Use of High-Cost Diabetes Drugs Varies Widely Across VA

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By Brenda L. Mooney

Despite a tightly managed national formulary, the use of high-cost drugs to treat diabetes shows “substantial” variation across the VA healthcare system, according to a new research letter.

The VA-funded report, published online by the Archives of Internal Medicine, notes that the adjusted percentage of patients with diabetes receiving oral medications who used a thiazolidinedione ranged from 1.4% at the lowest-using of 139 facilities to 25.4% at the highest. In addition, the adjusted percentage of patients receiving insulin who used long-acting analogues ranged from 4% percent to 71.2% across the VA.

Those results were surprising because, according to a research letter summary, “The Department of Veterans Affairs (VA), the largest integrated health care system in the United States, may serve as a model of efficient use of prescription drugs. It consistently ranks among the top of all US health care systems in objective ratings of quality of care for chronic diseases,and it does so with low medication costs. The VA negotiates steep price discounts with pharmaceutical manufacturers and engages in robust formulary management using a national formulary.”

The authors, led by Walid Gellad, MD, MPH, of the VA Pittsburgh Healthcare System, noted that while formularies “may exert powerful effects on medication choice,” they “can only go so far in standardizing healthcare delivery.”

Researchers looked at two classes of diabetes drugs — thiazolidinediones including rosiglitazone (Avandia) and pioglitazone (Actos) and long-acting insulin analogs such as detemir (Levemir) and glargine (Lantus) – and their use in 900,000 patients at VA clinics in 2009. Those patients received about 6.2 million prescriptions for type 2 diabetes during that time period, and researchers focused on drugs with relatively high cost and low certainty for improved outcomes.

According to the study, median use of thiazolidinediones was 8.2%, and median use of long-acting insulins was 40.6%.

The authors wrote that the variations are “likely driven by local physician norms or preferences about the use of newer drugs, which we were not able to measure.”

An invited commentary from Timothy Wilt, MD, MPH, of the Minneapolis VA, and Amir Qaseem, MD, PhD, of the American College of Physicians, said the findings show that there are “considerable challenges” to overcome in order to improve diabetes care.

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