A comparison of insulin use,glycemic control,and health care costs with insulin detemir and insulin glargine in insulin-naive patients with type 2 diabetes

Objectives: The goal of this study was to compare daily insulin use, glycemic control, and health care costs in insulin-naive patients with type 2 diabetes who initiated treatment with either insulin detemir or insulin glargine.Methods: This was a retrospective cohort analysis of health care claims data and laboratory results for adult, insulin-naive patients with type 2 diabetes who were enrolled in a large US managed care organization and initiated basal therapy with insulin detemir or insulin glargine between May 1, 2006, and December 31, 2006. The daily average consumption (DACON) of insulin was calculated as the total number of units dispensed (excluding the last fill) divided by the number of days between the index date and the date of the last fill of the index insulin. Glycemic control was evaluated by comparing mean glycosylated hemoglobin (HbA_1c) values in the preindex period (the 180 days before the index date) and the follow-up period (the 180 days after the index date). Mean all-cause and diabetes-related health care costs in the preindex and follow-up periods were calculated and compared.Results: The analysis included 48 patients initiating therapy with insulin detemir and 258 initiating therapy with insulin glargine. The mean age of the 2 cohorts was ~54 years, and most patients in each cohort were male (52.1% and 59.7%, respectively). Few patients in either cohort had a baseline HbA_1c value <7% (13% and 10%), suggesting poor glycemic control at the time of insulin initiation. After adjustment for confounders (eg, preindex diabetes medication), the DACON of insulin was comparable between cohorts (29.3 and 29.6 U/d; P = NS), as were follow-up HbA_1c values (8.2% and 7.9%). Insulin detemir and insulin glargine also were associated with comparable mean adjusted all-cause pharmacy costs ($3074 and $2899), medical costs ($2319 and $3704), and total health care costs ($6014 and $7023). However, insulin glargine was associated with significantly higher mean adjusted diabetes-related medical costs compared with insulin detemir ($1510 vs $707, respectively; P = 0.03), as well as significantly higher mean adjusted total diabetes-related health care costs ($3408 vs $2261; P = 0.03).Conclusions: In this managed care population of insulin-naive patients who initiated therapy with insulin detemir or insulin glargine, the daily insulin dose and glycemic control did not differ significantly between the 2 insulins. However, patients receiving insulin detemir incurred lower diabetes-related medical and total health care costs.     

Validation and use of resource utilization groups as a case-mix measure for long-term care

A companion article describes the development of a patient classification system for long-term care patients, Resource Utilization Groups (RUGs). Three potential limitations of this system and its development are addressed here: the use of a subjectively determined dependent variable, geographic limitation of the data to Connecticut skilled nursing facilities, and limited assessment of the quality of the facilities studied. Additional systems of Resource Utilization Groups were derived, using the same clustering technique but employing two separate data sets from the Battelle Human Affairs Research Center. These data bases provided an objective dependent variable, wide geographic distribution of both skilled nursing facilities and intermediate care facilities, and homes specifically selected on the basis of quality. The RUGs derived from the two sets of Battelle data and the initial RUG system showed remarkable similarity in their patient groupings and in the case-mix indexes developed for nursing homes. The concurrence of the results obtained for these three systems greatly strengthens the basis for the use of this classification system as a case mix measure for long-term care.     

Cost-effective use of microcomputers for quality assurance and resource utilization in the surgical intensive care unit

Need for organ system support, severity of illness, and the risk of life-threatening complications are major factors in determining the need for ICU care and directly affect ICU costs. Using a microcomputer and a relational database program, an ICU database was developed to study ICU utilization. The following information was collected for each ICU patient on admission, then daily, and on ICU discharge: demographic data, procedures, monitors used, laboratory tests, complications, outcome, and Acute Physiology and Chronic Health Evaluation (APACHE II) score as a measure of acuity. In our study, this information was used as a first step in an attempt to define categories of patients who might benefit most from intensive care and those who would not. From September 1, 1987 to March 1, 1989, 1,062 patients were admitted to the surgical ICU (SICU). Otorhinolaryngology (ENT) patients with major head and neck resections, routinely admitted to the SICU, were compared with those from other surgical services. The ENT patients had the lowest mean admission APACHE II (6.8 +/- 0.4 vs. 11.4 +/- 0.3), lowest mean daily APACHE II (7.8 +/- 0.4 vs. 13.2 +/- 0.1), lowest percent of ventilated patients (7.6% vs. 39.4%) and ventilator days (18.9% vs. 64.6%), and had the least monitoring by central venous catheters (20.9% vs. 57.1%) or pulmonary artery catheters (0.9% vs. 29.8%) (p less than .0001 for all of above). They also had the shortest mean ICU stay (1.2 +/- 0.1 vs. 3.3 +/- 0.2 days, p less than .05). The only complication in 105 ENT patients was one uncomplicated myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reduced hypoglycemia risk with insulin glargine: a meta-analysis comparing insulin glargine with human NPH insulin in type 2 diabetes

OBJECTIVE: Insulin glargine (LANTUS) is a once-daily basal insulin analog with a smooth 24-h time-action profile that provides effective glycemic control with reduced hypoglycemia risk (particularly nocturnal) compared with NPH insulin in patients with type 2 diabetes. A recent "treat-to-target" study has shown that more patients on insulin glargine reached HbA(1c) levels < or =7.0% without confirmed nocturnal hypoglycemia compared with NPH insulin. We further assessed the risk for hypoglycemia in a meta-analysis of controlled trials of a similar design for insulin glargine versus once- or twice-daily NPH insulin in adults with type 2 diabetes. RESEARCH DESIGN AND METHODS: All studies were 24-28 weeks long, except one 52-week study, for which interim 20-week data were used. RESULTS: Patient demographics were similar between the insulin glargine (n = 1,142) and NPH insulin (n = 1,162) groups. The proportion of patients achieving target HbA(1c) (< or =7.0%) was similar between insulin glargine-and NPH insulin-treated patients (30.8 and 32.1%, respectively). There was a consistent significant reduction of hypoglycemia risk associated with insulin glargine, compared with NPH insulin, in terms of overall symptomatic (11%; P = 0.0006) and nocturnal (26%; P < 0.0001) hypoglycemia. Most notably, the risk of severe hypoglycemia and severe nocturnal hypoglycemia were reduced with insulin glargine by 46% (P = 0.0442) and 59% (P = 0.0231), respectively. CONCLUSIONS: These results confirmed that insulin glargine given once daily reduces the risk of hypoglycemia compared with NPH insulin, which can facilitate more aggressive insulin treatment to a HbA(1c) target of < or =7.0% in patients with type 2 diabetes.     

甘精胰岛素对急性心肌梗死合并高血糖患者的疗效及安全性

目的观察甘精胰岛素对急性心肌梗死合并血糖升高患者的疗效及安全性。方法 52例急性心肌梗死合并高血糖患者,随机分为两组,常规胰岛素治疗组及甘精胰岛素治疗组,每组各26例。结果出院时空腹血糖平均值常规组和甘精胰岛素组分别为7.1mmol/L和6.9 mmol/L,两组之间差异无显著性(P>0.05),餐后2小时血糖平均值分别为9.4 mmol/L和9.5 mmol/L,两组之间差异无显著性(P>0.05),低血糖发生率分别为23.1%和3.8%,两组间有明显差异(P<0.05),平均住院日分别为7.1天及6.8天,两组间无显著性差异(P>0.05)。两组住院期间均无死亡病例。结论急性心肌梗死合并血糖升高患者,较常规胰岛素,甘精胰岛素疗效相似,安全性更高。     

Health care use and costs associated with use of a health club membership benefit in older adults with diabetes

OBJECTIVE—The purpose of this study was to determine whether elective use of a health plan–sponsored health club membership had an impact on health care use and costs among older adults with diabetes.RESEARCH DESIGN AND METHODS—Administrative claims for 2,031 older adults with diabetes enrolled in a Medicare Advantage plan were obtained for this retrospective cohort study. Participants (n = 618) in the plan-sponsored health club benefit (Silver Sneakers [SS]) and control subjects (n = 1,413) matched on SS enrollment index date were enrolled in the plan for at least 1 year before the index date. Two-year health care use and costs of SS participants and control subjects were estimated in regressions adjusting for baseline differences.RESULTS—SS participants were more likely to be male, had a lower chronic disease burden, used more preventive services, and had a lower prevalence of arthritis (P ≤ 05). SS participants had lower adjusted total health care costs than control subjects in the first year after enrollment (−$1,633 [95% CI −$2,620 to −$646], P = 0.001), and adjusted total costs in year 2 trended lower (−$1,230 [−$2,494 to $33], P = 0.06). Participants who made on average ≥2 SS visits/week in year 1 had lower total costs in year 2 ($2,141 [−$3,877 to −$405], P = 0.02) than participants who made <2 visits/week.CONCLUSIONS—Use of a health club benefit by older adults with diabetes was associated with slower growth in total health care costs over 2 years; greater use of the benefit was actually associated with declines in total costs.Health care costs associated with diabetes account for 32% of total Medicare spending (1). Clinical practice guidelines recommend physical activity as an important component of diabetes management (2) and for prevention of cardiovascular complications (3), but only 16% of individuals aged 65–74 years engage in at least 30 min of moderate activity ≥5 days/week (4). The benefits of physical activity for older adults include better health, improved functioning, increased quality of life, lower health care costs, and longer survival (5–8). There is growing recognition that environmental conditions and policies that promote physical activity can have an impact on modifiable behavioral risks and chronic conditions (9,10).Health plan promotion and direct support of physical activity via sponsored exercise programs have the potential to reach many people because 61% of younger Americans had employment-based health insurance in 2004 (11) and nearly 100% of older Americans have Medicare coverage. Two previous studies of a health plan–sponsored community-based group exercise program (EnhanceFitness) for Medicare Advantage plan enrollees showed that participants in a general population (12) and in a subgroup of members with diabetes (13) who made greater use of the exercise program had lower adjusted health care costs than less active participants and control subjects. A third study examined the cost impact of a health club membership (Silver Sneakers [SS]) sponsored by the same Medicare Advantage plan with older adult members and found that SS use was associated with slower growth in total health care costs, particularly for the most active SS participants (14).This study extends prior studies by examining whether the health care use and cost impacts of SS participation found in older adults also apply to the subset of older adults with diabetes who have the most to gain from regular physical activity. We compared dose effects of SS participation on health care use and costs, based on a dose threshold of <2 or ≥2 visits/week. This study may provide further evidence of whether health plan–sponsored health club memberships provide a return on investment for older adults with chronic conditions and the level of participation needed to reduce health care costs.     

西格列汀与格列齐特缓释片联用甘精胰岛素治疗2型糖尿病的疗效与安全性评价

目的 对西格列汀与格列齐特缓释片联合甘精胰岛素治疗2型糖尿病(T2DM)的疗效和安全性进行比较。方法 以83例T2DM患者为研究对象,按照随机数字表法分为观察组与对照组。观察组使用西格列汀联合甘精胰岛素的用药方案,对照组使用格列齐特缓释片联合甘精胰岛素的用药方案。均治疗16周,监测治疗前后空腹血糖(FPG)、餐后2 h血糖(2h PG)、糖化血红蛋白(Hb A1c)、空腹胰岛素水平(FIns)、胰岛素抵抗指数(HOMA-IR)、体质量指数(BMI)等指标以及胰岛素用量、不良反应的发生情况。结果 治疗后两组的血糖控制均改善,FPG、2h PG、Hb A1c、HOMA-IR水平较治疗前均明显下降,FIns均明显升高(P0.05)。治疗后水平比较,对照组FPG降低较观察组明显(P0.05),但是观察组2h PG降低更明显(P0.05);Hb A1c达标率、HOMA-IR两组间前后差值比较,差异无统计学意义(P0.05)。观察组的BMI水平较对照组下降了6.25%,胰岛素用量减少了12.92%,差异有统计学意义(P0.05)。安全性方面,观察组低血糖的发生率(2.38%),与对照组(9.76%)比较,差异有统计学意义(P0.05)。结论 西格列汀联用甘精胰岛素治疗2型糖尿病使血糖控制良好,安全性高。     

Transfusion therapy: improved patient care and resource utilization

Improving the quality of medical care while reducing costs is one of the major challenges facing the health care system in the United States. At a 1020-bed, tertiary-care, teaching hospital, the Transfusion Committee modified transfusion practice by establishing new transfusion guidelines based upon national standards rather than local practices and by implementing educational and monitoring systems. Over a 3-year period, the number of transfusions decreased, the types of transfused components changed, and the waste due to unused components decreased. From the baseline of Fiscal Year (FY) 1989 (89), the number of exposures to components from allogeneic blood donors for the patient population decreased by 11,015 in FY 90, 14,067 in FY 91, and 16,990 in FY 92, thereby decreasing the risk of transfusion-transmitted disease, transfusion reaction, and alloimmunization. As compared to costs in FY 89, the altered transfusion practices resulted in cost savings of $376,269 in FY 90, $566,375 in FY 91, and $684,704 in FY 92. Over the 3- year period, exposures to components from allogeneic blood donors for the patient population were reduced by 42,072, and the total cost savings was $1,627,348. The methodology and results should be reproducible at other hospitals.     

Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients

OBJECTIVE: To perform an analysis of healthcare resource utilization with intensive insulin therapy, which has recently been shown to reduce morbidity and mortality rates of mechanically ventilated critically ill patients in a surgical intensive care unit. Design: A post hoc cost analysis. SETTING: Surgical intensive care unit. PATIENTS: Patients were 1548 mechanically ventilated patients admitted to a surgical intensive care unit. INTERVENTIONS: A post hoc cost analysis was conducted based on data collected prospectively as part of a large randomized controlled trial. The analysis performed was a healthcare resource utilization analysis in which the cost of hospitalization in the intensive care unit was determined based on length of stay and the frequency of crucial cost-generating morbid events occurring in the intensive and conventional insulin treatment groups. Sensitivity analyses were performed to evaluate the robustness of the findings. Discounting of costs was not performed as treatment was limited to the intensive care stay and follow-up was not continued beyond hospitalization. MEASUREMENTS AND MAIN RESULTS: In the intensive treatment group, total treatment cost was 109,838 Euros (144 Euros per patient). In the conventional treatment group, total treatment cost was 56,359 Euros (72 Euros per patient). The excess cost of intensive insulin therapy was 72 Euros per patient. The total hospitalization cost in the intensive treatment group was 6,067,237 Euros (7931 Euros per patient) compared with 8,275,394 Euros (10,569 Euros per patient) in the conventional treatment group. The excess cost of intensive care unit hospitalization in the conventional vs. intensive treatment group was 2638 Euros per patient. These intensive care unit benefits were not offset by additional costs for care on regular wards. CONCLUSIONS: Intensive insulin therapy, which reduces morbidity and mortality rates of mechanically ventilated patients admitted to a surgical intensive care unit, is associated with substantial cost savings compared with conventional insulin therapy.     

Case-mix and resource use in long-term care

This study developed a case-mix patient classification system for long-term care. Patient assessment and resource consumption data, collected for 1.151 patients within 23 hospital-based and freestanding long-term care facilities in California, were used to develop a patient classification system made up of 13 homogeneous patient groups. The 13 groups, formed on the basis of nine patient assessment variables, explained 68.5% of the overall variance in resource use. The relatively high variance reduction achieved in the creation of a limited number of groups demonstrates the feasibility of developing measures of case mix based on patient resource use for long-term care. Case-mix classification may provide a useful tool for long-term care reimbursement reform.     

Health care expenditures for the elderly. Who pays for them?

The degree to which Medicare and Medicaid programs provide health coverage for the elderly still leaves a large financial burden on this population. Although the sale of supplementary health insurance to the elderly has been fraught with abuse, a policy purchased from a reputable organization can be advantageous. Knowledge of the large amount spent on personal health care will hopefully stimulate the search for alternative, less expensive ways to provide health care.