Implementation of a Health Plan Program for Switching from Analogue to Human Insulin and Glycemic Control among Medicare Beneficiaries with Type 2 Diabetes

Abstract

Importance: Prices for newer analogue insulin products have increased. Lower-cost human insulin may be effective for many patients with type 2 diabetes. Objective: To evaluate the association between implementation of a health plan-based intervention of switching patients from analogue to human insulin and glycemic control. Design, Setting, and Participants: A retrospective cohort study using population-level interrupted times series analysis of members participating in a Medicare Advantage and prescription drug plan operating in 4 US states. Participants were prescribed insulin between January 1, 2014, and December 31, 2016 (median follow-up, 729 days). The intervention began in February 2015 and was expanded to the entire health plan system by June 2015. Exposures: Implementation of a health plan program to switch patients from analogue to human insulin. Main Outcomes and Measures: The primary outcome was the change in mean hemoglobin A 1c (HbA 1c ) levels estimated over three 12-month periods: preintervention (baseline) in 2014, intervention in 2015, and postintervention in 2016. Secondary outcomes included rates of serious hypoglycemia or hyperglycemia using ICD-9-CM and ICD-10-CM diagnostic codes. Results: Over 3 years, 14635 members (mean [SD] age: 72.5 [9.8] years; 51% women; 93% with type 2 diabetes) filled 221866 insulin prescriptions. The mean HbA 1c was 8.46% (95% CI, 8.40%-8.52%) at baseline and decreased at a rate of -0.02% (95% CI, -0.03% to -0.01%; P <0.001% [95% CI, -0.008% to 0.010%]) of mean HbA 1c compared with the intervention period (P =.09 and P = 0.81, respectively). For serious hypoglycemic events, there was no significant association between the start of the intervention and a level (2.66/1000 person-years [95% CI, -3.82 to 9.13]; P =.41) or slope change (-0.66/1000 person-years [95% CI, -1.59 to 0.27]; P =.16). The level (1.64/1000 person-years [95% CI, -4.83 to 8.11]; P =.61) and slope (-0.23/1000 person-years [95% CI, -1.17 to 0.70]; P =.61) changes in the postintervention period were not significantly different compared with the intervention period. The baseline rate of serious hyperglycemia was 22.33 per 1000 person-years (95% CI, 12.70-31.97). For the rate of serious hyperglycemic events, there was no significant association between the start of the intervention and a level (4.23/1000 person-years [95% CI, -8.62 to 17.08]; P =.51) or slope (-0.51/1000 person-years [95% CI, -2.37 to 1.34]; P =.58) change. Conclusions and Relevance: Among Medicare beneficiaries with type 2 diabetes, implementation of a health plan program that involved switching patients from analogue to human insulin was associated with a small increase in population-level HbA 1c .