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Diabetes treatment w spacers-01.jpgHealth outcomes and costs associated with second line use of diabetes treatments  




Despite lower healthcare resource utilization and better HbA1c outcomes, compared to other diabetes drug classes, second-line use of GLP-1 inhibitors following metformin monotherapy was more costly and resulted in lower medication adherence and persistence.

Enterprise Analytics Core domain(s): CarelonRx, Policy guidance

Summary

Background

The 2018 or later American Diabetes Association treatment guidelines1 support second-line use of DPP-42, SGLT-23 , or GLP-14 inhibitors, following first-line treatment with metformin monotherapy, for type 2 diabetes.

Objective

This study compared health outcomes and costs associated with second-line use of DPP-4, SGLT-2, and GLP-1 inhibitors following metformin monotherapy, per IngenioRx policy.

Methods

The observational claims-based study compared three propensity score-matched retrospective cohorts of Elevance Health patients with a type 2 diabetes diagnosis. Comparisons were among DPP-4 vs SGLT-2 initiators (N=4611 each); SGLT-2 vs GLP-1 initiators (N= 3486 each); and DPP-4 vs GLP-1 initiators (N=4139 each) between January 2012 and June 2020.

Results

  • Patients who initiated GLP-1 and SGLT-2 inhibitors had lower healthcare resource utilization and better HbA1c outcomes compared to those who initiated DPP-4 inhibitors.
  • Though effective, use of GLP-1 inhibitors was more costly and associated with lower medication adherence and persistence compared to the other diabetes drug classes.

Key takeaways 

  • Health outcomes from this real-world evaluation of diabetes drug classes among the studied population support the treatment guidelines and clinical criteria for metformin and step edits for DPP-4, SGLT-2 and GLP-1 inhibitors at the time of these analyses.
  • There is an opportunity to improve adherence to all three classes of diabetes medications, though more effort may be required for GLP-1 inhibitor medications.
  • The use of GLP-1 and SGLT-2 inhibitors is evolving, and evidence from this project helps guide Elevance Health’s formulary policy. As newer therapy guidelines recommend first-line, rather than second-line, use of these therapies in targeted populations4, additional research is warranted to support evidence-based decisions.

1American Diabetes Association. Practice guideline resources. https://professional.diabetes.org/content-page/practice-guidelines-resources; 2Dipeptidyl Peptidase-4 Inhibitor -for e.g., Januvia/ Janumet, Tradjenta/ Jentadueto, Onglyza/ Kombiglyze; 3Sodium-glucose Cotransporter-2 Inhibitors -for e.g., Jardiance/Synjardy, Farxiga/Xigduo, Invokana/Invokamet; 4Glucagon-like Peptide 1 Inhibitors -for e.g., Victoza, Trulicity, Ozempic, Bydureon/Byetta


Carelon Research project team: John Barron, Amita Ketkar, Megan Reidy, Nicole Thomas, Jay Visaria 



For more information on a specific study or to connect with the Actionable Insights Committee, contact us at [email protected].

Carelon Research (formerly HealthCore, Inc.), a subsidiary of Elevance Health, conducted this study in collaboration with CarelonRx. Dissemination and sharing of the study results is limited to Elevance Health and its subsidiaries and included findings and implications are for Elevance Health and its affiliates’ internal use only. 

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Highlighted Studies

A real-world study of immunoglobulin (IG) reveals multiple cost-saving opportunities 

Hub Domain(s): Immunology, oncology, costs of care, IngenioRx, policy guidance
Summary: 

  • Background: Immunoglobulins (IG) are costly blood-derived products accounting for more than $500m in annual spending in the Anthem membership
  • Methods: HealthCore examined IG utilization using claims data to evaluate appropriateness of use, the extent of site-of-care optimization and non-preferred IG use.
  • Results: The findings revealed significant off-label use of IGs (30%), including 22% for indications that were neither approved by FDA nor covered by Anthem, but were accepted by other health plans; and 8% for indications that were neither approved by FDA nor covered by any health plan
    • Additionally, 25% of the IG use was observed in the most expensive site of administration of hospital outpatient (HOPD) and non-preferred IG use accounted for 71% of the total IG use
  • Key Takeaways: Examining the IG uses from various dimensions presents several opportunities to IngenioRx and Anthem:
    • Reducing off-label IG use represented an estimated $27.8m annual savings opportunity
    • Shifting IG utilization from HOPD to a less expensive site of care could drive a further estimated $6.3m in annual savings
    • The study also identified opportunities to increase the share of preferred IG products used by our patients.


Major depressive disorder (MDD) patients highly impacted by COVID-19 face daunting challenges

Hub Domain(s): COVID, member experience
Summary: 

  • Background: Disruption to daily life and lockdown measures that were imposed in an attempt to contain the spread of COVID-19 presented new hurdles for at-risk populations, such as patients with major depressive disorder (MDD)
  • Methods: Conducted a 2020 internet survey to understand reasons for antidepressant continuation, switching and discontinuation in patients with MDD; COVID-19 pandemic questions were developed and added to survey.
    • COVID-19 Pandemic Impact (CPI) score was calculated and, based on their CPI scores, patients were categorized as experiencing low (LPI), medium (MPI) or high pandemic impact (HPI).
  • Results: Compared with LPI and MPI patients, HPI patients reported:
    • Significantly more problems accessing healthcare; few reported not having health insurance benefits due to loss of/reduced health insurance coverage (Figure 1).
    • More challenges obtaining depression prescription medications in terms of:
      • Filling new/current prescription(s)
      • Receiving samples from healthcare providers
      • Paying for prescription(s) due to loss of/reduced health insurance coverage and/or pharmacy benefits
    • Since start of COVID-19 pandemic engaged in significantly more:
      • Alcohol, drug, and tobacco use
      • Unhealthy mindless eating
      • Sedentary behavior
  • Key Takeaways: Our findings are consistent with literature showing that traumatic events, e.g. pandemics, can negatively impact health behaviors.
    • More research is needed to explore the COVID-19 impact in other patient populations.
    • Education opportunities exist for health plans to increase awareness among providers and patients of possible short and long-term COVID-19 effects on health behaviors.

Figure 1: Impact of COVID-19 pandemic on accessing healthcare/mental healthcare

  • Publications: Poster presented at the Virtual American Society of Clinical Psychopharmacology (ASCP) Annual Meeting, June 1-4, 2021

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