A Real‐World Study of the Effect of Timing of Insulin Initiation on Outcomes in Older Medicare Beneficiaries with Type 2 Diabetes Mellitus

Abstract

OBJECTIVES To compare clinical and economic outcomes of early insulin initiation with those of delayed initiation in older adults with type 2 diabetes mellitus (T2DM). DESIGN Retrospective cohort study. SETTING Humana Medicare Advantage health insurance plan. PARTICIPANTS Older (≥65) Medicare beneficiaries with T2DM. MEASUREMENTS Subjects were grouped according to number of classes of oral antidiabetes drugs (OADs) they had taken before initiation of insulin: one (early insulin initiators), two, or three or more (delayed insulin initiators). One-year follow-up outcomes included change in glycosylated hemoglobin (HbA1c), percentage of older adults with HbA1c less than 8.0%, hypoglycemic events, and total healthcare costs. RESULTS Overall, 14,669 individuals were included in the analysis. Baseline and 1-year follow-up HbA1c levels were available for 4,028 (27.5%) individuals. Insulin was initiated early in 32% and delayed in 20%. At follow-up, unadjusted reduction in HbA1c was 0.9 ± 3.7% for the group with one OAD, 0.7 ± 2.4% for those with two, and 0.5 ± 3.6% for those with three or more. Early insulin initiation was associated with significantly greater reduction in HbA1c (0.4%; adjusted P <.001), 30% greater likelihood of achieving HbA1c less than 8.0% (adjusted odds ratio = 1.30, 95% confidence interval = 1.18–1.43), and no significant differences in total costs or hypoglycemia events (11.5% of early initiators vs 10.2% of delayed initiators; P = .32). CONCLUSION This study suggests beneficial effects of early insulin initiation in older adults with T2DM who do not have adequate glycemic control, without increasing the risk of hypoglycemia or greater total direct healthcare costs.

Therapeutic inertia in patients treated with two or more antidiabetics in primary care: Factors predicting intensification of treatment

“…Other factors also associated with greater odds, although to a lesser extent, were female gender, high Charlson index score, chronic kidney disease and presence of microvascular complications. All of these patient characteristics have been previously identified as being associated with the likelihood of, and/or time to, therapy intensification in the same direction as in our study . However, some studies have also reported decreased odds of treatment intensification or increased time to escalation with the presence of comorbid conditions …”

“…All of these patient characteristics have been previously identified as being associated with the likelihood of, and/or time to, therapy intensification in the same direction as in our study. 2,[17][18][19][28][29][30][31][32]35,[38][39][40][41][42][43][44][45][46][47][48][49][50][51] However, some studies have also reported decreased odds of treatment intensification or increased time to escalation with the presence of comorbid conditions. 31,40,50,52,53 From the previous literature and our own results, it appears that the profile of the patient with the greatest odds of treatment escala- to adequate care, because they are treated at centres within the public healthcare system, the pay-per-performance model of our institution advises against the use of drug classes other than metformin, sulphonylureas or insulin, and prescription of the newest (and more expensive) drugs entails negative economic incentives for the physicians.…”

Glycaemic control and hypoglycaemia burden in patients with type 2 diabetes initiating basal insulin in Europe and the USA

“…As seen in previous studies in populations initiating BI, these patients were characterized by elevated HbA1c levels at baseline; a high proportion of patients initiated BI with HbA1c > 9.0%, highlighting a disconnect between real‐world clinical practice and recommendations in clinical guidelines, and indicating a delay in initiating insulin far beyond the point of need. This is of critical concern given the need for tight glycaemic control and/or appropriate treatment intensification to reduce the risk of diabetes‐related complications, to help preserve β‐cell function and to achieve long‐term glycaemic goals . As such, the success of BI‐supported oral therapy is dependent on timely initiation during the natural history of T2DM in the individual patient.…”

“…This is of critical concern given the need for tight glycaemic control and/or appropriate treatment intensification to reduce the risk of diabetes-related complications, 15,[20][21][22] to help preserve β-cell function 23,24 and to achieve long-term glycaemic goals. [25][26][27] As such, the success of The broader literature supports a widespread existence of clinical or therapeutic inertia, 13,[28][29][30][31][32][33] with some patients in the UK experiencing more than 7 years of poor glycaemic control before initiating insulin. 13,32 Future research priorities should address how delays in insulin therapy initiation and how barriers to effective titration could be overcome.…”

Glycaemic outcomes of an Individualized treatMent aPproach for oldER vulnerable patIents: A randomized, controlled stUdy in type 2 diabetes Mellitus (IMPERIUM)

“…Sulphonylurea therapy continues to be commonly prescribed in monotherapy or in combination with other OAMs, and basal insulin continues to be recommended as first‐line injectable therapy to people with T2D . Despite the importance of avoiding hypoglycaemia in older patients, these therapies are still considered reasonably safe options in this population as reflected by studies examining treatment patterns . Sulfonylurea exerts its glucose‐lowering action primarily through stimulation of insulin secretion .…”