Patterns of medication initiation in newly diagnosed diabetes mellitus: quality and cost implications.

Six oral medication classes have been approved by the Food and Drug Administration for the treatment of type 2 diabetes. Although all of these agents effectively lower blood glucose, the evidence supporting their impact on other clinical events is variable. There also are substantial cost differences between agents. We aimed to evaluate temporal trends in the use of specific drugs for the initial management of type 2 diabetes and to estimate the economic consequences of non-recommended care. We studied a cohort of 254,973 patients, aged 18 to 100 years, who were newly initiated on oral hypoglycemic monotherapy between January 1, 2006, and December 31, 2008, by using prescription claims data from a large pharmacy benefit manager. Linear regression models were used to assess whether medication initiation patterns changed over time. Multivariate logistic regression models were constructed to identify independent predictors of receiving initial therapy with metformin. We then measured the economic consequences of prescribing patterns by drug class for both patients and the insurer. Over the course of the study period, the proportion of patients initially treated with metformin increased from 51% to 65%, whereas those receiving sulfonylureas decreased from 26% to 18% (P<.001 for both). There was a significant decline in the use of thiazolidinediones (20.1%-8.3%, P<.001) and an increase in prescriptions for dipeptidyl peptidase-4 inhibitors (0.4%-7.3%, P<.001). Younger patients, women, and patients receiving drug benefits through Medicare were least likely to initiate treatment with metformin. Combined patient and insurer spending for patients who were initiated on alpha-glucosidase inhibitors, thiazolidinediones, meglitinides, or dipeptidyl peptidase-4 inhibitors was $677 over a 6-month period compared with $116 and $118 for patients initiated on metformin or a sulfonylurea, respectively, a cost difference of approximately $1120 annually per patient. Approximately 35% of patients initiating an oral hypoglycemic drug did not receive recommended initial therapy with metformin. These practice patterns also have substantial implications for health care spending.

Desai NR ，Shrank WH ，Fischer MA ，Avorn J ，Liberman JN ，Schneeweiss S ，Pakes J ，Brennan TA ，Choudhry NK ... -  《-》

Initial choice of oral glucose-lowering medication for diabetes mellitus: a patient-centered comparative effectiveness study.

Berkowitz SA ，Krumme AA ，Avorn J ，Brennan T ，Matlin OS ，Spettell CM ，Pezalla EJ ，Brill G ，Shrank WH ，Choudhry NK ... -  《-》

Patterns of medication initiation in newly diagnosed diabetes mellitus: quality and cost implications.

Currently, 25 million Americans are known to have diabetes, with an additional 7 million cases believed to be undiagnosed. It is estimated that direct and indirect costs of diabetes top $200 billion. Due to the significant health and financial burdens associated with diabetes, it is imperative that this disease be treated quickly and aggressively. In 2009, the American Diabetes Association and the European Association for the Study of Diabetes developed a consensus statement regarding the treatment of type 2 diabetes, citing lifestyle modification and metformin as the preferred first line therapies. In this study, the authors looked at prescription claims data for adults who were newly initiated on oral hypoglycemic monotherapy between January 1, 2006, and December 31, 2008, to determine if initiation patterns changed over time, to evaluate how well the treatment guidelines were being followed, and to assess the economic consequences of prescribing patterns by drug class for both patients and insurers. The results showed that over the course of the study period the proportion of patients initially treated with metformin increased, whereas those receiving sulfonylureas as first-line therapy decreased. Thiazolidinediones experienced the greatest decrease, falling from 20% to 8%, while prescriptions for dipeptidyl peptidase-4 inhibitors increase from 0-7%. Over a 6-month period, patients taking metformin or sulfonylureas paid approximately $38 to $40 in co-pays while insurance paid about $77. Patients taking other agents paid approximately $130 in co-pays and insurance paid over $500. The authors concluded that based its cost and safety profile, metformin should be the first line drug therapy for patients with newly diagnosed type 2 diabetes. This CME multimedia activity, which is part of a 2-part multimedia activity on the management and treatment of diabetes, contains a video presentation and is available through the website of The American Journal of Medicine at http://amjmed.com/content/multimedia. Click on "Patterns of Medication Initiation in Newly Diagnosed Diabetes Mellitus: Quality and Cost Implications" to access this part of the multimedia program.

Liao EP 《-》

A retrospective cohort study of economic outcomes and adherence to monotherapy with metformin, pioglitazone, or a sulfonylurea among patients with type 2 diabetes mellitus in the United States from 2003 to 2005.

The aims of this study were to compare all-cause total health care costs and diabetes mellitus (DM)-specific health care costs between patients who were adherent or nonadherent to monotherapy with metformin, pioglitazone, or a sulfonylurea and to examine whether cost differences varied among patients using these oral antidiabetic drugs. This was a retrospective cohort study using data from the MEDSTAT MarketScan Research Databases. Patients aged 18 to 90 years who were continuously insured between 2003 and 2005 and had > or =2 outpatient claims or > or =1 inpatient claim with a diagnosis of DM (International Classification of Diseases, Ninth Revision, Clinical Modification code 250.xx) in 2003 were eligible for the study. To be part of the final sample, patients had to fill > or =2 prescriptions for metformin, pioglitazone, or a sulfonylurea during 2003, including > or =1 prescription during the last 3 months of the year. Patients were not eligible if they were taking polytherapy or a combination drug. All eligible patients were followed in 2004 and 2005. Adherence was calculated for each year using a medication possession ratio, and was dichotomized at > or =80% as either adherent or nonadherent. Annual all-cause health care costs and diabetes-specific costs were estimated using generalized linear models, adjusting for demographic characteristics, insurance, and comorbid conditions. A total of 108,592 patients who met the inclusion criteria were identified. Their mean age was 63 years; 49.8% (54,037/108,592) were women. More pioglitazone users resided in the north-central or south regions (81.3% [9364/11,520]) compared with metformin (62.4% [32,550/52,156]) or sulfonylurea (62.6% [28,105/44,916]) users (P < 0.001). Mean comorbidity scores were higher in the sulfonylurea (1.78) and pioglitazone (1.69) group than in the metformin group (1.45) (P < 0.001). Mean adherence ranged from 61.3% to 73.8% during the 2 years of follow-up. After adjustment, all-cause health care costs were $12,412 annually among adherent patients and $13,258 among nonadherent patients (difference, $846 [95% CI, $747 to $945]). Diabetes-related health care costs were $2230 annually among adherent patients and $2284 among nonadherent patients (difference, $55 [95% CI, $33 to $77]). In specific monotherapy groups, adjusted annual all-cause health care costs were $336 higher (95% CI, $216 to $456) for nonadherent metformin users, $1140 higher (95% CI, $793 to $1486) for nonadherent pioglitazone users, and $1509 higher (95% CI, $1339 to $1679) for nonadherent sulfonylurea users compared with adherent users. Compared with metformin users, sulfonylurea and pioglitazone users had greater adherence-related differences in all-cause health care costs (P < 0.05). There was no significant difference in diabetes-specific total costs between nonadherent and adherent patients taking metformin (difference, $6; 95% CI, -$31 to $20). Patients who were nonadherent to sulfonylureas had $271 higher (95% CI, $235 to $307) diabetes-specific costs per year than patients who were adherent to sulfonylureas. Patients who were nonadherent to pioglitazone had $433 lower (95% CI, -$516 to -$350) diabetes-specific costs per year than patients who were adherent to pioglitazone. Adherence with metformin, pioglitazone, or a sulfonylurea was associated with overall cost reductions in the patients studied, but these cost reductions varied by monotherapy. Adherence to sulfonylureas or pioglitazone was associated with greater total cost reductions than was adherence to metformin. Health systems that commit resources to improving interventions may be able to achieve a return on investment if adherence to oral antidiabetic agents can be improved.

Hansen RA ，Farley JF ，Droege M ，Maciejewski ML ... -  《-》

Comparative adherence to diabetes drugs: An analysis of electronic health records and claims data.

Non-adherence to medications is a major challenge in diabetes care. The objective of this brief report is to compare adherence rates for 6 major classes of diabetes medications: metformin, sulfonylurea, thiazolidinedione, basal insulin, DPP-4 inhibitors, and GLP-1 receptor agonists. We used a data source that linked electronic prescriptions with insurance claims to assess whether new electronic prescriptions for diabetes medications were followed by dispensing claims consistent with that prescription. After one year of follow-up, the daily medication possession probability (MPP) - a measure of overall adherence - at one year for sulfonylurea was 0.49 and for metformin was 0.46. Thiazolidinediones and basal insulin had a similar final daily MPP at 0.36 and 0.39, respectively, which was significantly lower than that for sulfonylurea or metformin (P < .05). GLP-1 receptor agonists and DPP-4 inhibitors were also comparable to one another at a final daily MPP of .30 and .21, respectively (P < .05 compared to any of the aforementioned drug classes). In summary, the rates at which diabetes drugs are prescribed, and the rates at which patients actually take them, differ substantially. Physicians should be aware of potentially significant challenges concerning adherence to newer agents.

Flory J ，Gerhard T ，Stempniewicz N ，Keating S ，Rowan CG ... -  《-》