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Medication Non-Adherence in Diabetes: A Look at Costs

Medication Non-Adherence in Diabetes: A Look at Costs

Oral medications and insulin are cornerstones of diabetes man­agement, but as many as one-third of patients with the disease fail to derive optimal benefit from therapy due to medication non-adherence (MNA). Studies have also linked MNA with higher disease-related, inpatient, and emergency department utilization and costs. Unfortunately, many MNA analyses focusing on cost have been limited by small sample size, an absence of precise adherence measures, or cross-sectional design, among other limitations. In an issue of Diabetes Care, my colleagues and I published an article designed to overcome previous research limitations and add to our existing knowledge on the effects of MNA on cost. In our study, we used a multivariate, generalized, linear, mixed model in order to account for shared correlations among cost variables. We then estimated the inpatient, outpatient, and pharmacy-related costs in a group of more than 740,000 veterans in the United States with type 2 diabetes over a 5-year period. Inpatient Costs: A Key Driver According to our findings, the costs of MNA among patients with diabetes are quite large and appear to be mostly driven by inpatient expenditures. All annual cost categories increased by about 3% per year. MNA was associated with 37% lower pharmacy costs and 7% lower outpatient costs but 41% higher inpatient costs. The potential cost savings that might be achieved from improving medication adherence are substantial. Based on sensitivity analyses, improving adherence for MNA patients would lead to annual estimated cost savings that range between $661 million and $1.16 billion. Wanted: More Successful Interventions The findings from our study are significant to both health services researchers and healthcare policy makers....
Diabetes & Fracture Hospitalization Risk

Diabetes & Fracture Hospitalization Risk

Published research has indicated that people with type 2 diabetes are at increased risk for bone fractures. The link between diabetes and fracture risk, however, has historically depended upon the location of the fracture being investigated. Few large, community-based studies of fracture risk have explored possible associations of diagnosed diabetes, undiagnosed diabetes, and fracture risk. “The risk of fracture-related hospitalizations was higher among adults with diagnosed diabetes than those without the disease.” In an effort to fill the void in available research, my colleagues and I conducted a study that compared the risk of fracture-related hospitalization in people without diabetes to those with diagnosed and undiagnosed diabetes. We also examined associations of diabetes medication use and chronic hyperglycemia with fracture risk. Our study—published in Diabetes Care—used data from the NIH-funded Atherosclerosis Risk in Communities Study, a community-based population. Diabetes Increases Risks Results from our investigation showed that the risk of fracture-related hospitalizations was higher among adults with diagnosed diabetes than those without the disease. The risk of fracture-related hospitalization was nearly twice as high for people with diagnosed diabetes. These findings remained even after adjusting for important risk factors, such as age, sex, BMI, physical activity, and smoking. Conversely, fracture risk was similar between people with undiagnosed diabetes and those without the disease. Importantly, our analysis also revealed that fracture risk was higher in people with diagnosed diabetes who were treated with insulin. The risk was also higher in those with A1C levels of 8% or higher when compared with those who had A1Cs lower than 8%. The associations of diagnosed diabetes and fracture risk did not differ by...
Group Education & Older Diabetics

Group Education & Older Diabetics

Studies suggest that group-based diabetes education efforts can improve short- and long-term disease control among younger patients, but few analyses have explored the effect of these programs on older adults. Unfortunately, older adults are often underrepresented in diabetes edu­cation interventions because subtle changes in functional, cognitive, and psychosocial status can affect diabetes self-care. Many clinicians are reluctant to refer older patients to group education because they believe they may require more individual attention. In a secondary analysis study published in Diabetes Care, we examined whether community-dwelling older adults aged 60 to 75 with type 1 or type 2 diabetes would benefit from self-management interventions similarly to younger and middle-aged adults. We also tested if older adults benefited from group versus individual self-management interventions. Comparing Benefits of Diabetes Intervention In our analysis, patients were randomly assigned to one of three self-management interventions from diabetes educators that were delivered separately to those with type 1 or type 2 disease: 1. Highly structured group: Five group sessions were conducted over 6 weeks. Patients were taught how food, medication, and exercise affected A1C and actions they could take when levels were out of range. Between classes, patients set daily goals and practiced problem solving 2. Attention control group: Five group sessions were conducted over 6 weeks, but the sessions followed a manual-based standard diabetes education program. 3. Control group: One-on-one sessions were delivered for 6 months. During sessions, patients could receive any type of information they requested. According to our results, A1C levels improved equally in the older and younger groups at 3, 6, and 12 months with all interventions and for those...

Managing Cognitive Decline in Older Adults With Diabetes

This Physician’s Weekly feature on managing cognitive decline in older adults with diabetes was completed in cooperation with the experts at the American Diabetes Association. More than 25% of Ameri­cans aged 65 and older has diabetes, and the aging of the overall population has been identified as a significant driver of the diabetes epidemic. “Diabetes in older adults is associated with higher mortality, reduced cogni­tive and functional status, and increased risk of institutionaliza­tion,” explains Hermes Florez, MD, PhD, MPH. “Importantly, diabetes has been linked to sig­nificantly higher risks of cogni­tive impairment, a greater rate of cognitive decline, and increased risk of dementia.” While various complications of diabetes are well known and well researched, the effect diabetes has on the brain has historically received relatively little attention. “The risk of both diabetes and cognitive impairment increases with age,” Dr. Florez says. “The presentation of cognitive impairment in people with diabetes can vary, ranging from subtle executive dysfunction to overt dementia and memory loss. We’re starting to see links between diabetes and dementia and Alzheimer’s disease, but researchers are still conducting analyses to further increase our knowledge on these associations.”  Consensus Report on Diabetes in Older Adults In the December 2012 issue of Diabetes Care, the American Diabetes Association released a consensus report on diabetes and older adults. Dr. Florez, who was on the writing group that developed the report, says that an important component to managing older adults with diabetes is the role of cognitive impairment. “For older patients with diabetes, treatments will need to be simplified whenever possible, and caregivers should be involved during consultations. The presence of cognitive...

Glycemic Control After Surgery in Kids

Tight glycemic control appears to be achievable following cardiac surgery in children ages 0 to 36 months, with low rates of hypoglycemia, according to a randomized, control trial. The researchers noted, however, that tight glycemic control does not significantly change infection rates, mortality, length of stay, or measures of organ failure when compared with standard care. Abstract: New England Journal of Medicine, September 7, 2012...
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