The Solution to More Effective Diabetes Management: Better Products or Better Programs?

Despite the high incidence of diabetes, disease management remains elusive and the per patient costs have continued to escalate—all factors that have targeted diabetes as an open field for new drug development and new management strategies. But new approaches do not necessarily improve the quality of care if they are not effectively implemented. What needs to happen to see real advances in diabetes care?
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The incidence of diabetes in the United States has more than doubled over the past 35 years, according to Centers for Disease Control and Prevention estimates.1 During that same period, diabetes control remained elusive due to the progressive nature of the disease and the substantial contribution of lifestyle issues—primarily a diet high in sugars and carbohydrates, and lack of exercise.

All of this results in a growing population failing to achieve and maintain glucose control, putting them at risk for many complications ranging from kidney disease, neuropathies and blindness to heart attacks and strokes.

So it is no surprise that diabetes has become one of the major targets for new therapies. The number of new diabetes products to come to market over the past 15 years has exploded—21 drugs approved between 2000 and 2012 compared with 10 over the previous decade (1999-2000), with 16 more approved between 2013 and 2016 (Tables 1 and 2).2

FDA approved insulin

FDA approved insulin

The High Costs of Treatment

The costs of diabetes treatments are extremely high from a care standpoint, as diabetes is part of a compendium of metabolic disorders that lead to generally poor health and the increasing need for interventions. Estimates from various sources have indicated that the average diabetes patient spends between $1000 and $6000 per year for medications, test materials, and needles.3-5 Due to the high incidence of comorbid conditions in these patients (an average of 2.6 per patient), they spend another $1.05 on other medications and $0.70 on nondiabetes equipment for every $1 spent on diabetes medications.4 Insurers and employers also experience these high costs with diabetes medications ranked as the costliest nonspecialty medication class for 5 years running, according to one source.6 

Additionally, a number of new and evolving nonmedication care interventions for improving care have demonstrated improvements in diabetes care. From monitoring technology (pumps/pods) to medical homes7 to community programs8 to mobile apps,9 care interventions present new opportunities to achieve better outcomes. Each of these brings varying levels of direct and indirect costs into the health care system.

Yet, given the extensive amount of money spent on and resources provided for diabetes management, the question becomes: are better products or better programs the solution to more effective diabetes care?

Getting to Better Diabetes Care

The pathophysiology of diabetes suggests that comparison of cost per hemoglobin A1c (HbA1c) reduction for products and care programs is too simplistic a target and that simply adding to a patient’s treatment plan may not achieve the best results. Products perform better for patients when the care guides dosing titration to maximize glucose control while minimizing side effects—and programs perform better when the medication selection and use are optimized. Management approaches in diabetes still need to integrate the products available into individualized treatment plans that are supported by effective care programs, if they are to succeed.

Most often, the best combination of products and care programs results from combined patient/clinician/payer decisions that can vary according to local health system dynamics (integration of primary and specialty care); population characteristics (ethnicity and access to services); and organizational structures (profit status and service area). Each entity must enhance its assessment of the value of medications and care initiatives based on these variables in order to achieve further advances in the management of diabetes at the levels of both the individual patient and the entire diabetes community. 

Reaching the goal of effective diabetes management for all patients will require significant research to identify which combinations of products and programs are most likely to benefit individual patients. Multiple stakeholders must contribute to this research, including providers, payers, pharmaceutical companies, care management programs, technology solutions, and, certainly, patients. The level of engagement and cooperation will determine the ultimate outcome of achieving more effective diabetes management. 

References

1.     Centers for Disease Control and Prevention. Crude and age-adjusted incidence of diagnosed diabetes per 1,000 population aged 18-79 years, United States, 1980-2014. cdc.gov/diabetes/statistics/incidence/fig2.htm. Accessed November 9, 2016.

2.     US Food and Drug Administration. FDA-approved diabetes medicines. http://www.fda.gov/ForPatients/Illness/Diabetes/ucm408682.htm. Accessed November 9, 2016.

3.     Consumer Reports. Get help with the high cost of managing diabetes. http://www.consumerreports.org/cro/2013/01/get-help-with-the-high-cost-of-managing-diabetes/index.htm. Accessed November 9, 2016.

4.     American Diabetes Association. Economic costs of diabetes care in the US in 2007. Diabetes Care. 2008;31(3):596-615.

5.     Raloff J. The high cost of diabetes. Sci News. August 16, 2010. https://www.sciencenews.org/blog/science-public/high-cost-diabetes. Accessed November 9, 2016.

6.     Express Scripts. Diabetes: 5 Rx trends to explore ahead of ADA ’16. https://lab.express-scripts.com/lab/insights/industry-updates/diabetes-five-rx-trends-to-explore-ahead-of-ada-16. Published June 7, 2016. Accessed November 9, 2016.

7.     Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care. 2011;34(4):1047-1053. 

8.     Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43(2):173-184.

9.     Quinn CC, Sareh PL, Shardell ML. Mobile diabetes intervention for glycemic control: impact on physician prescribing. J Diabetes Sci Technol. 2014;8:362-370.