Medstat MercuryMD Micromedex PDR Solucient THOMSON HEALTHCARE DIFFERENCES IN HEALTHCARE UTILIZATION AND EXPENDITURES AMONG TYPE 2 DIABETES MEDICARE PATIENTS INITIATING ANALOG AND HUMAN INSULINS Margolis JM 1, Chu BC 1, Johnson B 1, Forma F 2, Alemayehu B 3 1 Thomson Healthcare, Ann Arbor, MI, USA 2 Novo Nordisk, Princeton, NJ, USA 3 Novo Nordisk, Princeton, NJ, USA (at time of study)

2 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Study Rationale Increases in glycemic control have been found with adjunctive insulin therapy in type 2 diabetes (T2D) Trends show use of adjunctive insulin therapy in T2D has been growing in the US. Researchers have been investigating whether these findings varied by type of insulin therapy used.

3 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Study Objective To compare the differences in direct healthcare utilization and expenditures among Medicare recipients with T2D initiating analog insulin versus human insulin.

4 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Methods Patient selection Total Medicare N = 3,887,712 ≥2 insulin Rxs in 180 days + Diabetes diagnosis n = 140,840 (3.6%) Enrolled 12 mos. pre & post Medical & Rx benefit n = 66,946 (47%) Type 2 diabetes only n = 17,171 (98%) Insulin naïve preindex n = 17,521 (26%) Analog only n = 8,991 (52%) Human only n = 5,015 (29%) Both n = 3,165 (19%)

5 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Methods Data source –2001–2006 MarketScan® Medicare Supplemental and Coordination of Benefits Database (Thomson Healthcare) Healthcare utilization and expenditures –Dependent variables included total, inpatient, ER, outpatient, and Rx –All-cause and diabetes-related –Compared treatment groups for pre-index and post-index periods. Generalized multi-valued propensity score weighting –To control for observable differences in distributions of pretreatment variables among treatment groups. Effects of covariates were modeled with generalized linear models.

6 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Descriptive Results Table 1. Patient Demographic and Clinical Characteristics *Newly treated patients were defined as having no pharmacy claim for any antihyperglycemic medication during the 12-month pre-index period. Analog InsulinHuman InsulinP-value Number of patients8,9915,015 % Female <0.001 Mean age (SD)73.2 (6.4)74.7 (6.8)<0.001 % Newly treated* <0.001 % Insurance Type Indemnity HMO POS PPO Other <0.001 Mean Deyo-Charlson Comorbidity Index Score (SD) 2.50 (1.92)2.78 (2.10)<0.001

7 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Descriptive Results Table 1. Patient Demographic and Clinical Characteristics *Newly treated patients were defined as having no pharmacy claim for any antihyperglycemic medication during the 12-month pre-index period. Analog InsulinHuman InsulinP-value Number of patients8,9915,015 % Female44.5%49.5%<0.001 Mean age (SD)73.2 (6.4)74.7 (6.8)<0.001 % Newly treated*8.5%25.6%<0.001 % Insurance Type Indemnity HMO POS PPO Other 69.9% 9.0% 2.3% 18.2% 0.6% 58.7% 17.7% 4.0% 19.1% 0.4% <0.001 Mean Deyo-Charlson Comorbidity Index Score (SD) 2.50 (1.92)2.78 (2.10)<0.001

8 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Descriptive Results Table 2. Unadjusted Mean Healthcare Utilization over 12-month Follow-up Period Analog InsulinHuman Insulin MeanS.D.MeanS.D.p-value Inpatient visits <0.001 Length of stay (days) <0.001 Emergency visits Office visits <0.001 Clinic visits Other O/P claims Analog insulin patients had overall lower all-cause healthcare utilization in the follow-up period, except for office visits.

9 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Descriptive Results Table 3. Unadjusted Mean Expenditures over 12-Month Follow-up Period Analog InsulinHuman Insulin MeanS.D.MeanS.D.P-value Total costs $17,002 $33,309 $18,747 $54, Total diabetes-related $3,909 $10,187 $3,482 $16, Inpatient visits $3,805 $16,738 $5,069 $34, Inpatient diabetes-related $970 $7,704 $1,305 $14, Emergency visits $162 $1,159 $184 $1, Office visits $703 $1,105 $592 $1,159<0.001 Clinic visits $23 $165 $26 $ Other O/P services claims $6,630 $24,198 $8,109 $32, Index Rx $629 $722 $327 $1,137<0.001 Other Diabetes-related Rx $1,130 $1,442 $707 $1,603<0.001 All non-index Rx $5,213 $5,837 $4,624 $7,834<0.001

10 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Descriptive Results Inpatient visits, length of stay, and ER visits were significantly lower for analog insulin patients, however the number of office visits was significantly higher for analog patients. Analog insulin patients had significantly lower total all-cause costs in the postindex period. Postindex diabetes-related costs were higher for analog patients, possibly attributable to the higher drug-related expenditures. Inpatient costs as well as other outpatient services were lower for analog patients. Office visit costs were higher for analog patients.

11 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Multivariable Analysis Multivariable analysis of the postindex costs was performed to control for effects of patient age, gender, geographic region, treatment onset (newly treated vs. continuing), insurance type, and preindex comorbidity (Deyo-Charlson comorbidity index scores). Focused on total costs, inpatient costs, and prescription costs (all-cause and diabetes-related)

12 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Multivariable Analysis Figure 1. Adjusted Mean Total Healthcare Costs for 12-Month Follow-Up Period

13 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Multivariable Analysis Figure 2. Adjusted Mean Inpatient Costs and Rx Costs for the 12-Month Follow-Up Period

14 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Multivariable Analysis Post-treatment all-cause total costs were not significantly different between analog and human subjects, however post-treatment diabetes-related costs were lower for human insulin patients. Analog patients had significantly lower inpatient costs, both all-cause and diabetes-related, while having significantly higher prescription costs (both all-cause and diabetes-related) compared to human insulin patients, consistent with descriptive results.

15 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Discussion Patients with T2D using adjunctive insulin showed different baseline characteristics depending on whether they were started on analog insulin or on human insulin. –Treatment groups’ differences at baseline could be contributing to differences seen during analysis of the post-treatment outcomes metrics. Health care resource utilization was generally lower for analog patients, except for office visits. After controlling for covariates, total all-cause healthcare costs were not found to be significantly different between these treatment groups. Inpatient costs, both all-cause and diabetes-related, were lower for analog patients. Prescription and office visit costs were higher for analog patients.

16 THOMSON HEALTHCARE ©2007 Thomson Healthcare. All rights reserved. Medstat MercuryMD Micromedex PDR Solucient Discussion Questions & comments Thank you !!