Economic evaluation of outpatients with type 2 diabetes mellitus assisted by a pharmaceutical care service / Avaliação econômica de pacientes ambulatoriais portadores de diabetes melito tipo 2 assistidos por um serviço de atenção farmacêutica

OBJECTIVE: To analyze the costs related to visits and drug prescription in outpatients with type 2 diabetes mellitus assisted by a pharmaceutical care service. SUBJECTS AND METHODS: A prospective and experimental study was carried out. Seventy one patients were divided into two groups: control and pharmaceutical care. Patients in the pharmaceutical care group were followed up monthly by a single clinical pharmacist. RESULTS: The pharmaceutical care group had a statistically significant reduction in costs of metformin and emergency department visits, and increased costs with their family physicians. On the other hand, the control group had a statistically significant increase of 21.3 percent in the general costs of treatment and visits. CONCLUSION: The pharmaceutical care group maintained the same costs related to drugs and visits, while the control group showed a significant increase in general costs.

OBJETIVO: Analisar os custos relacionados a medicamentos e consultas em pacientes portadores de diabetes melito tipo 2 acompanhados por um programa de atenção farmacêutica. SUJEITOS E MÉTODOS: Estudo prospectivo e experimental foi realizado em 71 pacientes, os quais foram divididos em dois grupos: atenção farmacêutica e controle. Os pacientes do grupo atenção farmacêutica foram acompanhados mensalmente por um farmacêutico clínico. RESULTADOS: O grupo atenção farmacêutica apresentou redução estatisticamente significativa no custo da metformina e nas visitas de pronto atendimento e aumento no custo das consultas de atenção primária. Por outro lado, o grupo controle apresentou elevação estatisticamente significativa nos custos gerais de tratamento farmacológico e nas consultas em geral na ordem de 21,3 por cento. CONCLUSÃO: O grupo atenção farmacêutica apresentou manutenção dos custos relacionados a consultas e medicamentos, enquanto o grupo controle apresentou aumento destes.

Economic evaluation of outpatients with type 2 diabetes mellitus assisted by a pharmaceutical care service.

OBJECTIVE: To analyze the costs related to visits and drug prescription in outpatients with type 2 diabetes mellitus assisted by a pharmaceutical care service. SUBJECTS AND METHODS: A prospective and experimental study was carried out. Seventy one patients were divided into two groups: control and pharmaceutical care. Patients in the pharmaceutical care group were followed up monthly by a single clinical pharmacist. RESULTS: The pharmaceutical care group had a statistically significant reduction in costs of metformin and emergency department visits, and increased costs with their family physicians. On the other hand, the control group had a statistically significant increase of 21.3% in the general costs of treatment and visits. CONCLUSION: The pharmaceutical care group maintained the same costs related to drugs and visits, while the control group showed a significant increase in general costs.

Willingness to pay for inhaled insulin: a contingent valuation approach.

PURPOSE: To determine the willingness to pay (WTP) of patients with diabetes mellitus for inhaled insulin. METHODS: A contingent valuation survey was administered to 96 diabetic outpatients at St. Michael's Hospital, Toronto, Canada. Standardised information about inhaled insulin and subcutaneous rapid-acting insulin was provided via video. Participants' WTP for their preferred product was elicited in Canadian dollars (Can dollars) using a 'payment-scale' method. RESULTS: The mean age of participants was 51.8 years (SD 13.4). Seventy-seven patients had type 2 and 19 had type 1 diabetes. Significantly more participants preferred inhaled insulin over subcutaneous insulin (85 vs 11; p < 0.01). Mean monthly WTP for inhaled insulin (153.70 Can dollars, SD 99.90) was significantly more than the typical 50 Can dollars per month for subcutaneous insulin (p < 0.01). Significantly more participants with type 2 diabetes using oral drugs than those with type 1 diabetes and using insulin preferred inhaled insulin (98.5% vs 69%, p < 0.001). Diabetic patients who did not use insulin were willing to pay significantly more than were insulin users (p < 0.001). Multiple regression analysis showed that income was significantly associated with WTP for inhaled insulin. CONCLUSION: Diabetic patients, particularly those who are not using insulin, indicated that they would prefer inhaled insulin over insulin injection and would be willing to pay a substantial amount per month to use it. An economic evaluation of inhaled insulin would provide important information to healthcare policy decision makers and private payers about its economic value.

A comparison of costs for four oral antidiabetic regimens within a managed care population.

A retrospective database analysis compared costs among patients with type 2 diabetes receiving four antidiabetic regimens: (1) repaglinide monotherapy, (2) metformin monotherapy, (3) repaglinide and metformin in combination, or (4) metformin and glyburide in combination. Pharmacy, medical, and total costs were measured for each cohort over a nine-month period. Although not statistically significant, total adjusted costs were lowest for the repaglinide-metformin combination ($8,924), followed by metformin monotherapy ($9,448), metformin and glyburide ($9,576), and repaglinide monotherapy ($11,910). These results must be confirmed in larger populations, but they imply that differences in pharmacy costs of repaglinide-metformin therapy are offset by measurable medical cost savings.

Economic model of first-line drug strategies to achieve recommended glycaemic control in newly diagnosed type 2 diabetes mellitus.

OBJECTIVE: To assess the short-term direct medical costs and effectiveness associated with achieving recommended glycaemic goals using commonly prescribed first-line oral antihyperglycaemic medications in type 2 diabetes mellitus. MATERIALS AND METHODS: A literature-based, decision-tree model was developed to project the number of patients achieving glycosylated haemoglobin values of <7% on oral therapies and the associated costs over a 3-year timeframe. For each first-line strategy, patients could progress to combination therapy using two or more agents prior to the introduction of insulin. The overall cost of treatment included costs (2001/2002 values; US dollars) of comprehensive medical care, laboratory tests, patient education, drug therapy, home glucose monitoring and adverse events. RESULTS: At 3 years, the overall cost of treatment for the various first-line strategies was 6,106 US dollars for glipizide gastrointestinal therapeutic system, 6,727 US dollars for metformin immediate release, 6,826 US dollars for metformin extended release, 7,141 US dollars for glibenclamide (glyburide)/metformin, 7,759 US dollars for rosiglitazone and 9,298 US dollars for repaglinide. Costs of comprehensive routine medical care ranged from approximately 1,538-2,128 US dollars in year 1 and from approximately 952-1,543 US dollars in subsequent years, for controlled and uncontrolled patients, respectively. Adverse events represented <1%, and drug therapies represented approximately 50%, of the overall cost, respectively. Substantial cost differences between the strategies were seen within the first year. Regardless of first-line therapy, patients progressed quickly to combination therapies, with effectiveness among the agents being similar. CONCLUSIONS: Short-term costs required to provide comprehensive diabetes care and achieve glycemic goals can be substantial. The model suggests a sulphonylurea strategy may provide similar effectiveness with cost savings over other agents and should be considered when selecting an initial drug therapy in newly diagnosed patients with type 2 diabetes mellitus.

Glyburide compared to insulin for the treatment of gestational diabetes mellitus: a cost analysis.

OBJECTIVE: To compare the costs associated with glyburide compared to insulin for the treatment of gestational diabetes unresponsive to dietary therapy. STUDY DESIGN: A cost model was designed. The model excluded costs that were identical for both treatment arms, such as the cost of monitoring glucose control. Insulin treatment costs included average wholesale drug costs, wholesale delivery costs (syringes, alcohol pads), and costs of office staff educating patients. Glyburide costs were based on average wholesale drug costs. Downstream costs of potential inpatient evaluation for hypoglycemia were included in the model. RESULTS: In our baseline model, glyburide was significantly less costly than insulin for the treatment of gestational diabetes. The average cost saving per patient based on wholesale drug costs and hospital costs was US$165.84. Actual retail drug savings and hospital charge savings are potentially considerably greater. The strongest determinant of cost savings was medication cost. The model was less sensitive to the one-time costs of inpatient treatment and patient education. CONCLUSION: Glyburide is less costly than insulin for the treatment of gestational diabetes. Cost models can be useful to physicians deciding between two equally efficacious medications, allowing them to incorporate information about their individual practice styles with a complex balance of cost implications.

A short term cost-effectiveness model for oral antidiabetic medicines in Europe.

A short term (6-month) cost-effectiveness model has been developed to simulate current medical practice and disease progression in patients with type 2 (non-insulin-dependent) diabetes mellitus uncontrolled by diet and exercise. The model is based on decision-analytical techniques and includes probabilities of switching between treatments, the reason for the switch and the most common switch options. Effectiveness and economic measures are the 2 main outcomes. In order to assess effectiveness, we use symptom-free days with acceptable control (SFDACs), which represent each day of treatment without adverse events or symptoms, and with acceptable control of glucose and lipids. For the economic evaluation, only incremental costs incurred directly by a health insurance system are considered. This model should prove useful in the evaluation of new oral antidiabetic agents, since the short term aim of antidiabetic therapy is to provide adequate control in the absence of adverse effects and symptoms (a prerequisite for successful long term treatment). Furthermore, short term analysis provides data for comparing initial investment in drug therapy with potential savings over a longer treatment period.

Cost-effectiveness analyses of the conversion of patients with non-insulin-dependent diabetes mellitus from glipizide to glyburide and of the accompanying pharmacy follow-up clinic.

At the Department of Veteran's Affairs Outpatient Clinic in Columbus, Ohio, patients with non-insulin-dependent diabetes mellitus who were receiving glipizide therapy were converted to glyburide therapy over a 6-month period starting in mid-1993. A pharmacy follow-up clinic was instituted to help patients with problems associated with the transition. The conversion was intended to reduce costs by converting from a more expensive to a less expensive drug (in terms of acquisition cost) within the same therapeutic class. An initial analysis of the conversion indicated a savings of $65,000.00 to the Department of Veterans' Affairs (VA) based on the drug acquisition cost differential alone. The purpose of our study was to retrospectively evaluate the cost-effectiveness of the conversion and pharmacy follow-up clinic from the perspective of the VA pharmacy department. Relevant costs and effectiveness (percentage of patients who achieved good glycemic control) were examined for three groups: group I--patients who were treated with glipizide, group II--patients who were treated with glipizide; group II--patients who were switched from glipizide to glyburide, accompanied by a pharmacy follow-up clinic; and group III--patients who were switched from glipizide to glyburide, with no follow-up clinic. Overall, group II had the lowest costs, and group II had to be the most effective. Cost-II effectiveness analysis indicated that, in general, the conversion from glipizide to glyburide was cost-effective. Incremental analysis performed for the follow-up group over the no follow-up group showed that for every 1% of patients who achieved good glycemic control, the VA would spend $1.01 more for the follow-up groups. This was considered to be cost-effective for the VA.

Formulary conversion from glipizide to glyburide: a cost-minimization analysis.

Economic pressure prompted us to search for and implement cost-saving strategies at Bronx Municipal Hospital. This paper describes a cost-minimization analysis of the impact of formulary substitution of glyburide for glipizide on glycemic control, safety, and costs. In 76 patients with computerized prescription records, switching from a mean daily glipizide dose of 19 mg to a mean daily glyburide dose of 10.2 mg did not affect glycemic control. A subset of 33 elderly patients experienced only three drug-related adverse events during the 2-year observation period. The conversion program yielded a 51% reduction in overall expenditures for oral hypoglycemic agents between 1991 and 1993. These findings indicate that our conversion program was successful, which has led to its becoming a model for other New York City municipal outpatient pharmacies.

Effect of value-added utilities on prescription refill compliance and Medicaid health care expenditures--a study of patients with non-insulin-dependent diabetes mellitus.

An estimated 20 million Americans suffer from diabetes. Patients with non-insulin-dependent diabetes mellitus (NIDDM) comprise approximately 90% of the diabetic population. An estimated 10-30% of patients with NIDDM withdraw from their prescribed regimen within 1 year of diagnosis, and of the remainder, nearly 20% administer insufficient medication to facilitate an adequate reduction in blood glucose. A randomized trial was undertaken to discern the effect of pharmacy-based value-added utilities on prescription-refill compliance with sulfonylurea therapy and health service utilization. The subjects were 258 Medicaid beneficiaries from the state of South Carolina, previously untreated for NIDDM, prescribed 5 mg of the second-generation sulfonylurea glyburide twice daily, and monitored with regard to prescription-refill compliance and health service utilization for 1 year. Subjects provided informed consent and were randomly assigned to one of four experimental groups: (i) the control cohort received standard pharmaceutical care with each dispensing of glyburide; (ii) the second cohort received standard pharmaceutical care and was mailed a medication-refill reminder 10 days prior to each sequential refill date; (iii) the third cohort received standard pharmaceutical care and was provided unit-of-use packaging with each prescription-refill request; (iv) the fourth cohort received standard pharmaceutical care, mailed medication-refill reminders, and unit-of-use packaging. Analysis of variance (ANOVA) procedures revealed that patients receiving mailed prescription-refill reminders, unit-of-use packaging, or a combination of both interventions achieved a significant (P < or = 0.05) increase in the Medication Possession Ratio (MPR) for sulfonylurea therapy relative to controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of glipizide and glyburide in a health maintenance organization.

OBJECTIVE: To determine if there was a difference in the long-term glycemic control, average daily dose, and cost of therapy in patients with noninsulin-dependent diabetes mellitus (NIDDM) treated with glyburide and glipizide in a health maintenance organization (HMO). DESIGN: Retrospective evaluation of medical and pharmacy records. SETTING: Multispecialty group practice HMO. PATIENTS: 140 NIDDM patients being treated with either glyburide (n = 70) or glipizide (n = 70) were randomly selected from the populations of patients receiving either drug using computerized pharmacy records. MAIN OUTCOME MEASURE: Mean daily doses and blood glucose measurements (fasting blood glucose, random blood glucose, hemoglobin A1C) were stratified in 3-month periods from the time the drug therapy was started or the patient first presented to the clinic for a total of 18 months. Long-term glycemic control was defined as fasting blood glucose less than 8.33 mmol/L (150 mg/dL). RESULTS: The groups were comparable with regard to age (53.4 y glyburide, 56.7 y glipizide), gender (43 M:27 F glyburide, 47 M:23 F glipizide), race (38 W/16 B/16 H glyburide, 45 W/16 B/9 H glipizide), concurrent medical conditions, adverse effects, and compliance. Long-term glycemic control was similar in both groups. Although the number of subjects who were controlled (by definition) tended to be greater in the glyburide group, no clinical or statistical difference was found. There was no statistical difference in mean daily dose between the ethnic groups, but the small numbers preclude further analysis. The glipizide group had a larger percentage increase in dose within the first year than did the glyburide group; however, the percentage increase from the 3-month dose was similar after 18 months (22.7 percent glyburide, 27.5 percent glipizide.) Average daily cost of therapy, based on mean daily dose, was slightly lower for glyburide-treated patients. CONCLUSIONS: If glycemic control is similar with glyburide and glipizide, as seen in this study, economic considerations regarding choice of therapy and formulary inclusion may be appropriate.

Conversion from glipizide to glyburide: a prospective cost-impact survey.

Despite extensive clinical experience with second-generation oral hypoglycemic agents, the relative dosing equivalence of glyburide and glipizide remains controversial. A prospective survey was conducted to determine the feasibility and cost of converting noninsulin-dependent diabetic patients from glipizide to glyburide. A total of 211 patients previously stabilized on glipizide were converted to glyburide and returned to their respective clinics at least once during the following six months. The mean daily dose (+/- SD) of glipizide before conversion was 18.7 +/- 12.32 mg; the mean daily dose of glyburide after seven months was 9.9 +/- 6.52 mg (P less than 0.001, paired t test). Glyburide was well tolerated. The conversion program appeared to be successful and resulted in a 47% reduction in the mean daily dose after conversion from glipizide to glyburide, which, in turn, conferred a 43% savings in the projected yearly expenditures for second-generation oral hypoglycemics.