Evolution of Clinical Complexity, Treatment Burden, Healthcare Utilization, and Diabetes-Related Outcomes among Commercial and Medicare Advantage Beneficiaries with Diabetes in the U.S., 2006-2018

Abstract

<p> </p> <p><strong>Objective:</strong> To characterize trends in clinical complexity, treatment burden, healthcare utilization, and diabetes-related outcomes among adults with diabetes.</p> <p><strong>Research Design and Methods: </strong>A nationwide claims database was used to identify enrollees in commercial and Medicare Advantage plans who met claims criteria for diabetes between 01/01/2006 and 03/31/2019 and to quantify annual trends in clinical complexity (e.g., active health conditions), treatment burden (e.g., medications), healthcare utilization (e.g., ambulatory, emergency department [ED], and hospital visits), and diabetes-related outcomes (e.g., hemoglobin A1c [HbA1c] levels) between 2006 and 2018. </p> <p><strong>Results: </strong>Among 1,470,799 commercially-insured patients, the proportion with ≥10 active health conditions increased from 33.3% (95% CI 33.1%-33.4%) in 2006 to 38.9% (38.8%-39.1%) in 2018 (p=0.001), and the proportion taking ≥3 glucose-lowering medications increased from 11.6% (11.5%-11.7%) to 23.1% (22.9%-23.2%), (p=0.007). The proportion with HbA1c ≥8.0% (≥64 mmol/mol) increased from 28.0% (27.7%-28.3%) in 2006 to 30.5% (30.2%-30.7%) in 2015, decreasing to 27.8% (27.5%-28.0%) in 2018 (overall trend p=0.04). Number of ambulatory visits per patient/year decreased from 6.86 (6.84-6.88) to 6.19 (6.17-6.21), (p=0.001), while ED visits increased from 0.26 (0.257-0.263) to 0.29 (0.287-0.293), (p=0.001). Among 1,311,903 Medicare Advantage enrollees, the proportion with ≥10 active conditions increased from 51.6% (51.2%-52.0%) to 65.1% (65.0%-65.2%), (p<0.001), the proportion taking ≥3 glucose-lowering medications was stable at 16.6% (16.3%-16.9%) and 18.1% (18.0%-18.2%), (p=0.98), and the proportion with HbA1c ≥8.0% increased from 17.4% (16.7%-18.1%) to 18.6% (18.4%-18.7%), (p=0.008). Ambulatory visits per patient per year remained stable at 8.01 (7.96-8.06) and 8.17 (8.16-9.19), (p=0.23), but ED visits increased from 0.41 (0.40-0.42) to 0.66 (0.66-0.66), (p<0.001).</p> <p><strong>Conclusions: </strong>Patients with diabetes are becoming increasingly complex over time, have higher treatment burden, and experience more ED visits for potentially low acuity conditions.</p>