Prescription Patterns and the Cost of Antihyperglycemic Drugs in Patients With Type 2 Diabetes Mellitus in Germany

Uptake of new antidiabetic medicines in 11 European countries

BACKGROUND

Several new antidiabetic medicines (GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT-2 inhibitors) have been approved by the European Medicines Agency since 2006. The aim of this study was to evaluate the uptake of new antidiabetic medicines in European countries over a 10-year period.

METHODS

The study used IQVIA quarterly value and volume sales data January 2006-December 2016. The market uptake of new antidiabetic medicines together with intensity of prescribing policy for all antidiabetic medicines were estimated for Austria, Croatia, France, Germany, Hungary, Italy, Poland, Slovenia, Spain, Sweden, and the United Kingdom. The following measures were determined: number of available new active substances, median time to first continuous use, volume market share, and annual therapy cost.

RESULTS

All countries had at least one new antidiabetic medicine in continuous use and an increase in intensity of prescribing policy for all antidiabetic medicines was observed. A tenfold difference in median time to first continuous use (3-30 months) was found. The annual therapy cost in 2016 of new antidiabetic medicines ranged from EUR 363 to EUR 769. Among new antidiabetic medicines, the market share of DPP-4 inhibitors was the highest. Countries with a higher volume market share of incretin-based medicines (Spain, France, Austria, and Germany) in 2011 had a lower increase in intensity of prescribing policy. This kind of correlation was not found in the case of SGLT-2 inhibitors.

CONCLUSIONS

This study found important differences and variability in the uptake of new antidiabetic medicines in the included countries.

Costs and its drivers for diabetes mellitus type 2 patients in France and Germany: a systematic review of economic studies

BACKGROUND

Type 2 diabetes represents an increasingly critical challenge for health policy worldwide. It absorbs massive resources from both patients and national economies to sustain direct costs of the treatment of type 2 diabetes and its complications and indirect costs related to work loss and wages. More recently, there are innovations based on remote control and personalised programs that promise a more cost-effective diabetes management while reducing diabetes-related complications. In such a context, this work attempts to update cost analysis reviews on type 2 diabetes, focusing on France and Germany, in order to explore most significant cost drivers and cost-saving opportunities through innovations in diabetes care. Although both countries approach care delivery differently, France and Germany represent the primary European markets for diabetes technologies.

METHODS

A systematic review of the literature listed in MEDLINE, Embase and EconLit has been carried out. It covered interventional, observational and modelling studies on expenditures for type 2 diabetes management in France or Germany published since 2012. Included articles were analysed for annual direct, associated and indirect costs of type 2 diabetes patients. An appraisal of study quality was performed. Results were summarised narratively.

RESULTS

From 1260 records, the final sample was composed of 24 papers selected according to predefined inclusion/exclusion criteria. Both France and Germany revealed a predominant focus on direct costs. Comparability was limited due to different study populations and cost categories used. Indirect costs were only available in Germany. According to prior literature, reported cost drivers are hospitalisation, prescriptions, higher HbA1c and BMI, treatment with insulin and complications, all indicators of disease severity. The diversity of available data and included costs limits the results and may explain the differences found.

CONCLUSIONS

Complication prevention and glycaemic control are widely recognized as the most effective ways to control diabetes treatment costs. The value propositions of self-based supports, such as hybrid closed-loop metabolic systems, already implemented in type 1 diabetes management, are the key points for further debates and policymaking, which should involve the perspectives of caregivers, patients and payers.

Costs and where to find them: identifying unit costs for health economic evaluations of diabetes in France, Germany and Italy

BACKGROUND

Health economic evaluations require cost data as key inputs. Many countries do not have standardized reference costs so costs used often vary between studies, thereby reducing transparency and transferability. The present review provided a comprehensive overview of cost sources and suggested unit costs for France, Germany and Italy, to support health economic evaluations in these countries, particularly in the field of diabetes.

METHODS

A literature review was conducted across multiple databases to identify published unit costs and cost data sources for resource items commonly used in health economic evaluations of antidiabetic therapies. The quality of unit cost reporting was assessed with regard to comprehensiveness of cost reporting and referencing as well as accessibility of cost sources from published cost-effectiveness analyses (CEA) of antidiabetic medications.

RESULTS

An overview of cost sources, including tariff and fee schedules as well as published estimates, was developed for France, Germany and Italy, covering primary and specialist outpatient care, emergency care, hospital treatment, pharmacy costs and lost productivity. Based on these sources, unit cost datasets were suggested for each country. The assessment of unit cost reporting showed that only 60% and 40% of CEAs reported unit costs and referenced them for all pharmacy items, respectively. Less than 20% of CEAs obtained all pharmacy costs from publicly available sources.

CONCLUSIONS

This review provides a comprehensive account of available costs and cost sources in France, Germany and Italy to support health economists and increase transparency in health economic evaluations in diabetes.

The present and future scope of real-world evidence research in diabetes: What questions can and cannot be answered and what might be possible in the future?

The last decade has witnessed an exponential growth in the opportunities to collect and link health-related data from multiple resources, including primary care, administrative, and device data. The availability of these "real-world," "big data" has fuelled also an intense methodological research into methods to handle them and extract actionable information. In medicine, the evidence generated from "real-world data" (RWD), which are not purposely collected to answer biomedical questions, is commonly termed "real-world evidence" (RWE). In this review, we focus on RWD and RWE in the area of diabetes research, highlighting their contributions in the last decade; and give some suggestions for future RWE diabetes research, by applying well-established and less-known tools to direct RWE diabetes research towards better personalized approaches to diabetes care. We underline the essential aspects to consider when using RWD and the key features limiting the translational potential of RWD in generating high-quality and applicable RWE. Only if viewed in the context of other study designs and statistical methods, with its pros and cons carefully considered, RWE will exploit its full potential as a complementary or even, in some cases, substitutive source of evidence compared to the expensive evidence obtained from randomized controlled trials.

Trends in antidiabetic drug utilization and expenditure in Denmark: A 22-year nationwide study

AIMS

To examine the nationwide trends in antidiabetic drug utilization and expenditure in Denmark over the past 22 years.

METHODS

Data on antidiabetic use and expenditure from 1996 to 2017 were retrieved from the Register of Medicinal Product Statistics. Antidiabetic drug use is reported as defined daily dose (DDD) in total counts and per 1000 inhabitants/d. Expenditure is reported as volume sold in total counts per 1000 inhabitants and as annual mean expenditure.

RESULTS

Throughout the study period, the total use of antidiabetic drugs increased from 16.4 to 55.8 DDDs per 1000 inhabitants/d, while total expenditure increased from €59 to €286 m. The introduction of glucagon-like peptide-1 receptor agonists (GLP-1RAs), dipeptidyl peptidase-4 inhibitors and sodium-glucose co-transporter-2 inhibitors has, since 2005, led to considerable variation in the proportional use of the different drug classes. Use of insulin and insulin analogues accounted for the majority of the cost of antidiabetic drugs, peaking at 75% in 2008; however, its proportional impact on overall antidiabetic drug expenditure decreased to ~44% in 2017. In contrast, a steep increase in GLP-1RA expenditure was observed from 2010 to 2017, reaching an annual cost of €85 m (~29% of all antidiabetic expenditure).

CONCLUSION

Antidiabetic drug utilization and cost in Denmark has increased considerably over the last 22 years, in accordance with the increased incidence of type 2 diabetes and changes in treatment guidelines. The release of several novel antidiabetic drugs seems to be responsible for the increase in antidiabetic drug expenditure.

The place of gliclazide MR in the evolving type 2 diabetes landscape: A comparison with other sulfonylureas and newer oral antihyperglycemic agents

The sulfonylureas are effective oral glucose-lowering agents with a long history of clinical use. While all have the same general mechanism of action, their pharmacokinetic properties are influenced by factors such as dosage, rate of absorption, duration of action, route of elimination, tissue specificity, and binding affinity for pancreatic β-cell receptor. The result is a class of agents with similar HbA1c-lowering efficacy, but well-documented differences in terms of effects on hypoglycemia, and cardiovascular and renal safety. This review examines the differences between currently available sulfonylureas with a focus on how gliclazide modified release (MR) differs from other members of this class and from newer oral antihyperglycemic agents in the form of dipeptidyl peptidase-4 (DPP4) and sodium- glucose cotransporter 2 (SGLT2) inhibitors. The first part focuses on major outcome trials that have been conducted with the sulfonylureas and new oral agents. Consideration is then given to factors important for day-to-day prescribing including efficacy and durability, weight changes, hypoglycemia, renal effects and cost. Based on current evidence, third-generation sulfonylureas such as gliclazide MR possess many of the properties desired of a type 2 diabetes drug including high glucose-lowering efficacy, once-daily oral administration, few side effects other than mild hypoglycemia, and cardiovascular safety.

Prescription patterns and costs of antidiabetic medications in a large group of patients

AIMS

To determine the prescription patterns of antidiabetic medications and the variables associated with their use in a Colombian population.

METHODS

A cross-sectional study using a systematized database of approximately 3.5 million affiliates of the Colombian Health System. Patients of both genders and all ages treated uninterruptedly with antidiabetic medications for three months (June-August 2015) were included. A database was designed that included sociodemographic, pharmacological, comedication, and cost variables.

RESULTS

A total of 47,532 patients were identified; the mean age was 65.5 years, and 56.3% were women. Among the patients, 56.2% (n=26,691) received medication as monotherapy. The most prescribed medications were metformin, 81.3% (n=38,664), insulins, 33.3% (n=15,848), and sulfonylureas, 21.8% (n=10,370). Among the patients, 92.8% received comedications, including antihypertensives (79.7%), hypolipemiants (65.5%), antiplatelet drugs (56.3%), analgesics (33.9%), antiulcerants (33.1%), and thyroid hormone (17.3%). The cost per 1000 inhabitants/day was $1.21 USD for metformin, $3.89 USD for insulins, and $0.02 USD for glibenclamide.

CONCLUSIONS

Generally, rational prescription habits predominated, however in some cases an overuse of comedications (such as antiulcer drugs) and a large group of patients with high cost formulations were observed. Subsequent effectiveness and cost-benefit analyzes are required.

Low annual frequency of HbA1c testing in people with Type 2 diabetes in primary care practices in Germany

AIMS

To analyse the annual frequency of HbA_1c testing, as well as the factors associated with higher or lower testing frequency, in people with Type 2 diabetes mellitus in general practices and specialist diabetes practices in Germany.

METHODS

A total of 43 509 people diagnosed with Type 2 diabetes between January 2016 and December 2016 in 557 medical practices (51% of all practices) were included in this study. The primary outcome was the annual recorded frequency of HbA_1c testing in 2016. Multivariable logistic regression analyses were performed to identify variables associated with the odds of HbA_1c concentration being tested at least twice in 2016, using predefined demographic and clinical variables.

RESULTS

The mean (sd) number of reported HbA_1c tests was 2.7 (1.6) in 2016. Overall, 74% of individuals had at least two annual HbA_1c measurements. The likelihood of receiving ≥2 HbA_1c tests was inversely associated with stroke (odds ratio 0.81, 95% CI 0.74-0.89), shorter diabetes duration (≤1 year: odds ratio 0.77, 95% CI 0.70-0.84) and higher mean HbA_1c concentration (≥8.5%: odds ratio 0.85, 95% CI 0.76-0.94) and was positively associated with specialist diabetes care (odds ratio 1.24, 95% CI 1.14-1.36), hypertension (odds ratio 1.10, 95% CI 1.04-1.17), hyperlipidaemia (odds ratio 1.48, 95% CI 1.41 to 1.55), renal complications (odds ratio 1.41, 95% CI 1.32 to 1.50), neuropathy (odds ratio 1.27, CI 1.20 to 1.35) and retinopathy (odds ratio 1.38, 95% CI 1.25 to 1.52).

CONCLUSIONS

Only three out of four individuals with Type 2 diabetes underwent at least two HbA_1c tests in Germany in 2016, which means that 25% of individuals underwent fewer tests than required by German guidelines.

Costs of Managing Patients with Diabetes in a Large Health Maintenance Organization in Israel: A Retrospective Cohort Study

INTRODUCTION

The aim of this study was to evaluate the direct costs of patients with diabetes ensured in a large health maintenance organization, Maccabi Health Services (MHS), in order to compare the medical costs of these patients to the medical costs of other patients insured by MHS and to assess the impact of poorly controlled diabetes on medical costs.

METHODS

A retrospective analysis of patients insured in MHS during 2012 was performed. Data were extracted automatically from the electronic database. A glycated hemoglobin (HbA1c) level of >9% (75 mmol/mol) was considered to define poorly controlled diabetes, and that of <7% (53 mmol/mol) and <8% (64 mmol/mol) to define controlled diabetes for patients aged <75 and ≥75 years, respectively. Multivariate analysis analyses were done to assess factors affecting cost.

RESULTS

Data on a total of 99,017 patients with diabetes were obtained from the MHS database for 2012. Of these, 54% were male and 72% were aged 45-75 years. The median annual cost of treating diabetes was 4420 cost units (CU), with hospitalization accounting for 56% of the total costs. The median annual cost per patient in the age groups 35-44 and 75-84 years was 2836 CU and 7033 CU, respectively. Differences between costs for patients with diabetes and those for patients without diabetes was 85% for the age group 45-54 years but only 24% for the age group 75-84 years. Medical costs increased similarly with age for patients with controlled diabetes and those with poorly controlled diabetes costs, as did additional co-morbidities. Costs were significantly impacted by kidney disease. The costs for patients with an HbA1c level of 8.0-8.99% (64-74 mmol/mol) and 9.0-9.99% (75-85 mmol/mol) were 5722 and 5700 CU, respectively. In a multivariate analysis the factors affecting all patients' costs were HbA1C level, male gender, chronic diseases, complications of diabetes, disease duration, and stage of kidney function.

CONCLUSIONS

The direct medical costs of patients with diabetes were significantly higher than those of patients without diabetes. The main drivers of these higher costs were hospitalizations and renal function. In poorly controlled patients the effect of HbA1c on costs was limited. These findings suggest that it is cost effective to identify patients with diabetes early in the course of the disease.

FUNDING

The work was sponsored by internal funds of the authors. Article processing charges for this study was funded by Novo Nordisk.