Publications and Products
The Economics of Diabetes Mellitus:
An Annotated Bibliography
COSTS
OF DIABETES
Direct
Medical Care
Prescription
Drug
168
TITLE:
Conversion from Glipizide to Glyburide: A Prospective Cost-Impact Survey.
Alexis, G.; Henault, R.; Sparr, H.B. Clinical Therapeutics 14(3):
409-417. May-June 1992.
OBJECTIVE:
To assess the feasibility and cost of converting patients with type 2
diabetes from glipizide to glyburide.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Conversion of a large number of patients from glipizide to glyburide was
found to be feasible and resulted in substantial cost savings.
RECOMMENDATION:
None.
ABSTRACT:
Researchers studied the cost of converting 211 men with type 2 diabetes
from glipizide to glyburide; both are oral hypoglycemic agents. Patients
had to be receiving stable doses of glipizide and not require insulin
at study entry. Programs were designed to educate both prescribers and
patients. Mean patient age was 66.0 " 8.24 years (range 42 to 82 years).
Mean daily glipizide dose at conversion was 18.7 " 12.32 mg (range 2.5
to 40 mg), and mean duration of glipizide therapy was 8.8 " 2.07 months
(range 4 to 13 months). After conversion, patients were followed for up
to 12 months. Mean daily glyburide dose was 8.3 " 5.68 mg initially and
9.9 " 6.52 mg at 7 months; mean change in daily dose thereafter was less
than 1 mg. The ratio of mean daily dose of glyburide to glipizide was
1:2.3 initially and 1:1.9 at 7 months. Eight patients stopped glyburide
and began using insulin; nine patients had insulin added to the glyburide
regimen. Daily dose was significantly lower with glyburide than with glipizide
in patients analyzed in all six subsets of glipizide dose. The average
wholesale price for a 5-mg dose was $0.289 for glipizide and $0.446 for
glyburide. The daily costs per patient were $1.08 (glipizide) and $0.88
(glyburide), respectively, and the average annual costs of treatment for
all patients were $83,242.43 and $68,010.41, respectively, based on the
average wholesale price. Costs based on Veterans Administration discounts
were $0.144 versus $0.156 per 5-mg dose, $0.54 versus $0.31 per day per
patient, and $41,477.20 versus $23,788.39 per year for all patients, respectively.
Conversion from glipizide to glyburide was well tolerated and resulted
in substantial cost savings. Potential savings were understated by limiting
the study group to the subset of patients who were stabilized on glipizide
and had sufficient follow-up data after conversion. 3 figures, 2 tables,
7 references.
169
TITLE:
Drug Consumption in Elderly Diabetics. Gram, J.; Damsgaard, E.M. Diabetes
Research and Clinical Practice. 7(4): 293-298. November 6, 1989.
OBJECTIVE:
To compare drug consumption for patients with diabetes versus a control
group.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Patient management.
Methodology: Statistical analysis.
Perspective: Health care system.
CONCLUSION:
More than 80 percent of patients with diabetes used drugs daily, versus
55 percent of controls. Patients with diabetes used more doses of cardiovascular
drugs than controls.
RECOMMENDATION:
Resources need to be allocated for preventing type 2 diabetes instead
of treating its complications.
ABSTRACT:
Drug use was studied in 228 patients with diabetes who resided in Fredericia,
Denmark; 52 were treated with insulin, 101 with oral hypoglycemic agents,
66 with diet only, and 9 were not treated. An age- and sex-matched control
group was selected (n = 223); both groups ranged in age from 60 to 74
years. Information on drug use was obtained through a questionnaire, an
interview, and inspection of the drugs. Daily use of prescribed and nonprescribed
drugs (antidiabetics excluded) was significantly more common in patients
with diabetes (82 percent) than in controls (55.6 percent). The median
number of different drugs used by patients with diabetes who took drugs
daily was 3.1; the corresponding number for the control group was 2.4.
When patients were analyzed by antidiabetic treatment (diet only, insulin,
no treatment, oral hypoglycemic agents), no significant differences were
found in the percentage who used drugs daily. However, as measured by
defined daily dose (DDD), drug use among those taking oral agents was
about 20 percent below that of the insulin-treated group and 30 percent
under the diet-only group. (Defined daily dose considers the average dose
per day when the drug is used for its main indication.) Among daily users,
patients with diabetes used 70 percent more DDDs of drug than controls
(antidiabetics excluded). The most used drugs (other than antidiabetics)
for both patients with diabetes and controls were from the cardiovascular,
central nervous system, and musculoskeletal groups. Patients with diabetes
in all treatment groups used significantly more DDDs of cardiovascular
drugs than controls. Patients treated with oral antidiabetics used significantly
fewer DDDs of cardiovascular drugs than the insulin and diet-only groups.
The authors previously found in the same study population that patients
with diabetes use primary health care services 2 to 3 times as often as
controls, have a hospital bed-day occupancy rate 2 to 3 times greater
than the general population of the same age, and have an estimated cost
of drug therapy more than 2.5 times higher than do controls. 3 tables,
14 references.
170
TITLE:
The Economics of Pharmacotherapy for Diabetes Mellitus. Costa, B.; Arroyo,
J.; Sabate, A. PharmacoEconomics. 11(Supplement 2): 139-158. February
1997.
OBJECTIVE:
To review the economics of drug therapy, including insulin treatment,
for type 1 and type 2 diabetes.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Review of studies.
Perspective: Health care system.
CONCLUSION:
It is essential to consider individual and social costs of diabetes and
to search for reliable indicators of the effectiveness of care for the
disease. Educational programs for patients and professionals are the most
logical way of rationalizing the use of drugs.
RECOMMENDATION:
Prescribers of drug therapy should follow experts' recommendations, even
if they do not seem efficient in the short term, as the implications of
diabetes must be viewed in the long term.
ABSTRACT:
Seventy to 75 percent of patients with type 2 diabetes take oral hypoglycemic
agents or antihyperglycemics, 20 to 25 percent take insulin (in some countries
these ranges are much different). Among the oral hypoglycemics, sulfonylureas
are the most widely used agents; the effectiveness of these drugs decreases
progressively, usually 5 to 10 years after initiation. Antihyperglycemic
agents cannot cause hypoglycemia. Insulin is essential in type 1 diabetes
and may be used in type 2. While expensive, its cost-benefit relationship
in type 1 is excellent. Most developed countries have two mechanized systems
for delivering insulin: injector pens and preloaded syringes. Self-Monitoring
devices and glucagon (for hypoglycemic emergencies) are also part of diabetes
management. Optimal treatment of type 2 diabetes probably requires diet,
exercise, and education initially, with drugs secondary. In obese patients
with type 2, an initial trial with antihyperglycemic drugs has been recommended.
The authors review prescription trends and drug consumption; in Spain,
drug consumption grew 72.6 percent from 1988 to 1994. A study (Rubin,
et al. 1994) in the United States concluded that in 1992 drugs and self-monitoring
devices accounted for 9 percent of all diabetes mellitus costs. Insulin
is not easily available in poorer countries, but it is generally free
there. In underdeveloped countries, diabetes-related mortality rates are
similar to Western rates 75 years earlier. The authors point out that
at present there is no effective drug treatment for specific long-term
complications of diabetes, such as retinopathy, neuropathy, and vascular
diseases. The authors also state that health education reduces costs of
drug therapy. 3 tables, 4 figures, 124 references.
171
TITLE:
Hypoglycemic Drugs in the Treatment of Non Insulin Dependent Diabetes
Mellitus (NIDDM) in Klong Toey Slum (abstract). Sitthi-amorn, C.; Chiamwongpaet,
S. Abstracts of the International Society for Technology Assessment
in Health Care. 1992:30.
OBJECTIVE:
To compare locally produced oral hypoglycemic agents with more expensive
imported agents in terms of their efficacy in treating patients with type
2 diabetes living in a slum area in Thailand.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Prospective.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
The imported oral hypoglycemic drugs were more effective in lowering blood
glucose concentrations than locally produced agents, but at almost double
the cost.
RECOMMENDATION:
Locally produced oral hypoglycemic agents have a role in the treatment
of type 2 diabetes patients living in this area.
ABSTRACT:
The researchers randomly selected 67 patients with type 2 diabetes living
in a slum area in Thailand who were being treated with imported oral hypoglycemic
drugs. The patients were randomized into two groups: one group (n = 34)
took locally produced agents for 6 months, then imported agents with the
same generic name and dosage for another 6 months. The second group (n
= 33) reversed the process. Fasting blood glucose tests and assessments
of glycosolated hemoglobin were performed on all patients every 1 to 3
months throughout the 12-month study. Direct medical costs were assessed
by the costs of the medication, and direct nonmedical and indirect costs
were obtained through interviews. Patients had greater reductions in fasting
blood glucose and in glycosolated hemoglobin while on imported drugs.
However, the cost to achieve a 1 percent reduction in glycosolated hemoglobin
was almost twice as great using imported agents (41.2 Baht for imported
drugs versus 22.4 Baht for domestically produced drugs.
172
TITLE:
Labour Productivity Effects of Prescribed Medicines for Chronically Ill
Workers. Rizzo, J.A.; Abbott, T.A.; Pashko, S. Health Economics.
5(3): 249265. May-June 1996.
OBJECTIVE:
To estimate the costs and benefits to employers of covering prescription
drugs for workers with hypertension, heart disease, type 2 diabetes, or
depression.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Cost-benefit analysis.
Perspective: Societal.
CONCLUSION:
The net benefits to employers from covering prescription medicines for
these chronic illnesses are substantial.
RECOMMENDATION:
None.
ABSTRACT:
The authors used data from the 1987 National Medical Expenditure Survey
to estimate the costs and benefits of providing prescription coverage
for individuals aged 18 to 64 years afflicted with hypertension, heart
disease, depression, or type 2 diabetes. Benefits were measured by the
extent to which prescription medications decreased productivity losses
resulting from employee disability days. Assuming average compliance rates,
estimated average annual days saved from drug treatment were 3.5 for hypertension,
7.3 for heart disease, 9.1 for depression, and 16.1 for diabetes. Employer
costs of providing drug benefits were estimated as the difference between
total costs of the drugs and patients' out-of-pocket costs. The value
of days saved was computed by multiplying days saved by a wage rate of
$9.32 per hour (8-hour day assumed) times 1.25 to reflect fringe benefits.
With average compliance rates, estimated net benefits per employee (in
1987 dollars) by disease were $286 for hypertension, $633 for heart disease,
$822 for depression, and $1,475 for diabetes. When capital costs were
included, average net benefits to employers were even greater, ranging
from $503 for hypertension to $2,485 for diabetes. Additional benefits
could accrue if employees complied fully with their medications. 6 tables,
20 references.
173
TITLE:
Medication Cost Savings Associated with Weight Loss for Obese Non-Insulin-Dependent
Diabetic Men and Women. Collins, R.W.; Anderson, J.W. Preventive Medicine.
24(4): 369-374. July 1995.
OBJECTIVE:
To determine the savings in prescription costs associated with a weight
loss reduction program in obese patients with type 2 diabetes.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Prospective.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Significant short- and long-term savings in prescription costs were obtained
following a 12-week hypocaloric weight reduction program for obese individuals
with type 2 diabetes.
RECOMMENDATION:
In deciding upon the most appropriate treatment strategy for patients
with type 2 diabetes, careful consideration should be given to the treatment's
potential long-term medical and economic benefits.
ABSTRACT:
The authors determined the prescription cost savings associated with a
weight reduction program in obese patients with type 2 diabetes. Adult
patients with a history of type 2 diabetes of more than 1 year and a body
mass index of 30-40 kg/m2 were randomized to one of two 800-kcal, 12-week
weight loss interventions: five dietary supplements/day with no food (n
= 20) or two supplements per day and an evening meal (n = 20). Medication
usage was documented upon initiation of the program, after 12 weeks, and
1 year after completion of the diet. Participants' drug profiles were
costed through data from local pharmacies; insurance coverage was not
taken into account. A refundable fee of $100 (far below usual cost) was
paid for the weight loss program. Participants paid $25 weekly (nonrefundable)
for dietary supplements. Cost analysis was performed in the 32 patients
who took antidiabetes and/or antihypertensive medications. Patients lost
an average of 14.8 percent of their pre-diet body weight over the 12-week
study period; an average of 58.8 percent of the weight loss was maintained
at the 1-year follow-up. At the beginning of the diet, all antidiabetes
medications were reduced by 50 percent, and all diuretics (for hypertension)
were discontinued totally. Other antihypertensive medications were decreased
in various ways. Prior to the dietary interventions, total monthly prescription
costs for all medications and supplies averaged $82.00 per patient, or
$984 annually. Average monthly saving in prescription costs per patient
was $36.90 at midyear of the follow-up, corresponding to an estimated
average cost savings over the year of $442.80 per patient. Average monthly
pre-diet cost for antidiabetes and antihypertensive medications was $63.30
at follow-up (p < 0.001). After 1 year, average monthly costs for insulin
and oral hypoglycemic agents decreased to 59 percent and 88 percent of
their pre-diet values, respectively. 1 figure, 1 table, 12 references.
174
TITLE:
Oral Hypoglycemic Agents in the Treatment of Type II Diabetes. Tal, A.
American Family Physician. 48(6): 1089-1095. November 1993.
OBJECTIVE:
To review the pharmacologic properties, mechanism of action, therapeutic
effects, side effects, drug interactions, and costs associated with first-
and second-generation hypoglycemic agents.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Patient management.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
First-generation sulfonylureas are less expensive but less active than
second-generation sulfonylureas.
RECOMMENDATION:
None.
ABSTRACT:
The author reviewed and compared the properties of first- and second-generation
oral sulfonylureas used to treat patients with type 2 diabetes. Sulfonylureas
provide adequate glycemic control in approximately two-thirds of patients,
but about 50 percent of initially responsive patients have inadequate
control after 10 years. The average wholesale price per month (1992) for
equivalent therapeutic doses of the first-generation drugs tolbutamide,
acetohexamide, tolazamide, and chlorpropamide was $14.40, $12.40, $15.00,
and $19.20, respectively; their average generic cost per month was $2.70,
$11.90, $6.45, and $1.85, respectively. The corresponding average wholesale
prices per month for the second-generation drugs glipizide and glyburide
were $16.70 and $14.70, respectively. Overall, side effects occur in 3
to 4 percent of patients taking these drugs. Hypoglycemia is the major
complication; elderly patients may be at particularly high risk for severe
hypoglycemia. Twenty to 30 percent of severe hypoglycemic episodes are
related to drug interactions. New types of drugs are undergoing clinical
trials. 3 tables, 27 references.
175
TITLE:
Use of Health Maintenance Organization Data Bases to Study Pharmacy Resource
Usage in Diabetes Mellitus. Glauber, H.S.; Brown, J.B. Diabetes Care.
15(7): 870-876. July 1992.
OBJECTIVE:
To analyze pharmaceutical drug use by patients with diabetes enrolled
in a health maintenance organization (HMO) and estimate its cost.
CATEGORY:
Cost of diabetes (direct).
Type of
Study: Economic assessment.
Methodology: Cost analysis.
Perspective: Health care system.
CONCLUSION:
Patients with diabetes received significantly more medication at a greater
total cost than patients without diabetes. Computerized pharmacy databases
are useful for studying the epidemiology, patterns of care, and costs
of chronic disease.
RECOMMENDATION:
None.
ABSTRACT:
The authors analyzed data in the Kaiser Permanente Northwest pharmacy
database on medication usage by 871 patients with diabetes who were members
of the Kaiser plan for the entire year. Patients with diabetes were identified
from hospital discharge records, registration in diabetes education programs,
referral to specialists in diabetes or diabetes eye care, and prescriptions
for products used exclusively by patients with diabetes. Specificity of
patient identification was greater than 99 percent; sensitivity was 85
to 90 percent; prevalence of diabetes was 25.4 per 1,000 members. 1,002
patients were randomly selected from the identified group; a total of
131 with no drug insurance were excluded. A control group without diabetes
was matched for age, sex, and pharmacy insurance status. Mean number of
outpatient visits for patients with and without diabetes was 11.3 and
6.5 and the hospitalization rate was 366 and 105 admissions per year,
respectively. Costs were based on 1988 standard values, retail nonmember
price, dispensing cost, and overhead. Statistically, a higher percentage
of patients with diabetes received cardiovascular, antibiotic, nonsteroidal
anti-inflammatory, dermatologic, gastrointestinal, narcotic, vitamin,
respiratory, psychoactive, and hypolipidemic medications. Patients with
diabetes also received more than twice the number of prescriptions (31.5
vs. 14.4/yr, p < 0.001). Annual pharmacy expenses per patient per year
were statistically greater for patients with diabetes: $627.93 versus
$259.28, p < .001. Pharmacy costs accounted for approximately 17 percent
of the annual direct cost of care for patients with diabetes. 6 tables,
18 references.
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