Impact of atherosclerotic cardiovascular disease on healthcare resource utilization and costs in patients with type 2 diabetes mellitus in a real-world setting

Trends in direct health care costs among US adults with atherosclerotic cardiovascular disease with and without diabetes

OBJECTIVE

Population-based national data on the trends in expenditures related to coexisting atherosclerotic cardiovascular diseases (ASCVD) and diabetes is scarce. We assessed the trends in direct health care expenditures for ASCVD among individuals with and without diabetes, which can help to better define the burden of the co-occurrence of diabetes and ASCVD.

METHODS

We used 12-year data (2008-2019) from the US national Medical Expenditure Panel Survey including 28,144 U.S individuals aged ≥ 18 years. Using a two-part model (adjusting for demographics, comorbidities and time), we estimated mean and adjusted incremental medical expenditures by diabetes status among individuals with ASCVD. The costs were direct total health care expenditures (out-of-pocket payments and payments by private insurance, Medicaid, Medicare, and other sources) from various sources (office-based visits, hospital outpatient, emergency room, inpatient hospital, pharmacy, home health care, and other medical expenditures).

RESULTS

The total direct expenditures for individuals with ASCVD increased continuously by 30% from $14,713 (95% confidence interval (CI): $13,808-$15,619) in 2008-2009 to $19,145 (95% CI: $17,988-$20,301) in 2008-2019. Individuals with diabetes had a 1.5-fold higher mean expenditure that those without diabetes. A key driver of the observed increase in direct costs was prescription drug costs, which increased by 37% among all individuals with ASCVD. The increase in prescription drug costs was more pronounced among individuals with ASCVD and diabetes, in whom a 45% increase in costs was observed, from $5184 (95% CI: $4721-$5646) in 2008-2009 to $7501 (95% CI: $6678-$8325) in 2018-2019. Individuals with ASCVD and diabetes had $5563 (95% CI: $4643-$6483) higher direct incremental expenditures compared with those without diabetes, after adjusting for demographics and comorbidities. Among US adults with ASCVD, the estimated adjusted total direct excess medical expenditures were $42 billion per year among those with diabetes vs. those without diabetes.

CONCLUSIONS

In the setting of ASCVD, diabetes is associated with significantly increased health care costs, an increase that was driven by marked increase in medication costs.

Atherosclerotic Cardiovascular Disease in Type 2 Diabetes: A Retrospective, Observational Study of Economic and Clinical Burden in Sweden

INTRODUCTION

Individuals with type 2 diabetes (T2D) are at high risk of experiencing atherosclerotic cardiovascular disease (ASCVD), which is associated with morbidity, mortality and healthcare resource utilisation. Clinical guidelines recommend the use of glucose-lowering medications with cardiovascular benefits in individuals with T2D and cardiovascular disease, but there is evidence that this is not reflected in clinical practice. We used linked national registry data from Sweden to compare outcomes in people with T2D and ASCVD against matched controls with T2D without ASCVD, over 5 years. Direct costs (inpatient, outpatient and selected drug costs), indirect costs resulting from work absence, early retirement, cardiovascular events and mortality were examined.

METHODS

Individuals with T2D who were at least 16 years old and were alive and resident in Sweden on 1 January 2012 were identified in an existing database. In four separate analyses, individuals with a record indicating ASCVD according to a broad definition, peripheral artery disease (PAD), stroke or myocardial infarction (MI) before 1 January 2012 were identified using diagnosis and/or procedure codes and propensity score matched 1:1 to controls with T2D and without ASCVD, using covariates for birth, sex and level of education in 2012. Follow-up continued until death, migration from Sweden or the end of the study period in 2016.

RESULTS

In total, 80,305 individuals with ASCVD, 15,397 individuals with PAD, 17,539 individuals with previous stroke and 25,729 individuals with previous MI were included. Total mean annual costs per person were €14,785 for PAD (2.7 × costs for controls), €11,397 for previous stroke (2.2 × controls), €10,730 for ASCVD (1.9 × controls) and €10,342 for previous MI (1.7 × controls). Indirect costs and costs of inpatient care were the major cost drivers. ASCVD, PAD, stroke and MI were all associated with an increased likelihood of early retirement, cardiovascular events and mortality.

CONCLUSIONS

ASCVD is associated with considerable costs, morbidity and mortality in individuals with T2D. These results support structured assessment of ASCVD risk and broader implementation of guideline-recommended treatments in T2D healthcare.

Prediction Models for Individual-Level Healthcare Costs Associated with Cardiovascular Events in the UK

OBJECTIVES

The aim of this study was to develop prediction models for the individual-level impacts of cardiovascular events on UK healthcare costs.

METHODS

In the UK Biobank, people 40-70 years old, recruited in 2006-2010, were followed in linked primary (N = 192,983 individuals) and hospital care (N = 501,807 individuals) datasets. Regression models of annual primary and annual hospital care costs (2020 UK£) associated with individual characteristics and experiences of myocardial infarction (MI), stroke, coronary revascularization, incident diabetes mellitus and cancer, and vascular and nonvascular death are reported.

RESULTS

For both people without and with previous cardiovascular disease (CVD), primary care costs were modelled using one-part generalised linear models (GLMs) with identity link and Poisson distribution, and hospital costs with two-part models (part 1: logistic regression models the probability of incurring costs; part 2: GLM with identity link and Poisson distribution models the costs conditional on incurring any). In people without previous CVD, mean annual primary and hospital care costs were £360 and £514, respectively. The excess primary care costs were £190 and £360 following MI and stroke, respectively, whereas excess hospital costs decreased from £4340 and £5590, respectively, in the year of these events, to £190 and £410 two years later. People with previous CVD had more than twice higher annual costs, and incurred higher excess costs for cardiovascular events. Other characteristics associated with higher costs included older age, female sex, south Asian ethnicity, higher socioeconomic deprivation, smoking, lower level of physical activities, unhealthy body mass index, and comorbidities.

CONCLUSIONS

These individual-level healthcare cost prediction models could inform assessments of the value of health technologies and policies to reduce cardiovascular and other disease risks and healthcare costs. An accompanying Excel calculator is available to facilitate the use of the models.

A cross-sectional study of the prevalence and clinical management of atherosclerotic cardiovascular diseases in patients with type 2 diabetes across the Middle East and Africa (PACT-MEA): Study design and rationale

AIM

To investigate the epidemiology and clinical management of patients with type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease (eASCVD) or high/very high ASCVD risk, defined by the 2021 European Society of Cardiology Guidelines, in seven countries in the Middle East and Africa (PACT-MEA; NCT05317845), and to assess physicians' attitudes and the basis for their decision-making in the management of these patients.

MATERIALS AND METHODS

PACT-MEA is a cross-sectional, observational study undertaken in Bahrain, Egypt, Jordan, Kuwait, Qatar, South Africa and the United Arab Emirates based on a medical chart review of approximately 3700 patients with T2D in primary and secondary care settings, and a survey of approximately 400 physicians treating patients with T2D.

RESULTS

The primary and secondary objectives are to determine the prevalence of eASCVD and high/very high ASCVD risk in patients with T2D. Current treatment with cardioprotective antidiabetic medication, the proportion of patients meeting the treatment criteria for reimbursement in the study countries where there is an applicable reimbursement guideline, and physician-reported factors in clinical decision-making in T2D management, will also be assessed.

CONCLUSIONS

This large cross-sectional study will establish the estimated prevalence and management of eASCVD and high/very high ASCVD risk in patients with type 2 diabetes across the Middle East and Africa.

Type 2 diabetes and cardiovascular disease: risk reduction and early intervention

People with type 2 diabetes (T2D) have a higher risk of cardiovascular (CV) disease (CVD) than those without. This increased risk begins with pre-diabetes, potentially 7-10 years before T2D is diagnosed. Selecting medication for patients with T2D should focus on reducing the risk of CVD and established CVD. Within the last decade, several antihyperglycemic agents with proven CV benefit have been approved for the treatment of hyperglycemia and for the prevention of primary and secondary CV events, including glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose cotransporter-2 inhibitors. T2D treatment guidelines recommend that an antihyperglycemic agent with proven CV benefit should be used after metformin in patients with high risk of or established CVD, regardless of glycated hemoglobin levels. Despite the availability of antihyperglycemic agents with proven CV benefit, and guidelines on when to use them, less than one in four patients with T2D and CVD receive this type of therapy. These findings suggest a potential gap between current recommendations and clinical practice. This article reviews the approved agents with CV indications, with a focus on injectable GLP-1RAs, and their place in the T2D treatment paradigm according to current guidelines. We aim to provide primary healthcare providers with in-depth information on subsets of patients who would benefit from this type of therapy and when it should be initiated, taking into consideration safety and tolerability and other disease factors. An individualized treatment approach is increasingly recommended in the management of T2D, employing a shared decision-making strategy between patients and healthcare professionals.

Healthcare costs associated with comorbid cardiovascular and renal conditions among persons with diabetes, 2008-2019

BACKGROUND

There is paucity of data examining healthcare costs among persons with comorbid diabetes and cardiorenal conditions.

OBJECTIVE

To elucidate the longitudinal trends and quantify the incremental healthcare costs associated with the following cardiorenal conditions: atherosclerotic cardiovascular disease (ASCVD), heart failure (HF), and kidney disease, among persons with diabetes.

METHODS

Medical Expenditure Panel Survey data (2008-2019) were used to identify adults with diabetes and comorbid cardiorenal conditions. Overall, medical and pharmaceutical costs were ascertained (in 2019 US dollars). Analyses were adjusted for 14 variables using a two-part regression model.

RESULTS

Among 32,519 adults with diabetes, the mean (standard error [SE]) annual healthcare costs were $13,829 ($213), with medical and prescription components contributing $9301 ($172) and $4528 ($98), respectively. Overall healthcare costs rose by 26.8% from $12,791 (2008-2009) to $16,215 (2018-2019) over the study period, driven by 42.5% and 20.3% increase in pharmaceutical and medical spending, respectively. Similar trends were observed for subgroup of persons with cardiorenal conditions. Compared to their counterparts without cardiorenal conditions and prior to adjustment, persons with ASCVD, HF and kidney disease incurred healthcare costs that were approximately 2.2, 3.3, and 2.7 times greater. After adjustment, comorbid ASCVD, HF and kidney disease were associated with annual excess spending of $8651 (95% CI $7729-$9573), $9373 (95% CI $9010-$9736), and $9995 (95% CI $8781-$11,209), respectively.

CONCLUSIONS

Study results are generalizable to non-institutionalized US persons. Healthcare costs associated with the management of diabetes are high-especially among those with comorbid cardiorenal conditions, and have risen in recent years.

Impact of cardiovascular disease on health care economic burden and resource utilization: a retrospective cohort study in adults in the United States with type 2 diabetes with or without stroke, myocardial infarction, and peripheral arterial disease

OBJECTIVES

To evaluate incidence of stroke, myocardial infarction (MI), and peripheral artery disease (PAD) in patients with type 2 diabetes mellitus (T2DM) and assess associated health care resource utilization (HCRU) and costs in the United States.

METHODS

Patients ≥18 years of age with a T2DM diagnosis, with or without incident stroke/MI/PAD, were indexed between 1 January 2012 and 31 December 2020, from the deidentified Optum Clinformatics Data Mart claims database. Incidence of stroke, MI, and PAD was evaluated in the year following T2DM. HCRU and costs were measured in the 12 months following study entry in patients with T2DM + stroke, T2DM + MI, and T2DM + PAD (experimental cohorts) and compared to HCRU and costs in patients with T2DM alone (control cohorts).

RESULTS

Incidence of stroke, MI, and PAD in patients with T2DM was 0.9% (n = 16,034), 0.7% (n = 13,681), and 4.1% (n = 68,479), respectively. Compared to matched patients with T2DM alone, patients with T2DM + stroke/MI/PAD had significantly higher total healthcare costs in the year post-index date (T2DM + stroke: +$5962 per patient per month [PPPM]; T2DM + MI: +$7932 PPPM; T2DM + PAD: +$2652 PPPM; p < .05). Patients with T2DM + stroke/MI/PAD had significantly higher mean HCRU than patients without stroke/MI/PAD in all categories measured.

CONCLUSION

Having stroke, MI, or PAD was associated with increases in HCRU and costs in patients with T2DM. Although PAD was associated with smaller per patient increases in total healthcare costs than patients with T2DM + stroke/MI, the higher frequency of incident PAD may make it more costly than MI or stroke in a large population of patients with T2DM.

Healthcare costs and hospitalizations in US patients with type 2 diabetes and cardiovascular disease: A retrospective database study (OFFSET)

AIM

To investigate the budget implications of treatment with glucagon-like peptide-1 receptor agonists (GLP-1 RAs) versus other glucose-lowering treatment (here termed 'standard of care' [SoC]) during 2012-2019.

MATERIALS AND METHODS

GLP-1 RA-naïve adults with type 2 diabetes (T2D) in the IBM MarketScan database with at least one glucose-lowering medication claim within 6 months after their first cardiovascular disease (CVD) hospitalization were included (index date was the date of first claim for a GLP-1 RA for the GLP-1 RA group, and the date of the first claim, independent of medication type, for the SoC group). Monthly healthcare costs and hospitalization risk over 12 months postindex date were compared for those who initiated a GLP-1 RA posthospitalization versus those with a claim for any other glucose-lowering medication.

RESULTS

Postindex date, mean observed total costs were lower for patients receiving a GLP-1 RA compared with SoC ($3853 vs. $4288). In adjusted analysis, both groups had similar total healthcare costs (P = .56). This was driven by significantly lower inpatient and outpatient costs and higher drug costs in the GLP-1 RA group compared with SoC (P < .001). Risks of all-cause (adjusted hazard ratio: 0.85) and CVD-related hospitalization (0.76) were significantly lower in the GLP-1 RA group compared with SoC (P < .001). Similar results were observed in a subgroup with atherosclerotic CVD.

CONCLUSIONS

These findings suggest that, in US patients with T2D and a CVD-related hospitalization, the added medical cost of treatment with GLP-1 RAs is offset by lower inpatient and outpatient care costs, resulting in budget neutrality against SoC.

Profile of cardiovascular disease risk in type 2 diabetes mellitus patients receiving statin therapy: A cross-sectional study

Background

Cardiovascular disease is still the number 1 cause of death globally. Meanwhile, type 2 diabetes mellitus (T2DM) is a risk factor for atherosclerosis vascular disease (ASCVD), so an assessment using Framingham Risk Score (FRS) is needed to predict the risk of ASCVD in the future.

Objective

Analyzing the risk factor of ASCVD using the Framingham Risk Score (FRS) in T2DM patients.

Methods

This study was conducted from July 2020 to July 2021, which the participants were measured for FRS including age, gender, current smoking, diabetes, blood pressure (systolic), high-density lipoprotein (HDL) cholesterol, total cholesterol (TC), and ASCVD risk score. The analysis employed multiple linear tests and ANOVA tests with p < 0.05.

Results

Several ASCVD risk factors in T2DM patients were found, including gender (t = 6.015; p < 0.001), age (t = 6.901; p < 0.001), HDL level (t = 2.287; p = 0.024), CT level (t = 5.273; p < 0.001), blood pressure (t = 5.850; p < 0.001), and current smoking (t = 2.638; p = 0.009). The results of analysis between ASCVD risk factor and level of ASCVD risk obtained a significant association (F = 36,642; p < 0.001).

Conclusion

Risk factors of ASCVD in T2DM patients such as gender, age, HDL level, CT level, blood pressure, and current smoking.

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Risk factors of ASCVD include gender, age, HDL level, CT level, blood pressure, and current smoking in T2DM patients.

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Significant ASCVD risk factors are age, gender, TC level, and blood pressure.

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The Framingham Risk Score is used to predict ASCVD in T2DM patients in the next 10 years.

Risk of early mortality and cardiovascular disease according to the presence of recently diagnosed diabetes and requirement for insulin treatment: A nationwide study

AIMS/INTRODUCTION

We estimated the hazards of cardiovascular diseases (CVDs) and early all-cause mortality in Korean adults according to the presence of recently diagnosed type 2 diabetes (type 2 diabetes for <5 years) and insulin use.

MATERIALS AND METHODS

We used the Korean National Health Insurance Service-National Sample Cohort database (2002-2015) for this longitudinal population-based study. Among adults aged ≥40 years without baseline CVD, individuals without diabetes or with recently diagnosed type 2 diabetes were selected (N = 363,919). The hazard ratios (HRs) for myocardial infarction (MI), stroke, and all-cause mortality during follow-up were analyzed according to three groups categorized by the presence of type 2 diabetes and insulin use.

RESULTS

Within a mean 7.8 years, there were 5,275 MIs, 7,220 strokes, and 15,834 deaths. The hazards for outcomes were higher in the insulin-treated type 2 diabetes group than in the non-diabetes group [HR (95% CI): 2.344 (1.870-2.938) for MI, 2.420 (1.993-2.937) for stroke, and 3.037 (2.706-3.407) for death], higher in the non-insulin-treated type 2 diabetes group than in the non-diabetes group [HR (95% CI): 1.284 (1.159-1.423) for MI, 1.435 (1.320-1.561) for stroke, and 1.135 (1.067-1.206) for death], and higher in the insulin-treated type 2 diabetes group than in the non-insulin-treated type 2 diabetes group [HR (95% CI): 1.914 (1.502-2.441) for MI, 1.676 (1.363-2.060) for stroke, and 2.535 (2.232-2.880) for death].

CONCLUSIONS

Recently diagnosed type 2 diabetes patients showed increased risks of incident CVDs and premature mortality, and insulin-treated group demonstrated an additional increase in the risks of these outcomes in adults with recently diagnosed type 2 diabetes, suggesting the need for intensified cardio-protective interventions for adults with insulin-treated type 2 diabetes.

Association between atherosclerotic cardiovascular disease risk score estimated by pooled cohort equation and coronary plaque burden as assessed by NaF-PET/CT

Pooled Cohort Equations (PCE) combines metabolic and non-metabolic parameters to predict the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). Therefore, we hypothesize that ASCVD risk score is correlated to global cardiac microcalcification, as assessed by 18F-sodium fluoride-positron emission tomography/computed tomography (NaF-PET/CT). Sixty-one individuals (53.4±8.9 years, 32 females, 100% Caucasian) without known ASCVD underwent NaF-PET/CT imaging. Global cardiac average SUVmean (aSUVmean), also known as the Alavi-Carlsen Calcification Score, was calculated across manually defined regions of interest on each axial slice for each individual. The 10-year ASCVD risk score was determined for each individual using the PCE as per ACC/AHA guidelines, and then individuals were categorized into low-, borderline-, intermediate-, and high-risk groups based on their score. Linear regression analysis was applied to compare each individual's ASCVD score and aSUVmean. Global cardiac aSUVmean stratified by groups estimated by 10-year ASCVD risk score were 0.67±0.09 for low risk (n=32), 0.70±0.11 for borderline risk (n=10), 0.72±0.10 for intermediate risk (n=17), and 0.78±0.10 for high risk (n=2). ASCVD risk score was significantly correlated to aSUVmean (r=0.27, P=0.03). This is among the first studies to compare ASCVD risk scores to cardiac plaque burden as assessed by NaF-PET/CT. Large, prospective studies are needed to further investigate the potential of NaF uptake in ASCVD.

Healthcare Costs of Diabetes and Microvascular and Macrovascular Disease in Individuals with Incident Type 2 Diabetes Mellitus: A Ten-Year Longitudinal Study

OBJECTIVE

The objective of this study was to estimate the incremental long-term costs associated with T2DM attributable to vascular diseases.

RESEARCH DESIGN AND METHODS

This retrospective cohort study identified newly diagnosed (incident) T2DM patients in 2007 (baseline to 01/01/2006) using the HealthCore Integrated Research Database, a repository of nationally representative claims data. Incident T2DM patients were 1:1 exact matched on age, gender and other factors of interest to non-DM patients, and followed until the earlier of 8 follow-up years or death. Patients with documented vascular disease diagnosis were identified during the study period. All-cause and T2DM/vascular disease-related annual healthcare costs were examined for each follow-up year.

RESULTS

The study included 13,883 individuals with T2DM and matched non-DM controls. Among individuals with T2DM, 11,792 (85%) had vascular disease versus 9251 (66.6%) non-T2DM between 01/01/2006 and 12/31/2015. Among T2DM patients, mean all-cause annual costs were greater than in non-T2DM patients ($13,806 vs $7,243, baseline, $21,745 vs $8,524, post-index year 1, $12,756-$14,793 vs $8,349-$9,940 years 2-8, p< 0.001), respectively. A similar trend was observed for T2DM/vascular disease-related costs (p< 0. 001). T2DM/vascular disease-related costs were largest during post-index year 1, accounting for the majority of all-cause cost difference between T2DM patients and matched non-DM controls. Incident T2DM individuals without vascular disease at any time had significantly lower costs compared to non-DM controls (p< 0. 001) between years 2-8 of follow-up.

CONCLUSION

Vascular disease increased the cost burden for individuals with T2DM. The cost impact of diabetes and vascular disease was highest in the year after diagnosis, and persisted for at least seven additional years, while the cost of T2DM patients without vascular disease trended lower than for matched non-DM patients. These data highlight potential costs that could be offset by earlier and more effective detection and management of T2DM aimed at reducing vascular disease burden.

Disease Burden and Healthcare Costs for T2D Patients With and Without Established Cardiovascular Disease in Sweden: A Retrospective Cohort Study

INTRODUCTION

Type 2 diabetes (T2D) is a complex chronic disease with an increasing prevalence worldwide. It is commonly associated with complications, such as cardiovascular disease (CVD). Patients with both T2D and established CVD are exposed to increased risk of further cardiovascular events, which means increased healthcare costs and impairments to quality of life and survival. To determine the added burden of CVD for T2D patients, we have analyzed the consumption and costs of healthcare and mortality in two T2D patient cohorts, with and without established CVD, respectively, during a 5-year follow-up in a Swedish region.

METHODS

Patients with T2D on 1 January 2012 were identified using the administrative database of Region Östergötland and the Swedish National Diabetes Register. Established CVD was defined as the presence of a CVD-related healthcare visit in the period 2002-2011. Identified T2D patients were then followed retrospectively for 5 years (2012-2016) and data collected on utilization of healthcare resources, healthcare costs, and survival. Data pertinent to the study were retrieved from regional databases and national registries.

RESULTS

On the index date (1 January 2012) there were 19,731 patients with T2D (prevalence 4.5%) in Region Östergötland, of whom 5490 had established CVD. Those patients with established CVD were older, more often men, and had longer diabetes duration and worse kidney function than those without. Compared to T2D patients without CVD, those with CVD had a significantly higher healthcare consumption, experienced higher costs, and had lower survival during the follow-up.

CONCLUSION

This study confirms that established CVD is common among patients with T2D (approximately 30%). Established CVD has negative effects on the utilization of healthcare resources, healthcare costs, and mortality. It is therefore very important to improve the treatment strategy of this patient group.

The prevalence of cardiovascular disease by vascular bed and impact on healthcare costs in a large, real-world population with type 2 diabetes

INTRODUCTION

The purpose of this study was to assess prevalence of atherosclerotic cardiovascular disease (ASCVD) according to number of affected vascular beds and the impact on healthcare utilization and costs in persons with type 2 diabetes mellitus (type 2 DM) and established ASCVD.

METHODS

In this retrospective, cross-sectional analysis, adults with type 2 DM and ASCVD in a large US administrative claims database were categorized by number of ASCVD-affected vascular beds (brain, heart, peripheral vasculature). Annual healthcare utilization and costs for 2015 were determined, including subgroup analyses by age group (18-44, 45-64, ≥65 years).

RESULTS

Among 539 089 individuals with type 2 DM and ASCVD, 47.0% had ASCVD affecting >1 vascular bed. The most prevalent ASCVD diagnoses were acute coronary syndrome (26.6%), peripheral arterial disease (24.5%) and stroke (18.6%). Mean annual total healthcare costs per person increased with increasing number of vascular beds, from 1 ($17 741) to 2 ($25 877) to 3 ($33 412). A similar pattern of increased healthcare utilization with increasing number of vascular beds was observed. Among individuals with 1 affected vascular bed, mean total healthcare costs per person were comparable across age subgroups; however, if >1 vascular bed was affected, the mean total healthcare costs were highest in the youngest age cohort.

CONCLUSIONS

These real-world data showed that almost half of individuals with type 2 DM and ASCVD had ASCVD affecting >1 vascular bed. A higher number of affected vascular beds were associated with higher mean total healthcare costs and utilization, with a disproportionate increase noted in younger relative to older people.