Diabetics Who Adhere to Their Medication Have a 31% Associated Lower Risk of Hospitalization

Lifestyle-related diseases stemming from tobacco, alcohol and obesity, have taken over infectious diseases such as HIV and malaria to become the greatest killer of people worldwide, says a new World Health Organization report. Indeed, chronic illnesses like cancer, heart disease and diabetes have reached global epidemic proportions and now cause more deaths than all other diseases combined.

Evidence shows that a comprehensive focus on prevention and improved treatment leads to dramatic declines in mortality rates. Currently, the report points out, the main focus of health care for non-communicable diseases (NCDs) in many low- and middle-income countries is hospital-centered acute care. This is a very expensive approach that will not contribute to a significant reduction of the NCD burden. It also denies people the health benefits of taking care of their conditions at an early stage.

To contain the diabetes worldwide epidemic, WHO says at least three interventions for prevention and management of diabetes are shown to reduce costs while improving health. Blood pressure and glycemic control, and foot care are feasible and cost-effective interventions for people with diabetes, including in low- and middle-income countries.

WHO’s recommendations have been validated by a new study in the U.S. which shows that individuals with diabetes who adhere to their medication have lower risk of hospitalization by one-third when compared to patients who do not adhere to their medication.

The results of the study by Prime Therapeutics (Prime), a thought leader in pharmacy benefit management, are being presented the last week in April at the Academy of Managed Care Pharmacy's 23rd Annual Meeting and Showcase in Minneapolis earlier this week.

Nearly 300 million people worldwide have (mostly type 2) diabetes. In the U.S. alone, more than 23 million Americans have been diagnosed with diabetes mellitus (DM) and each year another 1.6 million people are diagnosed with the condition.

Poor medication adherence has been associated with worse medical outcomes and increased medical costs for patients with diabetes in a single employer or the elderly.

Until now, there has been little data quantifying the potential value of improved outcomes and costs possible with better medication adherence in a large commercially insured population. In this study, one of the largest of its kind, more than 15,000 commercially insured individuals with a diabetes diagnosis medical claim were followed for one year.

"Our research found adherent individuals had $1,010 lower medical costs during the year," said Patrick Gleason, PharmD, director of Clinical Outcomes Assessment at Prime, in a press release. "Besides the medical cost savings, patients that adhere to their medications are likely to have improved health and increased quality of life. Yet in this study, we found one-quarter of patients do not stick to their diabetes medication, so the medical community must find ways to increase adherence for those most at-risk."

Researchers from Prime and one of its Blue Cross and Blue Shield clients reviewed pharmacy and medical claims from a commercial medical plan with 1.3 million members. The study identified individuals continuously enrolled between 2007 and 2009.

Researchers then focused on members who had either two separate office visits for diabetes or a diabetes-related hospitalization in 2008 and with a DM medication supply or a diagnosis of diabetes with microvascular disease. All medical and pharmacy claim costs were added up to determine the total cost of care.

A total of 15,043 members were followed for one year. Of that group, 73.9 percent (11,108 members) were adherent to their medication and 26.1 percent (3,935 members) were non-adherent. While those individuals adherent to DM medication had higher pharmacy costs which led to an increase in the overall total cost of care ($572), those adhering to medications were found to have a 31 percent lower risk of hospitalization and significantly lower overall medical costs ($1,010) than the non-adherent group.

Earlier studies, too, have shown that non-adherence with medication regimens results in increased use of medical resources, such as physician visits, laboratory tests, unnecessary additional treatments, emergency department visits, and hospital or nursing home admissions. Non-adherence may also result in treatment failure.

In the context of disease, medication non-adherence can be termed an "epidemic." More than 10% of older adult hospital admissions may be due to non-adherence with medication regimens. In one study, one-third of older persons admitted to the hospital had a history of non-adherence. Nearly one-fourth of nursing home admissions may be due to older persons' inability to self-administer medications.

Problems with medication adherence were cited as a contributing factor in more than 20% of cases of preventable adverse drug events among older persons in the ambulatory setting. It is estimated that non-adherence costs the US health care system $100 billion per year. In addition, approximately 125,000 deaths occur annually in the U.S. due to non-adherence with cardiovascular medications.

Of all age groups, older persons with chronic diseases and conditions benefit the most from taking medications, and risk the most from failing to take them properly. Among older adults the consequences of medication non-adherence may be more serious, less easily detected, and less easily resolved than in younger age groups.

Improving adherence with medication regimens can make a difference. A recently published study found that for a number of chronic medical conditions - diabetes, hypertension, hypercholesterolemia, and congestive heart failure - higher rates of medication adherence were associated with lower rates of hospitalization (see diagram), and a reduction in total medical costs.

How To Manage Diabetes On A Budget Without Cutting Corners

IF you have diabetes, there is no getting around the fact that taking care of yourself can be expensive. The cost of medical care, diabetes medications and supplies, and healthy foods add up. And these expenses can be difficult to manage even in the best of times.

Even in less developed economies like India and other countries in Asia and Latin America where the spread of diabetes has assumed epidemic proportions, while seeing your doctor and a pharmacist every month might seem expensive.

Popular blogger Scott Strumello has calculated that in 2007, medical bills contributed to 62.1% of all bankruptcies in the U.S. Between 2001 and 2007, the proportion of all bankruptcies attributable to medical problems rose by about 50%.

Contrary to popular assumptions, chronic illnesses dominate the top 2 categories, and diabetes ranks second, following only nonstroke neurologic problems (i.e., multiple sclerosis).
According to a study published online in The American Journal of Medicine indicated that the health problems that left patients with the highest out-of-pocket medical expenses weren't dominated by catastrophic illnesses. The article reports that among common diagnoses, the health problems that left patients with the highest out-of-pocket expenses were ranked as follows:
#1) Neurologic (e.g., multiple sclerosis): $34,167
#2) Diabetes: $26,971
#3) Injuries: 25,096
#4) Stroke: $23,380
#5) Mental illnesses: $23,178
#6) Heart disease: $21,955

Also, it is important to keep in mind that among the other categories, diabetes is a leading contributor to the stroke and heart disease categories. These are some pretty astonishing figures!

Another interesting observation: hospital bills are, not surprisingly, the largest single out-of-pocket expense for 48.0% of patients who file for bankruptcy, but the second-largest category isn't doctor's bills, its for prescription drugs for 18.6%. Doctors' bills isn't far behind, accounting for 15.1%, and premiums accounting for 4.1%. The remainder cited expenses such as medical equipment and nursing homes.

As a person with type 1 diabetes myself, I must admit that while this disease is anything but cheap, even I was a bit surprised by some of these findings, especially considering that in February 2009, the American Diabetes Association and others were citing studies which showed many Americans with diabetes were skipping certain medical treatments, drugs etc. due to the cost.

In the context of rising costs for managing a chronic disease such as diabetes, a small study from Ohio shows that in the long run regular visits to the doctor saves patients and their families money in the long run when

Columbus-area pharmacist Allen Nichol looked at two groups of diabetic patients on Medicaid at one physician's office – 40 who kept monthly appointments and took their medications as prescribed and 120 who did not. He worked with Dr. Charles May, a primary-care doctor at Grandview Family Practice, and gathered the data in 2008.

During the monthly appointments, they evaluated patients' blood pressure, cholesterol and blood-sugar levels. If the numbers were good, the patient would continue with the same medications; if not, Nichol would suggest a medication change. "We'd have a plan, like a coach of a football team planning the first quarter," Nichol said.

The study found that patients not being managed were hospitalized more than those who regularly saw their doctor and pharmacist. This resulted in a net savings of $5,582 per patient for the year, Nichol said.

Health leaders acknowledge the benefits of having pharmacists work with patients, whether at a doctor's office or a pharmacy. For example, all Medicare prescription-drug plans are required to pay for meetings between beneficiaries and pharmacists. Private health insurers have found that when patients meet with pharmacists, costly emergency-room visits and hospital admissions can be reduced.

Here are a few tips from NFB to help you ensure that you do not miss out on manage your condition during hard times when many patients find it difficult pay their medical bills.

General Financial Management
Having a budget and sticking to it is important for everyone, even more so during hard times. You should evaluate your personal or family budget at least once a year, or more often if your income or expenses are changing. Involve the entire family in discussing the budget and brainstorming for ways to save money.

Here are a few questions to consider:

• What is your monthly income?

• What are your monthly expenses for essentials (home, utilities, phone, food, transportation, medicine)?

• When are your bills due? Avoid late fees by paying bills on time.

• Do you have expenses that come once or twice a year (such as taxes and insurance)?

• Where does the money go from your wallet? Keep a diary of your spending.

• Identify non-essential expenses (entertainment, shopping as “stress management,” eating out).

Paying cash helps you stay within your limits. Use a credit card only in emergencies. If you have several cards, cancel most of them, and keep one and two. Pay off your credit card bill each month, so you aren’t paying high interest for carrying charges. If you have credit card debt, call your creditors to discuss options to deal with it, and try to negotiate a lower interest rate. If you feel you cannot do this, or if your debt load is overwhelming, seek consumer credit counseling from your bank or card issuer.

Healthy Eating on a Budget
Many people have the misconception healthy meals are always more expensive. Actually, healthy eating can save money through using smaller portion sizes and fewer high-calorie, high-priced foods.

Here is a list of tips to help you keep your food prices down:

• Plan a menu each week based on sales in grocery stores near you.

• Check what you already have to keep from buying what you do not need.

• Take a shopping list with you, and buy only what is on that list.

• Avoid going to the store if you are hungry, to make it easier to stick to your list.

• Store brand or generics are often just as good as name brand, and usually less expensive.

• Cook enough to have leftovers. Take the leftovers to work instead of buying lunch, or freeze the leftovers for a busy time.

• Add vegetables to casseroles, stews, or soups. This is a good way to increase your vegetables and stretch a meal.

If you manage your personal finances well, you’ll never find it difficult to skimp on managing expenses related to your medical condition.

Hospitalized Diabetics Should Have Higher Than Normal Sugar Levels

After hospitalization for hernia surgery two months ago, my blood sugar levels, which had been reasonably good, suddenly went haywire. Readings of 200+ mg/dl were common for a couple of days after surgery. My doctors said they were looking at a target of around 180 mg/dl, which they said was optimal. Still, I was unhappy that my A1c levels would be compromised.

So it was with interest that I read the new guidelines released by the American College of Physicians recommending that doctors not attempt intensive insulin therapy designed to achieve normal blood sugar levels in patients in medical or surgical intensive care units. These guidelines are for both people with diabetes and without the condition.

The college recommends that doctors should maintain blood sugar levels between 140 and 200 milligrams per deciliter (mg/dl) for anyone in medical or surgical intensive care.

These recommendations ‒ published in the February 15 issue of Annals of Internal Medicine ‒ are similar to the guidelines from the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE). However, those guidelines recommend that blood sugar levels should be kept below 180 mg/dl to reduce the risk of infection and other complications.

For reference, in a healthy person with type 2 diabetes, normal blood sugar levels would be between 70 mg/dl and 130 mg/dl before eating. And, even after eating (postprandial), the recommendation from the ADA is to keep blood sugar levels under 180 mg/dl.

Talking to Serena Gordon of Health.com Dr. Amir Qaseem, director of clinical policy in the medical education division of the American College of Physicians explained, “[High blood sugar] is a common finding in hospitalized patients, and it’s associated with a lot of complications, like delayed healing, increased infection, cardiovascular events, you name it. The prevailing thought in the past was that tightly controlling the blood sugar levels would reduce inflammation, clotting and other problems. But, there are also harms that are associated with lowering the blood glucose levels too much. [Low blood sugar] can be very dangerous.”

“The evidence isn’t clear on what range of blood sugar is best, but 140 to 200 mg/dl seems to minimize the risk of hypoglycemia [in surgical or medical units],” said Qaseem. “We felt it was better to stick with a range that is a little bit higher.”

The American Association of Clinical Endocrinologists (AACE) and the American Diabetes Association (ADA) have also published updated guidelines for treating high blood glucose while avoiding low blood glucose in hospitalized patients.

The main objectives of the 2009 AACE/ADA recommendations were to identify reasonable, achievable, and safe glycemic targets and to describe the protocols, procedures, and system improvements needed to facilitate their implementation. For most patients a blood glucose target of 140-180 mg/dl is recommended and appropriate use of insulin is the preferred approach for achieving safe, optimal glucose control.

“Hyperglycemia in hospitalized patients is common and associated with increased risk of infection, mortality, and increased cost,” said AACE President Daniel Einhorn, MD, FACP, FACE. “Although near normalization of glucose in these patients appears to be of no greater benefit than moderate glycemic targets, ignoring hyperglycemia in this population is no longer acceptable.”

There is substantial observational evidence linking hyperglycemia in hospitalized patients (with or without diabetes) to poor outcomes. Although initial small studies suggested that intensive glycemic control (insulin infusion with goal blood glucose targets of 80-110 mg/dl) improved outcomes in surgical ICU and medical ICU patients, subsequent trials have failed to show a benefit or have even shown increased mortality of intensive targets compared to more moderate targets (140-180 mg/dl). Moreover, these recent studies have highlighted the risk of severe hypoglycemia resulting from attempts to completely normalize blood glucose.

“Both over treatment and under treatment of hyperglycemia in hospitalized patients are patient safety issues,” said Robert R. Henry, MD, President, Medicine and Science for the American Diabetes Association. “Coordinated, interdisciplinary teams have been shown to achieve both safe and effective control of hyperglycemia in hospitalized patients.”

The recent ACP guidelines are for the most part consistent with the AACE/ADA recommendations. AACE/ADA maintains that the upper limit of 180 mg/dl is safe and justified by data on benefits of glycemic control and the harms of uncontrolled hyperglycemia. Practitioners should take heart in the commonality of recommendations among all the organizations to address hospital hyperglycemia in the safest manner.

Dr. Mary Korytowski, a professor of medicine at the University of Pittsburgh School of Medicine, and a member of the board of directors of the American Diabetes Association, concurs that intensive insulin management in medical and surgical units isn’t the best way to manage blood sugar any more. “(But) 200 mg/dl is probably too high. The 2009 ADA/AACE guidelines recommend 180 mg/dl, which is consistent with postprandial numbers in diabetes care. The problem is that if you set the target too high, those numbers may be even higher when someone starts giving insulin to bring those numbers down,” she explains.

“These guidelines should not be interpreted to mean that glucose control isn’t important for critically ill patients: It is. And it’s important not to let the blood sugar get too high because of the risk of complications, like a higher risk of infection and fluid and electrolyte abnormalities,” she says, adding that it’s important to remember these guidelines give a range of options. “Managing blood sugar closer to the lower end is probably better,” she concludes.

Also see how illness can affect blood sugar levels in people with diabetes from the American Diabetes Association.