There is a delay in the use of insulin for patients with uncontrolled type 2 diabetes mellitus. This directly affects the costs related to diabetes treatment.
The lifetime cost for the treatment of type 2 diabetes mellitus (T2DM) demands more than $80,000 per person. Glycemic control contributes not only to diminishing the complications related to the T2DM, but it can also have an important impact on the treatment costs.
Metformin is commonly recommended for diabetes treatment at the time of diagnosis. However, if the patient is not able to maintain the target for the glycosylated hemoglobin (HbA1c, a test measuring blood sugar levels) within three months, the glucagon-like peptide-1 (GLP-1) receptor agonist or insulin is also prescribed. Treatment strategies are also dependent on different factors such as age, comorbidities, and glycemic control. The timing of treatment intensification (the introduction of additional therapies) represents an important resource since it can avoid potential T2DM complications and unnecessary costs if not delayed (i.e., clinical inertia, the lack of treatment intensification). Therefore, a study published in the BMJ Open Diabetes Research and Care by Bonafede and collaborators described treatment intensification patterns and the medical costs related to T2DM treatment in the USA.
The authors analyzed more than one million cases of adults older than 18 years of age diagnosed with T2DM in databanks of medical insurance companies. The patients were followed for one to four years, and classified as (1) having not received any treatment in the year prior to or following diagnosis, (2) newly initiated on noninsulin antidiabetic drugs (NIAD) and had not received any antidiabetic medications, (3) newly initiated on basal insulin but could have previously used other antidiabetic medications or (4) newly started prandial or mixed insulin but could have previously used other antidiabetic medications. HbA1c values, macrovascular and microvascular complications, and comorbidities associated with T2DM were also considered. The total annual medical costs were based on emergency department visits, inpatient stays, outpatient and endocrinologist visits, diabetes-related prescriptions, and supplies. They were expressed in US dollars.
It was observed that clinical inertia occurred in cohorts 3 and 4. These patients received NIAD when they could have benefited more from insulin therapy since they remained under a poor glycemic control for a long time. As well, treatment intensification with insulin was not used as a therapeutic strategy. The second-line therapy was mainly based on sulfonylureas and thiazolidinediones (their use were decreased over time), dipeptidyl peptidase-4 (DPP-4) inhibitors and glucagon-like peptide (GLP-1) agonists (their use were increased over time). Nonadherence to insulin therapy was associated with interference to the activities of daily living. The medical costs were higher for patients in cohorts 3 and 4 due to the increased number of visits to endocrinologists and hospitalizations as a result of disease progression or adverse effects of insulin. The complex insulin regimen was another important factor explaining the higher medical costs. Some limitations include an absence of information about body composition, lifestyle modifications, and health behavior. Databank considers requested medication without any information on whether the patient used the respective medicine. Other factors that limit the results are concerning to the absence of information about adherence and potential side effects. Costs and contraindications can also have a significant impact on the results.
The study demonstrates that clinical inertia exists for patients with poor glycemic control and it has a negative impact on the medical costs associated with diabetes. The authors suggest that health education programs for both patients and physicians should be implemented as an important strategy for the treatment intensification in patients with uncontrolled T2DM.
Written By: Vagner Raso