Tatiana Dilla

Adherence to Therapies in Patients with Type 2 Diabetes

Adherence to therapy is defined as the extent to which a person’s behavior in taking medication, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider. Patients presenting with type 2 diabetes mellitus are initially encouraged to maintain a healthy diet and exercise regimen, followed by early medication that generally includes one or more oral hypoglycemic agents and later may include an injectable treatment. To prevent the complications associated with type 2 diabetes, therapy frequently also includes medications for control of blood pressure, dyslipidemia and other disorders, since patients often have more than three or four chronic conditions. Despite the benefits of therapy, studies have indicated that recommended glycemic goals are achieved by less than 50% of patients, which may be associated with decreased adherence to therapies. As a result, hyperglycemia and long-term complications increase morbidity and premature mortality, and lead to increased costs to health services. Reasons for nonadherence are multifactorial and difficult to identify. They include age, information, perception and duration of disease, complexity of dosing regimen, polytherapy, psychological factors, safety, tolerability and cost. Various measures to increase patient satisfaction and increase adherence in type 2 diabetes have been investigated. These include reducing the complexity of therapy by fixed-dose combination pills and less frequent dosing regimens, using medications that are associated with fewer adverse events (hypoglycemia or weight gain), educational initiatives with improved patient–healthcare provider communication, reminder systems and social support to help reduce costs. In the current narrative review, factors that influence adherence to different therapies for type 2 diabetes are discussed, along with outcomes of poor adherence, the economic impact of nonadherence, and strategies aimed at improving adherence.

Systematic review of the economic aspects of nonadherence to antipsychotic medication in patients with schizophrenia

Purpose There is strong evidence supporting the link between nonadherence to antipsychotic medication and relapse of schizophrenia. However, less obvious are the economic consequences of nonadherence. The systematic review reported here evaluated the economic aspects of nonadherence to antipsychotic medication. Methods A systematic review of scientific papers in the PubMed MEDLINE, Embase, PsychINFO, BIOSIS, and Evidence-Based Medicine Reviews databases was undertaken. Studies that measured adherence to antipsychotic medication and that provided comparative information on health care costs were included. Results Eight studies met the inclusion criteria. All were observational. Despite the differences between the studies in terms of design, adherence measures, and cost components analyzed, the results of this systematic review indicate that nonadherence to antipsychotic medication is associated with increased hospitalization rates and resource utilization, resulting in increased direct health care costs. Conclusion Nonadherence to antipsychotic medication results in poor health and economic outcomes; therefore, the authors suggest endorsing interventions aimed at improving adherence because they can improve patient health without substantially increasing costs.

Cost-effectiveness analysis of pemetrexed versus docetaxel in the second-line treatment of non-small cell lung cancer in Spain: results for the non-squamous histology population

BackgroundThe objective of this study was to conduct a cost-effectiveness evaluation of pemetrexed compared to docetaxel in the treatment of advanced or metastatic non-small cell lung cancer (NSCLC) for patients with predominantly non-squamous histology in the Spanish healthcare setting.MethodsA Markov model was designed consisting of stable, responsive, progressive disease and death states. Patients could also experience adverse events as long as they received chemotherapy. Clinical inputs were based on an analysis of a phase III clinical trial that identified a statistically significant improvement in overall survival for non-squamous patients treated with pemetrexed compared with docetaxel. Costs were collected from the Spanish healthcare perspective.ResultsOutcomes of the model included total costs, total quality-adjusted life years (QALYs), total life years gained (LYG) and total progression-free survival (PFS). Mean survival was 1.03 years for the pemetrexed arm and 0.89 years in the docetaxel arm; QALYs were 0.52 compared to 0.42. Per-patient lifetime costs were € 34677 and € 32343, respectively. Incremental cost-effectiveness ratios were € 23967 per QALY gained and € 17225 per LYG.ConclusionsPemetrexed as a second-line treatment option for patients with a predominantly non-squamous histology in NSCLC is a cost-effective alternative to docetaxel according to the € 30000/QALY threshold commonly accepted in Spain.

Adherencia y persistencia terapéutica: causas, consecuencias y estrategias de mejora

En los paı́ses desarrollados, las tasas de adherencia a los tratamientos en enfermedades crónicas se sitúan alrededor del 50%. Esta cifra es considerablemente menor en los paı́ses en vı́as de desarrollo, según un reciente informe de la Organización Mundial de la Salud (OMS), que califica la falta de adherencia como un )problema mundial de gran magnitud*. Es necesario entender la importancia del problema y poner en marcha estrategias adecuadas para solucionarlo. El presente artı́culo se centra fundamentalmente en analizar las consecuencias clı́nicas y económicas que produce el incumplimiento y los motivos por los que se origina este problema. Asimismo se identifican diferentes estrategias encaminadas a su mejora.

Healthcare Costs Associated with Change in Body Mass Index in Patients with Type 2 Diabetes Mellitus in Spain

AbstractBackground: Weight management is considered a key therapeutic strategy in type 2 diabetes mellitus. However, little is known about the impact of weight loss or body mass index (BMI) reduction on type 2 diabetes-related healthcare costs. Objective: The aim of this study was to estimate the economic impact of change in BMI among patients with type 2 diabetes mellitus from the Spanish healthcare system perspective. Methods: The ECOBIM study is an observational, non-interventional study in which data on BMI change and costs incurred by patients with type 2 diabetes were collected cross-sectionally and retrospectively for a 12-month period. Generalized linear mixed models were applied to estimate the effects of (i) BMI change in general (one-slope model); (ii) BMI gain and no BMI gain (two-slope model); and (iii) BMI gain and no BMI gain among obese and non-obese patients (four-slope model). Results: We studied 738 patients with a mean (SD) age of 66 (11) years and BMI of 30.6 (5.2) kg/m2. During the 12-month study period, 41.2% of patients gained BMI (BMI gainers) and 58.8% experienced either loss (52.2%) or no change (6.6%) in BMI (non-BMI gainers). One-unit gain (or loss) in BMI was significantly (p<0.001) associated with a 2.4% cost increase (or decrease) [one-slope model]. Every unit gain in BMI was associated with a 20.0% increase in costs among BMI gainers while losing one unit was associated with an 8.0% decrease in costs among non-BMI gainers (two-slope model, p<0.01). The economic benefit associated with reducing one BMI unit was 9.4% cost decrease in obese and 2.7% in non-obese patients (4-slope model). Conclusion: An increase in BMI among patients with type 2 diabetes was associated with increased 1-year direct healthcare costs. A reduction in BMI was associated with appreciable short-term economic benefits, especially in obese patients.

The cost-effectiveness of exenatide once weekly compared with exenatide twice daily and insulin glargine for the treatment of patients with type two diabetes and body mass index ≥30 kg/m2 in Spain

Abstract Objective: The objective of this analysis was to estimate the cost-effectiveness of exenatide once weekly (EQW) for the treatment of type two diabetes mellitus (T2DM) in Spain. EQW was compared against exenatide twice daily (EBID) and insulin glargine (IG). Methods: The IMS CORE Diabetes Model was used to project clinical and economic outcomes for patients with T2DM treated with EQW, EBID, and IG. Treatment effects and patient baseline characteristics were taken from the DURATION 3 and pooled DURATION 1 and 5 studies, in the comparison against IG and EBID, respectively. Unit costs and health state utility values were derived from published sources. To reflect diabetes progression, patients started on EQW or EBID, switching to insulin glargine after 3 years. The analysis was conducted from the perspective of the Spanish National Health Service over a time horizon of 35 years with costs and outcomes discounted at 3%. The base case included patients with a BMI > 30 kg/m2, which is in line with current prescription restrictions in Spain. Uncertainty was addressed through extensive one-way sensitivity analyses around key model parameters and a comprehensive probabilistic sensitivity analysis. Results: When compared with EBID, EQW was the dominant strategy, i.e., less costly and more effective. When compared to IG, the incremental cost-effectiveness ratio was estimated at €12,084 per QALY gained. Sensitivity analysis indicated that the model projections were robust to the various scenarios tested. Limitations: Primary limitations of the analysis are common to other T2DM analyses and include the extrapolation of short-term clinical data to the 35 year time horizon and uncertainty around optimum treatment durations. Conclusion: The analyses indicate that EQW is a cost-effective option for the treatment of T2DM patients in Spain for patients with a BMI > 30 kg/m2 considering a willingness-to-pay threshold of €30,000 per QALY gained.

Evaluación económica de medicamentos: experiencias y vías de avance

La evaluacion economica de medicamentos (EEM) ha experimentado un fuerte crecimiento en los ultimos anos, debido a la progresiva aplicacion de la eficiencia como criterio de priorizacion en un entorno en el que los recursos

Treatment adherence and persistence: Causes, consequences and improvement strategies [Adherencia y persistencia terapéutica: Causas, consecuencias y estrategias de mejora]

En los paı́ses desarrollados, las tasas de adherencia a los tratamientos en enfermedades crónicas se sitúan alrededor del 50%. Esta cifra es considerablemente menor en los paı́ses en vı́as de desarrollo, según un reciente informe de la Organización Mundial de la Salud (OMS), que califica la falta de adherencia como un )problema mundial de gran magnitud*. Es necesario entender la importancia del problema y poner en marcha estrategias adecuadas para solucionarlo. El presente artı́culo se centra fundamentalmente en analizar las consecuencias clı́nicas y económicas que produce el incumplimiento y los motivos por los que se origina este problema. Asimismo se identifican diferentes estrategias encaminadas a su mejora.

No big data without small data: learning health care systems begin and end with the individual patient

The apparent contradiction between the population focus of big data and the practice of personalized medicine contributes to the relatively scarce and slow applications of big data in medicine compared with other areas of knowledge. The technologic development and the implementation of EMRs may give rise to a learning health care system in which every doctor–patient encounter becomes the connecting link between the population and the individual. To generate valuable knowledge, big data must come from high‐quality individual clinical data. There are no big data without small data. EMRs may be used to integrate research into medical care, thereby conducting point of care research (e.g. randomized database studies). However, big data will not achieve its full potential if it is not used to improve health outcomes for the individual patients from whom the data were generated. EMRs should aid doctors in personalizing medical care and contribute towards the engagement of patients in research and care. The continuous interaction between the individual patient and the population, between clinical research and medical care, between the world of big data and that of small data is an essential step towards achieving a true learning health care system.

El impacto de la obesidad en el manejo y evolución de la diabetes mellitus

Objetivo Estudiar el manejo y evolucion de la diabetes mellitus tipo 2 (DM2) en Atencion Primaria (AP) en Espana y los factores implicados, especialmente la obesidad. Diseno Estudio epidemiologico, transversal, multicentrico, retrospectivo. Participantes Se incluyeron pacientes con DM2 mayores de 20 anos seleccionados consecutivamente en 30 centros de AP, en 16 comunidades autonomas (CCAA). Metodos Se recogio informacion sobre edad, sexo, nivel educativo, duracion de DM2, HbA1c, tratamiento e indice de masa corporal (IMC). Resultados De un total de 294 pacientes, 50% hombres, con edad media (DE) 67,5 anos (10,2) e IMC 28,9 (4,5) kg/m2, el 58,16% presentaban niveles de HbA1c >6,5%, el 38% era obeso o severamente obeso. El 93,9% seguia tratamiento farmacologico para su diabetes. Se mostraron diferencias significativas en el valor medio de HbA1c entre el grupo con sobrepeso y el grupo con obesidad severa (test de Tukey-Kramer). Se observaron diferencias en la presencia de complicaciones macrovasculares entre pacientes con peso normal y pacientes obesos (p=0,006). Pacientes con menor grado de alfabetizacion mostraron 3,39 mas probabilidad de ser obesos o severamente obesos que pacientes con estudios secundarios o universitarios (p=0,0041; 95% intervalo de confianza [IC] 1,47-7,80), y los pacientes con estudios primarios 2,22 veces mas (p=0,038; 95% IC 1,04-4,73). Un 47,8% refirieron un cumplimiento elevado. Los obesos y severamente obesos presentaron 2,2 veces mas probabilidad de presentar cumplimiento bajo o moderado que los no obesos (p=0,002; 95% IC 1,31-3,74). Conclusiones Los resultados obtenidos en esta poblacion sugieren que la variable obesidad se relaciona con mas complicaciones macrovasculares, peor control metabolico y peor cumplimiento.