Starting insulin therapy in patients with type 2 diabetes: effectiveness, complications, and resource utilization

R. A. Hayward, W. G. Manning, S. H. Kaplan, E. H. Wagner and S. Greenfield
Veterans Affairs Center for Practice Management and Outcomes Research, Ann Arbor Veterans Affairs Medical Center, 48113-0170, USA. rhayward@umich.edu

CONTEXT: Although experimental studies show that insulin therapy can be safe and efficacious in improving glycemic control in type 2 diabetes under optimal conditions (ie, using patient volunteers with close monitoring under strict study protocols), little is known about its effectiveness, complication rates, and associated resource utilization in actual clinical practice. DESIGN: Cohort study. SETTING: Large staff-model health maintenance organization. PARTICIPANTS: A total of 8668 patients with type 2 diabetes cared for by generalist physicians from 1990 through 1993. OUTCOME MEASURES: Resource use (hospitalizations, outpatient visits, laboratory testing, and home glucose monitoring) and glycemic control were evaluated using combined clinical, survey, and administrative information systems data. Detailed clinical case-mix data, including a newly validated case-mix method, the Total Illness Burden Index, were collected on a subsample of 1738 patients. RESULTS: Among patients starting insulin therapy, hemoglobin A1c (HbA1c) decreased by 0.9 percentage point (95% confidence interval, 0.7-1.0) at 1 year compared with those receiving stable medication regimens; however, 2 years after starting insulin therapy, 60% still had HbA1c levels of 8% or greater. There was no evidence that some primary care physicians achieved better results than other primary care physicians when starting insulin therapy in their patients. Patients with the poorest baseline glycemic control achieved substantially greater HbA1c reductions; those with a baseline HbA1c level of 13% had a 3-fold greater decline in HbA1c than those whose baseline HbA1c level was 9%. For a subset of all patients for whom detailed clinical case-mix data were obtained, those taking insulin had higher resource use than those taking sulfonylureas, independent of illness severity. After adjusting for age, sex, race, socioeconomic status, disease duration, and severity of diabetes and comorbidities, insulin users had slightly more laboratory tests performed, 2.4 more outpatient visits per year, and almost 300 more fingersticks for home glucose testing per year compared with sulfonylurea users (all P<.01). Although 15% of patients receiving insulin therapy reported weekly symptoms of hypoglycemia, insulin therapy was not associated with an increase in emergency department visits (after case-mix adjustment) and resulted in only 0.5 hypoglycemia-related hospitalizations per 100 patient-years. CONCLUSIONS: For patients with type 2 diabetes who were cared for by generalist physicians, starting insulin therapy was generally safe and effective in achieving moderate glycemic control in patients who initially had poor glycemic control. However, insulin therapy was associated with increases in resource use and was rarely effective in achieving tight glycemic control, even for those with moderate control.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Efficacy and Safety of Colesevelam in Patients With Type 2 Diabetes Mellitus and Inadequate Glycemic Control Receiving Insulin-Based Therapy
Goldberg et al.
Arch Intern Med 2008;168:1531-1540.
ABSTRACT | FULL TEXT  

Does Physician Communication Influence Older Patients' Diabetes Self-Management and Glycemic Control? Results From the Health and Retirement Study (HRS)
Heisler et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2007;62:1435-1442.
ABSTRACT | FULL TEXT  

Mechanisms for Racial and Ethnic Disparities in Glycemic Control in Middle-aged and Older Americans in the Health and Retirement Study
Heisler et al.
Arch Intern Med 2007;167:1853-1860.
ABSTRACT | FULL TEXT  

Insulin Therapy for Maximal Glycemic Control in Type 2 Diabetes Mellitus
Spellman
JAOA: Journal of the American Osteopathic Association 2007;107:260-269.
ABSTRACT | FULL TEXT  

Social status, risky health behaviors, and diabetes in middle-aged and older adults.
Wray et al.
J. Gerontol. B Psychol. Sci. Soc. Sci. 2006;61:S290-S298.
ABSTRACT | FULL TEXT  

Use of a Glucose Algorithm to Direct Diabetes Therapy Improves A1C Outcomes and Defines an Approach to Assess Provider Behavior.
Miller et al.
The Diabetes Educator 2006;32:533-545.
ABSTRACT | FULL TEXT  

An Open, Randomized, Parallel-Group Study to Compare the Efficacy and Safety Profile of Inhaled Human Insulin (Exubera) With Metformin as Adjunctive Therapy in Patients With Type 2 Diabetes Poorly Controlled on a Sulfonylurea.
Barnett et al.
Diabetes Care 2006;29:1282-1287.
ABSTRACT | FULL TEXT  

Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting
Ziemer et al.
The Diabetes Educator 2005;31:564-571.
ABSTRACT | FULL TEXT  

Truths and Consequences
Ullman
DOC News 2005;2:15-15.
FULL TEXT  

A Real-World Approach to Insulin Therapy in Primary Care Practice
Hirsch et al.
Clin. Diabetes 2005;23:78-86.
FULL TEXT  

Insulin Analogues
Hirsch
NEJM 2005;352:174-183.
FULL TEXT  

A Direct Efficacy and Safety Comparison of Insulin Aspart, Human Soluble Insulin, and Human Premix Insulin (70/30) in Patients With Type 2 Diabetes
Bretzel et al.
Diabetes Care 2004;27:1023-1027.
ABSTRACT | FULL TEXT  

Glycosylated Hemoglobin, Cardiovascular, and Renal Outcomes in a Pharmacist-Managed Clinic
Cioffi et al.
The Annals of Pharmacotherapy 2004;38:771-775.
ABSTRACT | FULL TEXT  

Quality Improvement Initiatives: Issues in moving from diabetes guidelines to policy
Hayward et al.
Diabetes Care 2004;27:B54-B60.
ABSTRACT | FULL TEXT  

Effects of Health Maintenance Organization Coverage of Self-monitoring Devices on Diabetes Self-care and Glycemic Control
Soumerai et al.
Arch Intern Med 2004;164:645-652.
ABSTRACT | FULL TEXT  

Diabetes Diagnosis and Weight Loss in Middle-Aged Adults
Wray et al.
Research on Aging 2004;26:62-81.
ABSTRACT  

The Treat-to-Target Trial: Randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients
Riddle et al.
Diabetes Care 2003;26:3080-3086.
ABSTRACT | FULL TEXT  

Prevention and Treatment of Type 2 Diabetes Mellitus in Children, With Special Emphasis on American Indian and Alaska Native Children
Gahagan et al.
Pediatrics 2003;112:e328-e328.
ABSTRACT | FULL TEXT  

The Association between Three Different Measures of Health Status and Satisfaction among Patients with Diabetes
Kerr et al.
Med Care Res Rev 2003;60:158-177.
ABSTRACT  

Outpatient Insulin Therapy in Type 1 and Type 2 Diabetes Mellitus: Scientific Review
DeWitt and Hirsch
JAMA 2003;289:2254-2264.
ABSTRACT | FULL TEXT  

How Well Do Patients' Assessments of Their Diabetes Self-Management Correlate With Actual Glycemic Control and Receipt of Recommended Diabetes Services?
Heisler et al.
Diabetes Care 2003;26:738-743.
ABSTRACT | FULL TEXT  

Inhibition of Kv2.1 Voltage-dependent K+ Channels in Pancreatic beta -Cells Enhances Glucose-dependent Insulin Secretion
MacDonald et al.
J. Biol. Chem. 2002;277:44938-44945.
ABSTRACT | FULL TEXT  

Lifetime Costs of Complications Resulting From Type 2 Diabetes in the U.S.
Caro et al.
Diabetes Care 2002;25:476-481.
ABSTRACT | FULL TEXT  

Incorporating the Results of Diabetes Research Into Clinical Practice: Celebrating 25 years of Diabetes Research and Training Center translation research
Clark et al.
Diabetes Care 2001;24:2134-2142.
FULL TEXT  

Hypoglycemia in Patients With Type 2 Diabetes Mellitus
Miller et al.
Arch Intern Med 2001;161:1653-1659.
ABSTRACT | FULL TEXT  

Comprehensive Evaluation of Community-Based Diabetic Patients: Effect of feedback to patients and their physicians: a randomized controlled trial
Hiss et al.
Diabetes Care 2001;24:690-694.
ABSTRACT | FULL TEXT  

Impact of Automated Calls With Nurse Follow-Up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System: A randomized controlled trial
Piette et al.
Diabetes Care 2001;24:202-208.
ABSTRACT | FULL TEXT  

Effect of Improved Glycemic Control on Health Care Costs and Utilization
Wagner et al.
JAMA 2001;285:182-189.
ABSTRACT | FULL TEXT  

How Cost-Effective Is the Treatment of Dyslipidemia in Patients With Diabetes but Without Cardiovascular Disease?
Grover et al.
Diabetes Care 2001;24:45-50.
ABSTRACT | FULL TEXT  

Cost-Effectiveness of Treating Hyperlipidemia in the Presence of Diabetes : Who Should Be Treated?
Grover et al.
Circulation 2000;102:722-727.
ABSTRACT | FULL TEXT  

What Can We Do to Improve Physical Function in Older Persons With Type 2 Diabetes?
Caruso et al.
J. Gerontol. A Biol. Sci. Med. Sci. 2000;55:372M-377.
ABSTRACT | FULL TEXT  

Cost-Utility Analysis of Screening Intervals for Diabetic Retinopathy in Patients With Type 2 Diabetes Mellitus
Vijan et al.
JAMA 2000;283:889-896.
ABSTRACT | FULL TEXT  

Barriers to Control of Blood Glucose in Diabetes Mellitus
Dalewitz et al.
American Journal of Medical Quality 2000;15:16-25.
ABSTRACT  

Pharmacologic Therapy for Type 2 Diabetes Mellitus
DeFronzo
ANN INTERN MED 1999;131:281-303.
ABSTRACT | FULL TEXT  

The Unreliability of Individual Physician "Report Cards" for Assessing the Costs and Quality of Care of a Chronic Disease
Hofer et al.
JAMA 1999;281:2098-2105.
ABSTRACT | FULL TEXT  

Glycemic Control With Diet, Sulfonylurea, Metformin, or Insulin in Patients With Type 2 Diabetes Mellitus: Progressive Requirement for Multiple Therapies (UKPDS 49)
Turner et al.
JAMA 1999;281:2005-2012.
ABSTRACT | FULL TEXT  

Diabetes Care and Patient-Oriented Outcomes
Berger and Muhlhauser
JAMA 1999;281:1676-1678.
FULL TEXT  

Insulin Treatment for Type 2 Diabetes
Riddle et al.
JAMA 1998;279:1523-1526.
FULL TEXT  

IS INSULIN THERAPY EFFECTIVE FOR TYPE 2 DIABETES?
JWatch General 1997;1997:4-4.
FULL TEXT