Cost-Related Medication Nonadherence in Adults With Diabetes in the United States: The National Health Interview Survey 2013-2018

Cost-related medication nonadherence in adults with hypertension in the USA: implications for healthcare quality

BACKGROUND

Hypertension is a significant risk factor for cardiovascular diseases, and it contributed to 685 875 deaths in 2022 in the United States. While antihypertensive medications are effective, cost-related medication non-adherence (CRN) can hinder treatment. This study examined CRN among adults with hypertension, comparing older (≥65 years) and younger (18-64 years) individuals.

METHODS

This analytical cross-sectional study utilized data from the National Health Interview Survey Sample from 2019 to 2022. Inclusion criteria involved responding yes to the question 'Have you ever been told by a doctor or health professional that you have hypertension?' and 'Are you currently taking medications for hypertension?'. Participants who lacked responses to any relevant questions were excluded (n = 4441). Participants were stratified into two age groups: 18-64 years old and ≥65 years old. CRN was determined based on measures such as skipping doses, taking less medication, delaying prescription refills, and forgoing medication due to the cost for any medication. Covariates included age, race, ethnicity, sex, insurance status, financial hardship, comorbidities, and geographical region. Unadjusted and adjusted logistic regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Of 48 559 hypertensive adults, there was a higher percentage of men in the 18-64 years age group compared with the group aged over 65 (51% vs 46%, P-value < .001). In addition, most women (54.0%) were over 65, compared with 48.6% in women between age 18 and 64 years (P-value < .001). Women aged 18-64 years more likely (adjusted odds ratio (aOR) 1.44; 95% CI 1.18, 1.75) to experience CRN than men. Notably, uninsured individuals in both the 18-64 (aOR 2.21; 95% CI 1.51, 3.25) and ≥ 65 (aOR 5.55; 95% CI 1.36, 22.75) age groups were at increased risk of facing CRN.

CONCLUSION

To mitigate CRN, health quality strategies like prescribing generics, connecting patients with assistance programs, and implementing policies to reduce out-of-pocket costs are essential.

Cost-related non-adherence in US adults with heart failure: a repeated cross-sectional analysis of the medical expenditure panel survey, 2012 to 2021

OBJECTIVES

To investigate the prevalence and potential determinants of cost-related non-adherence (CRNA) in US adults with heart failure (HF).

DESIGN

A serial cross-sectional analysis using nationally representative data from 2012 to 2021 of the US Medical Expenditure Panel Survey.

SETTING

Population-based.

PARTICIPANTS

Adult participants with HF diagnosis.

OUTCOME MEASURES

Self-report of never getting or delaying getting prescription medicine because of costs.

RESULTS

We included 1753 patients with HF (mean age 69.36 [95% CI, 68.23 to 70.48]) years, 47.85% men and 17.09% non-Hispanic Black. The overall weighted prevalence of CRNA was 7.94% (6.40-9.81), increasing from 3.09% (1.29-7.24) in 2012 to 13.69% (8.99-20.32) in 2018 and decreasing to 8.71% (3.82-18.67) in 2021. The prevalence of CRNA was higher among patients <65 years than those ≥65 years (11.78% vs 6.04%), and was more prevalent among patients with lower family income, with no insurance or public insurance, and with a greater comorbidity burden. The highest prevalence of CRNA was found among uninsured patients (18.54 [8.01-37.30]). Among patients <65 years, patients with CRNA had significantly lower utilisation of sodium glucose cotransporter-2 inhibitors and slightly lower use of beta blockers and ACEi/ARBs. The out-of-pocket cost for medication was higher among those with CRNA, especially cost on central nervous system medicines.

CONCLUSIONS

CRNA was prevalent among patients with HF, disproportionately affecting those younger than 65 years, with lower socioeconomic status, and higher comorbidity burden. Interventions are needed to reduce financial burden and enhance medication adherence.

Comparison of Dose Escalation Versus Switching to Tirzepatide Among People With Type 2 Diabetes Inadequately Controlled on Lower Doses of Dulaglutide : A Randomized Clinical Trial

BACKGROUND

Tirzepatide, a once-weekly glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist approved for the treatment of adults with type 2 diabetes or obesity, showed clinically meaningful reductions in hemoglobin A1c (HbA1c) and body weight in the SURPASS phase 3 clinical trial program.

OBJECTIVE

To compare efficacy and safety of escalation of dulaglutide dose versus switching to tirzepatide in inadequately controlled type 2 diabetes.

DESIGN

Multicenter, randomized, open-label, phase 4 trial (SURPASS-SWITCH [A Phase 4, Randomized, Open-Label, Active-Controlled Study to Investigate the Efficacy and Safety of Switching from Weekly Dulaglutide to Weekly Tirzepatide in Adults with Type 2 Diabetes], ClinicalTrials.gov: NCT05564039).

SETTING

38 sites across 5 countries.

PARTICIPANTS

Adults with HbA1c 7.0% or greater to 9.5% or less, stable body weight, body mass index of 25 kg/m2 or greater, receiving a stable dose of dulaglutide (0.75 or 1.5 mg) for at least 6 months and 0 to 3 oral antihyperglycemic medications for at least 3 months.

INTERVENTION

Escalation of dulaglutide to 4.5 mg or maximum tolerated dose (MTD) or switching to tirzepatide.

MEASUREMENTS

The primary end point was change from baseline in HbA1c at week 40. The key secondary end point was change from baseline in weight at week 40.

RESULTS

A total of 282 adults were randomly assigned to tirzepatide (n = 139) or dulaglutide (n = 143). Change from baseline in HbA1c at week 40 was -1.44% (SE, 0.07) with tirzepatide, 15 mg or MTD, and -0.67% (SE, 0.08) with dulaglutide, 4.5 mg or MTD (estimated treatment difference, -0.77% [95% CI, -0.98% to -0.56%; P < 0.001]). Change from baseline in weight at week 40 was -10.5 kg (SE, 0.5) with tirzepatide and -3.6 kg (SE, 0.5) with dulaglutide (estimated treatment difference, -6.9 kg [CI, -8.3 to -5.5 kg; P < 0.001]). Serious adverse events were reported by 10 (7.2%) tirzepatide and 10 (7.0%) dulaglutide participants. The most common treatment-emergent adverse events were nausea and diarrhea.

LIMITATION

Open-label design.

CONCLUSION

In SURPASS-SWITCH, switching treatment to tirzepatide provided additional HbA1c reduction and weight loss compared with escalating treatment with dulaglutide.

PRIMARY FUNDING SOURCE

Eli Lilly and Company.

Stakeholder perspectives on facilitators and barriers to implementing a zero-dollar copay program for chronic conditions study

BACKGROUND

Type 2 diabetes mellitus (T2D) remains a pressing public health concern. Despite advancements in antidiabetic medications, suboptimal medication adherence persists among many individuals with T2D, often due to the high cost of medications. To combat this issue, Blue Cross and Blue Shield of Louisiana (Blue Cross) introduced the $0 Drug Copay (ZDC) program, providing $0 copays for select drugs. This study sought to explore barriers and facilitators to the successful implementation of Blue Cross's ZDC program (updated version).

METHODS

Focus group discussions and interviews were conducted with health plan leadership, health coaches and providers who participate in the health plan organization's healthcare quality improvement program. Focus group discussions and semi-structured interviews were conducted between October 2022 and July 2023. Discussion guides were developed collaboratively and tailored to each participant group. Interviews were recorded, transcribed and analysed using NVivo® qualitative analysis software. A descriptive, qualitative analysis was conducted, resulting in the identification of seven codes and subsequent candidate themes.

RESULTS

In total, 15 participants were interviewed: 6 were Blue Cross administrators, 5 were health coaches and 4 were Quality Blue providers. Overall, participants had positive feedback on the ZDC program and perceived that it has significant benefits for patients and the health system but could be improved, and four themes related to implementation barriers and facilitators, effectiveness and potential areas of improvement were identified: (1) the ZDC program reduces friction for patients, prescribers and the health system; (2) the program is aligned with the values of health systems, insurers and providers, facilitating implementation success; (3) expanding coverage (drug classes and conditions) and education (for providers and patients) could maximize program benefits; and (4) coronavirus disease 2019 (COVID-19) did not negatively impact program administration because the $0 copay was programmed at the benefit level.

CONCLUSIONS

The ZDC program aligns goals and can benefit patients, providers and patients. The program can have the largest potential if it is expanded to include new medications and new conditions, and if there is more education for patients and providers. Regardless of challenges, reduced-copay programs have the potential to improve medication adherence, improve HbA1C control and improve overall health outcomes. Trial Registration This study was approved by the Tulane University Institutional Review Board, IRB #2020-1986.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Ebekozien O, Echouffo-Tcheugui JB, Ekhlaspour L, Garg R, Khunti K, Lal R, Lingvay I, Matfin G, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Bannuru RR. 1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Medication adherence and related factors among older adults with type 2 diabetes who use home health care

Medication adherence is important for diabetes management, to reduce complications and mortality. Home health care (HHC) has been recognized as a solution for medication adherence, because it provides easy community access and implementation of interventions. However, little is known about the relationship between HHC and medication adherence. Therefore, this study aimed to identify medication adherence and associated factors among older adults receiving HHC for type 2 diabetes, analyzing dispensing records in South Korea. The patients' average medication possession ratio was 88.5 %, with 64.6 % categorized as the adherence group. Factors affecting medication adherence included the number of HHC advanced practice nurses with specific certifications, out-of-pocket medication costs, sex, age, residence, dementia or cognitive impairment, the number of concomitant medications, and the Charlson Comorbidity Index. Notably, a higher number of HHC advanced practice nurses with specific certifications were significantly associated with adherence, suggesting that HHC could be an alternative approach to enhance medication adherence.

Burden of disease scenarios by state in the USA, 2022-50: a forecasting analysis for the Global Burden of Disease Study 2021

BACKGROUND

The capacity to anticipate future health issues is important for both policy makers and practitioners in the USA, as such insights can facilitate effective planning, investment, and implementation strategies. Forecasting trends in disease and injury burden is not only crucial for policy makers but also garners substantial interest from the general populace and leads to a better-informed public. Through the integration of new data sources, the refinement of methodologies, and the inclusion of additional causes, we have improved our previous forecasting efforts within the scope of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to produce forecasts at the state and national levels for the USA under various possible scenarios.

METHODS

We developed a comprehensive framework for forecasting life expectancy, healthy life expectancy (HALE), cause-specific mortality, and disability-adjusted life-years (DALYs) due to 359 causes of disease and injury burden from 2022 to 2050 for the USA and all 50 states and Washington, DC. Using the GBD 2021 Future Health Scenarios modelling framework, we forecasted drivers of disease, demographic drivers, risk factors, temperature and particulate matter, mortality and years of life lost (YLL), population, and non-fatal burden. In addition to a reference scenario (representing the most probable future trajectory), we explored various future scenarios and their potential impacts over the next several decades on human health. These alternative scenarios comprised four risk elimination scenarios (including safer environment, improved behavioural and metabolic risks, improved childhood nutrition and vaccination, and a combined scenario) and three USA-specific scenarios based on risk exposure or attributable burden in the best-performing US states (improved high adult BMI and high fasting plasma glucose [FPG], improved smoking, and improved drug use [encompassing opioids, cocaine, amphetamine, and others]).

FINDINGS

Life expectancy in the USA is projected to increase from 78·3 years (95% uncertainty interval 78·1-78·5) in 2022 to 79·9 years (79·5-80·2) in 2035, and to 80·4 years (79·8-81·0) in 2050 for all sexes combined. This increase is forecasted to be modest compared with that in other countries around the world, resulting in the USA declining in global rank over the 2022-50 forecasted period among the 204 countries and territories in GBD, from 49th to 66th. There is projected to be a decline in female life expectancy in West Virginia between 1990 and 2050, and little change in Arkansas and Oklahoma. Additionally, after 2023, we projected almost no change in female life expectancy in many states, notably in Oklahoma, South Dakota, Utah, Iowa, Maine, and Wisconsin. Female HALE is projected to decline between 1990 and 2050 in 20 states and to remain unchanged in three others. Drug use disorders and low back pain are projected to be the leading Level 3 causes of age-standardised DALYs in 2050. The age-standardised DALY rate due to drug use disorders is projected to increase considerably between 2022 and 2050 (19·5% [6·9-34·1]). Our combined risk elimination scenario shows that the USA could gain 3·8 additional years (3·6-4·0) of life expectancy and 4·1 additional years (3·9-4·3) of HALE in 2050 versus the reference scenario. Using our USA-specific scenarios, we forecasted that the USA could gain 0·4 additional years (0·3-0·6) of life expectancy and 0·6 additional years (0·5-0·8) of HALE in 2050 under the improved drug use scenario relative to the reference scenario. Life expectancy and HALE are likewise projected to be 0·4-0·5 years higher in 2050 under the improved adult BMI and FPG and improved smoking scenarios compared with the reference scenario. However, the increases in these scenarios would not substantially improve the USA's global ranking in 2050 (from 66th of 204 in life expectancy in the reference scenario to 63rd-64th in each of the three USA-specific scenarios), indicating that the USA's best-performing states are still lagging behind other countries in their rank throughout the forecasted period. Regardless, an estimated 12·4 million (11·3-13·5) deaths could be averted between 2022 and 2050 if the USA were to follow the combined scenario trajectory rather than the reference scenario. There would also be 1·4 million (0·7-2·2) fewer deaths over the 28-year forecasted period with improved adult BMI and FPG, 2·1 million (1·3-2·9) fewer deaths with improved exposure to smoking, and 1·2 million (0·9-1·5) fewer deaths with lower rates of drug use deaths.

INTERPRETATION

Our findings highlight the alarming trajectory of health challenges in the USA, which, if left unaddressed, could lead to a reversal of the health progress made over the past three decades for some US states and a decline in global health standing for all states. The evidence from our alternative scenarios along with other published studies suggests that through collaborative, evidence-based strategies, there are opportunities to change the trajectory of health outcomes in the USA, such as by investing in scientific innovation, health-care access, preventive health care, risk exposure reduction, and education. Our forecasts clearly show that the time to act is now, as the future of the country's health and wellbeing-as well as its prosperity and leadership position in science and innovation-are at stake.

FUNDING

Bill & Melinda Gates Foundation.

Estimating the economic impact of blister-packaging on medication adherence and health care costs for a Medicare Advantage health plan

BACKGROUND

Medication nonadherence is a persistent challenge in the United States, leading to increased health care resource utilization (HCRU) and health care costs and worsened health outcomes. Medicare Star Ratings is a program developed by the Centers for Medicare and Medicaid Services (CMS) to evaluate Medicare health plan quality and performance. Three of the Medicare Part D Star Ratings quality measures assess medication adherence, showing the importance CMS places on improving medication adherence in older adults. Although a variety of medication adherence-enhancing interventions are available to help promote adherence among patients, one intervention that has shown success historically is blister-packaging.

OBJECTIVE

To model the potential impact of blister-packaging chronic medications on HCRU and health care costs in the Medicare population.

METHODS

An economic model was developed to assess the potential impact of blister-packaging the 3 Medicare Star Ratings adherence measure medication classes: renin-angiotensin system antagonists (RASAs), statins, and noninsulin antidiabetics. The model perspective was that of a hypothetical Medicare Advantage health plan with a plan size of 100,000 members. A 12-month time horizon was used in the model. The dichotomous adherence threshold in the model was set at 80% or greater of the proportion of days covered (PDC). Literature-based references were used to inform both the impact of blister-packaging on the number of patients who become adherent as well as the impact of medication adherence on HCRU and health care costs for each of the medication classes. One-way sensitivity analyses and several scenario analyses were conducted to assess model uncertainty.

RESULTS

Owing to increased adherence from the blister-packaging intervention, the hypothetical health plan in the analysis saw 776 additional members adherent to RASAs, 1,651 additional members adherent to statins, and 414 additional members adherent to oral antidiabetics. Although medication expenditure increased for all 3 medication classes (RASAs: $274,963; statins: $730,083; oral antidiabetics: $100,529), medical costs decreased across all classes (RASAs: -$4,098,848; statins: -$5,549,699; oral antidiabetics: -$917,968). Total net health care costs decreased by $3,823,885 for RASAs (-$3.19 per member per month [PMPM]), $4,819,616 for statins (-$4.02 PMPM), and $817,438 for oral antidiabetics (-$0.68 PMPM). The entire Medicare Advantage population scenario analysis saw reductions in total health care costs of $1,081,394,737 for RASAs, $1,362,987,376 for statins, and $231,171,496 for oral antidiabetics.

CONCLUSIONS

Dispensing chronic medications with blister-packaging for Medicare Advantage health plan patients was modeled to reduce HCRU and health care costs. Future studies are needed to assess whether the impact of blister-packaging medications is tied to reductions in HCRU and health care costs in real-world settings.

Sex-based disparities with cost-related medication adherence issues in patients with hypertension, ischemic heart disease, and heart failure

IMPORTANCE AND OBJECTIVE

Identifying sources of sex-based disparities is the first step in improving clinical outcomes for female patients. Using All of Us data, we examined the association of biological sex with cost-related medication adherence (CRMA) issues in patients with cardiovascular comorbidities.

MATERIALS AND METHODS

Retrospective data collection identified the following patients: 18 and older, completing personal medical history surveys, having hypertension (HTN), ischemic heart disease (IHD), or heart failure (HF) with medication use history consistent with these diagnoses. Implementing univariable and adjusted logistic regression, we assessed the influence of biological sex on 7 different patient-reported CRMA outcomes within HTN, IHD, and HF patients.

RESULTS

Our study created cohorts of HTN (n = 3891), IHD (n = 5373), and HF (n = 2151) patients having CRMA outcomes data. Within each cohort, females were significantly more likely to report various cost-related medication issues: being unable to afford medications (HTN hazards ratio [HR]: 1.68, confidence interval [CI]: 1.33-2.13; IHD HR: 2.33, CI: 1.72-3.16; HF HR: 1.82, CI: 1.22-2.71), skipping doses (HTN HR: 1.76, CI: 1.30-2.39; IHD HR: 2.37, CI: 1.69-3.64; HF HR: 3.15, CI: 1.87-5.31), taking less medication (HTN HR: 1.86, CI: 1.37-2.45; IHD HR: 2.22, CI: 1.53-3.22; HF HR: 2.99, CI: 1.78-5.02), delaying filling prescriptions (HTN HR: 1.83, CI: 1.43-2.39; IHD HR: 2.02, CI: 1.48-2.77; HF HR: 2.99, CI: 1.79-5.03), and asking for lower cost medications (HTN HR: 1.41, CI: 1.16-1.72; IHD HR: 1.75, CI: 1.37-2.22; HF HR: 1.61, CI: 1.14-2.27).

DISCUSSION AND CONCLUSION

Our results clearly demonstrate CRMA issues disproportionately affect female patients with cardiovascular comorbidities, which may contribute to the larger sex-based disparities in cardiovascular care. These findings call for targeted interventions and strategies to address these disparities and ensure equitable access to cardiovascular medications and care for all patients.

A Costly Cure: Understanding and Addressing Financial Toxicity in Cardiovascular Disease Health Care Within the Domain of Social Determinants of Health

Cardiovascular disease (CVD) represents a significant financial burden on patients and families, compounded by both direct and indirect healthcare costs. The increasing prevalence of CVD, coupled with the rising costs of treatment, exacerbates financial toxicity-defined as the economic strain and associated physical, emotional, and behavioral consequences on patients. This review explores the scope of financial toxicity in CVD care, detailing its prevalence, associated risk factors, and the complex interplay with social determinants of health such as income, insurance status, and comorbidities. Drawing from models in oncology, we highlight key interventions aimed at mitigating financial toxicity, including patient counseling, financial navigation, and enhanced patient-physician cost discussions. By adopting these approaches, healthcare providers can better support patients with CVD in managing both their health and financial well-being, potentially improving clinical outcomes. Future research is needed to develop standardized assessment tools for financial toxicity in CVD and implement system-wide mitigation strategies.

Letter: Enhancing patient support through social work-Addressing economic challenges and medication non-adherence in liver disease management

This article is linked to Kim et al paper. To view this article, visit https://doi.org/10.1111/apt.18122

Rural-Urban Disparities in the Uptake of New Diabetes Medications

OBJECTIVE

This study assessed rural-urban differences in the uptake and use of glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase 4 (DPP-4) inhibitors, and sodium-glucose cotransporter 2 (SGLT2) inhibitors among U.S. adults with diabetes.

RESEARCH DESIGN AND METHODS

We calculated person-level annual total and out-of-pocket (OOP) expenditures for new, other, and all diabetes medications in the Medical Expenditure Panel Survey. We defined newer diabetes medications as GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors. The primary outcome was whether a person received a new diabetes medication during the year, and secondary outcomes were medication expenditures. The key independent variable was metropolitan statistical area (MSA) status. Logistic regression was used to estimate use rates of new diabetes medications by MSA status, and a two-part model was used to estimate individual-level annual total and OOP expenditures on new, other, and all diabetes medications.

RESULTS

We observed no significant difference (adjusted odds ratio 0.943, P = 0.37) in newer diabetes medication use. Individuals with diabetes in non-MSAs were more likely to have spending (probit coefficient 0.058, P = 0.06) and to spend more on other diabetes medications (combined marginal effect $103.13, P = 0.09), although this result was not statistically significant. This imbalance increased from $81.33 (P = 0.09) in 2003-2006 to $136.66 (P = 0.08) in 2017-2020.

CONCLUSIONS

Rural-urban diabetes outcome disparities are not likely to be the result of differences in the uptake of GLP-1 receptor agonist, DPP-4 inhibitor, and SGLT2 inhibitor medications.

Care of Diabetes and the Sacrifice of Evidence-Based Medicine and Health Equity

The American Diabetes Association and the European Association for the Study of Diabetes published a 2022 consensus report recommending changes in diabetes care. This Perspective raises three concerns: with how the report summarizes evidence, how it frames the social determinants of health (SDOH), and with its transnational composition and conflicts of interest. The Perspective analyzes three new clinical recommendations that change the role of metformin from first-line therapy to a first-line option, for the inclusion of weight management as a co-primary treatment goal with glycemic control for patients without cardiac or renal complications, and for addition of the SDOH as a universal component of diabetes care together with lifestyle changes and self-management support. The Perspective considers how the poor evidence assessments of the recommendations and the imprecise framing of the SDOH introduce bias. The composition of the panel's membership poorly represents and accounts for the challenges faced by vulnerable US communities or safety net providers. The report is placed in a historical context for diabetes of organized medicine's failures to overcome prejudices and promote health equity. The Perspective concludes that the report perpetuates a pattern of prejudice within organized medicine at the expense of scientific precision and health equity.

Prevalence, Associated Risk Factors, and Adverse Cardiovascular Outcomes of Statins Discontinuation: A Systematic Review

PURPOSE

Statins are widely prescribed for cardiovascular diseases (CVD) prevention; however, a significant proportion of users discontinue the medication for various reasons. This review aimed to determine the prevalence of statin therapy discontinuation, its associated factors, and adverse cardiovascular outcomes within the first year of discontinuation.

METHODS

The PubMed, EMBASE, ScienceDirect, SCOPUS, and Google Scholar databases were systematically searched from their inception to December 2022. Manual searches were also conducted on the bibliographies of relevant articles. Studies were included for qualitative data synthesis and assessed for methodological quality.

RESULTS

Fifty-two studies, predominantly cohort studies (n = 38), involving 4 277 061 participants were included. The prevalence of statin discontinuation within the first year of statin initiation ranged from 0.8% to 70.5%, which was higher for primary prevention indications. Factors frequently associated with an increased likelihood of statin discontinuation included male sex, nonWhite ethnicity, smoking status, and being uninsured. Conversely, discontinuation was less likely in patients with CVD who received secondary prevention statin therapy and in patients with polypharmacy. Furthermore, age showed diverse and inconsistent relationships with statin discontinuation among various age categories. Five studies that reported the cardiovascular risk of statin discontinuation within the first year of initiation showed significantly increased risk of discontinuation, including all-cause mortality (hazard ratio: 1.36-3.65).

CONCLUSION

Our findings indicate a high prevalence of statin discontinuation and an increased likelihood of adverse cardiovascular outcomes within the first year of discontinuation, despite wide variability across published studies. This review highlights the importance of addressing the modifiable risk factors associated with statin discontinuation, such as smoking and lack of insurance coverage.

Financial hardship and cost-related nonadherence to medication in patients with liver disease in the United States

BACKGROUND

Economic hardship associated with chronic liver disease (CLD) may delay timely access to healthcare.

AIM

To estimate the national burden of financial hardship across the spectrum of CLD in the United States (US) during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

A cross-sectional analysis was performed using the 2020-2021 US National Health Interview Survey database. The questionnaire defined financial hardship from medical bills and cost-related nonadherence to medications in patients with CLD. We used weighted survey analysis to obtain the national estimates.

RESULTS

While 6.9% (95% confidence interval [CI]: 6.7%-7.2%) out of 60,689 US adults (weighted sample: 251 million) reported financial hardship and inability to pay medical bills; 10.6% (95% CI: 8.3%-13.4%), 18.2% (95% CI: 14.5%-22.6%), 22.6% (95% CI: 11.0%-41.0%) with hepatitis, CLD/cirrhosis, and liver cancer experienced an inability to pay their medical bills due to financial hardship, respectively. 19.8% (95% CI: 15.9%-24.5%) and 23.3% (95% CI: 12.5%-39.3%) with CLD/cirrhosis and liver cancer, respectively experienced cost-related nonadherence to medications, compared to a tenth of US adults (10.7%, 95% CI: 10.3%-11.2%). CLD/cirrhosis demonstrated an independent association with financial hardship from medical bills and cost-related nonadherence to medications. Overall, these disparities were more pronounced in individuals aged <65 years old. In addition, over 40% of individuals with CLD/cirrhosis reported difficulties accessing medical care during the COVID-19 pandemic. CLD/cirrhosis showed an independent association with difficulties accessing medical care due to COVID-19.

CONCLUSIONS

Financial hardship from medical bills and cost-related nonadherence to medication can negatively impact individuals with CLD and need further evaluation.

Medication regimen complexity and its impact on medication adherence in patients with multimorbidity at a comprehensive specialized hospital in Ethiopia

Background

Medication regimen complexity (MRC) is suspected to hinder medication adherence in patients with multiple illnesses. Despite this, the specific impact on Ethiopian patients with multimorbidity is unclear. This study assessed MRC and its impact on medication adherence in patients with multimorbidity.

Methods

A hospital-based cross-sectional study was conducted on patients with multimorbidity who had been followed at the University of Gondar Comprehensive and Specialized Hospital (UoGCSH), Ethiopia, from May to July 2021. Medication complexity was measured using the validated Medication Regimen Complexity Index (MRCI) tool, and the Adherence in Chronic Diseases Scale (ACDS) was used to measure medication adherence. Pearson's chi-square test was used to examine associations between MRCI levels and medication adherence. Ordinal logistic regression analysis was used to determine the impact of MRC and other associated variables on medication adherence. Statistical significance was determined using the adjusted odds ratio (AOR) at p-value <0.05 and its 95% confidence range.

Results

Out of 422 eligible patients, 416 (98.6%) were included in the study. The majority of participants (57.2%) were classified as having a high MRCI score with a mean (±SD) score of 9.7 (±3.4). Nearly half of the patients (49.3%) had low medication adherence. Patients with medium (AOR = 0.43, 95% CI: 0.04, 0.72) and higher (AOR = 0.31, 95% CI: 0.07, 0.79) MRCI levels had lower odds of medication adherence. In addition, monthly income (AOR = 4.59, 95% CI: 2.14, 9.83), follow-up durations (AOR = 2.31, 95% CI: 1.09, 4.86), number of medications (AOR = 0.63, 95% CI: 0.41, 0.97), and Charlson comorbidity index (CCI) (AOR = 0.36, 95% CI: 0.16, 0.83) were significantly associated with medication adherence.

Conclusion

Medication regimen complexity in patients with multimorbidity was found to be high and negatively impacted the levels of medication adherence. Healthcare providers and other stakeholders should seek interventions aimed at simplifying drug regimen complexity and improving adherence.

The analysis of factors affecting medication adherence in patients with myasthenia gravis: a cross-sectional study

Background

Clinically, patients with myasthenia gravis are generally treated with drugs to improve their physical condition, and poor medication adherence can hinder their recovery. Many studies have shown the importance of medication adherence for effective treatment. Various factors may affect a patient's medication adherence; however, studies concerning medication adherence in patients with myasthenia gravis are rare.

Objectives

This study aimed to identify the factors related to medication adherence in patients with myasthenia gravis, and determine the possibility of predicting medication adherence.

Methods

This cross-sectional observational study was conducted among inpatients and outpatients with myasthenia gravis of the First Affiliated Hospital of Guangzhou University of Chinese Medicine in China. Data on patient demographics, disease-related characteristics, and medical treatment were collected. We evaluated medication adherence of the patients using the Morisky Medication Adherence Scale-8, Beliefs about Medicines Questionnaire, and the Self-efficacy for Appropriate Medication Use Scale.

Results

We distributed 200 questionnaires and finally retrieved 198 valid questionnaires. A total of 139 (70.2%) women participated in this study, and 81 (40.9%) among the 198 participants were aged 40-59 years. In total, 103 (52.0%) participants exhibited bad adherence to pharmacological treatment, and factors such as taking medication irregularly [odds ratio (OR) = 0.242, 95% CI = 0.093-0.627], the necessity of taking medicine (OR = 1.286, 95% CI = 1.142-1.449), the concerns of taking medicine (OR = 0.890, 95% CI = 0.801-0.988), and the self-efficacy for taking medications under difficult circumstances (OR = 1.194, 95% CI = 1.026-1.389) had statistically significant impacts on medication adherence.

Conclusion

Our study shows that taking medication irregularly and concerns of taking medicine are the risk factors for medication adherence. Meanwhile, the necessity of talking medicine and self-efficacy for taking medications under difficult circumstances are the protective factors for medication adherence. Our findings can help medical staff to enhance patients' medication adherence by informing patients necessary medical knowledge, emphasizing the necessity for medication, relieving patients' concerns regarding medication, and improving the self-efficacy for taking medications under difficult circumstances.

A systematic review of the economic burden of diabetes mellitus: contrasting perspectives from high and low middle-income countries

Introduction

Diabetes increases preventative sickness and costs healthcare and productivity. Type 2 diabetes and macrovascular disease consequences cause most diabetes-related costs. Type 2 diabetes greatly costs healthcare institutions, reducing economic productivity and efficiency. This cost of illness (COI) analysis examines the direct and indirect costs of treating and managing type 1 and type 2 diabetes mellitus.

Methodology

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, Cochrane, PubMed, Embase, CINAHL, Scopus, Medline Plus, and CENTRAL were searched for relevant articles on type 1 and type 2 diabetes illness costs. The inquiry returned 873 2011-2023 academic articles. The study included 42 papers after an abstract evaluation of 547 papers.

Results

Most articles originated in Asia and Europe, primarily on type 2 diabetes. The annual cost per patient ranged from USD87 to USD9,581. Prevalence-based cost estimates ranged from less than USD470 to more than USD3475, whereas annual pharmaceutical prices ranged from USD40 to more than USD450, with insulin exhibiting the greatest disparity. Care for complications was generally costly, although costs varied significantly by country and problem type.

Discussion

This study revealed substantial heterogeneity in diabetes treatment costs; some could be reduced by improving data collection, analysis, and reporting procedures. Diabetes is an expensive disease to treat in low- and middle-income countries, and attaining Universal Health Coverage should be a priority for the global health community.

Cost-Related Non-Adherence to Prescribed Medicines: What Are Physicians' Moral Duties?

As the price of pharmaceuticals and biologicals rises so does the number of patients who cannot afford them. In this article, we argue that physicians have a moral duty to help patients access affordable medicines. We offer three grounds to support our argument: (i) the aim of prescribing is to improve health and well-being which can only be realized with secure access to treatment; (ii) there is no morally significant difference between medicines being unavailable and medicines being unaffordable, so the steps physicians are willing to take in the first case should extend to the second; and (iii) as the primary stakeholder with a duty to put the individual patient's interests first, the medical professional has a duty to address cost-barriers to patient care. In articulating this duty, we take account of important epistemic and control conditions that must be met for the attribution of this duty to be justified.

Cost-related medication nonadherence in adults with COPD in the United States 2013-2020

BACKGROUND

Cost-related medication nonadherence (CRN) is associated with poor prognosis among patients with chronic obstructive pulmonary disease (COPD), a population that requires long-term treatment for secondary prevention. In this study, we aimed to estimate the prevalence and sociodemographic characteristics of CRN in individuals with COPD in the US.

METHODS

In a nationally representative survey of US adults in the National Health Interview Survey (2013-2020), we identified individuals aged ≥18 years with a self-reported history of COPD. Cross-sectional study.

RESULTS

Of the 15,928 surveyed individuals, a weighted 18.56% (2.39 million) reported experiencing CRN, including 12.50% (1.61 million) missing doses, 13.30% (1.72 million) taking lower than prescribed doses, and 15.74% (2.03 million) delaying filling prescriptions to save costs. Factors including age < 65 years, female sex, low family income, lack of health insurance, and multimorbidity were associated with CRN.

CONCLUSIONS

In the US, one in six adults with COPD reported CRN. The influencing factors of CRN are multifaceted and necessitating more rigorous research. Targeted interventions based on the identified influencing factors in this study are recommended to enhance medication adherence among COPD patients.

Outcomes and Attributes Patients Value When Choosing Glucose-Lowering Medications: A Mixed-Methods Study

This mixed-methods study sought to identify pharmacotherapy preferences among 40 noninsulin-treated adults with type 2 diabetes receiving care at two U.S. health care systems. Participants ranked by relative importance various health outcomes and medication attributes and then contextualized their rankings. Most participants ranked blindness (63%), death (60%), heart attack (48%), and heart failure (48%) as the most important health outcomes and glucose-lowering efficacy (68%) as the most important medication attribute, followed by oral administration (45%) and lack of gastrointestinal side effects (38%).

American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

Cost-related medication nonadherence in US adults with asthma: The National Health Interview Survey, 2013-2020

BACKGROUND

Asthma is a chronic disease that needs long-term control for secondary prevention. Health-related expenditures resulting from asthma are rising in the United States, and medication nonadherence is associated with adverse health outcomes in patients with asthma.

OBJECTIVE

To estimate the prevalence and risk factors of cost-related medication nonadherence (CRN) in individuals with asthma in the United States.

METHODS

We identified patients aged above or equal to 18 years with a history of asthma in nationally representative cross-sectional data, the National Health Interview Survey 2013 to 2020. Participants were considered to have experienced CRN if at any time in the 12 months they reported skipping doses, taking less medication, or delaying filling a prescription to save money. The weighted prevalence of CRN was estimated overall and by subgroups. Logistic regression was used to identify CRN-related characteristics.

RESULTS

Of the 26,539 National Health Interview Survey participants with a history of asthma, 4360 (15.77%; representing 3.92 million of the US population) reported CRN, with 10.12% (weighted 2.51 million) of patients skipping doses to save money, 10.82% (weighted 2.69 million) taking less medication to save money, and 13.35% (weighted 3.31 million) delaying filling a prescription to save money. The subgroups young, women, low income, no health insurance, currently smoking, and with comorbidities had a higher prevalence of CRN. The results of this sensitivity analysis did not differ from the overall results.

CONCLUSION

In the United States, 1 in 6 adults with a history of asthma is nonadherence with medications due to costs. Removing financial barriers to accessing medication can improve medication adherence in patients with asthma.

Antihypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with early development of chronic complications. Treatment of elevated blood pressure (BP), nephropathy, and dyslipidemia are critical to reduce morbidity. Data are needed on adherence to BP- and lipid-lowering medications in young adults with youth-onset diabetes.

Objective

To assess adherence and factors associated with adherence to BP- and lipid-lowering medications in young adults with youth-onset type 2 diabetes and diagnoses of hypertension, nephropathy, or dyslipidemia.

Design, Setting, and Participants

This cohort study measured medication adherence with 3 monthly unannounced pill counts at 2 time points 1 year apart during iCount, conducted during the last years (2017-2019) of the observational phase of the Treatment Options for Type 2 Diabetes in Adolescents and Youth study. Psychosocial factors associated with medication adherence were examined. Participants included individuals with youth-onset type 2 diabetes with hypertension, nephropathy, or dyslipidemia receiving diabetes care in their communities. Data were analyzed from September 2022 to September 2023.

Main Outcomes and Measures

The main outcome was BP- and lipid-lowering medication adherence, with low adherence defined as using less than 80% of pills and high adherence, at least 80% of pills. Psychosocial factors were measured using the Beliefs about Medicines Questionnaire and Material Needs Insecurities Survey.

Results

Of 381 participants in iCount, 243 participants (mean [SD] age, 26.12 [2.51] years; 159 [65.43%] women) with hypertension, nephropathy, or dyslipidemia were included in analysis. Among 196 participants with hypertension or nephropathy, 157 (80.1%) had low adherence. Participants with low adherence, compared with those with high adherence, were younger (mean [SD] age, 25.99 [2.41] vs 27.26 [2.41] years; P = .005), had higher glycated hemoglobin A1c (mean [SD], 10.33% [2.66 percentage points] vs 8.85% [2.39 percentage points]; P = .001), shorter diabetes duration (mean [SD], 12.32 [1.49] vs 12.90 [1.46] years; P = .03), and less education (eg, 17 participants [10.83%] vs 0 participants with no high school diploma; P = .004). Of 146 participants with dyslipidemia, 137 (93.8%) had low adherence and only 9 participants (6.2%) had high adherence. Of 103 participants with low adherence to BP-lowering medications and using oral hypoglycemic agents, 83 (80.58%) had low adherence to oral hypoglycemic agents. Beliefs that medications are necessary were higher for participants with high adherence to BP-lowering medications than those with low adherence in unadjusted analyses (mean [SD] necessity score, 16.87 [6.78] vs 13.89 [9.15]; P = .03). In adjusted multivariable analyses of participants with hypertension or nephropathy, having at least 1 unmet social need (odds ratio [OR], 0.20; 95% CI, 0.05-0.65; P = .04) and medication concerns (OR, 0.63; 95% CI, 0.40-0.96; P = .01) were associated with worse medication adherence 1 year follow-up. Diabetes distress, self-efficacy, depressive and anxiety symptoms, and self-management support were not associated with 1-year medication adherence.

Conclusions and Relevance

These findings suggest that adherence to BP- and lipid-lowering medications was very poor in this cohort. To improve medication adherence and prevent early vascular events, approaches that identify and address medication concerns and unmet social needs are needed.

Medication Cost Concerns and Disparities in Patient-Reported Outcomes Among a Multiethnic Cohort of Patients With Systemic Lupus Erythematosus

OBJECTIVE

Concerns about the affordability of medications are common in systemic lupus erythematosus (SLE), but the relationship between medication cost concerns and health outcomes is poorly understood. We assessed the association of self-reported medication cost concerns and patient-reported outcomes (PROs) in a multiethnic SLE cohort.

METHODS

The California Lupus Epidemiology Study is a cohort of individuals with physician-confirmed SLE. Medication cost concerns were defined as having difficulties affording SLE medications, skipping doses, delaying refills, requesting lower-cost alternatives, purchasing medications outside the United States, or applying for patient assistance programs. Linear regression and mixed effects models assessed the cross-sectional and longitudinal association of medication cost concerns and PROs, respectively, adjusting for age, sex, race and ethnicity, income, principal insurance, immunomodulatory medications, and organ damage.

RESULTS

Of 334 participants, medication cost concerns were reported by 91 (27%). Medication cost concerns were associated with worse Systemic Lupus Activity Questionnaire (SLAQ; beta coefficient [β] 5.9, 95% CI 4.3-7.6; P < 0.001), 8-item Patient Health Questionnaire depression scale (PHQ-8; β 2.7, 95% CI 1.4-4.0; P < 0.001), and Patient-Reported Outcomes Measurement Information System (PROMIS; β for physical function -4.6, 95% CI -6.7 to -2.4; P < 0.001) scores after adjusting for covariates. Medication cost concerns were not associated with significant changes in PROs over 2-year follow-up.

CONCLUSION

More than a quarter of participants reported at least 1 medication cost concern, which was associated with worse PROs. Our results reveal a potentially modifiable risk factor for poor outcomes rooted in the unaffordability of SLE care.

Advances in the management of type 2 diabetes in adults

Type 2 diabetes is a chronic and progressive cardiometabolic disorder that affects more than 10% of adults worldwide and is a major cause of morbidity, mortality, disability, and high costs. Over the past decade, the pattern of management of diabetes has shifted from a predominantly glucose centric approach, focused on lowering levels of haemoglobin A1c (HbA1c), to a directed complications centric approach, aimed at preventing short term and long term complications of diabetes, and a pathogenesis centric approach, which looks at the underlying metabolic dysfunction of excess adiposity that both causes and complicates the management of diabetes. In this review, we discuss the latest advances in patient centred care for type 2 diabetes, focusing on drug and non-drug approaches to reducing the risks of complications of diabetes in adults. We also discuss the effects of social determinants of health on the management of diabetes, particularly as they affect the treatment of hyperglycaemia in type 2 diabetes.

A phase-I randomized euglycemic clamp study to demonstrate the pharmacokinetic and pharmacodynamic equivalence of an insulin degludec biosimilar (B01411) with the reference product in healthy Chinese volunteers

BACKGROUND

B01411 is a biosimilar candidate manufactured by Jilin Huisheng Biopharmaceutical Co. Ltd for the reference insulin degludec (Tresiba) (IDeg). This study aimed to evaluate the pharmacokinetics (PK), pharmacodynamics (PD), and safety of the two IDeg products and to assess the PK/PD similarity of B01411 compared with the reference IDeg product.

RESEARCH DESIGN & METHODS

A single-center, single-dose, randomized, crossover, open-labeled, phase I, euglycemic clamp study in healthy Chinese subjects to examine the bioequivalence of B01411 (0.4 U/kg) compared with the reference IDeg product. Blood samples were collected at a predefined time for the analysis of blood glucose (BG), IDeg, and C-peptide concentrations. The glucose infusion rate (GIR) was adjusted to maintain the BG at approximately 0.28 mmol/L below baseline throughout the clamp.

RESULTS

Thirty-two subjects (20 males and 12 females) were enrolled, 31 of whom received both treatments. The 90% confidence intervals for the ratio of the least-squares geometric means for AUCIDeg,0-24 h, AUCGIR,0-24 h, IDegmax, and GIRmax were all in the range of 0.80-1.25. Only one adverse event of puncture site bruising occurred once in a subject in the B01411 group.

CONCLUSION

B01411 exhibited a pharmacokinetic and pharmacodynamic similarity to the reference product. Both IDeg products were well tolerated.

CLINICAL TRIAL REGISTRATION

http://www.chinadrugtrials.org.cn/index.html#. Identifier is CTR20192122.

A Qualitative Study of Perspectives of Older Adults on Deintensifying Diabetes Medications

BACKGROUND

While many older adults with type 2 diabetes have tight glycemic control beyond guideline-recommended targets, deintensifying (stopping or dose-reducing) diabetes medications rarely occurs.

OBJECTIVE

To explore the perspectives of older adults with type 2 diabetes around deintensifying diabetes medications.

DESIGN

This qualitative study used individual semi-structured interviews, which included three clinical scenarios where deintensification may be indicated.

PARTICIPANTS

Twenty-four adults aged ≥65 years with medication-treated type 2 diabetes and hemoglobin A1c <7.5% were included (to thematic saturation) using a maximal variation sampling strategy for diabetes treatment and physician specialty.

APPROACH

Interviews were independently coded by two investigators and analyzed using a grounded theory approach. We identified major themes and subthemes and coded responses to the clinical scenarios as positive (in favor of deintensification), negative, or ambiguous.

KEY RESULTS

Participants' mean age was 74 years, half were women, and 58% used a sulfonylurea or insulin. The first of four major themes was fear of losing control of diabetes, which participants weighed against the benefits of taking less medication (Theme 2). Few participants viewed glycemic control below target as a reason for deintensification and a majority would restart the medication if their home glucose increased. Some participants were anchored to their current diabetes treatment (Theme 3) driven by unrealistic views of medication benefits. A trusting patient-provider relationship (Theme 4) was a positive influence. In clinical scenarios, 8%, 4%, and 75% of participants viewed deintensification positively in the setting of poor health, limited life expectancy, and high hypoglycemia risk, respectively.

CONCLUSIONS

Optimizing deintensification requires patient education that describes both individualized glycemic targets and how they will change over the lifespan. Deintensification is an opportunity for shared decision-making, but providers must understand patients' beliefs about their medications and address misconceptions. Hypoglycemia prevention may be a helpful framing for discussing deintensification.

Telehealth Intervention to Improve Uptake of Evidence-Based Medications among Patients with Type 2 Diabetes and Heart Failure or Cardiovascular Disease

INTRODUCTION

Sodium glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide 1 receptor (GLP-1) agonists are recommended for patients with type two diabetes (T2D) and atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) to reduce cardiovascular-related mortality. The objective of this study was to evaluate a telehealth targeted medication review (TMR) program to identify patients for uptake of these evidence-based medications.

METHODS

This was an observational descriptive study of a TMR program for Medicare-enrolled, Medication Therapy Management-eligible patients in one insurance plan. Prescription claims and patient interviews identified individuals who would benefit from SGLT-2 inhibitors or GLP-1 agonists. Facsimiles were sent to providers of patients with educational information about the targeted medications. Descriptive statistics described characteristics and proportion of patients prescribed targeted medications after 120 days. Bivariate statistical tests evaluated associations between age, sex, number of medications, number of providers, and poverty level with adoption of targeted medications.

RESULTS

A total of 1106 of 1127 had a facsimile sent to their provider after a conversation with the patient. Among patients with a provider facsimile, 69 (6%) patients filled a prescription for a targeted medication after 120 days. There was a significant difference in age between individuals who started a targeted medication (67 ± 10 years) compared with patients who did not (71 ± 10 years) (p = 0.001).

CONCLUSIONS

A TMR efficiently identified patients with T2D and ASCVD or HF who would benefit from evidence-based medications. Although younger patients were more likely to receive these medications, the overall uptake of these medications within four months of the intervention was lower than expected.

Trends and Disparities in Glycemic Control and Severe Hyperglycemia Among US Adults With Diabetes Using Insulin, 1988-2020

IMPORTANCE

There have been major advances in insulin delivery and formulations over the past several decades. It is unclear whether these changes have resulted in improved glycemic control for patients with diabetes.

OBJECTIVE

To characterize trends and disparities in glycemic control and severe hyperglycemia in US adults with diabetes using insulin.

DESIGN, SETTING, AND PARTICIPANTS

This serial population-based cross-sectional study used data from the National Health and Nutrition Examination Survey (NHANES) between 1988-1994 and 1999-2020. Participants were nonpregnant US adults aged 20 years or older who had a diagnosis of diabetes and were currently using insulin.

EXPOSURES

Diabetes diagnosis and use of insulin.

MAIN OUTCOMES AND MEASURES

Trends in glycemic control (glycated hemoglobin [HbA1c] level <7%) and severe hyperglycemia (HbA1c level >10%; to convert percentage of total hemoglobin to proportion of total hemoglobin, multiply by 0.01; to convert to millimoles per mole, multiply by 10.93 and subtract by 23.50) overall and by age, race and ethnicity, and indicators of socioeconomic status were evaluated using logistic regression. Analyses incorporated sample weights to account for oversampling of certain populations and survey nonresponse.

RESULTS

There were 2482 participants with diabetes using insulin included in the analyses (mean [SD] age, 59.8 [0.4] years); 51.3% were men, 7.0% were Mexican American individuals, 17.9% were non-Hispanic Black individuals, and 65.2% were non-Hispanic White individuals. From 1988-1994 to 2013-2020, the proportion of patients with diabetes who received insulin and achieved glycemic control did not significantly change, from 29.2% (95% CI, 22.6%-36.8%) to 27.5% (95% CI, 21.7%-34.2%). Mexican American adults who received insulin were less likely than non-Hispanic White adults to achieve glycemic control, and disparities increased during the study period. The proportion of adults with severe hyperglycemia did not significantly change and was 14.6% (95% CI, 12.0-17.5) in 2013-2020. Adults who were Mexican American or non-Hispanic Black, were uninsured, or had low family income had the highest prevalence of severe hyperglycemia.

CONCLUSIONS AND RELEVANCE

In this population-based cross-sectional study of NHANES data over the past 3 decades, glycemic control stagnated and racial and ethnic disparities increased among US adults with diabetes who received insulin. Efforts to improve access to insulin may optimize glycemic control and reduce disparities in this population.

Sex differences in predictive factors for onset of type 2 diabetes in Japanese individuals: A 15-year follow-up study

AIMS/INTRODUCTION

The increase in the number of patients with type 2 diabetes mellitus is an important concern worldwide. The goal of this study was to investigate factors involved in the onset of type 2 diabetes mellitus, and sex differences in long-term follow up of people with normal glucose tolerance.

MATERIALS AND METHODS

Of 1,309 individuals who underwent screening at our facility in 2004, 748 individuals without diabetes were enrolled. Correlations of metabolic markers including serum adiponectin (APN) with onset of type 2 diabetes mellitus were examined over 15 years in these individuals.

RESULTS

The Kaplan-Meier curve for onset of type 2 diabetes mellitus for 15 years in the decreased APN group was examined. Hazard ratios for the APN concentration for onset of diabetes were 1.78 (95% confidence interval [CI] 1.20-2.63, P = 0.004) in all participants, 1.48 (95% CI 0.96-2.29, P = 0.078) for men and 3.01 (95% CI 1.37-6.59, P = 0.006) for women. During the follow-up period of 15 years, body mass index, estimated glomerular filtration rate, fatty liver, C-reactive protein and alanine aminotransferase in men were significant in univariate analysis, but only estimated glomerular filtration rate and fatty liver were significantly related to onset of type 2 diabetes mellitus in multivariate analysis. In women, body mass index, systolic blood pressure, triglyceride, fatty liver and APN were significant in univariate analysis, and APN was the only significant risk factor in multivariate analysis (P < 0.05).

CONCLUSIONS

There are differences between men and women with regard to targets for intervention to prevent the onset of type 2 diabetes mellitus. Individuals requiring intensive intervention should be selected with this finding to maximize the use of limited social and economic resources.

Subjective Financial Hardship from Medical Bills Among Patients with Heart Failure in the United States: The 2014-2018 Medical Expenditure Panel Survey

BACKGROUND

Heart failure (HF) poses a substantial economic burden to the United States (US) healthcare system. In contrast, little is known about the financial challenges faced by patients with HF. In this study, we examined the scope and sociodemographic predictors of subjective financial hardship from medical bills in patients with HF.

METHODS

In the Medical Expenditure Panel Survey (MEPS; years 2014-2018), a US nationally representative database, we identified all patients who reported having HF. Any subjective financial hardship from medical bills was assessed based on patients reporting either themselves or their families 1) having difficulties paying medical bills in the past 12 months, 2) paid bills late, or 3) unable to pay bills at all. Logistic regression was used to evaluate independent predictors of financial hardship among patients with HF. All analyses took into consideration the survey's complex design.

RESULTS

A total of 116,563 MEPS participants were included in the analysis, of whom 858 (0.7%) had a diagnosis of HF, representing 1.8 million (95% CI 1.6 to 2.0) patients annually. Overall, 33% (95% CI 29% to 38%) reported any financial hardship from medical bills with 13.2% not being able to pay bills at all. Age ≤65 years and lower educational attainment were independently associated with higher odds of subjective financial hardship from medical bills.

CONCLUSION

Subjective financial hardship is a prevalent issue among patients with HF in the US, particularly those who are younger and have lower educational attainment. There is a need for policies that reduce out-of-pocket costs in the care of HF, an enhanced identification of this phenomenon in the clinical setting, and approaches to help minimize financial toxicity in patients with HF while ensuring optimal quality of care.