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Challenges in Diabetes Management: Glycemic Control, Medication Adherence, and Healthcare Costs

Challenges in Diabetes Management: Glycemic Control, Medication Adherence, and Healthcare Costs

Healthcare Costs Associated With Poor Glycemic Control
Diabetes-related healthcare costs are higher for patients with poor glycemic control compared with patients achieving and sustaining target A1C goals. A strong association between glycemic control and diabetes-related costs was found in an analysis of medical and pharmacy claims from a cohort of patients with diabetes (N = 6780).9 Annual diabetes-related costs for patients with uncontrolled A1C levels (>7%) were 32% higher than for patients whose A1C levels were on target (≤7%).9 Of course, diabetes-related complications are significant contributors to patient healthcare costs; an elevated risk of complications (eg, retinopathy, PVD) in patients whose A1C levels were not on target was observed.9 In a longitudinal analysis, costs of direct medical care and prescription medications for patients with type 2 diabetes with controlled glycemia (A1C ≤7%) were significantly lower (P <.05) than in patients with poor glycemic control (A1C >9%).10

Key Challenges and Unmet Needs in Diabetes Management
Suboptimal A1C control rates persist despite the development of new therapies indicated for the treatment of diabetes. Skyler remarked, “[Over the] last 2 decades, as we try to tackle the disease, there have been more than 40 new diabetes treatment options approved by the US Food and Drug Administration; yet, despite that, there has been very little change in A1C and the proportion of patients who have achieved [glycemic] control.” According to Skyler, key contributors to the lack of improvement in glycemic control include the complexity of diabetes treatment regimens and insufficient convenience of use for certain medications, which result in deficient patient adherence to medication.

Poor patient adherence to diabetes medications is a well-identified challenge to achieving glycemic control or lowering A1C. Skyler noted that “medication[s] may be filled, but it doesn’t mean that the patient takes them.” A retrospective cohort study using community-acquired clinical data from the UK reported that 13% to 15% of patients were adherent to all diabetes medications (Figure 111).11 Importantly, there was a clear association between adherence to glucose-lowering treatment and the corresponding decrease in A1C. The association was found to be consistent across all commonly used oral diabetes drugs, and the findings were consistent between the 2 data sets examined (the Clinical Practice Research Database and the Genetics of Diabetes and Audit Research Tayside Study database). Nonadherent patients, or patients taking on average less than 80% of the intended duration of prescription medication, did not achieve glycemic control; nonadherent patients had approximately half of the expected reduction in A1c compared with adherent patients.11

Another retrospective cohort study, which utilized the US MarketScan Commercial and Medicare Supplemental health insurance claims databases (2009-2012), compared adherence and persistence among patients with diabetes initiating dipeptidyl peptidase 4 inhibitors (DPP4is), sulfonylureas, and thiazolidinediones (TZDs) over 1- and 2-year follow-up periods.12 During 1-year follow-up, 47.3% of DPP4i initiators, 41.2% of sulfonylurea initiators, and 36.7% of TZD initiators were medication-adherent. During 2-year follow-up, these percentages decreased to 40.5%, 34.6%, and 27.9% for DPP4i, sulfonylurea, and TZD initiators, respectively.12 A proposed explanation for the greater adherence to DPP4is observed in this study was the better tolerability profile of DPP4is compared with both sulfonylureas and TZDs; however, more data are needed to confirm this hypothesis.12

Additionally, a meta-analysis of published studies that examined adherence to prescribed oral antihyperglycemic agents in patients with type 2 diabetes found that the proportion of adherent patients ranged from 44.4% to 89.8%; the pooled mean proportion of adherent patients was 67.9% (95% CI, 59.6%-76.3%).13 Furthermore, persistence estimates ranged from 41.0% to 81.1% with a mean of 56.2% (95% CI, 46.1%-66.3%), while discontinuation estimates ranged from 9.9% to 60.1%, with a mean of 31.4% (95% CI, 17.6%-45.3%).13 Many different patient-, prescription-, and prescriber-related factors contribute to nonadherence to diabetes medications; these may include patient age, education, health beliefs, insurance coverage, out-of-pocket costs, prescription drug channel (mail vs retail), pill burden, regimen complexity and convenience, and prescriber specialty.14-16 In any case, nonadherence places substantial health and economic burdens upon individuals and healthcare systems.

Skyler emphasized the costs and consequences associated with poor medication adherence and the resulting poor glycemic control. “Poor [medication] adherence and poor persistence translate to an increased risk of hospitalization, which tremendously adds to [direct medical] cost, [as well as] all-cause mortality rate, where there is a progressive increase of hospitalization with less adherence. Cost issues here are enormous,” he said. In a recently published study of epidemiological and economic data for 184 countries, which Skyler highlighted during the presentation, the estimated global cost of diabetes for 2015 was $1.31 trillion (95% CI, $1.28-$1.36). Of note, indirect costs of diabetes (ie, labor-force dropout, absenteeism, presenteeism, and mortality) accounted for 34.7% (95% CI, 34.7%-35.0%) of the overall burden.17 North America was the most affected region relative to gross domestic product as well as the largest contributor to global absolute costs; in other words, North America was found to have the highest absolute economic burden of diabetes.17

Numerous studies support Skyler’s point. For example, in an analysis of claims data, Lau et al reported that patients nonadherent to oral diabetes medications in 2000 were at higher risk of hospitalization in 2001 (odds ratio [OR], 2.53; 95% CI, 1.38-4.64).18 In a systematic review, 7 of 8 studies (87.5%) that evaluated hospitalization with respect to diabetes medication adherence showed a statistically significant association between higher levels of adherence and decreased hospitalizations. In fact, patients with <80% adherence may be at more than twice the risk for being hospitalized for a diabetes- or cardiovascular-disease–related event (OR, 2.53; 95% CI, 1.38-4.64); however, patients with ≥80% adherence ratios may be at a 29% decreased risk of hospitalization for any cause (OR, 0.71; 95% CI, 0.51-0.98) when adjusting for disease severity, demographics, and comorbidities.19 A retrospective cohort study of patients in the Kaiser Permanente of Colorado diabetes registry determined that nonadherent patients had higher mean A1C, systolic and diastolic blood pressure, and LDL-C levels; higher all-cause hospitalization (P <.001); and higher all-cause mortality (P <.001) as compared with adherent patients with diabetes.20

As rising healthcare costs continue to be one of the biggest challenges facing our nation and the world, it is particularly important to identify areas where costs can be lowered and care improved for patients with chronic diseases like diabetes.21 US medical claims data from 2005 -2008 suggest that improving and sustaining patient adherence to diabetes medications leads to a statistically significant estimated 13% decreased risk of hospitalization and emergency department (ED) visits (P <.001).21 If nonadherent patients with diabetes became adherent to diabetes medication, it could save the United States an estimated $4.68 billion annually in healthcare expenditures ($3.95 billion in hospitalizations and $735 million in ED visits). On top of that, an added benefit of increasing the adherence would eliminate potential hospitalizations and ED visits and save an estimated $3.61 billion, for an a combined potential savings of $8.30 billion each year.21

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