Epidemiological burden of depression and its impact on adherence to oral hypoglycemic agents and related economic outcomes in patients with type 2 diabetes

Presence of depression in patients with type 2 diabetes may affect their adherence to oral hypoglycemics and consequently glycemic control and economic outcomes. These potential effects may be more significant when one considers that depression is highly prevalent in patients with diabetes. This study involved two phases. Phase one of the study examined the epidemiological relationship between depression and type 2 diabetes. Phase two of the study examined the impact of depression on patterns of use and adherence to oral hypoglycemics in newly diagnosed type 2 diabetes patients. Impact of depression on expenditures related to type 2 diabetes and overall health care was also estimated. The study also tested the mediating influence of adherence between depression and type 2 diabetes expenditures. Results of phase one of the study indicated that depression was more prevalent in patients with type 2 diabetes as compared to a control group. Results also indicated that females with depression were more likely to develop type 2 diabetes as compared to those without depression. Phase two results indicated that patients without depression had a more favorable pattern of oral hypoglycemic use with a significantly lower proportion of non-depressed patients switching, augmenting, or discontinuing their oral hypoglycemics as compared to depressed patients. Depressed patients were also found to have significantly lower adherence to oral hypoglycemics as compared to non-depressed patients. Multivariate analyses indicated that patients with depression incurred 21.30% higher type 2 diabetes related costs as compared to non-depressed patients. This difference was primarily due to a higher probability of an ER/hospitalization episode in depressed patients. Similarly, patients with depression had 32.10% higher overall health care costs as compared to patients without depression. Depression was associated with increased costs in all areas of health care such as ER/hospitalization, outpatient, and prescription costs. Mediation analysis indicated that adherence to oral hypoglycemics was not a mediator between depression and type 2 diabetes related expenditures. Thus, depression could have potentially impacted type 2 diabetes related outcomes directly through a physiological effect on glycemic levels or indirectly through its impact on adherence to other behaviors such as diet or exercise

An Evaluation of Medicaid Programs Using Medication Use-Related Quality Measures

Objective: To assess quality of care provided to Medicaid beneficiaries using medication use-related quality indicators. Methods: This study is a retrospective analysis of 2006 & 2007 Medicaid administrative claims data from 45 states and DC. Eleven medication use-related measures (adherence/persistence and standard of care) from the AHRQ initial core set were included. A composite measure of medication use-related quality was also created. Patient case-mix adjusted measure scores were computed using hierarchical logistic regression models. States were ranked on both case-mix adjusted and unadjusted scores and categorized into top (?20%), medium (60%) and bottom (?20%) performers. Agreement in rankings and groups based on adjusted and unadjusted scores were determined using Kendall\u27s ? b and Cohen\u27s ?. Cross-state variations in measure scores were described using coefficient of variation and choropleth maps. Multi-level models were used to assess the amount of variation in measures explained by the state level. Results: National benchmarks on medication use-related measures for Medicaid for 2007 ranged from 31.5% for the AD chronic measure to 66.8% for the ICS measure. There was substantial variation in the 13 measures being studied with coefficient of variation ranging from 6.7 for the ICS measure to 20.5 for the MI1 measure. The best performing state Medicaid programs also had significant room for improvement across all measures. There was a lack of agreement in grouping based on crude and case-mix adjusted methods for majority of the measures (?=0.22-0.74), except for the ICS measure (?=0.91). A very small proportion of variation in the study measures (1.5 – 5.7%) was explained by the state level random effect. Conclusions: This study highlights the need for including medication use-related measures in the Medicaid adult quality measure set, considering the substantial variation in scores across states and the considerable room for improvement. States could create a composite measure of medication use-related quality using the approach used in this study if they find it burdensome to report on multiple measures. The study showcased the lack of agreement in crude and case-mix adjusted scores. Medicaid programs should consider the study findings before publicly reporting on crude scores

Impact Of Refill Synchronization On Medication Adherence For Chronic Diseases

Objectives: The objective of this study is to assess the impact of medication synchronization (med sync) on medication adherence for three drug classes under the CMS Star Rating system i.e. oral diabetes, hypertension and cholesterol. Methods: A quasi-experimental pre-post study design was employed using pharmacy prescription fill data from various independent community pharmacies located in different regions of Mississippi. Using Proportion of Days Covered (PDC), medication adherence before and after the med sync was calculated. Total study period of one year for each patient including six months of pre-period and post-period was used for the analysis. Descriptive statistics were calculated. Wilcoxon-Signed Rank test was performed to compare the pre-period adherence to post-period adherence. Proportion of adherent patients before and after the med sync were also compared using McNemar’s Exact Test. Using the obtained 2x2 contingency table odds ratio of being adherent in post-period as compared to pre-period was calculated. Results: A total of 56, 89 and 77 patients were found to meet the inclusion/exclusion criteria in diabetes, hypertension and cholesterol drug categories, respectively. The approximate average age of the patients for the three drug classes was as follows: diabetes 66 years (23-87 years, ± 11.03), hypertension: 70 years (41-101 years, ± 11.53) and cholesterol: 67 years (40-100 years, ± 11.85). Majority of the study sample belonged to 60-80 years of age and had PDC values ranging from 90-100 in both pre-period and post-period for all the three drug classes. Average post-period PDC (0.99) was higher than average pre-period PDC (0.94) and was also statistically different from each other for all the three drug classes. Increase in the proportion of adherent patients from pre-period to post-period was witnessed for the three drug classes i.e., diabetes (91.07% to 100%), hypertension (89.89% to 98.88%) and cholesterol (90.91% to 98.70%). However this increase was only statistically significant for the hypertension drug class (p=0.0215). Also, patients in post-period had higher odds of being adherent in post-period as compared to pre-period for all the three drug classes. Conclusions: The results indicated that after being enrolled in med sync, medication adherence generally improves

Impact of Disease Management on Utilization and Adherence With Drugs and Tests: The case of diabetes treatment in the Florida: A Healthy State (FAHS) program

OBJECTIVE—The purpose of this study was to evaluate the effect of telephonic care management within a diabetes disease management program on adherence to treatment with hypoglycemic agents, ACE inhibitors (ACEIs), angiotensin receptor blockers (ARBs), statins, and recommended laboratory tests in a Medicaid population

An Interprofessional Prediabetes and Diabetes Self--Management Education Quality Improvement Project Among Vulnerable Populations at a Tuberculosis Hospital

Background. Patients greatly benefit from diabetes self-management education (DSME) as it boosts knowledge and self-efficacy, decreases body weight, fasting blood sugar, and hemoglobin A1C levels, and improves overall health outcomes in a cost-effective manner. Unfortunately, many individuals with prediabetes and diabetes who qualify for DSMEs do not attend these classes nor receive sufficient prediabetes and diabetes support elsewhere to attain guideline recommended metrics. However, individuals from vulnerable populations and without DSME education experience disproportionate diabetes-related complications worsening health outcomes. Aims: Increase general prediabetes and diabetes knowledge, facilitate behavior change, improve glycemic, metabolic, and lipid values, and increase healthy dietary planning and physical activity among patients with prediabetes and diabetes. Purpose. Provide an interdisciplinary team DSME education program to patients at a tuberculosis hospital with diabetes and prediabetes in order to empower patients in self-management knowledge and skills in order to prevent or delay complications. Objectives. Review American Diabetes Association (ADA) medical care guidelines with providers, monitor changes to ordered dietary and medication regimens based on laboratory values as per guideline recommendations, reduce individual glycemic, metabolic, and lipid laboratory markers, improve patients’ verbalization of guideline-supported dietary and exercise recommendations, increase patient recognition of signs and symptoms of dysglycemia along with its management, and increase aerobic and resistance exercise participation. Interventions. Provide a closed-caption television (CCTV) prediabetes and diabetes educational programming, conduct weekly DSME classes, initiate a walking and yoga exercise program, encourage online educational module learning, and reinforce class and CCTV interventions with prediabetes and diabetes infographic handouts. Evaluation. Monitor the electronic health record for orders, laboratory results, and staff documentation of education and participation along with the use of patient surveys to assess changes in knowledge, motivation, and self-efficacy. Practice Implications. Many studies have researched the effectiveness of DSMEs in many settings, but none have studied the application of this intervention in a long-term care setting among individuals from vulnerable populations who are experiencing an acute bout of illness. The findings from this quality improvement project will help establish the efficacy of implementing prediabetes and diabetes education programs in hospitals as this presents an opportune time to educate patients

ASSOCIATION BETWEEN WARFARIN ADHERENCE TRAJECTORIES, HOSPITALIZATION RISK, AND HEALTHCARE UTILIZATION AMONG MEDICARE PATIENTS WITH ATRIAL FIBRILLATION: A GROUP-BASED TRAJECTORY MODELLING APPROACH

Introduction: Warfarin is the most commonly prescribed drug for stroke prevention among Atrial Fibrillation (AF) patients, especially in older adult populations, but medication nonadherence reduces its effectiveness in clinical practice. Group Based Trajectory Models (GBTM) have been used to identify distinct patterns of adherence behavior related to various medications and understand the patient characteristics associated with each trajectory. The objectives of the study were: 1) Describe trajectories of warfarin adherence among Medicare AF patients, 2) Assess impact of adherence trajectories on AF-related hospitalization, 3) Estimate the AF-related direct costs for each adherence trajectory group. Methods: We identified elderly AF patients initiating warfarin treatment during 2008-2010 using data from a random sample of Medicare beneficiaries. The study’s first aim is to classify patients into different trajectory groups based on their monthly adherence patterns using a Group-Based Trajectory Model (GBTM). A multinomial regression model was used to assess associations between baseline characteristics and adherence trajectories. The second aim is to evaluate the association between adherence trajectories and time to first hospitalization related to stroke or bleeding event. Hospitalization events due to bleeding or stroke were identified using corresponding ICD-9 codes, and a Cox proportional hazard model was performed. The third aim of the study is to calculate AF-related direct medical costs associated with each trajectory group. SASv9.4 was used for analysis. Results: Among 3,246 beneficiaries who met inclusion criteria, six adherence trajectories were identified: 1) rapid-decline non-adherence group (11.5%), 2) moderate non-adherence group (24%), 3) rapid-decline then increasing adherence group (6.8%), 4) moderate-decline non-adherence group (8.2%), 5) slow-decline non-adherence group (24.3%), and 6) perfect adherence group (25.3%). Even though no statistical significances were found in the hazard of hospitalization among the adherence groups, there were higher odds of hospitalization among the lower adherence groups compared to perfect adherence group. Outpatient and monitoring costs were significantly higher in the lower adherence trajectories compared to perfect adherence group. Conclusion:The GBTM is considered an innovative methodological approach that can be applied to longitudinal medication adherence data and account for the dynamic nature of adherence behavior in a better way than traditional adherence measures

Economic Implications of Patient-Related Factors in Diabetes Care

Diabetes mellitus is a chronic disease characterized by high blood sugar levels with serious complications, particularly if it is not adequately treated. It is increasingly prevalent and burdensome from both a health and economic standpoint globally, amounting to hundreds of billions of dollars in expenditure each year [1,2]. Also increasing are the numbers and types of pharmaceutical interventions being introduced to treat this disease. Over the next decade, numerous diabetes compounds currently in development are expected to be commercialized, making it essential for the most robust and accurate evidence to be available to healthcare decision-makers [3]. Approximately 90% of people with diabetes are diagnosed as Type 2 (T2D), most often in adulthood [4]. In contrast, Type 1 diabetes (T1D) patients are commonly diagnosed as juveniles, but live well into adulthood with effective treatment [4]. Consequently, adult patients with diabetes, namely T2D, are responsible for most of the health and economic burden of this disease. Therefore, much of the effort to improve outcomes and reduce costs in diabetes concentrates on this population