Healthcare Costs in Older Adults with Diabetes Mellitus: Challenges for Health Systems and for Society

Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus

The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.

Prevalence and predictors of co-occurring diabetes and hypertension in community-dwelling older adults

AIM

The objectives of the present study were to estimate the prevalence of co-occurring diabetes and hypertension among older adults, examine predictors of co-occurring diabetes and hypertension, and ascertain whether predictors varied by race.

METHODS

A retrospective analysis was carried out using a statewide survey of Alabama community-dwelling older adults (n = 1204). Measures of central tendency and frequency distributions were used for univariate analysis. Logistic regression was used to predict co-occurring diabetes and hypertension.

RESULTS

The prevalence of co-occurring diabetes and hypertension among older adults was 17%. African American race (OR 2.28, 95% CI 1.596-3.255), body mass index ≥30 (OR 2.45, 95% CI 1.732-3.463), heart disease (OR 1.93, 95% CI 1.355-2.756) and eye disease (OR 1.44, 95% CI 1.018-2.024) were associated positively with co-occurring diabetes and hypertension.

CONCLUSIONS

The prevalence of co-occurring diabetes and hypertension among older adults was alarmingly high. The notable difference in the likelihood of co-occurring diabetes and hypertension is representative of a racial health disparity that largely disfavors African American older adults. Findings from the present study highlight a need for identification of older adults who have and who are at risk of co-occurring diabetes and hypertension in the general population and in clinical settings, and the development and implementation of suitable interventions, particularly targeting older African American adults. Geriatr Gerontol Int 2018; 18: 1356-1360.

Index of Healthy Aging in Chinese Older Adults: China Health and Retirement Longitudinal Study

OBJECTIVES

To characterize the distribution of an index of healthy aging-the Chinese Healthy Aging Index (CHAI)-in Chinese adults aged 60 and older according to sociodemographic characteristics and geographic region and to examine the association between the CHAI and mortality, disability, and functional limitation over 4 years.

DESIGN

Nationally representative cohort study.

SETTING

China Health and Retirement Longitudinal Study.

PARTICIPANTS

Chinese adults aged 60 and older (N=3,740).

MEASUREMENTS

Six CHAI components (systolic blood pressure, peak expiratory flow, Telephone Interview for Cognitive Status, estimated glomerular filtration rate, fasting glucose, C-reactive protein) were scored 0 (healthiest), 1, and 2 (unhealthiest) according to sex-specific tertiles or clinically relevant cut-points and summed to construct the CHAI (range 0-12).

RESULTS

Mean CHAI score was 5.6; 5.7% had a score of 0 to 2 (healthiest), 23.0% a score of 3 or 4, 37.5% a score of 5 or 6, and 33.8% a score of 7 to 12 (unhealthiest). Participants who were younger, more educated, and married were much more likely to have an ideal CHAI profile (score 0-2). Age-adjusted prevalence of an ideal CHAI profile ranged from 1.7% in the south to 8.1% in the north. After multivariable adjustment, persons with a CHAI score of 3 to 12 had substantially higher odds of mortality, disability, and functional limitation than those with a score of 0 to 2. The CHAI further stratified outcomes for persons with no clinically recognizable comorbidities.

CONCLUSION

Substantial variation exists in the CHAI according to sociodemographic characteristics and geographic regions. The CHAI could identify Chinese elderly adults with low risk of adverse outcomes and provide incremental value for risk prediction beyond clinically diagnosed comorbidities.

Assessment of hospital length of stay and direct costs of type 2 diabetes in Hubei Province, China

BACKGROUND

The incidence of type 2 diabetes is increasing, creating a huge burden for China's social healthcare system. This study aimed to evaluate hospital length of stay (LOS) based on admission characteristics and direct costs correlated with various types of complications for type 2 diabetic inpatients in Hubei Province, China.

METHODS

A total of 1528 inpatients diagnosed with type 2 diabetes discharged between April 1, 2013, and March 31, 2014, were included in this study. Information regarding patients' admission and hospitalization were obtained from the hospital information system. The relationship between admission characteristics and LOS, distribution of total costs, and types of complications were described and analysed.

RESULTS

(1) The mean LOS was 11.65 days (median: 10 days). Multiple linear regression analysis demonstrated that inpatients with New Cooperative Medical Scheme (NCMS), aged 80 and above, had longer LOS than the reference group, and inpatients with chronic or acute + chronic complications had shorter LOS than those without. (2) Mean total costs per patient were US$159.72 ± 130.83 (median: US$135.33), US$240.60 ± 166.58 (median: US$192.09), and US$247.98 ± 166.22 (median: US$200.99) for inpatients with no complications, chronic complications, and acute + chronic complications, respectively. Total and individual costs were significantly less for patients without complications than for those with the two types of complications (p < 0.001). (3) Mean total costs per patient were US$225.40 ± 115.32 (median: US$200.34), US$221.25 ± 177.64 (median: US$170.05), and US$275.18 ± 193.14 (median: US$217.91) for inpatients with microvascular complications, macrovascular complications, and microvascular + macrovascular complications, respectively. Total costs were significantly higher for patients with microvascular + macrovascular complications than for those with other types of chronic complications (p < 0.001). (4) Drugs were the greatest expense for patients, and the least expensive treatment was nursing care.

CONCLUSIONS

Medical insurance status, age, and type of complication may help to predict LOS for patients with type 2 diabetes in Hubei Province, China. The total and individual costs for patients with complications were higher than for those without, and hospitalization expenses posed a heavy burden. Efforts should be made to reduce the financial impact on patients by integrating the medical insurance system of urban and rural areas, and by reducing the risk of complications, especially microvascular complications.