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The American Journal of Managed Care August 2014
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Shirley Musich, PhD; Andrea Klemes, DO, FACE; Michael A. Kubica, MBA, MS; Sara Wang, PhD; and Kevin Hawkins, PhD
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Carrie H. Colla, PhD; William L. Schpero, MPH; Daniel J. Gottlieb, MS; Asha B. McClurg, BA; Peter G. Albert, MS; Nancy Baum, PhD; Karl Finison, MA; Luisa Franzini, PhD; Gary Kitching, BS; Sue Knudson,
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James D. Chambers, PhD, MPharm, MSc; Aaron Winn, MPP; Yue Zhong, MD, PhD; Natalia Olchanski, MS; and Michael J. Cangelosi, MA, MPH
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Economic Implications of Weight Change in Patients With Type 2 Diabetes Mellitus
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Economic Implications of Weight Change in Patients With Type 2 Diabetes Mellitus

Kelly Bell, MSPhr; Shreekant Parasuraman, PhD; Manan Shah, PhD; Aditya Raju, MS; John Graham, PharmD; Lois Lamerato, PhD; and Anna D’Souza, PhD
Modest weight loss (>3%) among metformin-treated patients with type 2 diabetes mellitus was associated with decreased costs, lower resource utilization, and lower rates of treatment discontinuation.

Objective

Assess the impact of weight change on costs, resource use, and treatment discontinuation among metformin-treated patients with type 2 diabetes mellitus (T2DM).


Study Design

Observational, retrospective cohort.


Methods

Adults with T2DM who were pre existing metformin-treated patients were included. Insulin users were excluded. Administrative data from January 1, 2000, to December 31, 2010, were linked to clinical data, and patients were placed into cohorts based on relative change in body weight. Three cohorts were created: weight loss (decrease >3%), weight neutral (change ≤3%), and weight gain (increase >3%). Inter-cohort differences in resource utilization, costs (2010 US$), and treatment discontinuation were evaluated using statistical models that adjusted for baseline characteristics.


Results

A total of 2110 patients (weight loss = 967; weight neutral = 970; weight gain = 173) were included; mean age was 59.6 years, 52.2% were women, 64.1% were Caucasian, and average baseline weight was 98.7 kg. The weight-loss cohort incurred significantly lower costs per year compared with the weight-neutral cohort, driven mainly by lower medical costs from reduced utilization. Weight reduction was associated with approximately $2200 and approximately $440 lower annual all-cause and T2DM-specific costs (P <.05), respectively. Patients who lost weight were 21% less likely to discontinue therapy. Weight gain was associated with a significant increase in all-cause costs of $3400 per year compared with the weight-neutral cohort; however, differences in T2DM-specific costs and discontinuation rates did not reach significance levels.


Conclusions
Weight loss (>3%) among patients with T2DM was associated with decreased costs and lower rates of treatment discontinuation. Hence weight-focused treatment approaches can help reduce the economic burden for patients with T2DM.


Am J Manag Care. 2014;20(8):e320-e329

Modest weight loss in patients with type 2 diabetes (T2DM) is associated with lower rates of treatment discontinuation and economic benefits, illustrated through reductions in both diabetes-specific and all-cause medical costs due to fewer hospital and emergency department visits. Weight gain is associated with increased all-cause medical costs but has no statistically significant impact on diabetes-specific costs or treatment discontinuation. Results of this study complement the clinical advantages of weight loss in patients with T2DM by highlighting its economic and treatment persistence benefits, and hence can help guide patients and health plans in making decisions regarding optimal disease management.

Type 2 diabetes mellitus (T2DM) is the most prevalent form of diabetes, accounting for 90% to 95% of cases affecting more than 20 million adults in the United States.1 In 2012, diabetes-related expenditures were estimated to be $176 billion2; nearly half of which, it is reported, go to treating diabetes-related complications such as cardiovascular disease, hypertension, neuropathy, retinopathy, and nephropathy.3,4



One factor that is strongly associated with T2DM risk is excess body weight, with more than 80% of patients with T2DM being either overweight or obese.5-8 Increased weight may impair glycemic control (via increased insulin resistance); elevate the risk of cardiovascular disease; and negatively affect mental health, body image, and persistence with therapy, which, in turn, may increase the risk for diabetes-related complications.8-10 Accordingly, weight gain can potentially impact the high expenditures associated with treatment of diabetes-related complications.



Conversely, weight loss in T2DM is associated with benefits such as better glycemic control, reduction in cardiometabolic risk factors, and prevention of disease progression through decreased diabetes complications.11-15 Although some recent literature has indicated that weight loss from a diet and exercise program (average weight loss of nearly 5% at 4 years) did not reduce cardiovascular events in T2DM patients,16 a large body of evidence suggests positive benefits.11-15 As a result, weight management as a part of lifestyle modification has become a key factor in T2DM treatment.17



Although there is abundant literature regarding the clinical manifestations of weight change in T2DM, evidence of its contribution to the economic burden of T2DM is relatively sparse. Preliminary evidence shows weight loss can significantly reduce diabetes-related costs.11,18 Furthermore, Brandle et al19 reported that a 10 kg/m2 increase in body mass index or presence of diabetes-related complications can increase direct costs by 10% to 30%.

In addition to being a predisposing condition, weight gain among T2DM patients can also be caused by anti-diabetic drugs; contributing to nonpersistence and potentially to subsequent disease progression. Metformin augmentation or alternate anti-diabetic therapies are becoming common treatment regimens as weight-focused treatment approaches gain importance in T2DM management. Newer anti-diabetic agents have similar effects on glycemic control, but differ in their side-effect profiles; some have been shown to possess weight-altering properties.20 To properly factor in these weight-altering properties during treatment selection, it is important to have a comprehensive understanding of the impact of weight change on T2DM outcomes. Hence, the goal of this study was to investigate the implications of real-world change in body weight (both weight gain and weight loss) on healthcare costs, resource utilization, and continuation of anti-diabetic pharmacotherapy among metformin-treated patients with T2DM.



METHODS

Study Design and Sample Selection

Data from January 1, 2000, through December 31, 2010, were utilized in this retrospective cohort study. The administrative databases of the Henry Ford Health System (HFHS), which comprises medical billing, pharmacy records, external claims for care provided outside of HFHS, and clinical data (such as laboratory values and vital signs) from electronic medical records (EMRs) and progress notes for patients receiving care within the HFHS, were employed in this analysis. The study population was identified from enrollees of a system-owned and -operated health maintenance organization (HMO), the Health Alliance Plan (HAP), who received care at HFHS—a vertically integrated healthcare system providing clinical services to the Michigan community, with over 2.5 million patient visits and 65,000 hospital admissions annually. The HAP enrolls more than 500,000 individuals from more than 3000 employers in the Detroit metropolitan area. Approximately 150,000 of these members receive care through HFHS.



 
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