BACKGROUND/AIMS: Many patients who would benefit from insulin therapy do not receive it or do not receive it in a timely manner. As such, clinical inertia is highly prevalent despite a key goal of T2DM treatment being achieving HbA1c control earlier and maintaining control longer. This study assessed treatment patterns and HbA1c control in a real world setting by evaluating patients with uncontrolled T2DM initiating treatment with basal insulin using a retrospective electronic medical record database.
MATERIALS AND METHODS: Patients with a T2DM diagnosis (ICD9CM codes 250.x0 or 250.x2) between 1/1/2007 and 12/31/2014, were identified in the GE Centricity database. Patients initiating basal insulin (date of first observed basal insulin record termed index date) and having an HbA1c test greater than 7% in the 6 months preindex date were identified. Patients were required to have 24 months preand 12 months postindex date physician history. Patients were stratified by duration of time with uncontrolled HbA1c (greater than 7%) before basal insulin initiation (i.e, less than 6, 612, 1218, 1824 months). Study measures included preand postindex date HbA1c and patient demographic and treatment characteristics.
RESULTS: A total of 37,053 patients met the inclusion criteria. Mean (SD) patient age and Charlson comorbidity index score was 60.4 (12.0) years and 1.0 (1.5), respectively, and 65.6% of patients received an oral antidiabetic agent in the 24 months before basal insulin initiation. Before initiating basal insulin, mean (SD) HbA1c was 9.5% (1.9), with 40.7% of patients uncontrolled less than 6 months, 15.3% uncontrolled 612 months, 16.0% uncontrolled 1218 months, and 28.0% uncontrolled 1824 months. There was little variation in baseline HbA1c by duration of time uncontrolled (range: 9.2% [1.7] for patients uncontrolled 612 months to 9.6% [1.8] for patients uncontrolled 1218 months). Patients with uncontrolled HbA1c <6 months had the largest change in HbA1c during followup (mean [SD] change in HbA1c of 1.2% [2.2], 62.3% had HbA1c less than 8%), while patients with uncontrolled HbA1c 1824 months had the smallest change in HbA1c during followup (mean [SD] change in HbA1c of 0.8% [1.8], 43.5% had HbA1c less than 8%). Despite improvements in HbA1c control during followup, only 20.3% of patients achieved HbA1c less than or equal to 7% and only 53.4% of patients achieved HbA1c less than or equal to 8%.
CONCLUSION: In a large clinical practice database, despite improvements in HbA1c following basal insulin initiation, over 46% of patients still had HbA1c greater than 8% during followup, with patients with the longest period of uncontrolled Hba1c during baseline the least likely to achieve HbA1c less than 8%. This study highlights a large unmet need in diabetes treatment and suggests there would be benefit from earlier introduction of basal insulin or alternative therapeutic options to assist patients in achieving HbA1c targets.
