Video Applying Sensor-Based Glucose Monitoring (CGM) to Reduce Cost-Intensive, Adverse Drug Events Associated with Diabetes Treatment - Eric Cannon, PharmD Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides Error loading media: File could not be played 00:0000:0000:0000:00 Applying Sensor-Based Glucose Monitoring (CGM) to Reduce Cost-Intensive, Adverse Drug Events Associated with Diabetes Treatment - Eric Cannon, PharmD Overview TranscriptChapters CONTINUE TO TEST Back to Symposium Hi, my name's ERic Cannon. Uh Chief pharmacy Officer with Select Health and Intermountain Healthcare in Salt Lake City Utah. And today I'm going to be talking about applying sensor based glucose monitoring to reduce cost intensive adverse drug events and how it's associated with treatment. In my in my regular job we manage the pharmacy benefits and the PBM services for over a million members that are associated with Select Health and Intermountain Healthcare. So this topic is one that is very pertinent for us today. And even we'll review some literature research that was done at Intermountain Healthcare as part of this presentation. So, to set the stage, let's talk a little bit about the epidemiology of diabetes. Uh 9.3 of the population have diabetes. Uh the number that's always amazing to me is, there's about 8.1 million people that are undiagnosed. If we break that down and look at it in terms of type one diabetes, that's about 1.25 million people. But we're gonna talk about some of the the adverse events or adverse impacts of diabetes. It's the leading cause of kidney failure. Ah It's the leading cause of new cases of blindness among adults. It's a major cause of heart disease and stroke And it's the 7th leading cause of death. So, if we break this down and look at the complications of diabetes, you can see on this side we've got hypertension, hyper epidemiologic heart disease and stroke, blindness, renal disease and amputations. On the next couple slides. I'm going to go into detail a little bit more on some of the research and what I'm trying to do is set the stage as we look at the data behind continuous glucose monitoring. What are the real benefits and what are the adverse events were trying to avoid? So let's start with heart disease, stroke hypertension. Uh, You know, 71 of people diagnosed greater than over the age of 18 Had blood pressure of 140 over 90. Um, we're we're in the process of using blood pressure medications. This is old data from 2009 to 2012, but very relevant today. Uh, these same numbers hold true. If we were to look at additional studies, if we look at cardiovascular death rates, It's about 1.7 times higher among adults Age 18 and older. There have been diagnosed with diabetes compared to peers that had not been diagnosed with diabetes. And then if we look at the hospitalization rate for heart attack, it's 1.8 times higher, uh Stroke 1.5 times higher. You get the idea that along with diabetes comes an increased risk of of all of these cardiovascular problems. If we look at blindness, as I mentioned early on, it's the leading cause of new cases of blindness among adults ages 20-74. Uh, if you look at the number of people greater than 44.2 million had diabetic retinopathy. Again, old numbers 2005-2008. But again, very relevant. Uh today, as we look at this, uh, and then if you look at this, 4.4 of those with diabetes had advanced diabetic retinopathy that could lead to severe vision loss. Let's talk about renal disease. And again, you know, another area where diabetes is the leading cause of something and in this instance it's kidney failure. We've got 49,000 people, a little more than that with diabetes that are beginning treatment for end stage renal disease each year. And then of 228,000 people with the Srd due to diabetes were living on chronic dialysis. And you know, you think about that impact. My wife ran into someone in the neighborhood this morning who said her husband was on dialysis at home. And sometimes we don't think it's around us, it's all around us. And I think, you know, one of those things that really has a true impact in our lives. If we look at the death rate among people with diabetes, seventh leading cause of death, uh you know, interestingly, 234,000 of those it was a contributing cause. But 69,000, almost 70,000 diabetes was the underlying cause of death. Ah You know, we know this is probably under reported and then uh the risk of death among those with diabetes is about twice that of people with a similar age. But without diabetes, let's talk about the economics here. You know, total cost of diabetes annually is about $245 billion. 100 and 76 billion of that is in direct medical costs. So that's hospitalizations, emergency care medications, office visits, all of those things run into work into that direct medical costs. We've got about $70 billion dollars in direct in direct medical costs. So that's things like absenteeism, reduced productivity or unemployment. So, uh, if we really look at the cost, it is enormous. Uh where do those costs breakout? Uh Initially in this study, that was done by the american diabetes Association, um, Inpatient care or hospitalizations were 43 of the costs. The number that was surprising to me, retail prescriptions, where 18 of the cost. I've seen some numbers now that that 43 has come down a little bit in terms of hospitalizations and the cost of medications has gone up again. Diabetic medications and supplies physician office visits. You can see the breakdown here on the screen. So what are the costs incurred by people that have a diagnosis of diabetes? Well average and annual expenditures. And again this is an older study. But the numbers still proportionately are true. Almost $14,000 in annual expenses with almost 8000 of that directly attributed to diabetes. Uh More than one in five healthcare dollars in the U. S. Goes to care for people that have been diagnosed with diabetes. If you think about that one in five sounds like a lot 20 of our health care costs are going to treat people with diabetes. So what are some of the predictors of cost? And I think this is one of those things that is, we talk about a disease state in order to really understand the benefits we may receive in treating that. What are the other things that help predict what the costs are? Um If in looking at a multi variant analysis, almost 1700 adults with diabetes for people that had coronary heart disease or hypertension, Their costs were increased by 300%. So $47,000 versus the $14,000. We talked about previously, depression costs increased by 50%. 31 32,000 versus 21. And then patients that had a baseline a one seat less than six Had costs 11 below patients with the baseline a one c of 10. And so we've got one more slide here. We'll look at in terms of what is the impact of a percent change in A one C. But you can clearly see it here. Um You know, people that have an in control a one c their costs 11 less than somebody that's not in control. So took this from the American diabetes Association's standards of medical care in diabetes. And it's really what is the assessment of glycemic control. And 2017 the D. A. Said there were two primary techniques available to patients and providers that was self monitoring of blood glucose and A one C. At the time. They said continuous glucose monitoring may have an important role assessing the effectiveness and safety of treatment in selected patients. Um That's from 2017 and I'm sure you know, things from the American Diabetes Association are progressing with continuous glucose monitoring picking up more and more favor. And I think as we look at the numbers, we'll see why that is happening. So maybe to remind you. And this is an old old data came out right after I got out of pharmacy school. That A long time ago. But uh really looking at what's the impact of a one change in a one c. And you can kind of see the breakdown here between patients. So Mean charge per patient without complications. A one c. of six uh $8600. Mean charged per patient with complications. Almost $3900. Again that's at that A one C. Of six. But then take a look at it down at 10%. You can see that number is now pushing $12,000 instead of 8500. And in the case of complications instead of being $3,900 or $39,000, it's almost $49,000. So clearly we know and you know, it's just kind of a common reminder for all of us that As we lower a one C, those costs reduce along with it. So let's take a look now at the value of continuous glucose monitoring this meta analysis. Looking at the change in A one C. They're comparing continuous glucose monitoring to self monitoring. They're looking at it in Children, adolescents and adults all with type one diabetes. And you can see here that uh in Children and adolescents at the study, the analysis favorite continuous glucose monitoring in adults again favored using continuous glucose monitoring And then in adults with compliance greater than 60%. Again favored continuous glucose monitoring. And I think, you know, being able to see continual drop in those numbers as we go down. Let's take a look at the effect of continuous glucose monitoring. This is on a one C. We've got 100 and 58 patients that were randomized to continuous glucose monitoring or usual care. So 105 in that C. G. M. Category 53 unusual care. Uh Looking at the C. G. M. Population, they had a baseline of 8.6. Actually both populations in this study had a baseline of 8.6 C. G. M. User saw a drop to 7.6 on their A. One C. And this is at 12 weeks. Uh And the usual care group also saw a drop but not as significant as we've seen with the continuous glucose monitoring group. Let's take this a little bit further. One of the things they did in this study was to look at the minutes per day That an individual is in a range that would be considered control. So 70 to 180 baseline for the continuous glucose group. They were at 660 minutes per day that they were in the range of being controlled. The usual care group was at 650 minutes. But after 12 weeks in 24 weeks. And this is a pooled analysis of both 12 and 24 weeks. You can see That number jumps up to 736 minutes per day that are actually in range. And in the usual care group they stayed flat At that 650 minute number. Now the other I guess measure here would be to say are we preventing adverse effects or acute events in terms of hypoglycemia? And so again they looked at minutes per day with a blood glucose of less than 70. Um You can see that it was 65 minutes less than 70. And the C. G. M. Group 72 before and then after the CGM group dropped from 65 to 43 minutes. So a significant drop in the amount of minutes spent in that hypoglycemic range, whereas the usual care group actually saw an increase from 72 to 80 minutes. Uh in terms of having those high folklife Simic events. Yeah. So let's look at this and you know, initially most of the studies we've looked at here have been in Type one diabetics. Uh we know that type ones represent about five of the diabetic population. So let's let's take a look at the other 95 of the population. Ah No surprise the numbers are very similar here. You know, they were looking at a baseline compared to day 215 to 230. Uh Somewhere in there you can see a one C. For the continuous glucose group dropped from 8.6 to 8.2. Uh The usual care group actually saw an increase. Not much of an increase 8.6 to 8.7. But there was an increase. Uh I think the important piece here that really came out of this though was severe hypoglycemia only happened in one control group patient. And at the end of the day, there was no difference in advance Where glucose was less than 70. They didn't see any diabetic ketoacidosis, they didn't see any hyper ice, smaller, high broke lives hyperglycemia either. So uh I saw some improvements, but then some of those other things that we would have been looking to see, you know, in terms of severe hypoglycemia, really didn't see any differences. This is the study I mentioned early on, that was done by Intermountain Healthcare uh was published this last fall in september, was published online. Ah One of the things they looked at was what are the what are the limitations of past research? As I mentioned, there was a heavy focus on the Type one diabetics. We know most of our population were treating as Type two. There was limited evaluation in terms of an integrated delivery network. And so, you know, there's a lot of things that come with an integrated delivery network. So along with that is data. We can talk about the clinical impact on care. We can talk about utilization, we can measure cost all at the same time. Uh This research was not focused on patients greater than 65 although there were patients that were greater than 65. And we'll talk about that uh Medicare advantage population here. When we look at the results, you see 99 patients enrolled uh in the continuous glucose. And excuse me, there are 99 patients enrolled, 50 on c. g. m and 49 on self monitoring. Uh of that, 99 patients, 93 of them had type two diabetes and six had type one. So what were the results? Well, both groups saw a reduction in their A. One C. S. The C. G. M. Arm, 0.6% reduction in A one C. The self monitoring arm reduction of minus one, Remind us .1. That was significant. One of the things though that was interesting to me was in the C. G. M. Arm. The odds of experiencing a glycemic excursion event Uh were reduced by 5.15 every 30 days. So this is a reduction of 5.1 every 30 days month over month. And at some point I would assume that bottoms out. But interesting finding there. So in terms of these events, what did it mean In terms of the data, you can see that any visit at all within the integrated delivery network? Mm hmm. The C. G. M. Group finished 56 visits During the period of the study versus the self monitoring group. That was at seven. You can see primary care visits just above, just below two versus three in the self monitoring specialty visits. 2.6 in the continuous glucose arm, 3.2 in the self monitoring E. D. visits were reduced, labs ordered were reduced. So um this is where that kind of point about the Medicare advantage members comes in uh what we saw was $417 per member per month, reduction in expense for the non Medicare advantage members. And that was the bulk of the study. And so for each member in the study, we saw a monthly reduction of $417 ah In looking at the Medicare advantage population though, we did see an increase in cost, but it was a very small, modest increase of cost just among those patients using uh C. G. M. S. Or self monitoring. So if you were to spread that across the population, probably knowing cost impact at all one way or the other, let's take a look here at another set of data retrospective real world study Looking at just over 2400 patients with type two diabetes that were on either short or rapid acting insulin. So focusing on the more severe type two population, they measured six months before they went on to see GM. In six months after they went on a C. G. M. And they were looking at acute diabetic related events. And they were looking at reductions in all cause inpatient hospitalization. If we break down what were those acute events, they were hypoglycemia, hypoglycemic coma, clinical hyperglycemia, diabetic ketoacidosis and hyper osmolarity. So that's the breakdown of what they were measuring. When we see where the results actually came out. Those adverse events from diabetes decreased From 0.18 events per patient per year At 0.072 with a P value less than .001. If we look at the hospitalization rate I'll cause hospitalization again it decreased from .42 events per patient per year down to point to a three against significant at .001. So let's talk quickly about the cost effectiveness. Uh One of those things that I think we all focus on uh and this is you know making some assumptions that A. C. G. M. Is cost effective at threshold of $100,000 per quality. Um In looking at it uh In those patients that have an A one c. Greater than seven, we can expect a reduction of about .53 in that a one c. The Icer 6 98,079 per quali. There was a large degree of uncertainty in this population uh definitely saw some adjustments that included improvements in quality of life, improvements in glucose control and reductions in microvascular complications. If we look at that population that already had an A. One C that we would consider to be in control, uh they were able to maintain an A one C. At 6.5. Uh and in this population the iceberg was $79,000 per quality adjusted life year. The confidence intervals were much narrower but still reflect some level of uncertainty. And you know, if it was really limited to preventing long term effects, if we're looking to see James to prevent long term effects Uh that icer would exceed $700,000 per falling. Um Maybe to put that into perspective a little bit. So if we look at this and uh this is from the American diabetes association. Uh they're looking at two different trials the diabetes control and complications trial or the D. C. C. T. Uh Where the trend towards lower risk of C. D. S. Cardiovascular events with intensive control. Uh In the post year nine year post follow on from D. C. C. T. You can see that there was a 57% reduction in the risk of non fatal and my stroke or cardiovascular death. I think you know that follow on is really important because D. C. T. T. S. Told us There was a trend towards lower cardiovascular events. But when they followed up after nine years, there definitely was at a 57 reduction. So in conclusion diabetes will continue to have significant clinical and economic consequences. And as we work to manage the cost of our population, deliver improved outcomes. Uh diabetes will be one of those things that we need to focus on the costs along with morbidity and mortality or increased in patients with uncontrolled glucose levels. So anything we can do to improve those as something we want to do and then looking at continuous glucose monitoring. It offers an opportunity in selected patients to improve their glucose control, something that we believe in strongly and we continue to put uh more patients onto the C. G. M. S. And at the same time making sure this is the appropriate patient to go onto the product. That's the end of my presentation and thank you very much. Published April 9, 2021 Created by Related Presenters Eric Cannon, PharmD, FAMCP Chief Pharmacy Benefits OfficerSelectHealthSalt Lake City, Utah
