Among Diabetes Patients, Cost Increases Linked With Guideline Non-Compliance

^{By Julie Gould}

Recent study findings show that higher diabetes-related costs are linked with reduced compliance to guidelines. The study findings were published in the Journal of Clinical & Translational Endocrinology.

Swapnil Rajpathak, executive director cardiometabolic team, Center for Observational Real World Evidence (CORE) at Merck & Co, Inc, and colleagues, observed 21,171 participants in order to understand the correlation between health-related outcomes and costs with high, intermediate, or low conformance to diabetes guidelines. 

Over 18 months of outcome assessment, the study authors found that among patients with diabetes with low versus high conformance to guidelines, pharmacy costs were significantly lower. However, diabetes-related outpatient costs were significantly higher. Additionally, at both 12 and 18 months, the study authors found that among those with intermediate versus high guideline conformance, diabetes-related outpatient costs were significantly increased. 

In order to understand the importance of adherence to evidence-based care guidelines in order to improve health outcomes and reduce costs, we spoke with Mr Rajpathak.

What existing data led you and your co-investigators to conduct this research?

The American Diabetes Association recommends treatment intensification for type 2 diabetes (T2D) patients who haven’t reached glycemic control, defined as a glycated hemoglobin (HbA1c) greater than 7% for most T2D patients.  However, therapeutic (clinical) inertia in relation to treatment intensification exists in real world and there is a lack of understanding of how conformance, or adherence, to such treatment guidelines impacts clinical and economic outcomes. Hence, we conducted this study.  

Please briefly describe your study and its findings. Were any of the outcomes particularly surprising?

This was a retrospective database analysis of adult T2D patients with a HbA1c greater than 7% who were commercially insured by, or receiving Medicare benefits, through Aetna.  This population was characterized by their conformance to current guidelines (low, intermediate, high) and clinical outcomes, healthcare resource utilization, and costs were assessed at 6, 12, and 18 months.  We found that while pharmacy costs were consistently lower in the low conformance group, diabetes-related outpatient costs were consistently higher at 6, 12 and 18 month in this group. Surprisingly, we also found that high conformance patients had higher rates of microvascular complications; however, this may be due to better detection of these conditions given that this group of patients represent those who seek care more regularly 

What are the possible real-world applications of these findings in clinical practice?

This study is consistent with findings of previous studies and supports that reduced conformance to guidelines leads to higher diabetes-related costs.  This has important implications in the real-world as it underscores the importance of adherence to evidence-based care guidelines to improve health outcomes and reduce costs. Physicians should monitor type 2 diabetes patients and evaluate their need for intensification regularly.

Do you and your co-investigators intend to expand upon this research?

Yes, as one of the next steps, we are planning to study the frequency of A1c testing in T2D patients and see if it has any impact on glycemic control or clinical outcomes. We hypothesize that those patients who don’t have regular testing are unlikely to be at optimal glycemic target. In addition, we plan to also expand our ongoing research on the social determinants of health into this area of therapeutic inertia. 

Is there anything else pertaining to your research and findings that you would like to add?

Therapeutic inertia remains an important issue in T2D patients, particularly since poor glycemic control is a significant risk factor the development of T2D complications. Creating more awareness among providers on the impact that conformance to guidelines may lead to more timely intensification and more T2D patients could reach their targeted glycemic control.  Our study further suggests such conformance may also be cost saving in the long term for the healthcare system. Future research should aim to further characterize the impact of conformance to guidelines in other populations and over a longer period to allow us to more fully elucidate its impact on clinical and economic outcomes. 

Reference:

Mehta RR, Edwards AM, Rajpathak S, Sharma A, Snow KJ, Iglay K. Effects of conformance to type 2 diabetes guidelines on health care resource utilization, clinical outcomes, and cost: A retrospective claims analysis. J Clin Transl Endocrinol. 2020;19:100215. Published 2020 Jan 31. doi:10.1016/j.jcte.2020.100215