Antidiabetic treatment patterns in a medicare advantage population in the United States.

BACKGROUND: Published guidelines for treatment of type 2 diabetes mellitus (T2DM) agree on initial pharmacotherapy. However, few specific recommendations on second-line agents are provided. OBJECTIVE: The objective of this study was to describe antidiabetic treatment patterns in Medicare Advantage patients with T2DM within 6 months of measurement of the glycosylated hemoglobin (HbA1c) level. RESEARCH DESIGN: This retrospective cross-sectional study utilized medical, pharmacy, and laboratory claims from a large Medicare Advantage with Prescription Drug (MAPD) coverage payer. MAPD members between 65 and 89 years old identified as having T2DM between 2009 and 2011 were eligible for inclusion. A 12-month baseline period before the first HbA1c value (index date) was evaluated for demographic and clinical differences. Antidiabetic therapy was evaluated for 6 months post-index. The study population was stratified into three cohorts based on index HbA1c value: controlled (<8%, 64 mmoL/mol), uncontrolled (≥ 8%, 64 mmoL/mol and <10%, 86 mmoL/mol), and severely uncontrolled (≥ 10%, 86 mmoL/mol). RESULTS: Despite elevated HbA1c values (≥ 8%, 64 mmoL/mol), 7-8% of patients did not receive antidiabetic therapy during the post-index period. Metformin and sulfonylureas were the oral antidiabetics (OADs) most frequently used as monotherapy. The majority of patients on combination therapy were on two or more OADs and higher injectable use was observed in the severely uncontrolled cohort. Metformin was included in >60% of the combination regimens with metformin + sulfonylurea being the most common. CONCLUSION: This study suggests suboptimal treatment of those not in glycemic control (HbA1c ≥ 8%, 64 mmoL/mol). Many patients classified as severely uncontrolled based on HbA1c received only monotherapy. Opportunities exist for treatment modification within this population to achieve tighter glycemic control.

The burden of diabetes mellitus for medicare beneficiaries.

The objective was to estimate health care costs and utilization for Medicare beneficiaries with type 1 (T1DM) or type 2 (T2DM) diabetes and their respective matched control cohorts. A retrospective claims cohort analysis was used to assess direct health care cost and utilization of health services in 2009 for patients aged 65-89 who were enrolled in a Medicare Advantage Plus prescription drug plan. Patients were matched 1:1 with patients without diabetes. All-cause health care costs for 2009 were calculated as the sum of all medical and pharmacy claims. The analysis included 6562 patients with T1DM and an equal number of matched controls, and 194,775 patients with T2DM and an equal number of matched controls. There were no significant demographic differences between cohorts for matched variables. Patients with T2DM had significantly higher mean Deyo/Charlson Comorbidity Index scores compared with their controls (2.47 versus 0.77; P<0.001), although all groups reported a high rate of costly comorbidities such as hypertension and heart disease. Mean all-cause health care costs per patient per year were significantly higher for patients with T1DM and T2DM versus controls for inpatient hospitalizations; outpatient, office, and emergency room visits; pharmacy expenditures; and total health care costs for 2009 (T1DM group: $20,701±$30,201; T1DM-matched control group: $6,537±$10,441; T2DM group: $10,437±$18,518; T2DM-matched control group: $6,505±$11,140). Diabetes escalates health care costs for Medicare Advantage Plus patients compared with patients in the same plan without diabetes, regardless of comorbidities.

Opioid-paracetamol prescription patterns and liver dysfunction: a retrospective cohort study in a population served by a US health benefits organization.

BACKGROUND: Paracetamol (acetaminophen) is the most common cause of acute liver failure (ALF). ALF attributed to paracetamol is most often associated with the following features: an unintentional overdose, a single product, an opioid-paracetamol combination, duration of <7 days, and a median dose of 7.5 g/day. Currently, the recommended maximum daily dose of paracetamol is 4 g. OBJECTIVES: The aims of the study were to determine opioid-paracetamol prescription patterns, including prescriptions exceeding the recommended dose of paracetamol (4 g/day) [prescriptions and beneficiaries]; examine factors associated with receiving opioid-paracetamol prescriptions in excess of paracetamol 4 g/day; and evaluate opioid-paracetamol prescription patterns for beneficiaries with liver dysfunction. METHODS: A retrospective cohort study examining prescription data of 4.8 million beneficiaries from a US health benefits organization from 1 January 2009 through 31 December 2009. The main outcomes examined were daily paracetamol dose and liver dysfunction. RESULTS: A large proportion (8.1%) of the 5.3 million prescriptions for opioid-paracetamol exceeded the recommended maximum daily dose of paracetamol (4 g/day), putting over one-quarter of a million (255 123 [18.9%]) of the 1.35 million beneficiaries receiving an opioid-paracetamol prescription at risk of toxicity. The most frequently prescribed products that exceeded paracetamol dose guidelines contained dextropropoxyphene and hydrocodone. Multiple factors, including type of product (i.e. dextropropoxyphene or oxycodone-containing), geographical location (Midwest), strength of the paracetamol in the opioid-paracetamol product (>325 mg) and prescriber specialty (dentist, physician assistant), were associated with high-dose paracetamol prescriptions. Liver dysfunction was diagnosed in 3818 cases, and 23.4% of these beneficiaries received an opioid-paracetamol prescription in the 90 days prior to the liver dysfunction diagnosis. CONCLUSIONS: Although most opioid-paracetamol prescriptions are written and dispensed for <4 g/day of paracetamol, a significant portion of beneficiaries are being prescribed and dispensed excessive doses of paracetamol. Efforts to curtail this practice may involve provision of prescriber and pharmacist education, utilization of benefit manager systems to flag excessive dosing or that require confirmation of dosing, and implementation of US FDA recommendations supported by these data.

Incorporating tailored interactive patient solutions using interactive voice response technology to improve statin adherence: results of a randomized clinical trial in a managed care setting.

The current study presents the impact of a behavior change program to increase statin adherence using interactive voice response (IVR) technology. Subjects were affiliated with a large health benefit company, were prescribed a statin (index) and had no lipid-lowering pharmacy claims in the previous 6 months, and were continuously enrolled in the plan for 12 months prior and 6 months post index statin. Potential subjects (1219) were contacted by the IVR system; 497 gave informed consent. Subjects were asked to respond to 15 questions from the IVR that were guided by several behavior change theories. At the conclusion of the questions, subjects were randomly assigned to either a control group (n = 244), who received generic feedback at the conclusion of the call and were then mailed a generic cholesterol guide, or an experimental group (n = 253), who received tailored feedback based on their cholesterol-related knowledge, attitudes, beliefs, and perceived barriers to medication adherence, and were mailed a tailored guide that reinforced similar themes. Subjects in the experimental group had the opportunity to participate in 2 additional tailored IVR support calls. The primary dependent variable was 6-month point prevalence, defined as claims evidence of a statin on days 121-180 post index statin. Subjects in the experimental group had a significantly higher 6-month point prevalence than the controls (70.4% vs. 60.7%, P < 0.05). Results of this study suggest that a behavioral support program using IVR technology can be a cost-effective modality to address the important public health problem of patient nonadherence with statin medication.