy according to AAN guidelines.

Opioid use in the management of diabetic peripheral neuropathy (DPN) in a large commercially insured population

OBJECTIVE

To examine the proportion of diabetic peripheral neuropathy (DPN) patients receiving pharmacologic DPN treatments and specifically to identify the rates and factors associated with opioid use and first-line opioid use.

METHODS

A 10% sample of IMS-LifeLink claims data from 1998 through 2008 was used. The study population consisted of diabetic patients who met DPN criteria using a validated DPN algorithm. Multivariable logistic regression controlling for demographics, comorbidities, and other clinical characteristics was used to identify factors associated with any DPN pharmacologic treatment, any opioid use, and first-line opioid treatment. Sensitivity analyses were conducted to explore variations in exclusion criteria as well as opioid use definitions.

RESULTS

A total of 666 DPN patients met inclusion criteria and pharmacologic treatment was received by 288 patients (43.24%) and of those, 154 (53.47%) had DPN-related opioid use and 96 (33.33%) received opioid as first-line treatment. Persons with diabetic complications were more likely to use opioids (odds ratio=4.53; 95% confidence interval, 1.09-18.92). Food and Drug Administration-approved DPN agents duloxetine 1.04% (n=3) and pregabalin 5.56% (n=16) had much lower rates of use. DPN-related drug use and DPN-related opioid usage increased as we used less restrictive samples in sensitivity analyses.

CONCLUSIONS

Opioids were the most frequently prescribed first-line agents for DPN. More than 50% of DPN patients remained untreated with pharmacologic agents 1 year after a DPN diagnosis.

Healthcare utilization and costs in diabetes relative to the clinical spectrum of painful diabetic peripheral neuropathy

AIMS

Diabetic peripheral neuropathy (DPN) accompanied by painful symptoms is known as painful DPN (pDPN). This study characterized healthcare resource utilization and costs in patients with DPN, pDPN, and severe pDPN relative to diabetes only.

METHODS

Four adult cohorts were identified from the Humedica database: type 2 diabetes without DPN (n=288,328); DPN (n=35,050); pDPN (DPN subjects with a pain score ≥1 on a 0-10 numeric rating scale; n=3449); and severe pDPN (pain scores 7-10; n=1824). Resource utilization and costs for 12-months post-diagnosis were compared for diabetes relative to the other cohorts.

RESULTS

Demographic characteristics were different across cohorts. Relative to diabetes alone, DPN, pDPN, and severe pDPN were characterized by significantly higher proportions of patients with resource utilization for all resource categories (all P<0.0001); the highest resource use generally observed for severe pDPN. Total annual direct medical costs were $6632 for diabetes only, with costs for DPN ($12,492), pDPN ($27,931), and severe pDPN ($30,755) significantly higher (all P<0.0001); outpatient costs were consistently the primary driver of total costs.

CONCLUSIONS

Patients with DPN, pDPN, and severe pDPN had significantly greater healthcare resource utilization and costs than patients with diabetes only, with the highest burden associated with severe pDPN.

Assessment of pain and impact of care among patients with painful diabetic peripheral neuropathy

OBJECTIVES To assess the prevalence of painful diabetic peripheral neuropathy (DPN), evaluate the impact of DPN on patients' function and quality of life, and assess patient satisfaction with their current DPN treatment. DESIGN Cross-sectional study. SETTING Patient-centered medical home model at an internal medicine clinic in Chicago, from November 1, 2011, through November 1, 2012. PARTICIPANTS 71 patients with type 1 or type 2 diabetes aged 45 to 85 years and receiving diabetes education and medication management from the clinic pharmacist. INTERVENTION Paper survey administered to patients during clinic visits. MAIN OUTCOME MEASURES DPN history; DPN impact on activity level, sleep, and quality of life; and satisfaction with current DPN treatment. RESULTS Of the 71 participants, 22% (n = 15) reported a diagnosis of DPN from their providers; however, 54% (n = 37) reported burning, aching, or tenderness in their hands, arms, legs, or feet. More than 50% of patients with these symptoms had experienced them for more than 1 year. Fewer than one in five patients (14% [n = 5]) reporting symptoms indicative of painful DPN were receiving treatment. CONCLUSION DPN may be underdiagnosed and undertreated in this patient population, which represents a potential opportunity for pharmacists to help patients with diabetes meet their quality of care goals.

Clinical and resource utilization patterns in patients with refractory neuropathic pain prescribed pregabalin for the first time in routine medical practice in primary care settings in Spain

CONTEXT AND OBJECTIVE

To describe clinical and resource utilization patterns in patients with refractory neuropathic pain (NeP) who were prescribed pregabalin for the first time in routine medical practice in primary care settings.

METHODS

Post-hoc analysis of a 12-week prospective observational study including pregabalin naïve adult patients with refractory chronic NeP of at least 6-months duration. Self-reported pain intensity, disability, sleep disturbances, symptoms of anxiety and depression, disability, health-related quality of life (HRQoL), health care resource utilization, and corresponding costs were assessed in this post-hoc analysis.

RESULTS

One thousand three hundred fifty-four patients were enrolled in the study, and three treatment groups were identified: (1) 598 patients replaced prior pain treatments with pregabalin as monotherapy; (2) 589 added pregabalin to their existing pain treatments; and (3) 167 other pain treatments were prescribed according with physician routine medical practice. Statistically significant differences were reported at baseline for intensity of pain, patient disability, severity of depressive symptoms, and HRQoL (P < 0.01 in all cases). No statistically significant differences were reported among the three treatment groups for anxiety severity or sleep disturbances. Subjects who received add-on pregabalin had greater use of direct and indirect resources vs the other groups, resulting in significantly higher quarterly overall costs per patient: €2,397 (2,308), €2,470 (1,857), and €3,110 (2,496), respectively (P < 0.001).

CONCLUSION

These findings suggest that primary care physicians chose pregabalin as an option for treating refractory patients who tended to have much more severe NeP profiles, costing society more than when they chose other therapeutic strategies not including pregabalin.

Economic evaluation of duloxetine as a first-line treatment for painful diabetic peripheral neuropathy in Mexico

OBJECTIVE

To perform an economic evaluation of duloxetine, pregabalin, and both branded and generic gabapentin for managing pain in patients with painful diabetic peripheral neuropathy (PDPN) in Mexico.

RESEARCH DESIGN AND METHODS

The analysis was conducted using a 3-month decision model, which compares duloxetine 60 mg once daily (DUL), pregabalin 150 mg twice daily (PGB), and gabapentin 600 mg three-times daily (GBP) for PDPN patients with moderate-to-severe pain. A systematic review was performed and placebo-adjusted risk ratios for achieving good pain relief (GPR), adverse events (AE), and withdrawal owing to intolerable AE were calculated. Direct medical costs included drug acquisition and additional visits due to lack of efficacy (poor pain relief) or intolerable AE. Unit costs were taken from local sources. Adherence rates were used to estimate the expected drug costs. All costs are expressed in 2010 Mexican Pesos (MXN). Utility values drawn from published literature were applied to health states. The proportion of patients with GPR and quality-adjusted life years (QALY) were assessed.

RESULTS

Branded-GBP was dominated by all the other options. PGB was more costly and less effective than DUL. Compared with branded-GBP and PGB, DUL led to savings of 1.01 and 1.74 million MXN (per 1000 patients). The incremental cost per QALY gained with DUL used instead of generic-GBP was $102 433 MXN. This amount is slightly lower than the estimated gross domestic product per capita in Mexico for 2010. During a second-order Monte Carlo simulation, DUL had the highest probability of being cost-effective (61%), followed by generic-GBP (25%) and PGB (14%).

LIMITATIONS

Study limitations include a short timeframe and using data from different dosage schemes for GBP and PGB.

CONCLUSIONS

This study suggests that DUL provides overall savings and better health outcomes compared with branded-GBP and PGB. Administering DUL rather than generic-GBP is a cost-effective intervention to manage PDPN in Mexico.

Evaluation of healthcare resource utilization and costs in employees with pain associated with diabetic peripheral neuropathy treated with pregabalin or duloxetine

OBJECTIVE

To evaluate changes in healthcare resource use and costs after initiating pregabalin or duloxetine in employees with pain associated with diabetic peripheral neuropathy (pDPN).

METHODS

Employees (18-64 years old) with a DPN diagnosis and at least one pDPN-related pain medication claim were identified using the MarketScan Commercial Database (2005-2008). Propensity scored matched pregabalin and duloxetine new starts were evaluated in the 6-month pre- and 6-month post-initiation periods. Study outcomes including imputed medically-related work loss, prescription and healthcare utilization, and associated expenditures were analyzed using univariate statistics and multivariate models in a difference-in-difference approach.

RESULTS

A total of 473 employees in each treatment group were identified. Mean age was 53.6 (SD 7.0) years for pregabalin and 53.5 (SD 7.4) years for duloxetine. There were no pre-index differences between groups. Adjusted marginal effects were not statistically significant for pre-to-post changes in opioid utilization (p = 0.328), number of pDPN-related analgesic medications (p = 0.506), all-cause healthcare costs (p = 0.895), indirect costs (p = 0.324), or pDPN-attributable expenditures (p = 0.359).

LIMITATIONS

Claims analysis is limited in accounting for all patient and plan differences, and by the reliability of medical claims for diagnosis coding. The sample size of the matched cohorts may have limited the power of the analysis to detect differences.

CONCLUSIONS

There were no significant pre-to-post differences between pregabalin and duloxetine treatment groups in pDPN-related analgesic medication use, or pDPN-attributable, all-cause, and indirect expenditures.

Comorbidities, healthcare service utilization and costs for patients identified with painful DPN in a managed-care setting

OBJECTIVE

This study examined the association of comorbidities, healthcare service use, and costs for diabetes patients with and without painful diabetic peripheral neuropathy (pDPN).

METHODS

This was a retrospective, cohort analysis of data from members of a health maintenance organization. Patients with pDPN identified from a previously validated algorithm that was based on inclusion ICD-9 diagnosis codes consistent with signs and symptoms of peripheral neuropathy, as well as ICD-9 diagnosis codes to exclude non-diabetic etiologies. These subjects were matched 2 : 1 to patients without pDPN on age (+/-4 years), gender, and HbA(1c) stratum (<7%, 7-9%, and >9%) based on median HbA(1c) measured in 2002. Administrative data associated with outpatient and hospital-based care for the year 2003 were used to estimate healthcare service utilization and costs. Chi-square, univariate, and multivariate regression analyses were employed to estimate the variation in healthcare service utilization and costs.

RESULTS

After applying inclusion and exclusion criteria, 1543 patients with pPDN were matched to 3069 patients without pDPN among prevalent diabetes cases. Patients with pDPN had significantly higher prevalence of comorbidities, including twice as many limb infections and nearly ten-fold greater limb amputations, and had consistently higher healthcare service utilization and costs across categories of care. The likelihood of any hospital admission for pDPN patients was more than 2.5-fold higher relative to patients without pDPN, and the excess cost associated with pDPN was estimated to be almost $6000 for the calendar year.

CONCLUSIONS

The presence of pDPN in patients with diabetes was associated with significantly greater comorbidity, greater healthcare service utilization, and higher costs. While this study is limited to the direct medical care costs borne by the health plan, given the association of comorbidities and cost for patients with pDPN, further investigation is needed to determine if management approaches that are effective across chronic illnesses may prove to be beneficial for high cost diabetes patients.