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McDaniel CC, Lo-Ciganic WH, Chou C. Diabetes-related complications, glycemic levels, and healthcare utilization outcomes after therapeutic inertia in type 2 diabetes mellitus. Prim Care Diabetes 2024; 18:188-195. [PMID: 38185576 DOI: 10.1016/j.pcd.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/09/2024]
Abstract
AIMS To assess diabetes-related complications, glycemic levels, and healthcare utilization 12 months after exposure to therapeutic inertia among patients with type 2 diabetes mellitus (T2D). METHODS This retrospective cohort study analyzed data from the OneFlorida Clinical Research Consortium (electronic health records from Florida practices/clinics). The cohort included adult patients (≥18 years old) with T2D who had an HbA1c≥7.0% (53 mmol/mol) recorded from January 1, 2014-September 30, 2019. Therapeutic inertia (exposed vs. not exposed) was evaluated during the six months following HbA1c≥7.0% (53 mmol/mol). The outcomes assessed during the 12-month follow-up period included diabetes-related complications (continuous Diabetes Complications and Severity Index (DCSI)), glycemic levels (continuous follow-up HbA1c lab), and healthcare utilization counts. We analyzed data using multivariable regression models, adjusting for covariates. RESULTS The cohort included 26,881 patients with T2D (58.94% White race, 49.72% female, and mean age of 58.82 (SD=13.09)). After adjusting for covariates, therapeutic inertia exposure was associated with lower DCSI (estimate=-0.14 (SE=0.03), p < 0.001), higher follow-up HbA1c (estimate=0.14 (SE=0.04), p < 0.001), and lower rates of ambulatory visits (rate ratio=0.79, 95% CI=0.75-0.82). CONCLUSIONS Findings communicate the clinical practice implications and public health implications for combating therapeutic inertia in diabetes care.
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Affiliation(s)
- Cassidi C McDaniel
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA.
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, University of Florida, College of Pharmacy, Gainesville, FL, USA; Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh, Pittsburgh, PA, USA; North Florida/South Georgia Veterans Health System, Geriatric Research Education and Clinical Center, Gainesville, FL, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Harrison College of Pharmacy, Auburn University, Auburn, AL, USA; Department of Medical Research, China Medical University Hospital, Taichung City, Taiwan
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Hankosky ER, Katz ML, Fan L, Liu D, Chinthammit C, Brnabic AJM, Eby EL. Predictors of insulin pump initiation among people with type 2 diabetes from a US claims database using machine learning. Curr Med Res Opin 2023; 39:843-853. [PMID: 37139823 DOI: 10.1080/03007995.2023.2205795] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE Insulin pump use is increasing among people with type 2 diabetes (T2D), albeit at a slower rate compared to people with type 1 diabetes (T1D). Factors associated with insulin pump initiation among people with T2D in the real-world are understudied. METHODS This retrospective, nested case-control study aimed to identify predictors of insulin pump initiation among people with T2D in the United States (US). Adults with T2D who were new to bolus insulin use were identified from the IBM MarketScan Commercial database (2015-2020). Candidate variables of pump initiation were entered into conditional logistic regression (CLR) and penalized CLR models. RESULTS Of the 32,104 eligible adults with T2D, 726 insulin pump initiators were identified and matched to 2,904 non-pump initiators using incidence density sampling. Consistent predictors of insulin pump initiation across the base case, sensitivity, and post hoc analyses included continuous glucose monitor (CGM) use, visiting an endocrinologist, acute metabolic complications, higher count of HbA1c tests, lower age, and fewer diabetes-related medication classes. CONCLUSIONS Many of these predictors could represent a clinical indication for treatment intensification, greater patient engagement in diabetes management, or proactive management by healthcare providers. Improved understanding of predictors for pump initiation may lead to more targeted efforts to improve access and acceptance of insulin pumps among persons with T2D.
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Affiliation(s)
- Emily R Hankosky
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Michelle L Katz
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Ludi Fan
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Dongju Liu
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | | | - Alan J M Brnabic
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
| | - Elizabeth L Eby
- Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, USA
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Jeong IS, Kang CM. Time to Diagnosis and Treatment of Diabetes Mellitus among Korean Adults with Hyperglycemia: Using a Community-Based Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12090. [PMID: 36231389 PMCID: PMC9566253 DOI: 10.3390/ijerph191912090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To identify the time from hyperglycemia to diabetes mellitus (DM) diagnosis and treatment, the risk factors for diabetes development, and the prevalence of comorbidities/complications in patients > 40 years of age. METHODS This secondary data analysis study used data from the Korean Genome and Epidemiology Study. The participants comprised 186 patients who did not have diabetes at baseline, but developed hyperglycemia at the first follow-up. The average and median periods until DM diagnosis and treatment were calculated using Kaplan-Meier survival analysis. RESULTS Of the 186 participants, 57.0% were men and 35.5% were 40-49 years old. The average time to DM diagnosis and treatment was 10.87 years and 11.34 years, respectively. The risk factors for the duration of DM were current smoking, body mass index (BMI), fasting blood sugar (FBS), and postprandial 2-hour glucose (PP2). The risk factors for the duration of diabetes treatment were current smoking, hypertension, BMI, FBS, and PP2. The development of one or more comorbidities or diabetes complications was identified at the time of DM diagnosis (36.5%) and DM treatment (41.4%). CONCLUSIONS As diabetes complications occur at the time of DM, and early treatment can impact the development of diabetes complications or mortality, it is necessary to establish a referral program so that participants presenting with high blood sugar levels in the screening program can be diagnosed and treated in a timely manner.
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Affiliation(s)
- Ihn-Sook Jeong
- College of Nursing, Pusan National University, Yangsan 50612, Korea
| | - Chan-Mi Kang
- Department of Nursing, Dong-Eui Institute of Technology, Busan 47230, Korea
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Davidson MB. Effect of Diabetes-Trained Nurse Practitioners on Glycemic Outcomes: Their Suggested Use in Busy Primary Care Practices. Clin Diabetes 2021; 39:293-296. [PMID: 34421205 PMCID: PMC8329016 DOI: 10.2337/cd20-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A Federally Qualified Health Center received ongoing external support for half-time salaries for two nurse practitioners to treat people with poorly controlled diabetes (A1C >9.0%) in the clinic's diabetes program using approved detailed treatment protocols. Patients were treated for 1 year and graduated from this program if their A1C fell to <7.5%. Ninety-one percent graduated, and treatment was deemed to have failed in 9% who did not achieve an A1C <7.5% by the end of the year of treatment. The suggestion is made to assign a specially trained diabetes nurse or physician assistant to serve many primary care providers at important clinical junctures to improve diabetes outcomes throughout busy primary care practices.
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Mansour AA, Alibrahim NTY, Alidrisi HA, Alhamza AH, Almomin AM, Zaboon IA, Kadhim MB, Hussein RN, Nwayyir HA, Mohammed AG, Al-Waeli DKJ, Hussein IH. Prevalence and correlation of glycemic control achievement in patients with type 2 diabetes in Iraq: A retrospective analysis of a tertiary care database over a 9-year period. Diabetes Metab Syndr 2020; 14:265-272. [PMID: 32272433 DOI: 10.1016/j.dsx.2020.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/18/2020] [Accepted: 03/19/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND This study was designed to assess the achievement of a glycated hemoglobin (HbA1c) target in Iraqi type 2 diabetes mellitus (T2DM) patients via retrospective analysis of a tertiary care database over a 9-year period. METHODS A total of 12,869 patients with T2DM with mean (SEM) age: 51.4(0.1) years, and 54.4% were females registered into Faiha Specialized Diabetes, Endocrine and Metabolism Center(FDEMC) database between August 2008 and July 2017 were included in this retrospective study. Data were recorded for each patient during routine follow-up visits performed at the center every 3-12 months. RESULTS Patients were under oral antidiabetic drugs (OAD; 45.8%) or insulin+ OAD (54.2%) therapy. Hypertension was evident in 42.0% of patients, while dyslipidemia was noted in 70.5%. Glycemic control (HbA1c <7%) was achieved by 13.8% of patients. Multivariate analysis revealed <55 years of age, female gender, >3 years duration of diabetes, HbA1c >10% at the first visit, presence of dyslipidemia, and insulin treatment as significant determinants of an increased risk of poor glycemic control. BMI <25 kg/m2 and presence of hypertension were associated with a decreased risk of poor glycemic control. CONCLUSION Using data from the largest cohort of T2DM patients from Iraq to date, this tertiary care database analysis over a 9-year period indicated poor glycemic control. Younger patient age, female gender, longer disease duration, initially high HbA1c levels, dyslipidemia, insulin treatment, overweight and obesity, and lack of hypertension were associated with an increased risk of poor glycemic control in Iraqi T2DM patients.
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Affiliation(s)
- Abbas Ali Mansour
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq.
| | - Nassar T Y Alibrahim
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Haider A Alidrisi
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Ali H Alhamza
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Ammar M Almomin
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Ibrahim Abbood Zaboon
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Muayad Baheer Kadhim
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Rudha Naser Hussein
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Hussein Ali Nwayyir
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Adel Gassab Mohammed
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Dheyaa K J Al-Waeli
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
| | - Ibrahim Hani Hussein
- Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), Basrah Health Directorate, University of Basrah, Basrah, Iraq
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Myers J, Bravata DM, Sico J, Myers L, Chaturvedi S, Cheng E, Baye F, Zillich AJ. The quality of medication optimization among patients with transient ischemic attack or minor stroke. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Jaclyn Myers
- Department of Pharmacy Practice Purdue University College of Pharmacy Indianapolis Indiana
| | - Dawn M. Bravata
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
| | - Jason Sico
- Departments of Internal Medicine and Neurology Yale University School of Medicine New Haven Connecticut
| | - Laura Myers
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
| | | | - Eric Cheng
- Department of Neurology VA Greater Los Angeles Healthcare System Los Angeles California
| | - Fitsum Baye
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
| | - Alan J. Zillich
- Department of Pharmacy Practice Purdue University College of Pharmacy Indianapolis Indiana
- Health Services Research and Development (HSR&D) Center for Health Information and Communication Richard L. Roudebush VA Medical Center Indianapolis Indiana
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Kent DJ, McMahill-Walraven CN, Panozzo CA, Pawloski PA, Haynes K, Marshall J, Brown J, Eichelberger B, Lockhart CM. Descriptive Analysis of Long- and Intermediate-Acting Insulin and Key Safety Outcomes in Adults with Type 2 Diabetes Mellitus. J Manag Care Spec Pharm 2019; 25:1162-1171. [PMID: 31405345 PMCID: PMC10397971 DOI: 10.18553/jmcp.2019.19042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As new biosimilar and follow-on insulins enter the market, more data are needed on safety, effectiveness, and patterns of use for these products to inform prescriber and patient decision-making regarding treatment. Additionally, data are needed regarding real-world patterns of use to inform future studies comparing the safety and effectiveness of bio-similars to already approved agents for diabetes treatment. OBJECTIVE To analyze the medication use patterns, adverse events, and availability of glycated hemoglobin (A1c) values for adult patients with type 2 diabetes mellitus (T2DM) who use long-acting insulin (LAI) or neutral protamine Hagedorn (NPH), an intermediate-acting insulin. METHODS We used the Biologics and Biosimilars Collective Intelligence Consortium's (BBCIC) distributed research network (DRN) for this descriptive analysis. The analysis time frame was January 1, 2011, to September 30, 2015, and included patients continuously insured for at least 183 days before the first date of a filled prescription for LAI or NPH insulin alone or with rapid- or short-acting insulin or sulfonylureas, whether newly starting insulin or switching to a different product. Insulin exposure episodes were the unit of analysis, and patients were classified in cohorts according to treatment. We followed patients until end of health plan enrollment or the end of the study period. We used occurrence of a study outcome, switch to another medication regimen, discontinuation of the current medication, or study end date to mark the end of an insulin episode. We describe demographics and availability of A1c values for analysis. Study outcomes included severe hypoglycemic events and major adverse cardiac events (MACE). RESULTS We identified 103,951 patients with T2DM from a database of 39.1 million patients with commercial or Medicare Advantage pharmacy and medical benefits, who contributed 279,533 unique insulin exposure episodes. Most episodes (89%) included patients using LAI, and 52% of patients contributed data to 2 or more exposure cohorts. Insulin episodes lasted an average of 3.5 months, and patients had an average follow-up of 8.6 months. The unadjusted rate of severe hypoglycemic events requiring medical attention was 96.9 per 10,000 patient-years at risk (10kPYR). The unadjusted incident MACE rate was 676.9 events per 10kPYR. 38,330 T2DM patients in the BBCIC DRN had a baseline A1c available, and of those, less than 50% had a follow-up A1c result. CONCLUSIONS Among patients with T2DM, our observed insulin patterns of use and rates of severe hypoglycemic outcomes and MACE are consistent with other studies. We noted a paucity of A1c results available, which implies that additional data sources may be needed to augment the BBCIC DRN. DISCLOSURES This study was coordinated and funded by the Biologics and Biosimilars Collective Intelligence Consortium (BBCIC) and represents the independent findings of the BBCIC Insulins Principal Investigator and the BBCIC Insulins Research Team. Lockhart is employed by the BBCIC and the Academy of Managed Care Pharmacy (AMCP). Eichelberger was employed by the BBCIC and AMCP at the time of this study. McMahill-Walraven is employed by Aetna, a CVS Health business. Panozzo, Marshall, and Brown are employed by Harvard Pilgrim Healthcare Institute. Aetna was reimbursed for data and analytic support from Harvard Pilgrim Healthcare Institute and the Reagan Udall Foundation for the U.S. Food and Drug Administration. Aetna receives external funding through research grants and subcontracts with Harvard Pilgrim Healthcare Institute, which are funded by the FDA, NIH, PCORI, BBCIC, Pfizer, and GSK; the Reagan-Udall Foundation for IMEDS; and PCORI for the ADAPTABLE Study. This work was previously presented as a poster at AMCP Nexus 2018; October 22-25, 2018; in Orlando, FL.
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Affiliation(s)
| | | | | | | | | | - James Marshall
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
| | - Jeffrey Brown
- Harvard Pilgrim Healthcare Institute, Boston, Massachusetts
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Nordyke RJ, Appelbaum K, Berman MA. Estimating the Impact of Novel Digital Therapeutics in Type 2 Diabetes and Hypertension: Health Economic Analysis. J Med Internet Res 2019; 21:e15814. [PMID: 31599740 PMCID: PMC6914106 DOI: 10.2196/15814] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Behavioral interventions can meaningfully improve cardiometabolic conditions. Digital therapeutics (DTxs) delivering these interventions may provide benefits comparable to pharmacologic therapies, displacing medications for some patients. OBJECTIVE Our objective was to estimate the economic impact of a digital behavioral intervention in type 2 diabetes mellitus (T2DM) and hypertension (HTN) and estimate the impact of clinical inertia on deprescribing medications. METHODS Decision analytic models estimated health resource savings and cost effectiveness from a US commercial payer perspective. A 3-year time horizon was most relevant to the intervention and payer. Effectiveness of the DTx in improving clinical outcomes was based on cohort studies and published literature. Health resource utilization (HRU), health state utilities, and costs were drawn from the literature with costs adjusted to 2018 dollars. Future costs and quality-adjusted life years (QALYs) were discounted at 3%. Sensitivity analyses assessed uncertainty. RESULTS Average HRU savings ranged from $97 to $145 per patient per month, with higher potential benefits in T2DM. Cost-effectiveness acceptability analyses using a willingness-to-pay of $50,000/QALY indicated that the intervention would be cost effective at total 3-year program costs of $6468 and $6620 for T2DM and HTN, respectively. Sensitivity analyses showed that reduced medication costs are a primary driver of potential HRU savings, and the results were robust within values tested. A resistance to deprescribe medications when a patient's clinical outcomes improve can substantially reduce the estimated economic benefits. Our models rely on estimates of clinical effectiveness drawn from limited cohort studies with DTxs and cannot account for other disease management programs that may be implemented. Performance of DTxs in real-world settings is required to further validate their economic benefits. CONCLUSIONS The DTxs studied may provide substantial cost savings, in part by reducing the use of conventional medications. Clinical inertia may limit the full cost savings of DTxs.
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Affiliation(s)
| | | | - Mark A Berman
- Better Therapeutics, LLC, San Francisco, CA, United States
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Davidson MB, Davidson SJ. Effect of Remote Glucose Monitoring Utilizing Computerized Insulin Dose Adjustment Algorithms: A Pilot Project. Diabetes Ther 2019; 10:523-533. [PMID: 30721451 PMCID: PMC6437238 DOI: 10.1007/s13300-019-0565-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Primary care physicians are often challenged to adjust insulin doses. To facilitate this process, we evaluated in a safety net clinic the work flow and glycemic effects of remote glucose monitoring utilizing Federal Drug Administration (FDA) cleared, Conformité Européenne (CE) registered software that contained computerized algorithms for insulin dose adjustments to help clinicians make dosing decisions for insulin-requiring patients. METHODS Patients taking insulin for at least 6 months with HbA1c levels of at least 8.0% measured glucose levels with a meter attached to their smartphones. Readings were automatically transmitted to a secure, Health Insurance Portability and Accountability Act (HIPAA)-approved server. Values were analyzed every 2-3 weeks and reports, including recommendations for insulin dose changes, were sent to a clinic nurse practitioner (NP) who modified or accepted the recommendations. A staff person contacted patients with the new doses determined by the NP. RESULTS Insulin regimens included basal alone (N = 11), basal/bolus (N = 14), and self-mixed/split (N = 3). Baseline HbA1 levels of 10.0% fell to 8.1% at 3 months (N = 28) and 7.6% at 6 months (N = 17) without any clinic visits for dose adjustments. There were 268 reports which allowed providers to see 268 other patients during these avoided clinic visits. The NP agreed with 82% of the recommendations. The total doses of insulin increased by 24%. No patient experienced severe hypoglycemia or visited an emergency department for hypoglycemia. CONCLUSION Remote glucose monitoring utilizing computerized insulin dose adjustment algorithms saved time for both providers and patients while effectively improving glycemia. FUNDING The Leonard M. Lipman Charitable Trust and Mellitus Health.
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Affiliation(s)
- Mayer B Davidson
- Charles R. Drew University, Los Angeles, CA, USA.
- Mellitus Health Inc., Los Angeles, CA, USA.
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Brixner D, Ermakova A, Xiong Y, Sieradzan R, Sacks N, Cyr P, Taylor SD. Clinical and Economic Outcomes of Patients with Type 2 Diabetes on Multiple Daily Injections of Basal-bolus Insulin (MDI) Therapy: A Retrospective Cohort Study. Clin Ther 2019; 41:303-313.e1. [PMID: 30709610 DOI: 10.1016/j.clinthera.2018.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 12/19/2018] [Accepted: 12/23/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Therapy for patients with type 2 diabetes (T2DM) not achieving hemoglobin (Hb) A1c targets may progress from an oral antidiabetic drug (OAD) to added basal insulin and then to multiple daily injections of basal-bolus insulin (MDI); however, the relative clinical and economic burden experienced by patients prescribed MDI for T2DM is not well quantified. The intent of this work was to describe direct medical costs, health care resource utilization, and glycemic control in patients with T2DM exposed to MDI in a clinical practice setting. METHODS This retrospective cohort study used administrative claims data (2012-2015, United States) from patients aged 18 to 64 years with T2DM prescribed OAD, basal insulin, or MDI therapy. Eligible patients had continuous enrollment from ≥6 months before to 12 months after the date of the index prescription drug claim. Patients eligible for inclusion in the MDI cohort had ≥2 pharmacy claims each for basal and bolus insulin from the index date through the postindex period. Glycemic control, defined as an HbA1c value of <7% during the last 9 postindex months, was assessed in a subset of patients with HbA1c data available from that period. Descriptive analyses were performed. FINDINGS We identified 225,135 patients with T2DM and claims for an OAD (n = 188,230), basal insulin (n = 23,724), or MDI (n = 13,181). The mean age was 51 or 52 years in each cohort; 54% to 59% of patients in each cohort were men. The mean Charlson comorbidity index scores were 0.8, 1.4, and 1.8, respectively; the percentages of patients with obesity and diabetes-related complications were greatest in the MDI cohort compared with OAD and basal insulin cohorts. The mean direct medical costs (all-cause; year-2015 US $) were $9368 in the OAD cohort, $14,420 in the basal insulin cohort, and $25,624 in the MDI cohort; diabetes-related costs were $3396, $7285, and $13,538. In the OAD, basal insulin, and MDI cohorts, 7%, 9%, and 14% of patients had ≥1 hospitalization, and 17%, 20%, and 24% had ≥1 emergency department visit, while 5%, 7%, and 11% had ≥1 diabetes-related hospitalization, and 8%, 11%, and 15% had ≥1 diabetes-related emergency department visit. Glycemic control was found in 64%, 22%, and 15% of patients in the OAD, basal insulin, and MDI cohorts. IMPLICATIONS These findings suggest that patients prescribed MDI therapy for T2DM have greater disease burden, experience greater medical costs and health care resource utilization, and exhibit poorer glycemic control than do patients treated with OAD or basal insulin therapy.
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Affiliation(s)
- Diana Brixner
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Anastasia Ermakova
- Health Economics and Outcomes Research, Becton Dickinson, Franklin Lakes, NJ, USA
| | - Yan Xiong
- Health Economics and Outcomes Research, Becton Dickinson, Franklin Lakes, NJ, USA
| | - Ray Sieradzan
- Medical Affairs, Becton Dickinson, Franklin Lakes, NJ, USA
| | | | | | - Stephanie D Taylor
- Health Economics and Outcomes Research, Becton Dickinson, Franklin Lakes, NJ, USA.
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Barnes GD, Li Y, Gu X, Haymart B, Kline-Rogers E, Almany S, Kozlowski J, Krol G, McNamara M, Froehlich JB, Kaatz S. Periprocedural Bridging Anticoagulation: Measuring the Impact of a Clinical Trial on Care Delivery. Am J Med 2019; 132:109.e1-109.e7. [PMID: 30076828 DOI: 10.1016/j.amjmed.2018.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/16/2018] [Indexed: 11/29/2022]
Abstract
Use of bridging anticoagulation has been shown to be harmful and without benefit in warfarin-treated patients with atrial fibrillation. We performed a quasi-experimental interrupted time series analysis between 2010 and 2017 in the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) collaborative before and after the BRIDGE trial publication (July 2015). Predicted use of bridging at the end of the study period was calculated with and without the effect of the BRIDGE trial after adjustment for patient-level clustering. Predictors of bridging anticoagulation use in the post-BRIDGE trial period were analyzed. In adjusted analyses, the use of bridging anticoagulation declined from a predicted 27.8% (95% confidence interval, 20.5%-35.1%) to 13.6% (95% confidence interval, 9.0%-18.2%) at the end of 2017 (P = .001) in response to the BRIDGE trial. Use of bridging anticoagulation declined similarly among atrial fibrillation patients at low risk for stroke (29.0% to 14.4%) and intermediate or high risk for stroke (38.0%-20.3%). Younger age and a prior history of stroke were independent predictors of bridging anticoagulation use following the BRIDGE trial publication. The BRIDGE trial publication is associated with a rapid and significant decline in the use of periprocedural bridging anticoagulation.
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Affiliation(s)
| | - Yun Li
- School of Public Health, University of Michigan, Ann Arbor
| | | | | | | | - Steven Almany
- Beaumont Health/Oakland University School of Medicine, Royal Oak, Mich
| | - Jay Kozlowski
- Huron Valley Sinai Hospital, Commerce Township, Mich
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Jabbar A, Mohamed WMIBW, Ozaki R, Mirasol R, Treuer T, Lew T, Qi R, Sheu WHH, Deerochanawong C, Babineaux SM. Patterns and trends in insulin initiation and intensification among patients with type 2 diabetes mellitus in the Western Pacific region. Curr Med Res Opin 2018; 34:1653-1662. [PMID: 29863422 DOI: 10.1080/03007995.2018.1484712] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Current and future estimates of the burden of diabetes for the Western Pacific (WP) region are among the highest in the world. Verifying Insulin Strategy and Initial Health Outcome Analysis (VISION) was an 18 month observational study that explored treatment approaches in patients with type 2 diabetes mellitus (T2DM) initiating insulin in the WP region. METHODS A total of 1065 patients aged ≥18 years with T2DM initiating insulin therapy in normal clinical course were enrolled from Hong Kong, Malaysia, Philippines, Taiwan and Thailand. Participants' data was recorded by the treating physicians. Patient-reported outcomes (PROs) were assessed using questionnaires completed by participants. RESULTS The mean age of patients was 57.2 years with mean glycosylated hemoglobin (HbA1c) of 10.0%. About 66% of patients had an HbA1c ≥9.0% at insulin initiation despite 74% of them being on two or more oral antidiabetic agents at the time of insulin initiation. Basal insulin was initiated in 72% and premixed insulin in 27% of patients. Changes in insulin therapy was observed in 63% of patients and, by the end of study, 28% achieved HbA1c levels of <7.5%. The proportion of patients completely satisfied with their insulin treatment increased over the study course and the quality of life (QoL) score increased from baseline to the study end. CONCLUSION As high HbA1C levels indicate a delayed start of insulin therapy, timely initiation and early intensification of insulin therapy is necessary in the region to achieve adequate glycemic control in time and prevent diabetes complications. Data from PROs suggests that the insulin treatment improves QoL in most patients.
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Affiliation(s)
| | | | - Risa Ozaki
- c The Chinese University of Hong Kong , Hong Kong , China
| | | | | | | | - Rong Qi
- g Eli Lilly and Company , Indianapolis , IN , USA
| | - Wayne H-H Sheu
- h Division of Endocrinology and Metabolism, Department of Internal Medicine , Taichung Veterans General Hospital , Taichung , Taiwan
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Blonde L, Raccah D, Lew E, Meyers J, Nikonova E, Ajmera M, Davis KL, Bertolini M, Guerci B. Treatment Intensification in Type 2 Diabetes: A Real-World Study of 2-OAD Regimens, GLP-1 RAs, or Basal Insulin. Diabetes Ther 2018; 9:1169-1184. [PMID: 29675797 PMCID: PMC5984932 DOI: 10.1007/s13300-018-0429-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Treatment guidelines recommend a stepwise approach to glycemia management in patients with type 2 diabetes (T2D), but this may result in uncontrolled glycated hemoglobin A1c (HbA1c) between steps. This retrospective analysis compared clinical and economic outcomes among patients with uncontrolled T2D initiating two oral antidiabetes drugs (OADs), glucagon-like peptide-1 receptor agonists (GLP-1 RAs), or basal insulin in a real-world setting. METHODS Adults with T2D on OAD monotherapy were identified in the MarketScan claims database (2007-2014). Those initiating two OADs (simultaneously or sequentially), GLP-1 RAs, or basal insulin were selected (date of initiation was termed the 'index date'); patients were required to have HbA1c > 7.0% in the 6 months pre-index date. HbA1c was compared from 6 months pre- to 1-year post-index. Annual all-cause healthcare utilization and costs were reported over the 1-year follow-up period. RESULTS Data for 6054 patients were analyzed (2-OAD, n = 4442; GLP-1 RA, n = 361; basal insulin, n = 1251). Baseline HbA1c was high in all cohorts, but highest in the basal-insulin cohort. Treatment initiation resulted in reductions in HbA1c in all cohorts, which was generally maintained throughout the follow-up period. Average HbA1c reductions from the 6 months pre- to 1 year post-index date were -1.2% for GLP-1 RA, -1.6% for OADs, and -1.8% for basal insulin. HbA1c < 7.0% at 1 year occurred in 32.6%, 47.5%, and 41.1% of patients, respectively. Annual healthcare costs (mean [SD]) were lowest for OAD (US$10,074 [$22,276]) followed by GLP-1 RA (US$14,052 [$23,829]) and basal insulin (US$18,813 [$37,332]). CONCLUSION Despite robust HbA1c lowering following treatment initiation, many patients did not achieve HbA1c < 7.0%. Basal insulin, generally prescribed for patients with high baseline HbA1c, was associated with a large reduction in HbA1c and with higher costs. Therapy intensification at an appropriate time could lead to clinical and economic benefits and should be investigated further. FUNDING Sanofi U.S., Inc.
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Affiliation(s)
- Lawrence Blonde
- Department of Endocrinology, Ochsner Medical Center, New Orleans, LA, USA.
| | - Denis Raccah
- University Hospital Sainte Marguerite, Marseille, France
| | | | - Juliana Meyers
- RTI Health Solutions, Research Triangle Park, Durham, NC, USA
| | | | - Mayank Ajmera
- RTI Health Solutions, Research Triangle Park, Durham, NC, USA
| | - Keith L Davis
- RTI Health Solutions, Research Triangle Park, Durham, NC, USA
| | | | - Bruno Guerci
- Diabetology Department, University of Lorraine, Vandoeuvre-Lès-Nancy, France
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14
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Hunt B, Kragh N, McConnachie CC, Valentine WJ, Rossi MC, Montagnoli R. Long-term Cost-effectiveness of Two GLP-1 Receptor Agonists for the Treatment of Type 2 Diabetes Mellitus in the Italian Setting: Liraglutide Versus Lixisenatide. Clin Ther 2017. [PMID: 28625506 DOI: 10.1016/j.clinthera.2017.05.354] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Maintaining glycemic control is the key treatment target for patients with type 2 diabetes mellitus. In addition, the glucagon-like peptide-1 (GLP-1) receptor agonists may be associated with other favorable treatment characteristics, such as reduction in body weight and reduced risk of hypoglycemia compared with traditional diabetes interventions. The aim of the present analysis was to compare the long-term cost-effectiveness of 2 GLP-1 receptor agonists, liraglutide 1.8 mg and lixisenatide 20 μg (both administered once daily), in the treatment of patients with type 2 diabetes failing to achieve glycemic control with metformin monotherapy in the Italian setting. METHODS The IMS CORE Diabetes Model was used to project long-term clinical outcomes and subsequent costs (in 2015 Euros [€]) associated with liraglutide 1.8 mg versus lixisenatide 20 μg treatment in a cohort with baseline characteristics derived from the open-label LIRA-LIXI trial (Efficacy and Safety of Liraglutide Versus Lixisenatide as Add-on to Metformin in Subjects With Type 2 Diabetes; NCT01973231) over patient lifetimes from the perspective of a health care payer. Efficacy data were taken from the 26-week end points of the same trial, including changes in glycated hemoglobin, body mass index, serum lipid levels, and hypoglycemic event rates. Outcomes projected included life expectancy, quality-adjusted life expectancy, cumulative incidence and time to onset of diabetes-related complications, and direct medical costs. Outcomes were discounted at 3% annually, and sensitivity analyses were performed. FINDINGS Liraglutide 1.8 mg was associated with improved discounted life expectancy (14.07 vs 13.96 years) and quality-adjusted life expectancy (9.18 vs 9.06 quality-adjusted life years [QALYs]) compared with lixisenatide 20 μg. These improvements were mostly attributable to a greater reduction in glycated hemoglobin level with liraglutide 1.8 mg versus lixisenatide 20 μg, leading to reduced incidence and increased time to onset of diabetes-related complications. Compared with lixisenatide 20 μg, liraglutide 1.8 mg was associated with increased total costs over patient lifetimes (€41,623 vs €41,380), but this was offset by lower costs of treating diabetes-related complications (€26,682 vs €27,476). Liraglutide 1.8 mg was associated with an incremental cost-effectiveness ratio of €2001 per QALY gained versus lixisenatide 20 μg. At a willingness-to-pay threshold of €30,000 per QALY gained, liraglutide 1.8 mg had a probability of 77.2% of being cost-effective. IMPLICATIONS Based on long-term projections, liraglutide 1.8 mg is likely to be considered cost-effective compared with lixisenatide 20 μg for the treatment of patients with type 2 diabetes in Italy.
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Affiliation(s)
- Barnaby Hunt
- Ossian Health Economics and Communications, Basel, Switzerland.
| | | | | | | | - Maria C Rossi
- Center for Outcomes Research and Clinical Epidemiology (CORESEARCH), Pescara, Italy
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15
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Gunnarsson C, Ryan MP, Marelli C, Baker ER, Stewart PM, Johannsson G, Biller BMK. Health Care Burden in Patients With Adrenal Insufficiency. J Endocr Soc 2017; 1:512-523. [PMID: 29264506 PMCID: PMC5686625 DOI: 10.1210/js.2016-1064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 04/06/2017] [Indexed: 02/03/2023] Open
Abstract
Objective: This study aimed to estimate the annual health care burden for patients with adrenal insufficiency [AI; primary (PAI), secondary to pituitary disorder (PIT), and congenital adrenal hyperplasia (CAH)] using real-world data. Methods: Using a US-based payer database comprising >108 million members, strict inclusion criteria with diagnostic codes and pharmacy records were used to identify 10,383 patients with AI. This included 1014 patients with PAI, 8818 with PIT, and 551 with CAH, followed for >12 months. Patients were matched 1:1 to controls, based on age (±5 years), sex, insurance, and region. Multivariable expenditure models were estimated for each AI cohort vs controls as well as subsets by glucocorticoid therapy (hydrocortisone, dexamethasone, prednisone, or multiple therapies). A separate multivariable model was estimated to assess the association between adherence and expenditures. Results: Total annual health care expenditure estimates were significantly higher (P < 0.0001) in all AI cohorts compared with matched controls (PAI $18,624 vs $4320, PIT $32,218 vs $6956, CAH $7677 vs $4203). Patients with AI have more frequent inpatient hospital stays with up to eight to 10 times more days in the hospital per year than their matched controls. In each AI cohort, patients on multiple steroid therapies had higher expenditures in comparison with patients using hydrocortisone therapy alone. In PAI and PIT cohorts taking hydrocortisone only, fewer expenditures were found in higher adherence subsets. Conclusion: Patients with AI demonstrate a substantial annual health care burden. Expenditures vary by underlying cause and treatment and are reduced in patients with higher adherence to glucocorticoid replacement.
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Affiliation(s)
- Candace Gunnarsson
- CTI Clinical Trial and Consulting Services Inc., Covington, Kentucky 41011
| | - Michael P Ryan
- CTI Clinical Trial and Consulting Services Inc., Covington, Kentucky 41011
| | | | - Erin R Baker
- CTI Clinical Trial and Consulting Services Inc., Covington, Kentucky 41011
| | - Paul M Stewart
- Medical School, University of Leeds, Leeds LS2, United Kingdom
| | - Gudmundur Johannsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 405 30 Göteborg, Sweden
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Boston, Massachusetts 02114
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