Trends in the Pharmaceutical Treatment of Diabetes and Implications for Financial Burdens, 1997-2007

Slide presentation from the AHRQ 2010 conference.

On September 27, 2010, Eric Sarpong, made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (1.79 MB). Free PowerPoint® Viewer (Plugin Software Help).


Slide 1

Trends in the Pharmaceutical Treatment of Diabetes and Implications for Financial Burdens, 1997-2007

Trends in the Pharmaceutical Treatment of Diabetes and Implications for Financial Burdens, 1997-2007

Eric Sarpong, Didem M. Bernard and G. Edward Miller
AHRQ Annual Conference.
September 27, 2010
 

Slide 2

Overview

Overview

  • Diabetes is a chronic, progressive and costly disease (2007, $174 billion)
  • Trends in anti-diabetic drugs are important
    • Increasing disease prevalence
    • Chronic comorbidities
    • More aggressive treatments
    • Newer and more expensive drugs
  • Implications of current trends for out-of-pocket (OOP) financial burdens in non-elderly persons with diabetes
    • High OOP costs due to increased drug spending may:
      • Burden individuals/families
      • Prevent timely health services use
        • Lead to costly long-term complications

Slide 3

Previous Literature on Financial Burdens for Health Care

Previous Literature on Financial Burdens for Health Care

  • Bernard et al. (2006) found that adults with diabetes:
    • Had greater risks of high burdens
    • Had lower incomes
    • Paid a higher share of total expenditures out-of-pocket
  • Banthin and Bernard (2006) found that between 1996 and 2003:
    • Prevalence of high financial burdens increased for the entire the U.S. population and within several subgroups

Slide 4

Objective

Objective

  • Part I
    • Examine trends in anti-diabetic medication use and expenditures
    • Describe characteristics of persons with diabetes
  • Part II
    • Examine OOP financial burdens among non-elderly persons with diabetes
      • The Elderly (≥ 65 years) are different
        • Have Medicare and mostly unemployed
  • To help inform targeted policies for non-elderly persons, at increased risk of high burdens

Slide 5

Data

Data

  • Use MEPS for the years 1997 through 2007
    • Nationally representative data—U.S. civilian non-institutionalized population
    • Part I—years 1997 through 2007
    • Part II—first year of 2005-2007 panels
  • Detailed information on drug purchases including:
    • Therapeutic classifications and quantity purchased
    • Source of Payment:
      • OOP payments by families
      • Private and public insurance payments
  • Detailed information on health conditions, economic and socio-demographic variables

Slide 6

Defining and Measuring OOP Burden using MEPS

Defining and Measuring OOP Burden using MEPS

OOP financial burden
             =
Total family OOP spending
Total family income

  • Categorize OOP financial burdens using thresholds
    • Individuals have high burden if family OOP ≥ 10% of family income

Slide 7

Part I

Part I

Slide 8

Increase in treated prevalence of diabetes, 1997 and 2007

Increase in treated prevalence of diabetes, 1997 and 2007

Bar chart data:

1997: 3.6%
2007: 6.3%**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997 and 2007.
** Difference in 1997 and 2007 estimates significant at p < .05.

Slide 9

Increase in comorbid conditions among persons with treatment for diabetes, 1997 and 2007

Increase in comorbid conditions among persons with treatment for diabetes, 1997 and 2007

 19972007
Cardiovascular disease13.117.2**
Hypertension46.164.8**
Hyperlipidemia1552.8**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997 and 2007.
** Difference in 1997 and 2007 estimates significant at p < .05.

Slide 10

Changes in diabetes treatment, 1997 and 2007

Changes in diabetes treatment, 1997 and 2007

 19972007
Orals59.977.3**
Insulin38.224.4**
Non-insulin Injections 4.1

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997 and 2007.
** Difference in 1997 and 2007 estimates significant at p < .05.

Slide 11

Changes in use of oral medication classes, 1997 and 2007

Changes in use of oral medication classes, 1997 and 2007

 19972007
Sulfonylureas51.240.2**
Biguanides21.255.2**
Thiazolidinediones4.724.6**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997 and 2007.
** Difference in 1997 and 2007 estimates significant at p < .05.

Slide 12

Change in total expenditures per user, 1997-1998 and 2006-2007

Change in total expenditures per user, 1997-1998 and 2006-2007

 1997-19982006-2007
All therapeutic classes500944**
Sulfonylureas298211**
Biguanides381297**
Thiazolidinediones1,0131,121**
Insulin331918**
Non-insulin injectables 1,297
Oral combinations 577

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997 and 2007.
** Difference in 1997 and 2007 estimates significant at p < .05.

Slide 13

Change in out-of-pocket expenditures per user, 1997-1998 and 2006-2007

Change in out-of-pocket expenditures per user, 1997-1998 and 2006-2007

 1997-19982006-2007
All therapeutic classes221273**
Sulfonylureas16789**
Biguanides174116**
Thiazolidinediones190250**
Insulin132257**
Non-insulin injectables 258
Oral combinations 179

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 1997-1998 and 2006-2007.
** Difference in 1997-1998 and 2006-2007 estimates significant at p < .05

Slide 14

Percentage of persons with treatment for diabetes by sex and age, 2006-2007

Percentage of persons with treatment for diabetes by sex and age, 2006-2007

Overall: 6.1
Male: 6.0
Female: 6.1
Age 0 to 17: 0.2
Age 18 to 44: 2.0
Age 45 to 64: 11
65 and over: 19.4**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2007.
(**), [*] Differences from the reference category significant at (p < 05) and [p < 10]

Slide 15

Percentage of persons with treatment for diabetes by health insurance status and race-ethnicity, 2006-2007

Percentage of persons with treatment for diabetes by health insurance status and race-ethnicity, 2006-2007

Overall: 6.1

Health insurance status: Less than 65: 0
Any private: 4.0
Public only: 5.5**
Uninsured: 3.1
65 and over: 0
Medicare only: 19.7
Medicare and private: 17.9
Medicare and other public: 26.9**

Race-ethnicity:
non-Hispanic White: 6.1
non-Hispanic Black: 7.6**
non-Hispanic Other: 5.3
Hispanic: 5.3

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2007.
(**), [*] Differences from the reference category significant at (p < 05) and [p < 10]

Slide 16

Percentage of persons with treatment for diabetes by education and income, 2006-2007

Percentage of persons with treatment for diabetes by education and income, 2006-2007

Overall: 6.1

Education
Less than high school: 9.1**
High school: 6.9
At least some college: 4.5

Income
Poor/negative: 6.9
Near poor: 8.5**
Low income: 7.1
Middle income: 5.8
High income: 5.4

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2006-2007.
(**), [*] Differences from the reference category significant at (p < 05) and [p < 10]

Slide 17

Summary: Trends in the Pharmaceutical Treatment of Diabetes, 1997 to 2007

Summary—Trends in the Pharmaceutical Treatment of Diabetes, 1997 to 2007

  • Proportion using major classes
    • Increase in oral use
    • Decrease in insulin use
    • Introduction of non-insulin injectables
  • Proportion using specific classes of orals:
    • Decreased use of (older) sulfonylureas
    • Increased use of (newer) biguanides and thiazolidinediones (TZDs)
  • Persons most likely to report treatment for diabetes
    • Those 65 years and older
    • Those with public insurance (< 65 years) and Medicare-Medicaid (≥ 65 years)
    • Non-Hispanic Blacks, the near poor, those with less than high school education and

Slide 18

Part II

Part II

Slide 19

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by sex and age, 2005-2007

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by sex and age, 2005-2007

Overall: 24.3

Sex:
Men: 21.1
Women: 27.2**

Age in years:
0 to 34: 14.6
35 to 49: 20.6**
50 to 64: 27.1**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, first year of 2005-2007 panel data.
(**), [*] Differences from the reference category significant at (p < .05) and [p < .10]

Slide 20

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by health insurance status and race-ethnicity, 2005-2007

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by health insurance status and race-ethnicity, 2005-2007

Overall: 24.3

Health insurance status: Any private: 17.9
Public only: 34.1**
Uninsured: 44.21**

Race-ethnicity:
non-Hispanic White/Other: 22.9
non-Hispanic Black: 25.9
Hispanic: 28.5**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, first year of 2005-2007 panel data.
(**), [*] Differences from the reference category significant at (p < .05) and [p < .10]

Slide 21

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by education and income, 2005-2007

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by education and income, 2005-2007

Overall: 24.3

Education
Less than high school: 35.7**
High school: 23.9
At least some college: 18.0

Income
Poor: 45.8**
Near Poor/Low income: 32.7
Middle income: 25.0
High income: 9.7

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, first year of 2005-2007 panel data.
(**), [*] Differences from the reference category significant at (p < .05) and [p < .10]

Slide 22

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by type of treatment and comorbid conditions, 2005-2007

Out-of-pocket financial burdens among non-elderly persons with treatment for diabetes by type of treatment and comorbid conditions, 2005-2007

Overall: 24.3

Type of Treatment
No anti-diabetic medications: 22.7
Injectables and orals: 37.3**
Injectables-only: 24.8
One oral class: 18.4**
Two or more oral classes: 24.5

Comorbid conditions
No comorbid condition: 17.9
Any comorbid condition: 27.5**

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, first year of 2005-2007 panel data.
(**), [*] Differences from the reference category significant at (p < .05) and [p < .10]

Slide 23

Summary - OOP financial burden in the non-elderly diabetes population, 2005-2007

Summary—OOP financial burden in the non-elderly diabetes population, 2005-2007

  • Non-elderly diabetes patients most likely to experience high burden:
    • Were: ages 50-64, women, uninsured, poor and Hispanics
    • Had less than a high school education
    • Had one or more co-morbidities
    • Used both insulin/injectables and oral medications

Slide 24

Logit: Dependent variable out-of-pocket financial burdens = 10%

Logit: Dependent variable out-of-pocket financial burdens = 10%

Independent VariablesOdds Ratios
Age in years 
 0-341.00
 35-491.69
 50 to 642.65**
Sex 
 Male1.00
 Female1.27*
Race/ethnicity 
 non Hispanic White/other1.00
 non-Hispanic Black0.73*
 Hispanic0.79
Health insurance status 
 Any private1.00
 Public only0.95
 Uninsured2.61**
Income 
 Poor7.82**
 Near Poor/Low income4.23**
 Middle income3.00**
 High income1.00
Education 
 Less than high school1.42*
 High school1.05*
 At least some college1.00
Comorbid conditions 
 No comorbid condition1.00
 Any comorbid condition1.51**
Type of Treatment 
 No anti-diabetic medications1.00
 Injectables and orals1.65*

Source: Center for Financing, Access, and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2005-2007.
(**), [*] Differences from the reference category significant at (p < .05) and [p < .10]

Slide 25

Summary of Multivariate Analysis: OOP financial burden in the non-elderly diabetes population, 2005-2007

Summary of Multivariate Analysis: OOP financial burden in the non-elderly diabetes population, 2005-2007

  • Non-elderly persons with higher odds of high burdens:
    • Those ages 50-64, women, uninsured, poor
    • Had less than a high school education
    • Had one or more co-morbidities
    • Used both insulin/injectables and oral medications
  • Non-elderly persons with lower odds of high burdens:
    • Were non-Hispanic blacks
    • Used one oral class of medication
    • Had high incomes

Slide 26

Conclusions

Conclusions

  • Part I
    • We highlight:
      • Growing shift away from sulfonylureas towards the use biguanides and thiazolidinediones (TZDs)
      • Swift diffusion of newer and relatively expensive classes of anti-diabetic drugs
    • We describe characteristics of persons with diabetes
  • Part II
    • We shed light on:
      • Subpopulations of non-elderly more likely to experience OOP financial burdens

Slide 27

Conclusions (cont'd)

Conclusions (cont'd)

  • Diabetes prevalence falls disproportionately on the vulnerable in society
    • Imposes high financial burden for health care
  • The Affordable Healthcare Act may help alleviate some of the financial burden
  • Our study will help inform targeted policies and additional subsidies for non-elderly persons
    • Some may still have difficulties paying for necessary medical care—even with insurance coverage

Slide 28

Limitations and Future Research

Limitations and Future Research

  • Limitations:
    • We did not distinguish the different types of diabetes
    • Our results are descriptive in nature
  • Future research:
    • Estimate a causal model
Current as of December 2010
Internet Citation: Trends in the Pharmaceutical Treatment of Diabetes and Implications for Financial Burdens, 1997-2007. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2010/sarpong/index.html