American Diabetes Association
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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

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posted on 2022-08-04, 18:43 authored by Tyler J. Benning, Herbert C. Heien, Rozalina G. McCoy


Objective: To characterize trends in clinical complexity, treatment burden, healthcare utilization, and diabetes-related outcomes among adults with diabetes.

Research Design and Methods: 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. 

Results: 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).

Conclusions: Patients with diabetes are becoming increasingly complex over time, have higher treatment burden, and experience more ED visits for potentially low acuity conditions.


This effort was funded by the National Institute of Health National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK114497. Study contents are the sole responsibility of the authors and do not necessarily represent the official views of NIH.