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Supplements Improving Adherence in the Treatment of Type 2 Diabetes Mellitus: Opportunities for Managed Care

The Economic Rationale for Adherence in the Treatment of Type 2 Diabetes Mellitus

Howard Wild, BS Pharm, RPh
Among patients with type 2 diabetes mellitus, adherence to prescribed medications has been reported to be as low as 60%, meaning that many patients may not be following the treatment plan that has been prescribed for them. The importance of treatment adherence is intuitive: better adherence would promote better outcomes. Data show this to be the case: for every 25% increase in medication adherence, a patient’s glycated hemoglobin (A1C) is reduced by 0.34%. Unfortunately, only a little more than half of patients with diabetes achieve an A1C target below 7%. Poor therapeutic adherence affects diabetes-related costs. Patients who are nonadherent are far more likely to require hospitalization and to incur significantly higher healthcare costs. The lesser costs of lower medication utilization in nonadherent patients are more than compensated for by the increased costs arising from poorer glycemic control, as multiple studies employing large managed care databases have demonstrated. Improvements in outcomes and reductions in costs related to the management of diabetes require focused efforts toward facilitating treatment adherence, efforts that should be undertaken by third-party payers in addition to physicians and patients.

(Am J Manag Care. 2012;18:S43-S48)
Patient adherence to prescribed therapies in type 2 diabetes mellitus (T2DM)—including lifestyle changes as well as medications—is an area of enormous importance because of the strong correlations between adherence, patient outcomes, and treatment costs.1,2 Because diabetes is a chronic condition, long-term adherence to therapy is a necessity, which differs from adherence to short-term therapy for an acute condition (eg, antibiotics, antacids). The topic of adherence to therapy in T2DM is of particular interest to managed care stakeholders because T2DM is a disease that affects a large number of patients and is associated with considerable costs. The relationship between treatment adherence and costs would appear to be intuitive; that is, the economic benefits of achieving better treatment adherence in terms of lower long-term costs would seem to justify the up-front costs of medications and therapeutic strategies that improve adherence. However, the high costs of specific medications, and the costs of implementing certain therapeutic strategies, mean that the use of a given medication or treatment strategy can only be justified from a cost perspective if the incremental improvement in adherence is associated with cost savings greater than the cost of therapy. This article focuses on key factors pertinent to the economic rationale for treatment adherence in T2DM.

The Cost of Diabetes in the United States

According to the American Diabetes Association (ADA), approximately 17.5 million people in the United States had a diabetes diagnosis (type 1 diabetes mellitus [T1DM] or T2DM) in 2007, a large increase from the ADA estimate of 12.1 million in 2002. In addition, approximately 6.6 million people in the United States had diabetes in 2007, and remained undiagnosed.3

The ADA estimates that the total costs related to diabetes in 2007 were $174 billion, $116 billion of which resulted from excess medical costs and $58 billion from lost productivity.3 An analysis of diabetes-related costs, performed by Dall et al, separated out both epidemiological and cost data related to T2DM versus T1DM. They determined that in 2007, 16.5 million of the 17.5 million people in the United States with diabetes had T2DM. Furthermore, they established that T2DM accounted for $159.5 billion of the $174 billion total costs, including medical costs of $105.7 billion and indirect costs of $53.8 billion.4 With regard to healthcare expenditures, the ADA data show that approximately half of these costs are attributable to hospitalization and to longer length of stay (LOS) per admission as compared with patients without diabetes. In 2007, outpatient medication and supplies attributable to diabetes cost $27.7 billion, including $3.7 billion for insulin (2.3% of total costs related to T2DM) and $8.6 billion for oral agents (5.4% of total costs related to T2DM).3

Rates of Adherence, Association With Achieving A1C Targets, and Consequences of Poor Glycemic Control

Given the large number of patients impacted by T2DM and the associated cost burden to payers, employers, and patients themselves, there exists a significant opportunity to improve outcomes and reduce costs. One potential target for improving outcomes is patient adherence to prescribed therapy. Improvements in adherence would improve glycemic control, and improvements in glycemic control would help reduce morbidity and mortality related to uncontrolled T2DM.2,5 Based on data from studies involving patients with diabetes in the United States, every percentage point reduction in glycated hemoglobin (A1C) is associated with a 40% reduction in the risk of microvascular complications such as kidney diseases, eye diseases, and neuropathies.6

The management of T2DM necessitates patient adherence to both drug and nondrug therapies. While lifestyle interventions remain an essential component of therapy, as recognized by professional guidelines for the management of T2DM,7 this article will focus on the health economic impact of improving adherence to drug therapy.

The ADA recommends an A1C target of less than 7%.7 However, a substantial proportion of individuals with diabetes do not achieve this goal. An analysis published in 2009 of data from the National Health and Nutrition Examination Survey (2003-2006) showed that only 57% of adults with diabetes achieved the ADA A1C target of less than 7%.8

In the case of drug therapy, adherence is the degree to which a patient takes a medication as prescribed. Methods of measuring adherence include direct methods (eg, observing the patient taking their medication) and indirect methods (eg, asking the patient whether they took their medication; counting pills; reviewing data regarding prescription refills).9

The importance of adherence to glycemic control may be seen in the results of a 1-year study of 1560 patients with T2DM which found that A1C was reduced by 0.34% for every 25% increase in medication adherence (P = .0009).5 In this study, adherence was assessed during clinic visits; patient-reported medication use was compared with the clinician-recommended medications from the previous visit.5 Despite the importance of adherence to glycemic control, there is room for improvement with regard to current levels of adherence. The rate of adherence to oral medications for glycemic control ranges from approximately 65% to 85%, and the rate of adherence to insulin ranges from approximately 60% to 80%. Regimens requiring more frequent dosing tend to have lower adherence rates.10 The impact of dosing schedule on adherence will be discussed in the other articles in this supplement.11,12

The potential consequences of poor adherence in terms of healthcare utilization and mortality were demonstrated in a study at Kaiser Permanente of Colorado, which included 11,532 patients with diabetes.5 This study found a 21.3% rate of nonadherence to treatment, where nonadherence was defined as filled prescriptions covering less than 80% of the total days during which medication should have been taken. Patients who were nonadherent to treatment had a higher risk of hospitalization and all-cause mortality compared with patients who were adherent (both P <.001).5

Cost Implications of Poor Adherence

There are multiple ways to evaluate the impact of treatment adherence on costs in diabetes. Broadly speaking, the available studies fall into 2 categories: a) those that compare levels of treatment adherence with measurable treatment costs and/or healthcare utilization, and b) those that do not necessarily evaluate adherence per se but examine the impact of poor glycemic control on treatment costs and/or healthcare utilization.

Relationship of Treatment Adherence to Costs and Healthcare Utilization

A recent literature review identified studies examining the association between treatment adherence and costs in T2DM, and found 12 out of 449 studies that met the authors’ inclusion criteria, all of them US studies involving inpatients, outpatients, and pharmacy claims.1 Seven of the 12 studies observed an inverse relationship between adherence and total healthcare costs, 4 observed an inverse relationship between adherence and hospitalization costs, and 1 study found no significant association between adherence and healthcare costs.1

A separate literature review, published in 2011, identified 37 studies that evaluated medication adherence in patients with diabetes and the corresponding use of healthcare resources among those patients as well as their success in glycemic control.13 A majority of the 23 studies that reported on correlations between adherence and glycemic control found a notable association. Of 8 studies that evaluated a link with healthcare utilization, 7 found that greater adherence was correlated with fewer hospitalizations. Patients with adherence ratios less than 80% had 2½ times the risk of hospitalization for reasons either directly related to diabetes or to cardiovascular disease (odds ratio = 2.53; 95% confidence interval, 1.38-4.64).13 These results are consistent with a large Medicare study that found that greater medication adherence was significantly associated with lower rates of hospitalization as well as lower healthcare costs.14

Finally, a systematic literature review, published in 2009, analyzed studies of healthcare costs related to rates of adherence in patients with diabetes. Out of 209 studies identified, 10 studies fulfilling the inclusion criteria were selected for analysis; included studies were based on claims data, 70% of which came from non–Medicare or Medicaid databases.15 The authors found a high degree of variability between studies regarding the reporting of additional costs arising from nonadherence. That said, higher levels of medication adherence were largely correlated with lower costs. One study observed an 8.6% decrease in annual total healthcare costs for every 10% increase in medication possession ratio for an antidiabetic medication.15

One potentially confounding factor in determining the relationship between drug adherence and hospitalization is the fact that patients’ disease severity is likely to affect both their adherence to therapy and their risk of hospitalization. A 2010 study of hospitalization in patients with diabetes sought to account for the influence of disease severity as well as other potentially influential factors including level of coinsurance.16 The authors found that patients with greater disease severity had higher levels of treatment adherence. The authors speculate that patients with less severe disease may be less adherent because they may not be experiencing recognizable symptoms. They further observed that an increase in treatment adherence from 50% to 100% was associated with a 23.3% reduction in the rate of hospitalization (from 15% to 11.5%), while emergency department (ED) visits were reduced by 46.2% (from 17.3% to 9.3%).The impact of such an increase in adherence on drug costs was found to be $766 per patient annually, while the savings in costs from reduced hospitalizations and ED visits was $886 per patient, which amounts to $1.14 gained in cost reductions for every $1.00 spent in additional drugs annually.16

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