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

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).  


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

  1997 2007
Cardiovascular disease 13.1 17.2**
Hypertension 46.1 64.8**
Hyperlipidemia 15 52.8**

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

  1997 2007
Orals 59.9 77.3**
Insulin 38.2 24.4**
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

  1997 2007
Sulfonylureas 51.2 40.2**
Biguanides 21.2 55.2**
Thiazolidinediones 4.7 24.6**

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

  1997-1998 2006-2007
All therapeutic classes 500 944**
Sulfonylureas 298 211**
Biguanides 381 297**
Thiazolidinediones 1,013 1,121**
Insulin 331 918**
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

  1997-1998 2006-2007
All therapeutic classes 221 273**
Sulfonylureas 167 89**
Biguanides 174 116**
Thiazolidinediones 190 250**
Insulin 132 257**
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 Variables Odds Ratios
Age in years  
 0-34 1.00
 35-49 1.69
 50 to 64 2.65**
Sex  
 Male 1.00
 Female 1.27*
Race/ethnicity  
 non Hispanic White/other 1.00
 non-Hispanic Black 0.73*
 Hispanic 0.79
Health insurance status  
 Any private 1.00
 Public only 0.95
 Uninsured 2.61**
Income  
 Poor 7.82**
 Near Poor/Low income 4.23**
 Middle income 3.00**
 High income 1.00
Education  
 Less than high school 1.42*
 High school 1.05*
 At least some college 1.00
Comorbid conditions  
 No comorbid condition 1.00
 Any comorbid condition 1.51**
Type of Treatment  
 No anti-diabetic medications 1.00
 Injectables and orals 1.65*

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 (Text Version). December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/news/events/conference/2010/sarpong/index.html

 

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