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Researchers examine the impact of medication costs and mental health care for patients with diabetes

When a diabetic patient's blood sugar levels are not sufficiently lowered with diet, exercise, and medication, they are more likely to suffer long-term complications such as blindness, limb amputation, and kidney failure. Patients who underuse their diabetes medication because they can't afford it suffer from poorer health than those for whom medication cost is not a problem, according to a recent study. Another study describes how to integrate depression management with diabetes care for patients who suffer from both diabetes and depression. Both studies were supported in part by the Agency for Healthcare Research and Quality (HS10281) and led by John Piette, Ph.D., of the University of Michigan. They are described here.

Piette, J.D., Wagner, T.H., Potter, M.B., and Schillinger, D. (2004, February). "Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care." Medical Care 42(2), pp. 102-109.

Medication costs can prompt diabetes patients to underuse needed medications, which in turn is associated with worse health, concludes this study. The investigators studied medication compliance among 766 adult diabetes patients from three Veterans Affairs (VA), one county, and one university health care system. They examined whether diabetes patients insured by the VA's extensive prescription drug coverage program had fewer cost-related medication adherence problems than those insured by other public and private sources of health insurance. They also looked at whether cost-related medication underuse was associated with worse health outcomes. The researchers linked results of a patient survey on ability to function and burden of diabetes symptoms to insurance information and hemoglobin A1C test results (higher A1C levels indicate poorer blood sugar control).

Fewer VA patients reported cost-related medication underuse (9 percent) than patients with private insurance (18 percent), Medicare (25 percent), Medicaid (31 percent), or no health insurance (40 percent). Medication underuse was much more common among patients with multiple chronic illnesses (who probably needed more types of medications), except those who used VA care. For example, the risk of cost-related medication underuse for patients with more than three coexisting illnesses was 2.8 times as high among privately insured patients as among VA patients and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance.

Medication underuse was linked to poorer health outcomes. Diabetes patients who reported cost-related medication underuse had A1C levels that were substantially higher than other patients, suffered more symptoms, and had poorer physical and mental functioning. The authors conclude that cost-related medication adherence problems could have serious health consequences that should be taken into account when employers, government agencies, and private health insurers define the limits of drug coverage for chronically ill patients.

Piette, J.D., Richardson, C., and Valenstein, M. (2004, February). "Addressing the needs of patients with multiple chronic illnesses: The case of diabetes and depression." American Journal of Managed Care 10(part 2), pp. 152-162.

Depression is twice as common among diabetes patients as in the general population, with 15 to 30 percent of diabetes patients meeting criteria for depression. Patients who suffer from both diabetes mellitus and depression (DM/D) are more likely to have poor glycemic control (excessively high blood sugar levels) and higher rates of complications such as stroke and heart attack than diabetes patients without depression. These vulnerable patients may benefit from an approach that integrates depression management with diabetes care, suggests this study.

After reviewing research on coexisting depression and diabetes, the investigators present a conceptual framework for integrating depression management with diabetes care in a managed care environment. Their review revealed that depression tends to diminish diabetes patients' overall quality of life, reduce physical activity levels, limit adherence to self-care regimens, and impair their ability to communicate effectively with clinicians, all of which are factors affecting diabetes management. Small randomized trials suggest that both antidepressant medication and cognitive behavioral therapies (CBTs) or related approaches may improve not only DM/D patients' depressive symptoms, but their physical health as well.

Based on these findings, the authors propose a potentially effective DM/D management strategy. DM/D management should include systematic identification of DM/D patients and quality-of-care reviews, proactive patient monitoring between outpatient visits, and intensive efforts to coordinate treatment across providers. It should also include increased patient access to CBT or related therapies that address depressive symptoms and diabetes self care, and there should be an emphasis on promoting physical activity to address both depressive symptoms and physiologic problems.

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