Healthcare resource utilization and costs assessment of type 2 diabetes patients initiating exenatide BID or glargine: a retrospective database analysis

Figures & data

Table 1.  Demographic and clinical characteristics of patients in the pre-index period.

	Pre-matching			Post-matching
	Exenatide (n = 7,255)	Insulin glargine (n = 2,819)	p-value	Exenatide (n = 2,506)	Insulin glargine (n = 2,506)	p-value
Age (years) at index, mean (SD)	52.8 (9.2)	54.4 (10.4)	<0.001	53.7 (9.4)	53.8 (10.0)	0.723
Age (years) at index, n (%)			<0.001			0.647
18–34	232 (3.2)	87 (3.1)		73 (2.9)	79 (3.2)
35–44	1,096 (15.1)	374 (13.3)		338 (13.5)	345 (13.8)
45–54	2,602 (35.9)	919 (32.6)		846 (33.8)	851 (34.0)
55–64	2,765 (38.1)	1,087 (38.6)		1,007 (40.2)	964 (38.5)
≥65	560 (7.7)	352 (12.5)		242 (9.7)	267 (10.7)
Gender, n (%)			<0.001			0.189
Male	3,322 (45.8)	1,630 (57.8)		1,456 (58.1)	1,410 (56.3)
Female	3,933 (54.2)	1,189 (42.2)		1,050 (41.9)	1,096 (43.7)
Insurance provider, n (%)			<0.001			0.976
Exclusive provider organization	1,168 (16.1)	440 (15.6)		408 (16.3)	405 (16.2)
Health maintenance organization	760 (10.5)	433 (15.4)		366 (14.6)	357 (14.2)
Independent	184 (2.5)	137 (4.9)		86 (3.4)	94 (3.8)
Other	2 (0.03)	2 (0.1)		2 (0.1)	1 (0.04)
Point of service	4,520 (62.3)	1,555 (55.2)		1,419 (56.6)	1,424 (56.8)
Preferred provider organization	621 (8.6)	252 (8.9)		225 (9.0)	225 (9.0)
Region, n (%)			<0.001			0.930
Midwest	1,802 (24.8)	933 (33.1)		804 (32.1)	801 (32.0)
Northeast	476 (6.6)	215 (7.6)		181 (7.2)	190 (7.6)
South	4,029 (55.5)	1,316 (46.7)		1,218 (48.6)	1,203 (48.0)
West	947 (13.1)	355 (12.6)		303 (12.1)	312 (12.5)
Medication/therapy variables, mean (SD)
Unique class of medications	8 (3.7)	7.3 (3.8)	<0.001	7.2 (3.4)	7.3 (3.7)	0.527
Pre-index resource use, n (%)
Endocrinologist visit	2,040 (28.1)	276 (9.8)	<0.001	283 (11.3)	272 (10.9)	0.620
Hospitalizations	436 (6.0)	520 (18.4)	<0.001	290 (11.6)	298 (11.9)	0.725
Emergency room visits	450 (6.2)	178 (6.3)	0.049	146 (5.8)	147 (5.9)	0.952
Pre-index total costs, mean (SD)
Total	9,350 (17,740)	17,511 (39,485.6)	<0.001	11,526 (25,335.3)	11,546 (23,421.6)	0.973
Inpatient	1,915 (13,265.9)	9,129 (33,684.9)	<0.001	4,132 (20,704.5)	4,149 (17,945.6)	0.986
Outpatient	4,789 (9,399.7)	5,981 (14,387.0)	<0.001	4,988 (10,695.6)	4,993 (11,347.4)	0.978
Emergency room	46 (389.2)	77 (703.4)	0.030	66 (566.5)	60.5 (567.2)	0.712
Prescription	2,598 (1,993.9)	2,323 (2,278.8)	<0.001	2,340 (1,585.7)	2,350 (2,296.5)	0.873
Diabetes complications
Diabetic retinopathy, eye disease (glaucoma, diabetic retinopathy, retinal bleeding, cataracts, age-related macular degeneration)	1,080 (14.9)	467 (16.6)	0.036	404 (16.1)	408 (16.3)	0.878
Renal failure/nephropathy	428 (5.9)	279 (9.9)	<0.001	182 (7.3)	191 (7.6)	0.628
Neuropathy	555 (7.6)	205 (7.3)	0.519	161 (6.4)	167 (6.7)	0.732
Amputation and/or foot ulceration/gangrene	77 (1.1)	61 (2.2)	<0.001	37 (1.5)	37 (1.5)	1.000
Macrovascular complications, n (%)
Myocardial infarction	31 (0.4)	49 (1.7)	<0.001	20 (0.8)	25 (1.0)	0.454
Ischemic heart disease	815 (11.2)	434 (15.4)	<0.001	322 (12.8)	322 (12.8)	1.000
Congestive heart failure	133 (1.8)	170 (6.0)	<0.001	83 (3.3)	84 (3.4)	0.937
Peripheral vascular disease	254 (3.5)	146.5.2)	<0.001	109 (4.3)	103 (4.1)	0.674
Stroke	85 (1.2)	66 (2.3)	<0.001	46 (1.8)	40 (1.6)	0.514
Other common comorbidities in diabetes, n (%)
Depression	458 (6.3)	148 (5.3)	0.044	126 (5.0)	128 (5.1)	0.898
Any mental health (excluding depression)	680 (9.4)	302 (10.7)	0.042	233 (9.3)	230 (9.2)	0.884
Obesity	1,101 (15.2)	265 (9.4)	<0.001	258 (10.3)	239 (9.5)	0.369
Hypertensive disease	4,904 (67.6)	1881 (66.7)	0.404	1,623 (64.8)	1,650 (65.8)	0.423
Dyslipidemia	5,368 (74.0)	1887 (66.9)	<0.001	1,709 (68.2)	1,716 (68.5)	0.832
Hypoglycemia	130 (1.8)	56 (2.0)	0.515	38 (1.5)	41 (1.6)	0.734
Comorbidities scores, mean (SD)
Pre-period Charlson score	1.4 (0.7)	1.6 (1.0)	<0.001	1.4 (±0.8)	1.4 (±0.8)	0.756
Pre-period number of diagnoses	9.2 (5.7)	9.7 (7.1)	0.005	8.8 (±5.9)	8.9 (±6.2)	0.637

P-values correspond to either an independent groups chi-square test or an independent groups t-test.

Table 2.  Resource utilization for matched cohorts in the post-index period.

	Exenatide (n = 2,506)	Insulin glargine (n = 2,506)	Risk reduction on exenatide(%), (odds ratio, confidence interval)	p-value
All hospitalizations, n (%)	306 (12.2)	369 (14.7)	19%, (OR: 0.81, 95% CI: 0.684, 0.948)	0.009
Macrovascular hospitalizations, n (%)	109 (4.4)	153 (6.1)	30%, (OR: 0.70, 95% CI: 0.544, 0.900)	0.005
Myocardial infarct hospitalizations	8 (0.3)	14 (0.6)	43%, (OR: 0.57, 95% CI: 0.239, 1.361)	0.206
Ischemic heart disease hospitalizations	81 (3.2)	109 (4.4)	26%, (OR: 0.74, 95% CI: 0.548, 0.985)	0.039
Congestive heart failure hospitalization	32 (1.3)	59 (2.4)	46%, (OR: 0.54, 95% CI: 0.348, 0.828)	0.005
Peripheral vascular disease hospitalization	11 (0.4)	23 (0.9)	52%, (OR: 0.48, 95% CI: 0.232, 0.978)	0.044
Stroke hospitalization	19 (0.8)	19 (0.8)	0%, (OR: 1.00, 95% CI: 0.528, 1.893)	1.000
Microvascular hospitalizations, n (%)	48 (1.9)	52 (2.1)	8%, (OR: 0.92, 95% CI: 0.620, 1.370)	0.686
Hypoglycemic events, n (%)	68 (2.7)	80 (3.2)	15%, (OR: 0.85, 95% CI: 0.609, 1.174)	0.317
Emergency room visits, n (%)	193 (7.7)	188 (7.5)	–3%, (OR: 1.03, 95% CI: 0.835, 1.268)	0.790

CI, confidence interval; n, number in group; OR, odds ratio.

P-values correspond to a logistic regression.

Figure 1.  Post-index use of antidiabetic medication. P-values correspond to McNemar tests.

Figure 2.  Post-index use of concomitant medications. P-values correspond to McNemar tests.

Table 3.  Inpatient, outpatient, and prescription breakdown of costs for matched cohorts in the post-index period.

Cost breakdown ($)	Exenatide (n = 2,506)		Insulin glargine (n = 2,506)		Difference in costs (B − A)	p-value
	Mean (A)	SD	Mean (B)	SD	Mean difference
Total	19,978	588	22,575	797	2,597	0.008
Inpatient/institutional care	4,419	410	6,387	547	1,968	0.004
Hospital	4,397	409	6,307	540	1,910	0.005
Macrovascular complications only	1,745	294	2,746	381	1,001	0.034
Microvascular complications only	333	92	395	112	62	0.658
Both microvascular and macrovascular complications	382	111	571	186	189	0.379
Nursing home/residential facility	22	8	80	36	58	0.101
Outpatient	8,956	307	10,280	418	1,324	0.011
Physician office visits	2,974	125	3,582	186	608	0.008
Hospital outpatient/ambulatory surgical center	5,076	245	5,742	318	666	0.099
Ambulance services	4	2	13	6	9	0.161
Home health visits	140	20	178	29	38	0.276
Hospice care	0	0	0	0	0	0.062
Laboratory	544	16	519	19	−25	0.278
Other ambulatory	218	32	247	37	29	0.549
Emergency room	94	12	105	13	11	0.529
Total prescription	6,509	72	5,803	92	−706	<0.001
Antidiabetic medications	3,315	33	2,430	29	−885	<0.001
Prescription, study medication	1,722	21	769	14	1324	<0.001
Prescription, non-study antidiabetic medication	1,592	24	1,661	24	69	0.049
Concomitant medications	2,895	57	3,084	83	189	0.056
Diabetes supplies/self-monitoring	80	1	80	2	0	0.872

Negative value indicates reduction in outcomes. Positive value indicates increase in outcomes.

P-values correspond to a non-parametric matched sample bootstrap.

SD, standard deviation.

eAppendix A.  Inclusion/exclusion criteria.

	Exenatide	Glargine
Use of ITT medication, with first such date identified as index date	43,119	14,5359
Index date between April 1, 2005 and June 30, 2007	27,747	65,598
No indication of type 1 or gestational diabetes at any time during the study period	22,563	25,142
At least one diagnosis of type 2 diabetes at any time during the study period OR at least two prescriptions for oral antidiabetic agents in the pre-index period	21,059	23,955
Continuous insurance coverage from 182 days pre-index date through 365 days post-index date	10,908	7,422
If exenatide-treated patient, no use of any insulin product during the entire study period	9,286	–
If glargine-treated patient, no use of any insulin (except glargine) or exenatide during the entire study period	–	3,806
At least 18 years of age at index date	9,269	3,803
Pre- and post-index period inpatient costs less than $500,000	9,264	3,791
Diagnosis of type 2 diabetes during pre-index period	8,648	3,605
At least two prescriptions of metformin, sulfonylurea, TZD, metformin-sulfonylurea, or metformin-TZD during pre-index period	7,255	2,819

ITT, intent to treat; TZD, thiazolidinedione.

Appendix B.  ICD-9 codes for comorbidities.

Diagnosis	ICD-9 * any ICD-9 starting with listed value will indicates relevant diagnosis. e.g., diabetes related instance includes 250, 2501, 25083, etc.
Diabetes related	250
Eye problems	25050, 25052, 36510, 36511, 36512, 36513, 36515, 36560, 36641, 36630
	3620, 3621, 3623, 3624, 3625, 3626, 3628, 3629, 3650, 3652, 3655, 3658, 3660, 3661, 3668, 3669
	361, 369
Nephropathy/renal failure	25040, 25042, 28521, 40301, 40311, 40391, 40402, 40412, 40492, V420, V451, V56, V562, V5632, V568, V560, V5631, 7910, 79100, 7531, 75310
	581, 582, 583, 584, 585, 586, 587, 588, 589
Neuropathy	25060, 25062, 3535, 35350, 5363, 53630, 3581, 35810, 4257, 42570, 4259, 42590
3371, 3572, 7135
354, 355
Amputation and/or foot Ulceration/gangrene	7071, 70710, 7078, 70780, 7079, 70790, 70714, 70715
7854
895, 896, 897
Myocardial infarction	410
Ischemic heart disease	411, 412, 413, 414
Congestive heart failure	40201, 40211, 40291, 40401, 40403, 40411, 40413, 40491, 40493
428
Peripheral vascular disease	25070, 25072, 44381, 44389, 4439, 44390, 4489, 44890
440
Stroke	4371, 43710, 43301, 43311, 43321, 43331, 43341, 43351, 43361, 43371, 43381, 43391, 43401, 43411, 43421, 43431, 43441, 43451, 43461, 43471, 43481, 43491
	430, 431, 432, 435, 436
Depression	2962, 2963
	311
Any mental health (excluding depression)	2960, 2961, 2964, 2965, 2966, 2967, 2968, 2969
	290, 291, 292, 293, 294, 295, 297, 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, 310, 312, 313, 314, 315, 316, 317, 318, 319
Obesity	27800, 27801, 27802
Hypertensive disease	401, 402, 403, 404, 405
Dyslipidemia	272
hypoglycemia	2508, 25080, 2703, 27030, 7750, 77500, 7756, 77560, 9623, 96230
	2510, 2511, 2512
Charlson Comorbidity Index factors - standard definition (may differ from the above)
Factor	ICD–9
Myocardial infarction	410, 412
Congestive heart failure	39891, 40201, 40211, 40291, 40401, 40403, 40411, 40413, 40491, 40493
	4254, 4255, 4257, 4258, 4259
	428
Peripheral vascular disease	0930, 4373, 4431, 4432, 4438, 4439, 4471, 5571, 5579, V434
	440, 441
Cerebrovascular disease	36234
	430, 431, 432, 433, 434, 435, 436, 437, 438
Dementia	2941, 3312
	290
Chronic pulmonary disease	4168, 4169, 5064, 5081, 5088
	490, 491, 492, 493, 494, 495, 496, 500, 501, 502, 503, 504, 505
Connective tissue disease–rheumatic disease	4465, 7100, 7101, 7102, 7103, 7104, 7140, 7141, 7142, 7148
	725
Peptic ulcer disease	531, 532, 533, 534
Mild liver disease	07022, 07023, 07032, 07033, 07044, 07054
	0706, 0709, 5733, 5734, 5738, 5739, V427
	570, 571
Diabetes without complications	2500, 2501, 2502, 2503, 2508, 2509
Diabetes with complications	2504, 2505, 2506, 2507
Paraplegia and hemiplegia	3341, 3440, 3441, 3442, 3443, 3444, 3445, 3446, 3449
	342, 343
Renal disease	40301, 40311, 40391, 40402, 40403, 40412, 40413, 40492, 40493
	5830, 5831, 5832, 5834, 5836, 5837, 5880, V420, V451
	582, 585, 586, V56
Cancer	2386
	140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 158, 159, 160, 161, 162, 163, 164, 165, 170, 171, 172, 174, 175, 176, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 200, 201, 202, 203, 204, 205, 206, 207, 208
Moderate or severe Liver disease	4560, 4561, 4562, 5722, 5723, 5724, 5728
Metastatic carcinoma	196, 197, 198, 199
AIDS/HIV	042, 043, 044