Achieving glycemic goal with initial versus sequential combination therapy using metformin and pioglitazone in type 2 diabetes mellitus.

OBJECTIVE: To compare glycemic goal achievement (HbA(1c) < 7%) in type 2 diabetes patients receiving initial metformin plus pioglitazone combination therapy and initial metformin monotherapy augmented with pioglitazone in a cohort follow-up study. RESEARCH DESIGN AND METHODS: Adult patients were identified from the Ingenix Impact database (01/01/99-03/31/07). Qualified patients had a baseline HbA(1c) ≥ 7%; a second laboratory value within 9 months; no other anti-diabetic prescriptions 6 months before or 30 days after treatment initiation; and continuous enrollment during baseline. The index date was the date on which the second medication was initiated. Goal achievement was compared independently at 6, 12 and 18 months using a chi-square test. Logistic regression was used to control for baseline differences. Last observation carried forward was used to impute missing HbA(1c) values. Sub-group analysis was conducted on patients with baseline HbA(1c) values between 7% and 9%, and >9%. MAIN OUTCOME MEASURES: The proportion of patients achieving glycemic goal at each specified time point. RESULTS: A total of 179 patients received initial combination therapy and 347 patients received sequential therapy. A greater proportion of initial combination patients achieved the glycemic goal compared to sequential patients at months 6, 12 and 18 (66.5 vs. 49.6%; 65.9 vs. 48.1%; 65.9 vs. 48.4%, respectively; p < 0.001 for all). Logistic regression confirmed these findings (odds ratios [OR]: 3.18-3.31). Sub-group analysis showed a more pronounced advantage for aggressive initial combination treatment among patients with HbA(1c) > 9% (OR: 5.39-6.04) than among patients with HbA(1c) between 7% and 9% (OR: 2.28-2.79). CONCLUSIONS: Initial combination therapy patients are more likely to achieve glycemic control than sequential therapy patients, especially for patients with baseline HbA(1c) > 9%. This study is limited by the relatively small sample size and the frequency of HbA(1c) reporting. Future research could examine goal achievement using a larger sample and more complete laboratory data to confirm these findings.

Prevalence rates and costs of metabolic syndrome and associated risk factors using employees' integrated laboratory data and health care claims.

OBJECTIVE: This study assessed the relative value of using laboratory, claims, or integrated laboratory-claims data to identify prevalence rates and costs of metabolic syndrome among Chevron Texaco Corporation, San Ramon, California, employees. METHODS: This study identified five metabolic syndrome risk factors by using three identification methods: (1) health-screening data, applying the National Cholesterol Education Program Adult Treatment Panel III and World Health Organization definitions; (2) employer-based claims data applying proxy International Classification of Diseases, 9th Revision definitions; and (3) integrated laboratory-claims data. Prevalence rates and costs of metabolic syndrome and associated risk factors were estimated. RESULTS: Laboratory-defined and claims-defined approaches underestimated metabolic syndrome prevalence rates compared with the integrated approach by 22.9% and 87.5%, respectively. Employees with metabolic syndrome had double the costs of those without any risk factors ($4603 vs $1859; P = 0.0384). CONCLUSIONS: Results suggest that integrating laboratory and claims data is a more balanced approach than either approach alone for identifying metabolic syndrome among Chevron employees.