Evidence-Based Diabetes Management

Measuring the Value of Better Diabetes Management

Published Online: April 12, 2013
Darius N. Lakdawalla, PhD; Michael R. Eber, BSE; Felicia M. Forma, BSc; Jeffrey Sullivan, MS; Pierre-Carl Michaud, PhD; Lily A. Bradley, MBA; and Dana P. Goldman, PhD
The growing burden of type 2 diabetes mellitus has outpaced the modest progress in the efficacy of diabetes medications. However, it is unclear whether we are  using our existing medications optimally. This article quantifies the value of addressing underuse of existing diabetes medications in the United States.   Interventions—new technologies, public policies, or clinical approaches—that double the rate of initiation of insulin generate a value on average of more than $15,000 over the lifetime of a patient developing diabetes between ages 51 and 60 years, or $12.6 billion in the aggregate. Interventions that improve  adherence would generate a value of more than $13,000 on average for the same patients, or $10.7 billion in the aggregate. The value of such interventions is on par with highly optimistic projections of technological progress in medication efficacy.

Type 2 diabetes mellitus (T2DM) continues to grow at a remarkable  rate. Diabetes incidence in the United States rose by more than 45% from 2002 to 2010, and its substantial costs make this trend particularly troubling. Diabetes  decreases quality of life, increases morbidity, reduces life expectancy by approximately 3 years in near-elderly cohorts, and imposes additional lifetime healthcare costs of roughly $200,000.1

Prevention is a natural response to the growing epidemic, and its social benefits appear to be quite large.1 Yet the  policy question of how to improve and extend the lives of the tens of millions of patients who already have or will soon develop the disease remains. Technological progress in treatment is one possibility. Indeed, the discovery of 8 new drug classes in the past 15 years has expanded the arsenal of medications for management of T2DM. Most of the benefits have accrued to patients who do not respond adequately or durably to older therapies (eg, metformin, sulfonylureas). As David Nathan observes,  drug classes “that have been developed recently are generally no more potent, and often less effective in lowering glycemia, than the 3 oldest classes.”2 In other   words, the newer drugs have benefited patients who are inappropriate for or unresponsive to established treatments by preventing longer-term macrovascular   and microvascular complications.3

Since a substantial segment of patients have not enjoyed major benefits from new treatments, it is worth asking whether we  are using existing therapies to the greatest benefit. In fact, evidence suggests underuse along at least 2 dimensions: 1) imperfect medication adherence4,5 and 2) delays in or lack of insulin initiation.6,7

First, it is widely understood that patients with chronic illness do not always adhere to their providers’ instructions. Patient adherence to oral blood glucose– lowering medication and insulin regimens generally ranges from 60 to 85 percent, with even lower adherence reported for certain populations, such as those covered by Medicaid.5 A number of earlier researchers have documented the impact of poor adherence on diabetes-related outcomes. 8-10

Second,  concerns arise about underuse of diabetes treatments. Many center on insulin because the injection regimen imposes inconvenience and other personal costs.7 This is unfortunate because compared with prevailing standards, earlier use of insulin may be warranted, particularly in patients with poor glycemic  control (ie, glycated hemoglobin [A1C] >9).11,12 Clinicians may be reluctant to initiate patients on insulin because it is taken as a sign of “defeat.”13

The healthcare delivery system also can delay insulin initiation because of the need for referral to an endocrinologist in complex cases.

In light of these  issues, we study whether and how poor adherence to and lower uptake of insulin therapy quantitatively contribute to the costs of diabetes on patients and the  healthcare system. Both the expansion of insulin use and the reduction of poor adherence are likely to require the investment of resources to develop  new policies, clinical approaches, and technologies. We are interested in the potential return on such investments.

To investigate these questions, we calculate and compare the lifetime benefits to patients of scenarios that improve adherence and increase insulin use. We then compare these benefits with the value of a scenario generating further improvements in the efficacy of diabetes medicines. In particular, we calculate the future technological progress that would be required in this scenario to match the value of expanding insulin therapy.

For all such scenarios, we simulate outcomes for a cohort of newly diagnosed US diabetes patients who are aged 51 years in either 2003 or 2004 and who  acquire diabetes between ages 51 and 60 years. We then examine the costs and benefits of each of the above scenarios, compared with current diabetes  management.

Overview of the Model

We use a well-established dynamic microsimulation model, the Future Elderly Model (FEM),14-17 to model the lifetime consequences of expanded insulin  use, improved patient adherence, and future progress in the efficacy of diabetes medicines. The model simulates health status, health spending, and  mortality experience of the US population with diabetes over the age of 50 years. The FEM is based on data from the Health and Retirement Study (HRS), a biennial survey of Americans 51 years and older that has been ongoing since 1992. We supplement the HRS with medical spending data from the Medicare  Current Beneficiary Survey and Medical Expenditure Panel Study for persons who would not be eligible for Medicare. The FEM is well suited for this study, because it allows the simulation of alternative lifetimes for patients aged 51+ years in different treatment environments. Further detail on the mechanics and implementation of the model are provided in the eAppendix (available at www.ajmc.com).

Treatment Options

Figure 1 gives a schematic view of how patients progress in the model. We model 3 steps in the management of diabetes. First, the model assigns an initial  A1C level. Second, it assigns a first-line oral drug treatment regimen. Finally, the model predicts whether insulin therapy is initiated and whether oral drug   therapy is modified.

Oral medications are categorized in 3 drug classes: metformin (biguanides), sulfonylureas, and thiazolidinediones (TZDs). They represent more than 90% of  the oral diabetes medications taken by HRS respondents.

PDF is available on the last page.