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The American Journal of Managed Care June 2020
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Health Care Resource Utilization Among Patients With T2D and Cardiovascular-, Heart Failure–, or Renal-Related Hospitalizations
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Health Care Resource Utilization Among Patients With T2D and Cardiovascular-, Heart Failure–, or Renal-Related Hospitalizations

Srinivas Annavarapu, MBBS, PhD; Sabyasachi Ghosh, MS; Yong Li, PhD; Chad Moretz, ScD, MS; Sharashchandra Shetty, PhD; and Todd Prewitt, MD
Among patients with type 2 diabetes (T2D), concurrent cardiovascular-, heart failure–, or renal-related hospitalization presents significant disease burden leading to poor quality of life.
ABSTRACT

Objectives: In patients with type 2 diabetes (T2D), comorbidity-related hospitalizations can have significant impact on longitudinal care. This study aimed to estimate incremental all-cause health care resource utilization (HCRU) and costs between patients with T2D who experienced cardiovascular (CV)–, heart failure (HF)–, or renal-related hospitalizations vs those who did not.

Study Design: This was a retrospective cohort study using data from a large national health plan.

Methods: Patients with T2D aged 18 to 90 years with CV, HF, or renal hospitalizations were identified from the Humana claims database from October 1, 2009, to September 30, 2015, and separated into CV, HF, and renal cohorts. Patients had 12 months of continuous enrollment prior to the date of first hospitalization (index) and were followed for up to 12 months. Per-patient per-month (PPPM) all-cause HCRU and costs for hospitalized patients were compared with those of no-CV, no-HF, and no-renal cohorts. Differences in baseline characteristics between cohorts were controlled for using generalized linear models.

Results: A total of 221,229, 68,126, and 120,105 patients were included in the CV, HF, and renal cohorts, respectively; these patients were older and had higher Deyo-Charlson Comorbidity Index scores than patients in the no-CV, no-HF, and no-renal cohorts. Adjusted for baseline covariates, they had higher mean PPPM inpatient stays, outpatient visits, emergency department visits, and total health care costs.

Conclusions: Among patients with T2D, concurrent CV, HF, or renal events present significant disease burden leading to poor quality of life. This information can be used to guide disease management strategies and interventions aimed at reducing comorbidity-related hospitalizations and health care costs, thus providing improved quality of life for these patients.

Am J Manag Care. 2020;26(6):e166-e171. https://doi.org/10.37765/ajmc.2020.43491
Takeaway Points

This study aimed to estimate incremental all-cause health care resource utilization and costs (total, medical, and pharmacy) between patients with type 2 diabetes who experienced cardiovascular (CV)–, heart failure (HF)–, or renal-related hospitalizations vs those did not.
  • Patients in the CV, HF, and renal cohorts were older and had higher Deyo-Charlson Comorbidity Index scores compared with patients in the no-CV, no-HF, and no-renal cohorts.
  • Per-member per-month hospitalizations, office visits, emergency department visits, and health care costs were significantly higher in the CV, HF, and renal cohorts.
  • Concurrent CV-, HF-, or renal-related hospitalization presents significant disease burden leading to poor quality of life.
Diabetes is a major public health concern in the United States; the American Diabetes Association (ADA) estimates that 24.7 million patients had a diagnosis of diabetes in the United States in 2017.1 Type 2 diabetes (T2D) accounts for 90% to 95% of all cases.2 Poorly controlled diabetes can cause macrovascular (eg, stroke, myocardial infarction) and microvascular (eg, neuropathy, nephropathy) complications.3-5 In addition to higher morbidity and mortality, diabetes is associated with direct health care costs of $237 billion in the United States, 29.4% of which are due to inpatient hospitalizations.1 In fact, of the projected 162 million hospital inpatient days in 2017, 22.6 million could be attributed to diabetes.1 The prevalence and economic burden of diabetes are increasing for patients 65 years and older, resulting in a greater financial burden to these patients and economic cost to the Medicare program.1,6

Patients with diabetes frequently experience comorbid conditions.3,7-11 The prevalence of these conditions was examined using data from the National Health and Nutrition Examination Survey (1999-2006), and the report revealed that for patients 60 years or older with diabetes, the proportions with comorbid coronary heart disease, stroke, congestive heart failure, and chronic kidney disease were 29.9%, 14.0%, 15.6%, and 40.0%, respectively.12 The high rate of comorbidities was expected because diabetes frequently occurs in multimorbidity (2 or more coexisting chronic conditions) clusters including hypertension, arthritis, and ischemic heart disease.13,14 For example, patients with comorbid diabetes and renal disease have a higher risk of cardiovascular (CV) mortality.15 Interestingly, the number of comorbid conditions has been reported to be higher for hospitalized patients with diabetes (2.6) compared with those without diabetes (1.3).6,16 As expected, management of patients with multimorbidity is challenging for a number of reasons, including low health system support, lack of guidance for health care professionals, impairment of patients’ overall health, and financial burden.17

One way to address the challenge of multimorbidity in patients with diabetes is through monitoring and early interventions to achieve glycemic control and treat comorbid conditions. This may be effective in reducing morbidity, mortality, and health care resource utilization (HCRU)18-20; however, real-world evidence is lacking in current literature regarding patient characteristics and HCRU for patients with T2D experiencing hospitalizations due to comorbid conditions such as CV-, heart failure (HF)–, or renal-related events. With the understanding that resource use and, therefore, likely costs will be higher in this population, the intent of the current study was to quantify the incremental HCRU and costs of specific comorbidity-related hospitalizations in patients with T2D in a primarily Medicare population.

METHODS

Study Design and Data Source

This was a retrospective cohort study using existing administrative claims data. The study was conducted using the Humana Inc health insurance claims database. The database contains integrated medical, pharmacy, behavioral, and laboratory-related claims, representing more than 12 million current and former Humana Medicare beneficiaries and commercially insured patients. The deidentified patient-level data include detailed use, outcomes, and cost data for health care services performed in inpatient and outpatient settings, prescription drug claims, and information on patient enrollment. The claims are linked through a patient identifier that remains constant regardless of benefit design, gap in coverage, or change of employer. These data have information for patients enrolled in commercial, Medicare Advantage, and prescription drug plans. The database has national coverage, with high proportions of members from Texas, Florida, and Ohio.

Study Population

The study period was from October 1, 2008, to September 30, 2016. Patients aged 18 to 90 years were identified during the 6-year identification period from October 1, 2009, to September 30, 2015 (Figure 1). Three separate cohorts of patients with at least 1 CV-, HF-, or renal-related hospitalization during the identification period were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes (eAppendix Table 1 [eAppendix available at ajmc.com]). The codes for CV events and HF were mutually exclusive. The date of first observed CV-, HF-, or renal-related hospitalization (index hospitalization) was defined as the index date; the month was defined as the index month.

The comparator cohort was defined based on random selection of 1 comparison patient from a pool of all patients who had any medical claims during the index month but did not experience any CV hospitalization during the identification period, including the index month, for each patient with at least 1 CV hospitalization. Patients without CV hospitalizations could have HF- or renal-related hospitalizations. This process was repeated for all patients in the CV cohort, without replacement, until a ratio of 1:1 was achieved. The date of the first medical claim during the index month was defined as the index date for each patient within the comparator cohort.

Similarly, comparator cohorts of patients without HF- and renal-related hospitalizations were identified for the cohort of patients with HF-related hospitalizations and the cohort of patients with renal-related hospitalizations, respectively.


 
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