An Economic Evaluation of the Relationship Between Glycemic Control and Total Healthcare Costs for Adults with Type 2 Diabetes: Retrospective Cohort Study

INTRODUCTION

Glycemic control is associated with better outcomes among individuals with type 2 diabetes (T2D). This research examines total US all-cause medical costs for adults with T2D with recommended glycemic control (HbA1c < 7%) compared to poor glycemic control (HbA1c ≥ 7%).

METHODS

The study used administrative claims data linked to HbA1c laboratory test results from January 1, 2015 through June 30, 2021 to identify adults with T2D with a recorded HbA1c test. Patients with recommended glycemic control at index date were propensity score matched to patients with poor glycemic control. General linear models and two-part models were used to compare all-cause outpatient, drug, acute care and total costs for 1 year post index date.

RESULTS

The study included 59,830 propensity-matched individuals. Results indicate that recommended glycemic control, compared to poor glycemic control, was associated with statistically significantly lower all-cause acute care ($23,868 ± $21,776 vs. $24,352 ± $22,223), drug ($10,277 ± $14,671 vs. $10,540 ± $14,928), and total medical costs ($41,381 ± $42,757 vs. $42,054 ± $43,422) but significantly higher outpatient costs ($7290 ± $12,028 vs. $7026 ± $11,587) (all p < 0.0001). Sensitivity analyses examined results based upon alternative HbA1c thresholds of ≤ 6.5% and < 8%. Results were generally robust to alternative HbA1c thresholds, with higher HbA1c thresholds associated with higher all-cause total costs as well as increased savings for having HbA1c below threshold.

CONCLUSIONS

Glycemic control was associated with significantly lower all-cause total, drug, and acute care medical costs. Given the high prevalence of T2D in the USA, our results suggest potential economic benefits associated with glycemic control for healthcare providers.

The Association Between Obesity and the 5-Year Prevalence of Morbidity and Mortality Among Adults with Type 2 Diabetes

INTRODUCTION

This retrospective claims database study examined the prevalence of mortality and morbidity among adults with type 2 diabetes (T2D) and obesity.

METHODS

The study used deidentified data from 2007 to 2021 from the Optum® Market Clarity Dataset. A cohort of adults with T2D and obesity were identified, and age- and sex-adjusted prevalence rates were calculated for mortality, a composite cardiovascular outcome (CCO), a composite microvascular outcome (CMO), and other complications. Results were examined overall and by obesity class (class 1, class 2, and class 3).

RESULTS

For the 15,970 adults included in the study, the prevalence of CCO and CMO after 5 years was 15.3% and 60.7%, respectively. The 5-year prevalence of mortality was 10.9%. There were statistically significant differences in prevalence rates by obesity class, with obesity class 3 associated with higher rates of morbidity and mortality compared to obesity classes 1 or 2. Specifically, after 5 years, the prevalence of mortality was 9.4%, 10.3% and 13.6% for obese classes 1, 2 and 3, respectively (P < 0.05 between class 3 and class 2 or 1). Similarly, For obesity classes 1, 2 and 3, the 5-year prevalence of CCO was 13.0%, 14.5% and 18.4% and the rates for CMO were 58.0%, 57.9% and 64.8%, respectively (both P < 0.05 between class 3 and class 2 or 1). Regarding other complications, differences in the prevalence of atherosclerotic cardiovascular disease (ASCVD) and obstructive sleep apnea (OSA) were statistically significantly higher with increasing obesity class.

CONCLUSIONS

The results indicate that for a cohort of adults with T2D and obesity, obesity class 3 is associated with significantly higher mortality and morbidity, including CCO, CMO, ASCVD and OSA. These findings suggest that treatment which reduces obesity among individuals with T2D may have significant health benefits, although additional studies are needed to confirm the results.

Five-year morbidity and mortality rates in a U.S. population with obesity with and without prediabetes

AIMS

This research examines the prevalence of morbidity and mortality among people with obesity with or without prediabetes.

METHODS

This observational study uses Optum® Market Clarity deidentified data from 2007 to 2020. Individuals with obesity without prediabetes (obesity only) were matched 1:1 to adults with prediabetes plus obesity based upon age, sex, race, ethnicity, and region. Age and sex adjusted prevalence rates and 95 % CIs were calculated for morbidity and mortality for each 365-day period post index date and over the entire 5-year post-period.

RESULTS

After 5-years, the adjusted mortality rate was 10.1 % for adults with obesity plus prediabetes and 6.9 % for adults with obesity only (p < 0.05). Five years post index date, the prevalence of type 2 diabetes was 25.3 % for people with obesity plus prediabetes and 9.2 % for people with obesity only (p < 0.05). Prevalence rates after 5 years for atherosclerotic cardiovascular disease (13.1 % v 8.1 %), composite cardiovascular outcome (7.0 % v 4.4 %) and composite cardio-renal outcome (8.9 % v 5.0 %) were significantly higher for adults with obesity plus prediabetes compared to adults with obesity only (all p < 0.05).

CONCLUSIONS

Results of this study indicate that the presence of prediabetes contributes to the development of additional morbidity and mortality in adults with obesity.

Trends in U.S. Insulin Use and Glucose Monitoring for People with Diabetes: 2009-2018

BACKGROUND

The delivery and administration of insulin has undergone many changes over the years. This research examines U.S. trends in insulin use among people with type 1 diabetes (T1D) or type 2 diabetes (T2D) in the U.S. from 2009 to 2018.

METHODS

The IBM^® MarketScan^® Commercial and Medicare databases were used to identify trends in insulin use over 10 years. The study included people with T1D or T2D who filled a prescription for insulin in any calendar year from 2009 to 2018. The analyses examined insulin regimen and delivery and the use of glucose monitoring systems. Generalized estimating equations were used to test whether trends were statistically significant.

RESULTS

Individuals with T1D were most commonly prescribed a basal and bolus insulin regimen or short/rapid insulin only, while for people with T2D the use of basal-only insulin increased significantly over the study period. In both groups there was a significant decline in the use of premix insulin from 2009 to 2018. Insulin pump use increased for individuals with T1D, while disposable pen use increased for people in both cohorts. In both cohorts, there was a statistically significant increase in the use of continuous glucose monitoring, although this increase was more pronounced and occurred earlier among individuals with T1D.

CONCLUSIONS

Results indicate significant changes in insulin regimens and delivery and glucose monitoring from 2009 to 2018. These findings suggest that insulin prescribing continues to change in response to the development of new therapeutics, advances in insulin delivery technology, and glucose monitoring systems.

The Association Between Sustained HbA1c Control and Long-Term Complications Among Individuals with Type 2 Diabetes: A Retrospective Study

INTRODUCTION

The prevalence of type 2 diabetes (T2D) represents a rising burden in the US and worldwide, with the condition shown to be associated with relatively large human and economic costs. Part of the reason for such high costs associated with T2D is that the condition is often accompanied by additional health-related complications. The goal of this research is to examine the association between glycemic control and diabetes-related complications for individuals with T2D.

METHODS

The Optum Clinformatics® Data Mart (CDM) database from 2007 to 2020 was used to identify adults with T2D. Individuals were classified as having sustained glycemic control (all hemoglobin A1c [HbA1c] < 7%) or poor glycemic control (all HbA1c ≥ 7%) over the 5-year post-period, and diabetes-related complications were identified based upon the Diabetes Complications Severity Index. Multivariable analyses examined the association between sustained glycemic control and diagnosis of a diabetes-related complication in the post-period.

RESULTS

Maintaining HbA1c < 7% over the 5-year post-period, compared to maintaining HbA1c ≥ 7%, was associated with reduced odds of the diabetes-related complications of cardiovascular disease (odds ratio [OR] = 0.76, 95% confidence interval [CI] 0.61-0.94), metabolic disease (OR = 0.37, 95% CI 0.22-0.600), neuropathy (OR = 0.62, 95% CI 0.45-0.84), nephropathy (OR = 0.81, 95% CI 0.69-0.94), and peripheral vascular disease (OR = 0.52, 95% CI 0.33-0.83). There was no statistically significant association between sustained glycemic control and cerebrovascular disease.

CONCLUSIONS

Sustained glycemic control was found to be associated with significant reductions in the odds of being diagnosed with diabetes-related complications over a 5-year post-period.

The Association Between HbA1c and 1-Year Diabetes-Related Medical Costs: A Retrospective Claims Database Analysis

INTRODUCTION

The American Diabetes Association (ADA) has identified a target hemoglobin A1c (HbA1c) < 7% as appropriate for most adults with type 2 diabetes (T2D). This research examines US diabetes-related healthcare costs for adults with T2D for individuals with glycemic control (HbA1c < 7%) compared to poor glycemic control (HbA1c ≥ 7%).

METHODS

The Optum Clinformatics^® Data Mart database from 2016 to 2020 was used to identify a cohort of adults with T2D who had a recorded HbA1c test (with first such date identified as the index date) and continuous insurance from 1 year prior through 1 year post index date. Patients with glycemic control were propensity matched to patients with poor glycemic control. Generalized linear models and two-part models examined diabetes-related outpatient, drug, acute care, and total costs over the 1-year post-period.

RESULTS

There were 34,538 propensity matched individuals included in the study. Results indicate that glycemic control (HbA1c < 7%), compared to poor glycemic control (HbA1c ≥ 7%) ,was associated with statistically significantly lower annual diabetes-related acute ($5671 ± $4216 vs $6138 ± $4211), outpatient ($6051 ± $4216 vs $7259 ± $7771), drug ($3739 ± $4581 vs $4288 ± $4788), and total costs care ($13,704 ± $10,635 vs $16,460 ± $10,885) (all P < 0.0001). Sensitivity analyses also examined results based upon alternative HbA1c thresholds which were chosen on the basis of expert guidelines and prior clinical trial thresholds (< 6%, ≤ 6.5%, < 8%, and ≤ 9%). In all cases, being below threshold was associated with statistically significantly lower diabetes-related total costs and component costs. Results also illustrate that, in general, higher HbA1c thresholds are associated with higher diabetes-related costs.

CONCLUSION

Glycemic control was found to be associated with significantly lower annual diabetes-related component and total costs. Results suggest economic benefits associated with having HbA1c at or below target.

Obesity and glycemic control among people with type 2 diabetes in the United States: A retrospective cohort study using insurance claims data

AIMS

To examine body mass index (BMI) and HbA1c for individuals with type 2 diabetes (T2D) in the United States.

METHODS

The retrospective study utilized data from IBM® MarketScan® Explorys® Claims-EMR Data for the years 2012-2019. Individuals with T2D and a recorded HbA1c laboratory result and BMI were included. The relationship between BMI and HbA1c was assessed descriptively and logistic regressions examined the relationship between benchmark BMI and the probability of having HbA1c above targets of 7% or 8% in the 1year post-period.

RESULTS

In our sample of 44,723 patients, results indicated that compared to individuals of normal weight, those classified as obese class I or obese class II were 24% more likely to have a last HbA1c≥7% (Odds Ratio [OR]=1.24; 95% Confidence Interval [CI] 1.14-1.35 for both obese class I and obese class II), while those classified as obese class III were 16% more likely (OR=1.16; 95% CI 1.06-1.27). Results were similar when using a HbA1c threshold of 8%.

CONCLUSIONS

Given the importance of glycemic control for people with T2D, these results suggest that treatments which reduce rates of obesity may help to improve health outcomes.

Trends in HbA1c and Body Mass Index Among Individuals with Type 2 Diabetes: Evidence from a US Database 2012-2019

INTRODUCTION

Given the high rates of obesity and poor glycemic control among individuals with type 2 diabetes (T2D), this study examines current trends in HbA1c and body mass index (BMI) as well as the association between HbA1c and BMI among adults with T2D.

METHODS

Data from the IBM® MarketScan® Explorys® Claims-EMR Data were used to construct eight annual cohorts for the years 2012-2019. Each annual cohort included adults identified with T2D who had at least one recorded HbA1c laboratory result and BMI value in the year of interest. Given these cohorts, trends in HbA1c and BMI were described over time using generalized estimating equation (GEE) tests.

RESULTS

Results indicate that, over the study period from 2012-2019, average BMI increased significantly and there was a decrease in the percentage of adults with T2D who achieved glycemic control. In addition, for all years, higher BMI classification was associated with higher HbA1c values. When examining results for patients in different age groups, the findings were generally consistent with the overall population. In each age group, but most notably the age 18-44 group, the mean BMI increased over time and higher BMI was associated with higher HbA1c.

CONCLUSION

Given the increase in BMI and decreasing percentage of individuals achieving glycemic control among adults with T2D found over the study period, therapies which decrease BMI as well as HbA1c can potentially have a significant impact on the management of T2D. The growing proportion of the younger age group with higher mean BMI may remain a key subgroup of interest.

Time to Failure on Oral Glucose-Lowering Agents for Patients with Type 2 Diabetes: A Retrospective Cohort Study

INTRODUCTION

Research has shown that glycemic control is associated with lower rates of microvascular and long-term cardiovascular complications. In the analyses reported here, we examined treatment failure on oral glucose-lowering agents (GLAs), defined as having sustained hemoglobin A1c (HbA1c) ≥  7%.

METHODS

This study utilized the IBM® MarketScan® Claims and Laboratory Data from 1 January 2012 through 30 June 2018. Adults with type 2 diabetes (T2D) were classified based upon the maximum number of classes of GLAs prescribed per day during the time period from 1 July 2012 through 31 December 2012. Patients were followed for 5.5 years in order to examine time to failure on oral GLAs, defined based upon receipt of ≥ 2 consecutive HbA1c results ≥ 7%. Multivariable analyses employing a Cox proportional hazards model were used to examine time to failure overall and based upon the number of index classes of oral GLAs prescribed. For patients who had sustained HbA1c above the threshold, multivariable analyses examined the duration of time that HbA1c remained above the threshold (i.e, glycemic burden) and whether or not an additional oral or injectable class of GLA was added to the patient treatment regimen (i.e., clinical inertia).

RESULTS

A total of 4156 patients were included in the study, of whom 16% were identified with sustained HbA1c ≥ 7% after 365 days (1 year) and 36% after 730 days (2 years), with half of all patients having sustained HbA1c above target after 1102 days (3 years). There was a statistically significant difference in time to having sustained HbA1c above target based upon index classes of therapy, with patients treated with more GLAs being quicker to have HbA1c above target (P < 0.0001). Among those patients who were found to have sustained HbA1c ≥ 7%, the average number of days in the post-period that HbA1c remained above target was 1026 (2.8 years). Only 36% of patients with sustained HbA1c above target added a GLA to their treatment regimen and, for patients who did add such a therapy, the average duration from identification of HbA1c above target until treatment intensification was 401 days (1.1 years). Multivariable analyses revealed that, among those with sustained HbA1c ≥ 7%, treatment with more classes of oral GLAs was associated with a significantly higher glycemic burden and significantly lower odds of clinical inertia.

CONCLUSION

These results indicate that for many patients treated with oral GLAs, glycemic control is not consistently achieved. For patients with above-target HbA1c , the results indicate a relatively large glycemic burden and clinical inertia towards treatment intensification. The findings illustrate some limitations associated with treatment of T2D with oral GLAs.

The direct and indirect economic burden of hypothyroidism in the United States: a retrospective claims database study

OBJECTIVE

To examine direct and indirect economic burden associated with hypothyroidism in the United States.

METHODS

Medical costs attributable to hypothyroidism were estimated for patients with hypothyroidism. Non-hypothyroid (euthyroid) controls were matched to patients with hypothyroidism based upon patient characteristics and availability of productivity data. Multivariable analyses examined resource utilization, annual medical costs, comorbidities, and productivity costs.

RESULTS

Estimates of hypothyroidism-related total medical costs ranged from $460 to $2,555 per patient per year. Compared to euthyroid controls, patients with hypothyroidism had significantly higher all-cause medical costs and medical resource utilization. For the subset of patients with available productivity data, hypothyroidism was associated with significantly higher absenteeism and long- and short-term disability costs but significantly lower worker's compensation costs.

CONCLUSIONS

Hypothyroidism is associated with significant direct and indirect economic burden among employed, commercially insured patients in the US. Clinical Significance: Despite the availability of relatively inexpensive generic therapies for hypothyroidism, this study found significant direct and indirect costs associated with the condition. The large number of patients diagnosed with hypothyroidism combined with increased costs associated with hypothyroidism result in a significant burden for patients, payers, and employers.

Healthcare outcomes for patients with type 2 diabetes with and without comorbid obesity

AIMS

Examine the burden of comorbid obesity associated with type 2 diabetes (T2D).

METHODS

The IBM® MarketScan® Explorys Claims Electronic Medical Records Data were used to identify adults with T2D, two recorded body mass index (BMI) values, and continuous insurance coverage from 1 year prior through 1 year post index date. Patients with index BMI ≥18 kg/m² and <30 kg/m² (normal/overweight) were matched to patients with index BMI ≥ 30 kg/m² (obese) using propensity score matching (PSM). Using the PSM cohort, multivariable analyses examined the association between obesity and patient comorbidities, healthcare costs, and resource utilization.

RESULTS

In the matched cohort (16,006 normal/overweight; 16,006 obese), multivariable analyses showed that obesity, compared to normal/overweight, was associated with increased odds of a diabetes-related comorbidity (Odds Ratio [OR] = 1.29; 95% Confidence Interval [CI] 1.21-1.38) and an obesity-related comorbidity (OR = 1.42; 95% CI 1.29-1.56). Obesity was also associated with significantly higher annual diabetes-related and all-cause total costs and resource utilization.

CONCLUSIONS

This research increases the knowledge of how patients with T2D and obesity should be of greater concern for healthcare providers compared to T2D patients without comorbid obesity, given their worse comorbidity profile, increased resource utilization, and higher healthcare costs.

The Association Between Adherence to Insulin Therapy and Health Care Costs for Adults with Type 2 Diabetes: Evidence from a U.S. Retrospective Claims Database

BACKGROUND

Research has shown that many patients with type 2 diabetes (T2D) are not adherent to their medication regimen.

OBJECTIVE

To examine the association between adherence to insulin therapy and all-cause health care costs for patients with T2D.

METHODS

This study used the IQVIA PharMetrics Plus Linkable to Ambulatory Electronic Medical Record data from January 1, 2012, through September 30, 2017. Patients were included if they were identified with T2D and initiated therapy on basal insulin (BAS) or basal-bolus (BAS-BOL) combination at any time from January 1, 2013, through October 1, 2016. Patients aged < 18 years, who used an insulin pump, identified as pregnant, or did not have continuous insurance coverage from 1 year before initiation on insulin therapy through 1 year after initiation were excluded. Descriptive statistics compared patient characteristics and costs (in U.S. 2017 dollars) between patients who were adherent or nonadherent to their insulin therapy in the 1-year postperiod, where adherence was defined as having proportion of days covered (PDC) of at least 80%. In addition, generalized linear models were used to compare costs between adherent and nonadherent patients, while controlling for patient characteristics, previous general health and comorbidities, resource utilization, medication use and type of insulin.

RESULTS

13,296 patients were included in the BAS cohort (5,502 adherent; 7,794 nonadherent) and 10,069 in the BAS-BOL cohort (2,006 adherent; 8,063 nonadherent). Adherent patients had significantly lower all-cause total unadjusted costs following initiation on BAS ($29,322 vs. $31,888, P = 0.0134) and BAS-BOL combination ($36,229 vs. $40,147, P = 0.0078). Drug costs comprised 39.5%-45.4% of costs among adherent patients and 23.0%-25.9% of costs among nonadherent patients. Multivariable analyses revealed that adherent patients had significantly lower adjusted all-cause total costs than nonadherent patients in the BAS cohort ($30,127 vs. $37,049, 95% CI for difference -$8,460 to -$5,384) and the BAS-BOL cohort ($36,603 vs. $44,702, 95% CI for difference -$9,129 to -$6,980).

CONCLUSIONS

In patients with T2D who initiated BAS or BAS-BOL combination therapy, adherence was associated with significantly lower all-cause total health care costs, despite significantly higher drug costs. These results illustrate the potential economic benefits associated with adherence to insulin therapy. DISCLOSURES": Eli Lilly and Company funded this study and was responsible for study design and execution. Bajpai, Eby, Faries, and Haynes are employees and own stock in Eli Lilly and Company. Lage received compensation from Eli Lilly and Company for her work on this research project.

The relationship between HbA1c reduction and healthcare costs among patients with type 2 diabetes: evidence from a U.S. claims database

OBJECTIVE

To examine the relationship between hemoglobin A1c (HbA1c) reduction and healthcare costs among patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

Truven MarketScan databases over the time-period from 2013 through 2017 were utilized. Patients with T2D who had an HbA1c laboratory result from 1 January 2014 through 1 January 2017 were included, first such date identified as the index date. Generalized linear models examined the relationship between HbA1c and one-year post-period all-cause and diabetes-related costs.

RESULTS

For patients with T2D (N = 77,622), multivariable analyses revealed that a 1% reduction in HbA1c was associated with a 2% reduction in all-cause total health care costs and a 13% reduction in diabetes-related total healthcare costs (both p < .0001), and that these reductions resulted in annual cost savings of $429 and $736, respectively. For patients with an index HbA1c ≥7% (N = 33,648), a 1% reduction in HbA1c was associated with a 1.7% reduction in all-cause total healthcare costs and a 6.9% reduction in diabetes-related healthcare costs (both p ≤ .0001), with associated annual cost savings of $545 and $555, respectively. The analyses also found that having an index HbA1c <7% compared to HbA1c ≥7% or having an index HbA1c ≥7% and subsequently reducing HbA1c to below 7%, was associated with significant cost reductions.

CONCLUSION

Results suggest that there are economic benefits associated with HbA1c reduction and that these benefits are seen for all patients with T2D and for patients whose index HbA1c is above the American Diabetes Association recommended target.

The Relationship Between Timing of Initiation on a Glucagon-like Peptide-1 Receptor Agonist and Glycosylated Hemoglobin Values Among Patients With Type 2 Diabetes

PURPOSE

This study examines the relationship between timing of initiation on a glucagon-like peptide-1 receptor agonist (GLP-1 RA) and glycosylated hemoglobin (HbA_1c) values.

METHODS

The IBM MarketScan databases were used to identify adults with type 2 diabetes mellitus (T2DM) who initiated GLP-1 RA therapy and had multiple recorded HbA_1c results. Time to GLP-1 RA initiation was proxied by the number of classes of glucose-lowering agents prescribed in the 2 years before GLP-1 RA initiation, with fewer glucose-lowering agents indicating initiation of a GLP-1 RA earlier in disease progression. Paired t tests examined differences in HbA_1c values from preperiod to 2-year postperiod. Multivariable analyses examined the relationship between time to GLP-1 RA initiation and postperiod HbA_1c values.

FINDINGS

Initiation on a GLP-1 RA was associated with a 0.6% reduction in HbA_1c values over 2 years (P < 0.0001). Earliest starts were associated with a 1.3% reduction in HbA_1c levels (P < 0.0001) and the highest likelihood of achieving a postperiod HbA_1c level <7% (odds ratio, 4.9; 95% CI, 3.0-8.1).

IMPLICATIONS

Results indicate that although initiation on a GLP-1 RA is generally associated with reduced HbA_1c levels, there may be additional clinical benefits associated with earlier initiation of a GLP-1 RA.

Chronic Medication Burden and Complexity for US Patients with Type 2 Diabetes Treated with Glucose-Lowering Agents

INTRODUCTION

Most adults with type 2 diabetes (T2D) have several chronic conditions treated with complex regimens and multiple medications. The burden and complexity of multiple medication use are associated with worse patient outcomes, including reduced adherence and increased costs, hospitalizations, mortality rates, and HbA1c. This study quantifies the chronic medication burden, regimen complexity, and potential medication interactions in patients with T2D using a nationwide claims database in the USA.

METHODS

Adults with T2D treated for greater than half of the year with at least one glucose-lowering agent (GLA) in 2017 were included in this descriptive study. Chronic medications were defined as all GLAs and non-GLA medications prescribed for at least 90 days in 2017 to at least 2% of the cohort. Medication burden, defined as the number of medications prescribed, was examined. Medication complexity, proxied by the Medication Regimen Complexity Index (MRCI), and potential use of interacting medications were also examined. Results were investigated for all chronic medications and were reported on the basis of the disease treated (diabetes or other condition) and the route of administration (oral or other).

RESULTS

On average, in 2017, the 814,156 patients included in the study filled prescriptions for 4.1 chronic medications (standard deviation [SD] = 2.0), 3.7 oral chronic medications (SD = 1.9), 1.5 GLAs (SD = 0.8), and 1.1 oral GLAs (SD = 0.7). The average MRCI was 14.7 for all chronic medications (SD = 7.4), with a mean of 12.4 for all oral chronic medications (SD = 6.3), 6.6 for all GLAs (SD = 3.8), and 4.9 for oral GLAs (SD = 2.6).

CONCLUSION

On average, patients with T2D used multiple medications, had a complex medication regimen, and were at potential risk of medication interactions. These findings suggest that patients, practitioners, pharmacists, and payers may benefit from interventions which decrease medication burden, complexity, and/or adverse events related to the treatment of T2D.

Generalizability of glucagon-like peptide-1 receptor agonist cardiovascular outcome trials to the overall type 2 diabetes population in the United States

AIM

To examine the generalizability of results from glucagon-like peptide-1 receptor agonist (GLP-1 RA) cardiovascular outcome trials (CVOTs) in the US type 2 diabetes (T2D) population.

MATERIALS AND METHODS

Patients enrolled or eligible for inclusion in four CVOTs (EXSCEL, LEADER, REWIND, and SUSTAIN-6) were examined in reference to a retrospective clinical database weighted to match the age and sex distribution of the US adult T2D population. We descriptively compared key baseline characteristics of the populations enrolled in each trial to those of the reference population and estimated the proportions of individuals in the reference population represented by those in the trials for each characteristic. We also estimated the proportions of individuals in the reference population that might have been enrolled in each trial based upon meeting the trial inclusion and exclusion (I/E) criteria.

RESULTS

No trial's enrolled population perfectly matched the reference population in key characteristics. The EXSCEL population most closely matched in mean age (62.7 vs. 60.5 years) and percentage with estimated glomerular filtration rate <60 (18.6 vs. 17.3%), while REWIND most closely matched in HbA1c, sex distribution, and proportion with a prior myocardial infarction. Based on I/E criteria, 42.6% of the reference population were eligible for enrolment in REWIND, versus 15.9% in EXSCEL, 13.0% in SUSTAIN-6, and 12.9% in LEADER.

CONCLUSIONS

Although none of the trials are fully representative of the general population, among the four trials examined, results from baseline REWIND were found to be more generalizable to the US adult T2D population than those of other GLP-1 RA CVOTs.

The association between the severity of chronic kidney disease and medical costs among patients with type 2 diabetes

AIMS

Examine healthcare costs across chronic kidney disease (CKD) stages for US patients with type 2 diabetes (T2D).

MATERIALS AND METHODS

IQVIA Real World Data Adjudicated Claims linked electronic medical records and insurance claims from January 1, 2012 through March 31, 2017 were used for this retrospective study. Adults diagnosed with T2D and comorbid CKD were included. General linear models incorporating splines were constructed, and information from these regressions were used to inform the relationship between medical costs and CKD. Multivariable analyses controlled for patient characteristics, vital signs, general health, prior medication use, prior visit to specialists, index A1c, and year of index date.

RESULTS

There were 6,645 individuals who met the study criteria. Results generally indicate sharp increases in annual total medical costs and non-drug medical costs in the 1 year post-period for patients with Stage 4 or 5 CKD (estimated glomerular filtration rate [eGFR] ≤ 30 mL/min/1.73 m²) with each 1 point reduction in eGFR from 30 associated with an increase of $1,870 in all-cause total medical costs (p < 0.0001) and $1,805 of all-cause non-drug medical costs (p < 0.0001). Similarly, each point decline below 30 mL/min was associated annual cost increases of $1,701 for CKD-related total medical costs, $1,695 for CKD-related non-drug medical costs, $173 for diabetes-related medical costs, and $187 for diabetes-related non-drug medical costs (all p < 0.0001).

LIMITATIONS

The investigation included only patients with medical insurance and laboratory test results, and results may not be generalizable to all T2D patients with CKD. The methodology allowed us to determine associations, not causation, and potential confounders, such as duration of diabetes, diet, exercise, or social support, could not be assessed.

CONCLUSIONS

Results indicate there are sharp and significant increases in medical costs among T2D patients with Stage 4 and 5 CKD compared to those with earlier stages of CKD.

Comment on generalizability of GLP-1 RA CVOTs in US T2D population

Previous research overstated the generalizability of the Exenatide Study of Cardiovascular Event Lowering trial results by omitting the restriction on the percentage of patients without a prior cardiovascular event.

The association between adherence to levothyroxine and economic and clinical outcomes in patients with hypothyroidism in the US

OBJECTIVE

To evaluate outcomes associated with adherence to levothyroxine (LT4) in the US adult hypothyroidism population.

METHODS

We used data from Truven's MarketScan databases from 1 July 2011 through 31 December 2015. Patients aged 18 or older were diagnosed with hypothyroidism (confirmed at least twice) and prescribed LT4. Patients were excluded if they did not have continuous insurance coverage or if they received a diagnosis of thyroid cancer or pregnancy during the study period. Multivariable analyses on a matched cohort of adherent and nonadherent patients examined the relationships among patient outcomes and adherence, defined as the proportion of days covered ≥80%. Outcomes included all-cause and hypothyroidism-related medical costs and resource utilization and comorbid diagnoses measured over the 1 year post-period following the first prescription for LT4. The analyses controlled for patient age, sex, region of residence, type of insurance coverage, diagnosing physician and pre-period general health status as proxied by the Charlson Comorbidity Index.

RESULTS

Prior to matching, there were 168,457 patients identified as adherent and 198,443 patients identified as nonadherent. The matched cohort consisted of 318,628 individuals, with equal numbers of adherent and nonadherent patients (n = 159,314). Patients who were adherent used significantly fewer resources and had significantly lower all-cause ($14,136 vs. $14,926; p < .0001) and hypothyroidism-related ($1672 vs. $1709; p < .0001) total costs, although the costs of drugs were higher in the adherent group. Furthermore, adherent patients, compared to nonadherent patients, were significantly less likely to be diagnosed with comorbid Addison's disease, bipolar disorder, chronic kidney disease, depression, migraine, obesity, type 1 diabetes or type 2 diabetes during the follow-up period.

CONCLUSIONS

Compared to nonadherence, adherence to LT4 among patients with hypothyroidism was associated with a significant reduction in all-cause and hypothyroidism-related costs and resource utilization as well as significantly lower rates of many comorbid diagnoses.

Adherence to Basal Insulin Therapy Among People with Type 2 Diabetes: A Retrospective Cohort Study of Costs and Patient Outcomes

INTRODUCTION

This research compares costs, resource utilization, and complications between adherent and nonadherent patients over the 3-year period post initiation on basal insulin therapy.

METHODS

The study utilized the US-based Truven Health MarketScan^® Research Databases from 2011 through 2015. Adults aged 18 years or older and identified with type 2 diabetes (T2D) who initiated therapy on basal insulin in 2012 were included. Patients were excluded if they were pregnant, filled their index basal insulin prescription via mail order, or were not continuously insured from 1 year before through 3 years following initiation of treatment with basal insulin. Instrumental variables were used to control for selection bias, and multivariable analyses were used to examine the associations between adherence to basal insulin therapy and costs, resource utilization, and acute complications.

RESULTS

A total of 21,363 individuals were included in the study. Three years after initiating therapy on basal insulin, patients who were adherent over time to basal insulin treatment therapy (33.8% of patients) had significantly higher diabetes-related drug costs. However, patients' adherence was associated with significantly lower diabetes-related outpatient, acute care, and total costs. Results for all-cause costs were similar. Adherent patients also had significantly fewer all-cause and diabetes-related hospitalizations and emergency room visits and were significantly less likely to be diagnosed with an acute complication.

CONCLUSIONS

Results of this study illustrate that despite higher drug costs, there are disease-specific and all-cause cost offsets and improved patient outcomes associated with adherence to basal insulin therapy for people with T2D.

FUNDING

Eli Lilly and Company.

Glucagon-Like Peptide-1 Receptor Agonist Use and Renal Impairment: A Retrospective Analysis of an Electronic Health Records Database in the U.S. Population

INTRODUCTION

The study characterizes the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in patients with type 2 diabetes (T2D) with and without renal impairment and examines the effects of such use on the clinical outcomes of estimated glomerular filtration rate (eGFR) and glycated hemoglobin (A1c).

METHODS

Data from the Practice Fusion electronic health records database from 1 January 2012 through 30 April 2015 were used. Adults with T2D who received serum creatinine laboratory tests and initiated therapy with a GLP-1 RA (N = 3225) or other glucose-lowering agent (GLA) (N = 37,074) were included in the analysis. The GLP-1 RA cohort was matched to cohorts initiating therapy any other GLA, and multivariable analyses examined the association between GLP-1 RA use and changes in eGFR or A1c at 1 year after therapy initiation.

RESULTS

In this study, only 5.7% of patients with an eGFR of < 30 and ≥ 15 mL/min/1.73 m² and 3.6% of patients with an eGFR of  < 15 mL/min/1.73 m² initiated therapy with a GLP-1 RA. Compared to other GLAs, at 1-year after initiation of therapy the use of a GLP-1 RA was associated with a significantly smaller decline in eGFR (- 0.80 vs. - 1.03 mL/min/1.73 m²; P = 0.0005), a significantly smaller likelihood of having a ≥ 30% reduction in eGFR (2.19 vs. 3.14%; P < 0.0001), and a significantly larger reduction in A1c (- 0.48 vs. - 0.43; P = 0.0064).

CONCLUSION

In clinical practice, the use of GLP-1 RAs in patients with a higher degree of renal impairment disease was limited. Compared to other GLAs, the use of GLP-1 RAs was associated with a significantly smaller decline in eGFR and a larger reduction in A1c over the 1 year following therapy initiation.

FUNDING

Eli Lilly and Company.

Medication adherence and improved outcomes among patients with type 2 diabetes

OBJECTIVES

Examine the association between adherence to glucose-lowering agents (GLAs) and patient outcomes in an adult type 2 diabetes (T2D) population.

STUDY DESIGN

Retrospective analysis.

METHODS

Truven's Commercial Claims and Encounters database supplied data from July 1, 2009, to June 30, 2014. Patients 18 to 64 years with T2D were included if they received a GLA from July 1, 2010, through June 30, 2011. Multivariable analyses examined the relationships among 3-year patient outcomes and adherence, defined as proportion of days covered 80% or more. Outcomes included all-cause medical costs, acute care resource utilization, and acute complications.

RESULTS

Although there was no statistically significant difference in total costs when comparing adherent and nonadherent patients ($38,633 vs $38,357; P = .0720), acute care costs ($12,153 vs $8233; P <.0001) and outpatient costs ($16,964 vs $15,457; P <.0001) were significantly lower for adherent patients. Adherence was also associated with a lower probability of hospitalization (22.71% vs 17.65%; P <.0001) and emergency department (ED) visits (45.61% vs 38.47%; P <.0001), fewer hospitalizations (0.40 vs 0.27; P <.0001) and ED visits (1.23 vs 0.83; P <.0001), and a shorter hospital length of stay (2.16 vs 1.25 days; P <.0001). Adherent patients were also less likely to be diagnosed with an acute complication in the 3-year post period (12.54% vs 9.64%; P <.0001).

CONCLUSIONS

Compared with nonadherence, adherence to GLAs among patients with T2D was associated with a significant reduction in acute care costs and resource utilization, outcomes that may positively impact the welfare of patients.

Trends in use of and complications from intrauterine contraceptive devices and tubal ligation or occlusion

BACKGROUND

Long-acting reversible contraceptives such as intrauterine devices (IUDs) are highly effective in preventing pregnancy, cost effective, and increasing in popularity. It is unclear whether changes in IUD use are associated with changes in rates of irreversible tubal sterilization. In this analysis, we evaluate changes in rates of tubal sterilization, insertion of copper or levonorgestrel (LNG) IUDs, and related complications over time.

METHODS

Data were obtained from a retrospective claims database (Optum^TM Clinformatics^TM Data Mart) of women aged 15 to 45 years who underwent insertion of copper or LNG IUD or tubal sterilization between 1/1/2006 and 12/31/2011. Outcomes of interest included annual rates of insertion or sterilization and annual rates of potential complications and side effects.

RESULTS

The number of women included in the analysis each year ranged from 1,870,675 to 2,016,916. Between 2006 and 2011, copper IUD insertion claim rates increased from 0.18 to 0.25% and LNG IUD insertion claim rates increased from 0.63 to 1.15%, while sterilization claims decreased from 0.78 to 0.66% (P < 0.0001 for all comparisons). Increases in IUD insertion were apparent in all age groups; decreases in tubal sterilization occurred in women aged 20 to 34 years. The most common side effects and complications were amenorrhea (7.36-11.59%), heavy menstrual bleeding (4.85-15.69%), and pelvic pain (11.12-14.27%). Significant increases in claims of certain complications associated with IUD insertion or sterilization were also observed.

CONCLUSION

Between 2006 and 2011, a decrease in sterilization rates accompanied an increase in IUD insertion rates, suggesting that increasing numbers of women opted for reversible methods of long-term contraception over permanent sterilization.

Obesity and glycemic control in patients with diabetes mellitus: Analysis of physician electronic health records in the US from 2009-2011

AIMS

Examine the association between obesity and glycemic control among patients with type 1 (T1DM) or type 2 diabetes mellitus (T2DM).

METHODS

Data from US physician electronic health records (Humedica®) from 2009-2011 were utilized. Patients were defined as having above-target glycemic control if they had an HbA1c ≥7% at any time during the study period. Multinomial logistic regressions were conducted separately for T1DM and T2DM patients, and examined associations between BMI categories and probability of having above-target glycemic control (≥7% and <8%, ≥8% and <9%, or ≥9%) while controlling for patient demographics, general health, comorbid conditions, and antihyperglycemic medication use.

RESULTS

There were 14,028 T1DM and 248,567 T2DM patients; 47.8% of T1DM and 63.4% of T2DM were obese (BMI ≥30kg/m(2)). For T1DM, being overweight (BMI 25-<30), obese class I (30-<35), II (35-<40), or III (≥40) was associated with a significantly higher probability of having HbA1c≥8% and <9% or ≥9%, while being overweight was associated with a significantly higher probability of having HbA1c ≥7% and <8% compared to normal BMI (BMI≥18.5 and<25). For T2DM patients, being overweight, obese class I, II, or III was associated with a significantly higher probability of having HbA1c ≥7% and <8%, ≥8% and <9%, or ≥9%.

CONCLUSIONS

For both T1DM and T2DM patients, there were positive and statistically significant associations between being overweight or obese and having suboptimal glycemic control. These findings quantify the associations between obesity and glycemic control, and highlight the potential importance of individual characteristics on glycemic control.

Associations between adherence and outcomes among older, type 2 diabetes patients: evidence from a Medicare Supplemental database

OBJECTIVE

To examine the association between adherence to glucose-lowering agents and patient outcomes, including costs, acute-care resource utilization, and complications, in an older, type 2 diabetic population.

DATA AND METHODS

The study used Truven's Medicare Supplemental database from July 1, 2009 to June 30, 2014. Patients aged 65 years or older were included if they had at least two type 2 diabetes diagnoses and received a glucose-lowering agent from July 1, 2010 through June 30, 2011. Multivariable analyses examined the relationships among 3-year patient outcomes and levels of adherence, proxied by the proportion of days covered. Outcomes included all-cause medical costs, diabetes-related medical costs, acute-care resource utilization, and acute complications.

RESULTS

In this study (N=123,235), higher adherence was linked to reduced costs and improved health outcomes. For example, comparing an individual with adherence of proportion of days covered <20% to one with proportion of days covered ≥80% illustrates an average saving of $28,824 in total 3-year costs. Furthermore, a 1% increase in adherence among 1,000 patients was associated with all-cause savings of $65,464 over 3 years. The probability of a hospitalization, an emergency room (ER) visit, or an acute complication decreased monotonically as adherence levels got higher, as did the number of hospitalizations, ER visits, and days hospitalized (P<0.005).

CONCLUSION

Higher adherence was associated with substantially less need for acute care, as indicated by a lowered probability of hospitalization or ER use, a reduced risk of an acute complication, and a decreased number of hospitalizations, ER visits, and days hospitalized. Higher adherence was also generally associated with lower all-cause and diabetes-related total costs, despite higher drug costs. These lower total costs were driven by the diminished acute care and outpatient costs. Results suggest that higher glucose-lowering agent adherence is associated with significant benefits for payers and older patients with type 2 diabetes.

Dosing of U-100 insulin and associated outcomes among Medicare enrollees with type 1 or type 2 diabetes

Objective

To examine costs, resource utilization, adherence, and hypoglycemic events among various doses of U-100 insulin regimens among elderly patients (age ≥65 years) diagnosed with diabetes.

Methods

Truven Health Analytics Medicare databases from January 1, 2008 through December 31, 2011 were utilized. General linear models with a gamma distribution and log link were used to examine costs, while logistic and negative binomial regressions were used to examine resource utilization and hypoglycemic events. Analyses controlled for patient characteristics, pre-period comorbidities, general health, and use of antidiabetic medications as well as index dose of insulin.

Results

All-cause inpatient, emergency room, and outpatients costs, as well as diabetes-related inpatient costs, were highest among individuals who were treated with an index dose of 10–100 units/day followed by >300 units/day, while drug costs and total costs generally increased as index dosage increased. Resource utilization generally followed the same pattern as costs, with number of office visits increasing as the dose increased and the highest hospital length of stay, number of hospitalizations, number of emergency room visits, and number of diabetes-related hospitalizations were generally highest among those in the lowest and highest index dose cohorts. Compared to patients who initiated with an index dose of 10–100 units/day, all other patients were significantly less likely to achieve an adherence threshold of 80% based upon index dose range, and while those with an index dose of >100–150 units/day were significantly more likely to experience a hypoglycemic event.

Conclusion

These results suggest that, for elderly individuals with diabetes, there is a higher patient burden among those who receive the lowest and highest insulin doses.

Outcomes of medicaid beneficiaries with schizophrenia receiving clozapine only or antipsychotic combinations

OBJECTIVE

Patients with treatment-resistant schizophrenia commonly receive nonrecommended drug regimens, including antipsychotic polypharmacy, sometimes in lieu of clozapine. This analysis compared utilization and cost outcomes for cohorts of Medicaid beneficiaries treated with clozapine monotherapy and with antipsychotic polypharmacy.

METHODS

Data were from the Medicaid MarketScan database. Patients (age 18-64) initiated second-generation antipsychotic polypharmacy or clozapine monotherapy between July 2006 and January 2009, had continuous Medicaid coverage from six months before (preperiod) through 12 months after (postperiod) treatment initiation, and had a diagnosis of schizophrenic disorder (ICD-9-CM code 295.XX). Study outcomes included disease-specific and all-cause hospitalization, emergency department use, and Medicaid payments. Logistic regression analyses and generalized linear models controlled for demographic factors, preperiod utilization, and comorbidities.

RESULTS

Characteristics associated with use of clozapine monotherapy (N=479) instead of antipsychotic polypharmacy (N=2,440) included younger age, fewer comorbidities, lower preperiod utilization rates, nonwhite race, and male sex. When the analysis controlled for baseline differences, clozapine monotherapy was associated with lower odds of mental disorder-related (odds ratio [OR]=.75, 95% confidence interval [CI]=.60-.95) or schizophrenia-related (OR=.70, CI=.54-.90) emergency department use but not with hospitalization or all-cause emergency department use. Total Medicaid payments were significantly lower for the clozapine group than for the polypharmacy group: reductions of $21,315 for all-cause, $17,457 for mental disorder-related, and $10,582 for schizophrenia-related payments.

CONCLUSIONS

Among nonelderly adult Medicaid beneficiaries with schizophrenia, treatment with clozapine instead of antipsychotic polypharmacy was associated with reduced disease-specific emergency department use and with reduced disease-specific and all-cause health care costs.

Updated cost-of-care estimates for commercially insured patients with multiple sclerosis: retrospective observational analysis of medical and pharmacy claims data

Background

For patients with multiple sclerosis (MS), previous research identified key disease sequelae as important cost drivers and suggested that among users of disease-modifying drugs (DMDs) in 2004, DMDs represented 73% of the total cost of care. More recent studies were limited to incident disease/treatment and/or excluded DMDs from cost estimates. To support contemporary pharmacoeconomic analyses, the present study was conducted to provide updated information about MS-related costs and cost drivers including DMDs.

Methods

For each of 2 years, 2006 and 2011, commercially insured, continuously eligible patients with ≥ 1 medical claim diagnosis of MS were sampled. MS-related charges were based on medical claims with MS diagnosis plus medical/pharmacy claims for DMDs. 2006 charges were adjusted to 2011 $ using the medical care component of the consumer price index (CPI). Subgroups of patients using DMDs (interferon [IFN] beta-1a intramuscular or subcutaneous, IFN beta-1b, glatiramer, natalizumab) in 2011 were identified. By-group differences were tested with bivariate statistics.

Results

Mean (standard deviation [SD]) age of 15,902 sample patients in 2011 was 47.6 (11.8) years, 76% female. Mean [SD] MS charges ($26,520 [$38,478] overall) were significantly (P < 0.001) higher for patients with common disease sequelae: malaise/fatigue (n = 2,235; $39,948 [$48,435]), paresthesia (n = 1,566; $33,648 [$45,273]), depression (n = 1,255; $42,831 [$51,693]), and abnormality of gait (n = 1,196; $48,361 [$55,472]). From 2006 to 2011, CPI-adjusted MS charges increased by 60%. Among patients treated with a single DMD in 2011, inpatient care was 6% of charges (range = 4%-8%; P = 0.155); outpatient care was 19% (range = 14%-20% except for natalizumab [29%]; P < 0.001); and DMDs were 75% (range = 67%-81%; P < 0.001).

Conclusions

Common MS sequelae remain important cost drivers. Although MS treatment costs are increasing, the proportion of MS charges due to DMDs in 2011 is similar to that reported in 2004.

Early discontinuation and restart of insulin in the treatment of type 2 diabetes mellitus

INTRODUCTION

Although the largest improvement in glycemic control occurs within the first 90 days of insulin therapy, little is known about early persistence on insulin therapy. This research aimed to identify predictors of early discontinuation and of subsequent restart of basal or mixture insulin among patients with type 2 diabetes mellitus (T2DM) and to assess the economic cost associated with such behaviors over a 1-year period.

METHODS

Truven's Health Analytics Commercial Claims and Encounters database was utilized for the study. Logistic regressions were used to examine factors associated with early discontinuation of insulin (basal or mixture) and, among patients who discontinued early, the factors associated with restarting. Cost regressions were estimated using generalized linear models with a gamma distribution and logistic link. Kaplan-Meier survival curves were used to examine time to discontinuation and time to restart among those who discontinued.

RESULTS

Multivariate analyses revealed that patient characteristics, prior healthcare resource utilization, comorbid diagnoses, and type of initiated insulin were associated with early discontinuation of insulin and of restarting among patients who discontinued early. Acute care (hospitalization and emergency room) costs were 9.6% higher among patients who discontinued early (P < 0.001), although outpatient, drug, and total costs were significantly lower among individuals who discontinued early. Among the early discontinuation subgroup, restarting insulin was associated with higher costs. Specifically: 11.3% higher acute care costs (P < 0.001), 24.0% higher outpatient costs (P < 0.001), 80.2% higher drug costs (P < 0.001), and 30.3% higher total costs (P < 0.001), compared to patients who discontinued early but did not restart insulin therapy in the 1-year post-period.

CONCLUSION

Among patients with T2DM who were initiated on insulin therapy, early discontinuation of insulin and its subsequent restart were associated with significantly higher acute care costs, which may signal a more complex and challenging subgroup of patients who tend to be less engaged in outpatient care and may have poorer long-term outcomes.

Comparison of rates of and charges from pregnancy complications in users of extended and cyclic combined oral contraceptive (COC) regimens: a brief report

OBJECTIVE

To evaluate pregnancy complication rates and related charges in users of 84/7, 21/7 and 24/4 combined oral contraceptives (COCs).

STUDY DESIGN

Data were obtained from the i3 InVision Data Mart™ retrospective claims database. Subjects were aged 15-40 years, first prescribed a COC between 1/1/2006 and 4/1/2011 and continuously insured for ≥1 year. 84/7 users were matched 1:1 to 21/7 and 24/4 users.

RESULTS

Pregnancy-related complication rates and associated charges were significantly lower with 84/7 vs. 21/7 and 24/4 regimens.

CONCLUSION

Preliminary data suggest 84/7 regimens may be associated with fewer pregnancy complications and lower related charges.

Glycemic control among patients with type 2 diabetes who initiate basal insulin: a retrospective cohort study

OBJECTIVE

To examine changes in glycemic control for patients with type 2 diabetes mellitus (T2DM) after initiation of basal insulin and factors associated with improved glycemic control.

METHODS

An analysis of retrospective medical records of patients with T2DM was examined using Humedica's electronic medical records database (January 2007-August 2012). Patients with T2DM, initiating basal insulin, age ≥ 21 years, with a recorded HbA1c test in both the 1 year prior and the 2 years post-initiation were included. A multivariate regression examined factors associated with changes in glycemic control. Logistic regressions examined factors associated with improvements or worsening of glycemic control, compared to relatively unchanged glycemic control.

RESULTS

Many (14,457) individuals met the inclusion-exclusion criteria. Multivariate analyses revealed that older age (p < 0.0001), residence in the Western region of the US (vs South) (p < 0.0001), Medicare insurance vs Medicaid or being uninsured (p = 0.0138), and higher household income (p = 0.0065) were associated with improved glycemic control. Patients diagnosed with comorbid peripheral vascular disease (p = 0.0072), cancer (p = 0.0019), obesity (p = 0.0002), moderate (p = 0.0103), and severe chronic kidney disease (p < 0.0001), or end-stage renal disease (p = 0.0075) in the pre-period were found to have significantly improved glycemic control in the post-period. Use of prandial insulin (p = 0.0087), pre-mix insulin (p = 0.0003) in the pre-period, a higher pre-period HbA1c score (p < 0.0001), and longer duration between pre-period and post-period HbA1c testing (p < 0.0001) were significantly associated with higher HbA1c levels in the post-period.

LIMITATIONS

Analyses rely on electronic medical records which cannot capture patient healthcare utilization occurring outside of the data capture system. Analyses do not control for insulin dosage or type of basal insulin prescribed.

CONCLUSIONS

Among patients with T2DM treated with basal insulin, a number of factors may influence glycemic outcomes. These findings suggest a role for a more personalized approach to the treatment of patients with T2DM.

Glycemic control and the first use of oral antidiabetic agents among patients with type 2 diabetes mellitus

OBJECTIVE

Examine how patients diagnosed with type 2 diabetes mellitus (T2DM) are treated with oral antidiabetic (OAD) agents and the relationship between treatment patterns and glycemic control.

RESEARCH DESIGN AND METHODS

Data were obtained from the i3 Invision Data Mart database (OptumInsight, Eden Prairie, MN, USA). The analyses examined 4627 individuals who received a first prescription for an OAD (with first date identified as index date) and received at least one HbA1c test in both the 1 year prior and 2 years post index date. Patients were categorized based upon their level of glycemic control pre index date and logistic multivariate analyses were used to examine the probability of a patient's first treatment pattern change being a switch, augmentation, or discontinuation compared to continuation on the intent-to-treat (ITT) OAD.

RESULTS

Men tended to have worse glycemic control at OAD initiation. During the post-period, younger patients were more likely to switch, augment or discontinue therapy, while patients initially treated with metformin were more likely to switch or augment therapy. Results indicated that patients with moderate or poor glycemic control, compared to those with good glycemic control, were significantly more likely to switch or augment therapy. Practice patterns revealed minimal use of insulin although, on average, many patients were above target HbA1c levels at initiation. Interpretation of results are limited by the fact that only a small subset of patients had valid HbA1c data and that the analyses was not able to account for other factors, such as race and weight, that may also impact the analyses.

CONCLUSIONS

Patient initial level of glycemic control was associated with changes in treatment patterns in the 2 years post initiation on an OAD, with patients with moderate or poor control more likely to switch or augment their ITT therapy, compared to individuals with good control.

The association between use of mealtime insulin pens versus vials and healthcare charges and resource utilization in patients with type 2 diabetes: a retrospective cohort study

OBJECTIVE

To compare all-cause and diabetes-related resource utilization and healthcare charges among adults with type 2 diabetes mellitus who initiated therapy with mealtime insulin disposable pens or vials.

METHODS

Data were obtained from the Innovus inVision database from January 1, 2006 through June 30, 2010. Generalized linear models with a gamma distribution and log link estimated the association between medical charges and use of mealtime insulin pens vs vials in the 1 year post-index date, while generalized linear models with a negative binomial distribution estimated resource utilization.

RESULTS

Controlling for patient characteristics, general health, and patient copayments, insulin therapy initiation with disposable pens, compared to vials, was associated with significantly fewer all-cause hospitalizations (1.45 vs. 1.66; p < 0.0001) as well as a significantly shorter hospital length of stay (2.16 days vs. 3.53 days; p < 0.0001). Pen use, compared to vials, was also associated with significantly fewer diabetes-related hospitalizations (1.36 vs. 1.47; p < 0.0001), and shorter hospital length of stay (1.12 days vs. 1.72 days; p < 0.0001). Despite higher diabetes-related drug charges ($3593 vs. $2755; p < 0.0001) associated with the use of pens, results showed significantly lower all-cause total healthcare charges ($42,150 vs. $53,340; p < 0.0001) and significantly lower diabetes-related total healthcare charges ($12,722 vs. $14,540; p < 0.0001) for patients who initiated therapy on mealtime insulin with pens compared to vials.

LIMITATIONS

Data were drawn from administrative claims and included only patients with medical and outpatient prescription drug benefit coverage. Hence, the results may not be generalizable. The retrospective analyses relied on diagnostic codes to identify patients, assess patient general health, and determine other values, rather than formal, clinical assessments. The analyses did not include indirect healthcare costs.

CONCLUSIONS

The administration of mealtime insulin via disposable pens, compared to vials, was associated with a significant reduction in all-cause and diabetes-related resource utilization and total healthcare charges.

Comparison of pregnancy rates in users of extended and cyclic combined oral contraceptive (COC) regimens in the United States: a brief report

OBJECTIVE

To evaluate pregnancy rates with 84/7, 21/7, and 24/4 combined oral contraceptives (COCs).

STUDY DESIGN

Data were obtained from the i3Invision Data Mart(TM) retrospective claims database. Subjects were 15 to 40 years; first prescribed COCs between January 1, 2006 and April 1, 2011; and continuously insured for ≥1 year. Eighty four over seven users (84/7) were matched 1:1 to 21/7 and 24/4 users.

RESULTS

One-year pregnancy rates were significantly lower with 84/7 than with 21/7 (4.4% vs. 7.3%; p<.0001) and 24/4 (4.4% vs. 6.9%, p<.0001) regimens.

CONCLUSION

Preliminary results suggest fewer pregnancies with 84/7 versus 21/7 or 24/4 regimens.

IMPLICATIONS

While newer COCs, including 84/7 and 24/4 regimens, potentially improve efficacy and alter bleeding profiles compared to 21/7 regimens, few data on comparative pregnancy rates with these regimens are available. In this retrospective claims analysis, real-world pregnancy rates were lower with 84/7 regimens versus 21/7 and 24/4 regimens.

Using observational analysis of multiple sclerosis relapse to design outcomes-based contracts for disease-modifying drugs: a feasibility assessment

OBJECTIVE

To assess predictors and costs of multiple sclerosis (MS) relapse, a potential outcome measure in payer-manufacturer risk-sharing agreements for disease-modifying drugs (DMDs).

METHODS

A retrospective cohort analysis of medical/pharmacy claims was used. Study patients had ≥1 DMD (interferon beta, glatiramer, natalizumab) claim, without DMD claims in a 6-month pre-period before DMD initiation; were aged 18-64 years and continuously enrolled from the pre-period through a 24-month post-period; and had ≥2 MS medical claims during the 30-month study period. Post-period relapse cohorts included: (1) severe (hospitalization with MS diagnosis); (2) moderate (outpatient services including intravenous methylprednisolone); and (3) none. Poisson regression modeled severe relapse frequency, logistic regression modeled ≥1 severe relapse, and generalized linear modeling predicted healthcare costs. Tested predictors included demographics, insurance type, index DMD, pre-period health status, and DMD medication possession ratio (MPR).

RESULTS

Severe relapse was experienced by 14.5% and moderate relapse by 13.8% of 2291 patients. In logistic regression, severe relapse was predicted by plan type; age (odds ratio [OR] = 1.018, 95% confidence interval [CI] = 1.005-1.031); pre-period Charlson Comorbidity Index (OR = 1.307, 95% CI = 1.166-1.464); pre-period proxy measure indicating impaired activities of daily living (OR = 1.470, 95% CI = 1.134-1.905); pre-period MS hospitalization (OR = 2.174, 95% CI = 1.537-3.074); and DMD non-adherence (MPR OR = 0.101, 95% CI = 0.068-0.151). Poisson regression results were similar. Predicted mean [standard deviation] all-cause healthcare expenditures were tripled for patients with severe compared with moderate relapse ($48,173 [$8665] and $13,334 [$1929], respectively).

LIMITATIONS

Commercially insured patients from a single payer; use may have been inconsistent with approved indications; proxy relapse measure may have misclassified patients.

CONCLUSIONS

Severe MS relapses requiring hospitalization, although affecting less than 15% of patients initiating DMD treatment, are associated with high medical costs. The only actionable predictor of severe relapse identified in observational analysis was MPR, raising questions about the feasibility of using observational data to guide outcomes-based contracting.

The relationship between alternative medication possession ratio thresholds and outcomes: evidence from the use of glatiramer acetate

OBJECTIVE

To examine how changes in the medication possession ratio (MPR) affect the probability of multiple sclerosis (MS) relapses and total and MS-related charges among patients treated with glatiramer acetate (GA).

METHODS

Data were obtained from i3 InVision™ Data Mart for January 1, 2006 through March 31, 2010. Patients were included if they were diagnosed with MS, initiated therapy with GA, and had continuous insurance coverage from 6 months prior through 24 months after initial use of GA (n=839). Multivariate regressions which controlled for patient characteristics examined the association between achievement of alternative MPR goals and patient relapses and charges.

RESULTS

Patients who achieved an MPR of at least 0.7 had significantly lower odds of relapse than those with MPR thresholds below 0.7, with achievement of a threshold of 0.7, 0.8, or 0.9, associated with an odds ratio of relapse of 0.545 (95% CI=0.351-0.824), 0.568 (95% CI=0.371-0.870), and 0.421 (95% CI=0.260-0.679), respectively. Attaining higher MPR thresholds resulted in larger reductions in direct medical charges, excluding GA and other MS-related drugs. MPR of 0.25 was associated with $1699 lower 2-year total direct medical charges (p=0.009) while a threshold of 0.95 was associated with $2136 lower total charges (p<0.001), compared to patients not reaching these respective thresholds. MPR of 0.90 was associated with $986 lower MS-related charges than for those with MPR<0.90 (p=0.050). Results also revealed an association between patient adherence to GA and statistically significant reductions in charges for specific components of care.

LIMITATIONS

Results are generalizable only to patients with medical and prescription benefit coverage without regard for functional status.

CONCLUSIONS

As adherence improved the odds of relapse decreased and charge offsets generally increased. Results suggest that, despite higher costs associated with increased usage of GA, patient outcomes are improved and there are cost-offsets associated with adherent use of GA.

Cost sharing, benefit design, and adherence: the case of multiple sclerosis

PURPOSE

The authors focus on understanding the relationship between costs and cost sharing on medication adherence for individuals who initiated a disease-modifying therapy (DMT) for the treatment of multiple sclerosis (MS). DMTs reduce the risk of relapse and are an essential component of MS treatment. Furthermore, the authors compare monthly payment levels for copayments versus coinsurance and estimate the effects on adherence.

METHODS

Using the MarketScan Commercial Claims and Encounters database evidence from July 1 2005 to March 31 2008, the authors employ a multivariate two-stage least-squares model (2SLS) to examine the impact of copayments or coinsurance on the medication possession ratio (MPR).

FINDINGS

Descriptive results show that the mean out-of-pocket (OOP) costs of DMT per month were higher for patients with coinsurance than for patients with copayments. For the cohort of patients with copayment there was little difference in monthly copayments across adherence thresholds. Regression analysis shows that an increase in cost sharing reduces adherence overall, but this effect was small and insignificant in the copayment cohort. In contrast, in the coinsurance cohort increased cost sharing was significantly associated with decreased adherence to DMT medication; with a 10% increase in cost sharing leading to an 8.6% decline in adherence.

IMPLICATIONS

Employers increasingly rely on coinsurance, despite evidence that reliance on coinsurance results in lower adherence. Our research findings suggest that coinsurance appears to be a greater obstacle to compliance, confirming predictions found in the theoretical literature.

ORIGINALITY

This research converted counts of injectable treatments into a continuous adherence measure. Previous literature on cost sharing did not examine MS.

Healthcare costs in postmenopausal women with hormone-positive metastatic breast cancer

OBJECTIVES

This study examines costs for postmenopausal women with hormone receptor positive (HR+) metastatic breast cancer (mBC).

METHODS

Data were obtained from the IHCIS National Managed Care Benchmark Database from 1/1/2001 to 6/30/2006. Women aged 55-63 years were selected for the study if they met the inclusion criteria, including diagnoses for breast cancer and metastases, and at least two fills for a hormone medication. Patients were followed from the onset of metastases until the earliest date of disenrollment from the health plan or 6/30/2006. Patient characteristics were examined at time of initial diagnoses of metastases, while costs were examined post-diagnosis of metastases and prior to receipt of chemotherapy (pre-chemotherapy initiation period) and from the date of initial receipt of chemotherapy until end of data collection (post-chemotherapy initiation period). Costs were adjusted to account for censoring of the data.

RESULTS

The study population consisted of 1,266 women; mean (SD) age was 59.05 (2.57) years. Pre-chemotherapy initiation, unadjusted inpatient, outpatient, and drug costs were $4,392, $47,731, and $5,511, while these costs were $4,590, $57,820, and $38,936 per year, respectively, post-chemotherapy initiation. After adjusting for censoring of data, total medical costs were estimated to be $55,555 and $70,587 in the first 12 months and 18 months, respectively in the pre-chemotherapy initiation period. Post-chemotherapy initiation period, 12-month and 18-month adjusted total medical costs were estimated to be $87,638 and $130,738.

LIMITATIONS

The use of an administrative claims database necessitates a reliance upon diagnostic codes, age restrictions, and medication use, rather than formal assessments to identify patients with post-hormonal women with breast cancer. Furthermore, such populations of insured patients may not be generalizable to the population as a whole.

CONCLUSIONS

These findings suggest that healthcare resource use and costs - especially in the outpatient setting - are high among women with HR+ metastatic breast cancer.

Glatiramer acetate and interferon beta-1a for intramuscular administration: a study of outcomes among multiple sclerosis intent-to-treat and persistent-use cohorts

OBJECTIVE

To study outcomes of multiple sclerosis (MS) patients treated with either glatiramer acetate (Copaxone) or interferon beta-1a for once-weekly, intramuscular administration (Avonex).

METHODS

An 'intent-to-treat' (ITT) cohort (n=1282) was established, consisting of patients diagnosed with MS who began therapy on either glatiramer acetate (GA) or intramuscular interferon beta-1a (IFN beta-1a-IM) and had continuous insurance coverage from 6 months before to 24 months after the date when they began taking the medication. A 'persistent use' (PU) cohort (n=639) was also constructed, consisting of individuals who, in addition to the criteria listed above, had a claim for GA or IFN beta-1a-IM within 28 days of the end of the 2-year post-period. Data were obtained from the i3 InVision Data Mart Database from July 2001 to June 2006. Multivariate regressions were used to examine both the 2-year total direct medical costs and the likelihood of relapse associated with the use of each of these alternative MS medications. A relapse was defined as either being hospitalized with a principal diagnosis of MS or having an outpatient visit with a MS diagnosis followed within 7 days by a claim for a corticosteroid. All regressions controlled a wide range of factors that may potentially affect outcomes.

RESULTS

In the ITT cohort, patients who started therapy on GA had a significantly lower 2-year risk of relapse (10.01 vs. 5.18%; p=0.0034) as well as significantly lower 2-year total medical costs ($44,201 vs. $41,121; p=0.0294). In the PU cohort, patients who used GA also had a significantly lower 2-year risk of relapse (7.25 vs. 2.16%; p=0.0048) as well as significantly lower total medical costs ($67,744 vs. 63,714; p=0.0445).

LIMITATIONS

The analyses relies on an administrative claims database of an insured population and hence, may not be generalizeable to other populations. In addition, such a database precludes measurement of lost work time, unemployment, caregiver burden or other costs associated with MS.

CONCLUSIONS

Results from this study indicate that the use of GA is associated with significantly lower probability of relapse as well as significantly lower 2-year total direct medical costs than IFN beta-1a-IM.

Glatiramer acetate and interferon beta-1b: a study of outcomes among patients with multiple sclerosis

INTRODUCTION

To study the medical cost and probability of relapse in patients with multiple sclerosis (MS) treated with either glatiramer acetate (GA) or interferon beta-1b (IFN beta.1b).

METHODS

Data were obtained from the i3 InVision Data Mart Database from July 2001 to June 2006. We established an "intent-totreat" (ITT) cohort (n=842) of patients diagnosed with MS who began treatment with either GA or IFN beta-1b and had continuous insurance coverage from 6 months before to 2 years after the date when they began taking the medication. We also created a "continuous use" (CU) cohort (n=418) of individuals who, in addition to the criteria listed above, used either GA or IFN beta-1b within 28 days of the end of the 2-year postperiod. Using multivariate regressions, we examined both the 2-year total average direct medical costs and the likelihood of relapse within this period associated with the use of each of these MS medications. We defined relapse as being either hospitalization with a principal diagnosis of MS or having an outpatient visit with a diagnosis of MS and then prescribed steroids within a 7-day period. All regression analyses controlled for a wide range of factors that may potentially affect outcomes.

RESULTS

In the ITT cohort, patients who started treatment with GA had a significantly lower 2-year estimated risk of relapse (13.54% vs. 5.31%; P=0.0006). In the CU cohort, patients who used GA also had a significantly lower 2-year estimated risk of relapse (10.91% vs. 2.09%; P=0.0018), as well as significantly lower average total medical costs ($53,157 vs. $48,130; P=0.0345).

CONCLUSIONS

Results from this study indicate that users of GA have a significantly lower probability of 2-year relapse than users of IFN beta-1b. In addition, among continuous users, the 2-year total average direct medical costs are significantly lower for users of GA than for users of IFN beta-1b.

The relationship between antipsychotic medication adherence and patient outcomes among individuals diagnosed with bipolar disorder: a retrospective study

BACKGROUND

Reducing hospitalizations and emergency room visits is important to improve patient outcomes. This observational study examined the association between adherence to antipsychotics and risk of hospitalizations and emergency room (ER) visits among patients with bipolar disorder.

METHODS

Claims data from commercial healthcare plans (Pharmetrics; January 2000 to December 2006) for patients with bipolar disorder receiving an antipsychotic prescription were examined. Adherence was analyzed over a 12-month follow-up period after the receipt of first prescription of an antipsychotic. Adherence to antipsychotics was measured by the medication possession ratio (MPR). The MPR was calculated as the number of days that an antipsychotic medication was filled as compared with the total number of days during the follow-up period. Logistic stepwise regressions examined the association between achievement of various adherence goals and patient outcomes (hospitalization or ER visit for mental health or any reason).

RESULTS

In total, 7,769 patients with bipolar disorder were included. The mean MPR was 0.417, with 61.7% of individuals having an MPR < 0.50, and 78.7% an MPR < 0.75. As adherence improved, the risk of hospitalization or ER visit declined. A significant reduction in the risk of hospitalization (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.75 to 0.98) or an ER visit (OR 0.84, 95% CI 0.74 to 0.96) for any cause was associated with an MPR >or= 0.75. An MPR >or= 0.80 was associated with a significant reduction in the risk of a mental health-related hospitalization (OR 0.82, 95% CI 0.70 to 0.95), while an MPR >or= 0.90 was associated with a significant reduction in risk of a mental health-related ER visit (OR 0.71, 95% CI 0.54 to 0.91).

CONCLUSION

Patients with lower antipsychotic adherence were at greater risk of hospitalizations and ER visits. Thus, any efforts to increase adherence, even in small increments, can be helpful in decreasing these risks.

Risk of rehospitalization among bipolar disorder patients who are nonadherent to antipsychotic therapy after hospital discharge

PURPOSE

The relationship between nonadherence to antipsychotic medication after hospital discharge and risk of rehospitalization in patients who were previously hospitalized for treatment of bipolar disorder was studied.

METHODS

Administrative claims data from 2000 through 2006 were obtained from commercial insurance plans. Patients age 18-64 years who were discharged from a hospital with a diagnosis of bipolar disorder and given a prescription for an antipsychotic 0-14 days after discharge comprised the study sample. Adherence to antipsychotic medication was determined by measuring the number of unique days during which medication was supplied during the treatment period, a calculation known as the medication possession ratio (MPR). Rehospitalization was considered to be an indicator of relapse. A multivariate, stepwise logistic regression, which controlled for patient characteristics, type of bipolar disorder, general health status, and comorbid conditions, was used to assess the relationship between medication non-adherence and rehospitalization.

RESULTS

A total of 1973 individuals were included in the analyses. The mean +/- S.D. MPR for this patient population was 0.46 +/- 0.32. Patients whose MPR was 0.75 or greater had a lower risk of all-cause rehospitalization (odds ratio [OR], 0.730; 95% confidence interval [CI], 0.580-0.919) and a lower risk of a mental-health-related rehospitalization (OR, 0.759; 95% CI, 0.603-0.955). As medication adherence increased above the MPR of 0.75, the risk of rehospitalization significantly decreased.

CONCLUSION

Among patients who were previously hospitalized for treatment of bipolar disorder, those who were adherent to their antipsychotic medication at least 75% of the time had lower risks of all-cause rehospitalization and mental-health-related rehospitalization.

Comparison of costs among patients with type 2 diabetes treated with exenatide or sitagliptin therapy

INTRODUCTION

Exenatide (Byetta, Amylin Pharmaceuticals Inc., CA, USA) and sitagliptin (Januvia, Merck & Co, NJ, USA) are two antidiabetic agents recently approved by the US Food and Drug Administration. The purpose of this analysis was to compare costs among patients with type 2 diabetes (T2D) treated with either of these agents.

METHODS

Data with dates of service from September 1, 2005 through August 31, 2007, were obtained from a large US retrospective claims database. Intent-to-treat cohorts of adults diagnosed with T2D who began taking either exenatide (n=1885) or sitagliptin (n=2482) and did not use the alternate medication in the 6-month follow-up period were created. Six-month total medical costs were estimated using stepwise multivariate regressions. Six-month total diabetes-related medical costs, a component of total medical costs, were also estimated using stepwise multivariate regressions. In addition, other cost components were examined using either stepwise multivariate regressions or a two-part model that controlled for the probability of using the medical service. Smearing estimates were used to transform estimated log costs into costs. The analysis controlled for the potential impact of patient demographics, general health, prior resource use, comorbidities, and timing of treatment initiation.

RESULTS

Exenatide was associated with lower total 6-month direct medical costs ($9340 vs. $9995; P<0.0001), despite some component costs being slightly higher with exenatide: diabetes-related drug costs ($1765 vs. $1743; P=0.0062), diabetes-related medical costs ($4142 vs. $4002; P<0.0001), and emergency room costs ($43 vs. $29; P=0.0388). Exenatide was associated with lower outpatient costs ($4498 vs. $5942; P<0.0001).

CONCLUSIONS

Compared with the use of sitagliptin, exenatide was associated with lower total medical costs (difference of $655) despite higher total diabetes-related costs (difference of $140). As a result, there appears to be overall cost savings associated with the use of exenatide relative to sitagliptin.

A comparison of costs among patients with type 2 diabetes mellitus who initiated therapy with exenatide or insulin glargine

BACKGROUND

Exenatide (Byetta) and insulin glargine (Lantus) are antidiabetic agents that are typically used after lack of response to an oral antidiabetic agent(s). Although previous research has examined the impact of these medications on glycaemic control, there is little information about the relative costs associated with the medications.

OBJECTIVE

To compare costs among patients with type 2 diabetes mellitus treated with exenatide or insulin glargine from a US third-party payer perspective.

METHODS

Data from a large, national administrative claims database were used in this study. The intent-to-treat (ITT) cohort included adults who were diagnosed with type 2 diabetes and initiated therapy with either exenatide (n = 4090) or insulin glargine (n = 1660). In addition, included patients were required to have no diagnoses of type 1 diabetes, to have received at least two prescriptions for an oral antidiabetic agent in the 6 months prior to first use of either exenatide or insulin glargine and to have continuous insurance coverage from 6 months before, to 12 months after, initiation on ITT medication. Annual total medical costs and total diabetes-related medical costs, in $US, year 2007 values, were estimated using stepwise multivariate regressions. Major cost components were also examined using either stepwise multivariate regressions or a two-part model that controlled for the probability of using the service. Smearing estimates were used to transform estimated log costs into costs. The analysis controlled for the potential impact of patient demographics, general health, prior resource use, co-morbidities and complications, and timing of treatment initiation.

RESULTS

Compared with insulin glargine, initiation of exenatide was associated with significantly lower total direct medical costs ($US19,293 vs $US23,782; p < 0.0001), inpatient costs ($US4121 vs $US7532; p < 0.0001), outpatient costs ($US9501 vs $US12,885; p < 0.0001), emergency department (ED) costs ($US82 vs $US131; p < 0.0001), total diabetes-related medical costs ($US7833 vs $US8536; p < 0.0001), diabetes-related inpatient costs ($US2172 vs $US3538; p < 0.0001) and diabetes-related outpatient costs ($US2739 vs $US3249; p < 0.0001). Initiation of exenatide was associated with significantly higher total overall drug costs ($US6885 vs $US5936; p < 0.0001) and diabetes-related drug costs ($US3160 vs $US2422; p < 0.0001).

CONCLUSIONS

Compared with the use of insulin glargine, use of exenatide was associated with significantly lower annual total direct medical costs and significantly lower total diabetes-related medical costs, despite higher total drug costs and higher diabetes-related drug costs. In addition, exenatide was associated with significantly lower total inpatient, outpatient, ED, and diabetes-related inpatient and outpatient costs.

Glatiramer acetate versus interferon beta-1a for subcutaneous administration: comparison of outcomes among multiple sclerosis patients

INTRODUCTION

We compared the outcomes of multiple sclerosis (MS) patients treated with either glatiramer acetate (GA) (Copaxone, Teva Pharmaceutical Industries, Israel) or interferon beta-1a for subcutaneous administration (IFN beta-1a-SC) (Rebif, Merck Serono, Switzerland).

METHODS

Data were obtained from i3's Lab Rx Database from July 2001 to June 2006. We established an 'intent-to-treat' (ITT) cohort (n=845) of patients diagnosed with MS who began therapy on either GA (n=542) or IFN beta-1a-SC (n=303) and had continuous insurance coverage from 6 months before to 24 months after the date they began taking the medication. We also created a 'continuous use' (CU) cohort (n=410) of individuals who, in addition to the criteria listed above, used either GA or IFN beta-1a-SC within 28 days of the end of the 2-year-post period. Using multivariate regressions, we examined both the 2-year total direct medical costs and the likelihood of relapse associated with the use of these two MS medications. We defined relapse as either being hospitalised with a diagnosis of MS, or being diagnosed with MS during an outpatient visit and then prescribed steroids within a 7-day period. All regressions controlled a wide range of factors that have potentially affected outcomes.

RESULTS

In the ITT cohort, patients who started therapy on GA had a significantly lower 2-year risk of relapse (5.92% versus 10.89%; P=0.0305), as well as significantly lower 2-year total medical costs (US$41,786 versus US$49,030; P=0.0002). In the CU cohort, patients who used GA also had a significantly lower 2-year risk of relapse (1.94% versus 9.09%; P=0.0049) and significantly lower total medical costs (US$45,213 versus US$57,311; P<0.0001).

CONCLUSIONS

Results indicate that, compared with the use of IFN beta-1a-SC, use of GA is associated with significantly lower probability of relapse as well as significantly lower 2-year total direct medical costs. In addition, these results are more pronounced among patients defined as continuous users.

Obesity and the use of insulin: a study of patients with type 2 diabetes in the UK

OBJECTIVE

This analysis examines how obesity affects the prescribing of insulin for individuals with type 2 diabetes and poor glycemic control.

METHODS

Data were obtained from the UK General Practice Research Database for the years 2000-2004. Patients were eligible if they had been identified as having type 2 diabetes and had undergone at least two valid glycosylated hemoglobin (HbA(1c)) tests. Additionally, patients had to have poor glycemic control on the index date (HbA(1c)>7.4), no use of insulin 6 months prior to the index date, and at least 30 months of data after the index date (N=6468). Descriptive statistics were used to examine unadjusted differences between obese and nonobese patients. A Cox proportional hazards model was applied to examine the relationship between obesity and the relative likelihood of initiation of insulin while controlling for differences in patient characteristics, medication use, and HbA(1c) levels.

RESULTS

Obese individuals were significantly younger (P<.01), significantly more likely to be treated with two oral antidiabetic agents (P=.02), and significantly less likely to be treated with oral monotherapy (P=.02). Controlling for a wide range of factors that may impact receipt of insulin, results revealed that obese individuals had a "hazard" of initiation of insulin significantly lower than that of nonobese patients (hazard ratio=0.814, P=.01).

CONCLUSIONS

Patient age, severity of illness, and prior medication use all affect whether the individual will be initially prescribed insulin. Moreover, the results of this study demonstrate that obesity is an additional critical factor in physicians' decision to begin treatment with insulin.

Costs and resource use of mild persistent asthma patients initiated on controller therapy

BACKGROUND

The treatment of mild persistent asthma is controversial.

OBJECTIVES

A retrospective database approach was used to evaluate different alternatives to treating mild persistent asthma. We hypothesized that treatment with inhaled corticosteroids (ICS) would result in lowest costs than treatment with leukotriene modifiers (LM) and combination therapy with ICS long-acting inhaled beta(2)-agonists (LABA) because it would be associated with fewer acute care visits and hospitalizations than LM and it would have lower drug acquisition costs than both ICS+LABA and LM.

METHODS

Costs and resource utilization were compared in 1,283 mild persistent asthma patients initiating regular use of either ICS, ICS+LABA, or LM. Mild persistent asthma patients were identified from a privately insured claims database (1999-2005) using an established algorithm. Wilcoxon rank-sum tests and generalized linear models were used to compare costs.

RESULTS

Of the total patients who met study criteria, 319 patients (24.9%) initiated regular ICS use, 414 (32.3%) ICS+LABA use, and 550 (42.9%) LM use. Over the 1 year after controller therapy initiation, asthma-related direct costs were significantly lower with ICS compared with ICS+LABA or LM ($819 for ICS, $1,094 for ICS+LABA, and $869 for LM, p < 0.001 for all comparisons). There were no significant differences in resource use.

CONCLUSION

In this analysis, physicians, despite guideline recommendations, chose to treat patients with mild persistent asthma more often with LM and ICS+LABA than with ICS. However, therapy with ICS was less costly than treatment with either LM or ICS+LABA, primarily due to differences in drug costs, and provided similar outcomes.