Recent Guidline research published by MedAdNews found that 6 in 10 Americans are now non-adherent to their medications. Now lets talk about what this really means in cost for diabetes patients and the strain medication non-adherence has on the US healthcare system.

The June 2005 issue of Medical Care, a journal by the American Public Health Association, published a study demonstrating that Diabetes patients who are highly compliant with their treatment programs have a 13% hospitalization risk for a diabetes-related problem, but patients with low compliance have more than twice the risk at 30%.

The same study stated the combined drug and medical costs for the most compliant patients average $4,570, which is almost 50 percent below the $8,867 cost for the least compliant group.

A recent report from the CDC states that diabetes rates are rising in the US. More than 23 million Americans have diabetes, with about 1.6 million new cases diagnosed among adults last year.

So currently, according to all these estimates, 13.8 M diabetics are non-adherent to their medication regimes, and cost the healthcare system $122 BILLION. With proper medication adherence, this figure can be reduced in half.

And this number is only going to go up, with almost 1M non-adherent diabetes added each year at a cost of $8.8 Billion.

And this is for one chronic disease.

There are several factors related to why patients are non-adherent to their medications and I do not mean to beat up on diabetics, but I just wanted to illustrate the real costs associated with not taking medications properly.

From Reuter’s Health, a report on Sex Bias in Control of Cancer Pain:

“How well pain is managed in people with cancer apparently differs between men and women, new research hints. Dr. Kristine A. Donovan, of the H. Lee Moffitt Cancer Center and Research Institute in Tampa, Florida, and colleagues examined pain severity and the adequacy of pain management in 131 cancer patients newly referred to a multidisciplinary cancer pain clinic.” Full Story

From LifeScript, a study that shows 1 in 5 Diabetics do not take their medication as prescribed. “Too many diabetics are neglecting to take life-saving prescription medicines regularly, one study warned. Published in the Archives of Internal Medicine, the study estimated that 21% of diabetics fail to adhere to their prescription schedule.” Full Story

Allan Showalter, MD from AlignMap discusses the Implications Of The Redundant Patient Compliance Review. I like to post abstracts and some compliance reviews, but his blog posts are always more insightful, biting and from an MD’s perspective. Full Story

And lastly, from the International Journal of STD and AIDS: Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil. Full Story.

OBJECTIVE
The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated.

RESEARCH DESIGN AND METHODS
A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care.

RESULTS
Youth who received MST had significantly fewer hospital admissions than control subjects (2 = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions.

CONCLUSIONS
The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

Purpose
The purpose of this study is to characterize the adherence and medication management barriers for adults with poorly controlled type 2 diabetes mellitus (DM) (those with A1c 9% or above) and to identify specific adherence characteristics associated with poor diabetes control.

Methods
This was a cross-sectional analysis of baseline data from a randomized, controlled diabetes intervention conducted in University of Washington (UW) Medicine Clinics in the greater Seattle, Washington, area. The goal of the original study was to evaluate the effect of a pharmacist intervention on improving diabetes control over 12 months.

Evaluation measures for medication adherence included self-reported adherence and medication management challenges using the Morisky question format and difficulty with taking medications for each diabetes medication based on the Brief Medication Questionnaire. Specific adherence characteristics associated with poor diabetes control (A1c >9%) were identified using multivariate regression analysis.

Results
Seventy-seven subjects (mean A1c, 10.4%; mean duration of DM, 7 years) were studied. The most common adherence challenges included paying for medications (34%), remembering doses (31%), reading prescription labels (21%), and obtaining refills (21%). Taking more than 2 doses of DM medication daily (β = .78, SE = 0.32, P = .02) and difficulty reading the DM medication prescription label (β = .76, SE = 0.37, P = .04) were significantly associated with higher hemoglobin A1c. Self-reported adherence was not related to A1c control.

Conclusions
In this study, we identified 2 factors that were associated with poorer A1c control. These findings highlight the importance of identifying potential challenges to medication adherence for those with DM and providing support to minimize or resolve these barriers to control.

MY THOUGHTS
I am glad to see another study that supports cost and forgetfulness as the two major factors of medication non-adherence, but at the same time I am not glad to see it. I had an interesting thought the other day: with companies and health plans reducing and eliminating co-pays for generic medications for chronic diseases, and with pharmacos’ PAPs, will this cost factor be eliminated in 10 years?

Most likely distribution and obtaining refills with then rise as factors, and forgetfulness is still #1 with 84% nationally. I have talked about a pharmacy system that will automatically send refills to patients, whether they trigger the refill or not. This eliminates some factors, but, this also has some problems. As one person who commented to a post last week, the way she takes her pills, she is on a 38 day schedule for a 30 day script – thus she would end up with extra pills every month.

As we all know, medication adherence is America’s #1 Drug Problem that needs to be addressed by all stake holders. I will continue to report what I find in my research to explore how we can “fix” this issue.

Some takeaways from the article. Everything NOT in quotes are my comments:

“We, as endocrinologists, are saying we truly recognize a state of pre-diabetes, and I think the most important issue is that there is not one unifying point that defines it, says Daniel Einhorn, vice president of the American Association of Clinical Endocrinologists.”

This is somewhat troubling as it seems the only way to detect this condition is blood monitoring.

“In an early release of the new recommendations, members of the endocrinologist group agreed that diagnosing pre-diabetes should be based on more than the results of blood glucose tests, such as history of diabetes during pregnancy and family history of the disease. The group also decided that changes in ways of living, not medication, should be the first line of treatment in staving off diabetes.”

I am happy to hear that changes in diet and lifestyle is the first line of defense instead of medication. That being said, I am on tricor and niaspan for high triglycerides – but I have adjusted my diet.

“The guidelines recommend that people with metabolic syndrome — defined by three or more of the following: elevated triglycerides, a low HDL (the so-called good cholesterol), a high fasting glucose, a big waist circumference and high blood pressure — be considered at high risk for pre-diabetes, as well as women with prior gestational diabetes, people with a family history of type 2 diabetes and obese patients.”

Yeah, three for me: HT, Low HDL, and type 2 in family.

“The new guidelines also advise that primary-care physicians and specialists address cardiovascular problems such as blood pressure and lipid levels when diagnosing pre-diabetes. Though there was some debate at the conference over whether medication should be used to treat pre-diabetes, the final consensus is that certain drugs may have a place if diet and exercise do not bring down glucose levels first.”

Again, exercise and diet should be the first treatment. So often, medications are prescribed instead of naturally treating the problem. And yes, I am a hypocrite, but my levels were so high, my doctor thought it best that I take medication until my levels drop to “safe” level – which I should accomplish at the end of July – then go off the meds.

With childhood obesity at an all time high (1 in 3 are obese or at risk), and diabetes following suit, something must be done. CT Senator Chris Dodd is proposing a task force and a Childhood Obesity Bill, so hopefully pre-diabetes and diabetes will be addressed.

One service that has helped me with resources and has provided me with a forum to discuss pre-diabetes and ask questions is TuDiabetes, a diabetes social network founded by the Diabetes Hands Foundation. Here is my profile. FD: Diabetes Hands Foundation has been offered to join Intelecare’s pro bono Enlighten Together Program like Diabetes Sisters.

From the Sun St.Kitts/Nevis by Akedia Christopher

The Rotary Club of St. Kitts is hosting a ‘Diabetes Day Camp’ Saturday at the St. Johnson’s Community Center in recognition of World Diabetes Day celebrated today.

President of the club, Leah Sahely, told the SUN in an interview that the event was organised in hope of helping diabetics “find answers to questions about managing this disease.” She added the “disease is serious and we are going to cover all aspects of diabetes.”

The day, as described by the Sahely, is going to consist of breakdown sessions which would enable question and answer segments at the end of each presentation. She added that letters were sent out to health centres and doctors alike asking them to identify patients to participate in the event.

She further mentioned they were presenting educational opportunities by way of lectures, on how to control the disease and “to reinforce the need for compliance.” This, she said, would act as a source of encouragement for diabetics to follow doctors’ orders and also to live healthy lives.

Sahely also mentioned that some of the doctors who will be making presentations include Bichara Sahely who would present an overview of the disease, Cavelle Hobson who would discuss medication availability and consequences of non-compliance and also Dr. Caroline Lawrence who would address cardiovascular complications which can be created and the importance of monitoring the disease .

Earl Clarke is also among the team, according to Sahely, and he is going to speak to the need for exercise and the value of it, along with dietician Magaret Stevens “who is going to talk about eating habits.”

The new insulin pen, which was made available this month, combines the insulin cartridge and syringe in a single unit, making regular use more convenient, which doctors say decreases claims of hypoglycemic episodes, emergency room and physician visits, and overall treatment costs.

“The pen is a huge, huge benefit in the treatment of diabetes,” said Reza Bonabi, M.D., a Diabetalogist and chairman of the diabetes committee at Providence Holy Cross Medical Center. “The pen will reduce dosage error, is easy to administer, and will decrease the cost of treatment for both the hospital and patient.”

Won Chan Lee, Ph.D., Abbott Laboratories’ Associates Director of Health Economics, studied the effects of the new device. “As evidenced by the marked improvement in medication adherence rates, patients who switched to the insulin pen found that its convenience and ease of use gave them a new ability to self-manage their condition and a resulting freedom from complications and visits to the emergency room,” Lee said.

“But our study also demonstrated a true ‘win-win’ situation, for individuals with diabetes and for society as a whole, due to significant decreases in the costs associated with hypoglycemic events — events that can be kept at a manageable level or avoidable, as long as a patient adheres to his or her treatment.”

Hospital employees also are less at risk at being pricked by a needle when using the pen to provide insulin to the patients, said Donna Ryan, Diabetes Department Coordinator at Providence Holy Cross Medical Center