The “cost” of treating to target: cross-sectional analysis of patients with poorly controlled type 2 diabetes in Australian general practice

Abstract

BackgroundTo describe the current treatment gap in management of cardiovascular risk factors in patients with poorly controlled type 2 diabetes in general practice as well as the associated financial and therapeutic burden of pharmacological treatment.MethodsCross-sectional analysis of data from the Patient Engagement and Coaching for Health trial. This totalled 473 patients from 59 general practices with participants eligible if they had HbA1c > 7.5%. Main outcome measures included proportions of patients not within target risk factor levels and weighted average mean annual cost for cardiometabolic medications and factors associated with costs. Medication costs were derived from the Australian Pharmaceutical Benefits Schedule.ResultsAverage age was 63 (range 27-89). Average HbA1c was 8.1% and average duration of diabetes was 10 years. 35% of patients had at least one micro or macrovascular complication and patients were taking a mean of 4 cardio-metabolic medications. The majority of participants on treatment for cardiovascular risk factors were not achieving clinical targets, with 74% and 75% of patients out of target range for blood pressure and lipids respectively. A significant proportion of those not meeting clinical targets were not on treatment at all. The weighted mean annual cost for cardiometabolic medications was AUD$1384.20 per patient (2006-07). Independent factors associated with cost included age, duration of diabetes, history of acute myocardial infarction, proteinuria, increased waist circumference and depression.ConclusionsTreatment rates for cardiovascular risk factors in patients with type 2 diabetes in our participants are higher than those identified in earlier studies. However, rates of achieving target levels remain low despite the large ‘pill burden’ and substantial associated fiscal costs to individuals and the community. The complexities of balancing the overall benefits of treatment intensification against potential disadvantages for patients and health care systems in primary care warrants further investigation.

Reducing cardiovascular disease risk in diabetes: a randomised controlled trial of a quality improvement initiative

“…Similarly, BP targets were not met by half the patients with diabetes, of whom more than one-quarter were not prescribed antihypertensive therapy. These treatment deficits are consistent with international experience, [8][9][10]16 and reflect modest improvements when compared with the findings of previous Australian studies of lipid 6,7 and BP 7,19 management.…”

“…A number of guidelines for managing CVD risk in people with diabetes have been published, but studies in Australia 6 , 7 and overseas 8 ‐ 10 have consistently found that these strategies have been only incompletely implemented. Most Australian studies, however, predate a number of targeted quality improvement (QI) programs, including the National Divisions Diabetes, Australian Primary Care Collaboratives, and National Integrated Diabetes Programs, as well as the introduction of targeted incentive payments to general practitioners and practices, and may therefore not accurately reflect current practice.…”

Impact of self‐care programmes in type 2 diabetes mellitus population in primary health care: Systematic review and meta‐analysis

“…Appropriate self‐management of DM is not only associated with good metabolic control, but also with addressing cardiovascular risk factors (CVRF) such as hypertension or hyperlipidaemia, for which adequate therapeutic control is often not obtained, despite increasing pharmacological attention (Furler et al, ). Obesity, another risk factor that can be modified by the adoption of a healthy lifestyle, is present in 30%–50% of people with T2DM and is becoming even more prevalent, especially among persons aged over 45 years with abdominal obesity (Caspard et al, ).…”

Clinical Approach to Diabetic Cardiomyopathy: A Review of Human Studies

“…Diabetic patients have a two-fold increase in short-term mortality rate following acute myocardial infarction, compared to non-diabetic patients, with the glucose admission profile being a better predictor of outcome than glycated hemoglobin (HbA1c) after a heart attack in diabetic patients [2]. Consequently, the management of cardiovascular risk factors in T2DM is of great clinical importance, with wider implications driven by the financial and therapeutic/side effect burden of pharmaceutical treatment [3]. This review focuses on human studies, including pathophysiology, diagnostic evaluation and management options, whilst highlighting the clinical importance of early DC identification for the optimization of treatment in diabetic patients.…”