Drug utilization and cost for erythropoiesis-stimulating agents in a long-term care resident population with chronic kidney disease.

OBJECTIVE: To compare drug-utilization patterns and costs in patients with chronic kidney disease (CKD), not on dialysis, yet receiving epoetin alfa (EPO) or darbepoetin alfa (DARB) in a long-term care setting. DESIGN: A retrospective analysis of pharmacy dispensing from January 2007 through March 2009, was conducted using the AnalytiCareSM LTC database. SETTING: Long-term care. PATIENTS, PARTICIPANTS: Patients>or=18 years of age, with >or=1 EPO or DARB dose dispensed, were included. Patients dispensed both agents, diagnosed with cancer, receiving chemotherapy, radiation therapy, or renal dialysis, were excluded. MAIN OUTCOME MEASURES: Mean cumulative erythropoiesis-stimulating agent (ESA) dose was used to calculate drug cost (using April 2009 wholesale acquisition cost) and dose ratio (Units EPO:mcg DARB). Results were also stratified by payer types. RESULTS: A total of 2,259 patients were identified (EPO 1,640; DARB 619). EPO patients were slightly older (76.1 vs. 74.8 years of age, P=0.021), with similar proportion of women, compared with DARB patients. Mean (SD) cumulative dose was 98,420 (122,381) Units for EPO and 360 (428) mcg for DARB, resulting in a dose ratio of 273:1 (Units EPO:mcg DARB). The corresponding drug cost was 42% higher with DARB than with EPO ($1,734 vs. $1,217, P<0.001). Stratified analysis by payer types yielded similar results (dose ratios: 299:1 and 270:1 [Units EPO:mcg DARB]); cost premiums: 30% and 44% for Medicare Part A/Facility and Medicare Part D/Medicaid groups, respectively. CONCLUSIONS: This study of long-term care CKD patients receiving ESAs reported 42% higher drug cost with DARB compared with EPO and a dose ratio of 273:1.

Use of basal insulin and the associated clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus: a retrospective chart review study.

BACKGROUND: The management of type 2 diabetes mellitus in long-term care (LTC) settings can be complex as a result of age-related complications. Despite guideline recommendations, sliding scale insulin remains commonplace in the LTC setting and data on basal insulin use are lacking. METHODS: This retrospective study used medical chart data and the Minimum Data Set from elderly LTC facility patients who received basal insulin (insulin glargine, insulin detemir, or neutral protamine Hagedorn insulin) for the treatment of diabetes, to investigate the practice patterns and associated clinical outcomes. RESULTS: A total of 2,096 elderly, insulin-treated patients in LTC were identified, with 59.5% of them (N=1,247) receiving basal insulin. Of these, more than 50% of patients received sliding scale insulin in co-administration with basal insulin. Despite its ease of use, insulin pen use was very low, at 14.6%. Significant differences were observed between the basal insulin groups for glycated hemoglobin level and dosing frequency. Hypoglycemia was uncommon -17.2% of patients experienced at least one event, and there was no significant difference in the prevalence of hypoglycemia between the groups. CONCLUSION: These data suggest the underutilization of basal insulin in the LTC setting and worryingly high combinational use with sliding scale insulin. Differences in glycated hemoglobin and dosing frequencies between types of basal insulin warrant further comparative effectiveness studies.

Association between different hemoglobin A1c levels and clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus.

OBJECTIVE: New guidelines recommend a target glycated hemoglobin (HbA1c) of 7.5% to 8.0% in elderly persons with type 2 diabetes mellitus (T2DM), but real-world data regarding outcomes associated with different HbA1c levels in the elderly are limited. This study assessed outcomes and their association with defined HbA1c thresholds and age ranges in insulin-treated, elderly, patients with T2DM in long-term care (LTC). DESIGN: Retrospective analysis of medical charts and the Minimum Data Set (MDS) for the period September 2010 through September 2011. SETTING: A total of 117 nursing homes in the United States. PARTICIPANTS: Eligible patients had resided in LTC for 3 months or more, had at least 1 full MDS assessment, 2 or more records of insulin dispensing with no pump use, and 1 or more HbA1c measurements. MEASUREMENTS: Outcomes that were measured included hypoglycemia, ketoacidosis, infections, falls, hospitalization, and emergency room (ER) visits. RESULTS: A total of 583 patients were included (mean age 78.9 years, mean chart observation length 55 days). In all groups, hypoglycemia was lowest in patients with an HbA1c level higher than 9.0%. In patients 75 years or older, infection rates were highest when HbA1c levels were higher than 9.0%. Falls increased by HbA1c level in patients aged 65 to 74 years, but decreased by HbA1c levels in patients 85 years or older. Ketoacidosis, hospitalization, and ER visits were low in all groups. CONCLUSION: These data suggest that better glycemic levels may not necessarily be associated with better clinical outcomes, and different age groups may exhibit different patterns, thereby supporting the call for individualized glycemic control among elderly patients.

Burden of sliding scale insulin use in elderly long-term care residents with type 2 diabetes mellitus.

OBJECTIVES: To examine prevalence, practice patterns, and associated burden of sliding scale insulin (SSI) therapy in elderly adults with type 2 diabetes (T2DM). DESIGN: A retrospective cross-sectional study assessing merged medical chart data and the Minimum Data Set. SETTING: One hundred seventeen long-term care (LTC) facilities in seven U.S. states. PARTICIPANTS: Elderly adults with insulin-treated T2DM (N=2,096) admitted to a LTC facility after January 1, 2009, who had been in the facility for at least 3 months before chart abstraction and had received treatment with non-SSI or SSI regimens. The latter were categorized into SSI-only, basal­SSI, prandial­SSI, basal­prandial­SSI, and multiple regimens with SSI. Data were collected from September 2010 through September 2011. MEASUREMENTS: Demographic and clinical characteristics were recorded. Fingerstick burden was assessed as the average number of fingersticks per week and average number without subsequent insulin administration. Other measures included glycosylated hemoglobin (HbA1c) and hypoglycemia events. RESULTS: Overall, 73.8% of participants received SSI therapy. SSI-treated participants were more likely to be younger (P=.01), non-white (P=.002), and receiving sulfonylurea (P=.004) than non-SSI treated participants. SSI therapy was associated with a mean±standard deviation of 19.9±7.9 fingersticks per week, of which 12.5±7.6 were not followed by insulin administration. Fewer SSI-treated participants than non-SSI treated participants had one or more HbA1c measurements of 7.0% or less (48.8% vs 57.2%) or 8.5% or less (85.2% vs 87.6%, respectively). Rates of hypoglycemia were similar in both groups (15.0% vs 14.9%). CONCLUSION: SSI therapy is widely used in LTC facilities and is associated with a high fingerstick burden. SSI regimens are associated with poorer glycemic control but a rate of hypoglycemia similar to that of non-SSI regimens.