The goal in the treatment of diabetes is normalization of blood glucose, and reduction Patients with type 1 diabetes require insulin …
April 2006
2002-2005 Trends
In the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Study Authors: Emily Cox, PhD; Doug Mager; Andy Behm, PharmD; and Steve Miller, MD
MEMBER CLINICAL ECONOMIC
EVIDENCE-BASED
PHARMACY BENEFIT DESIGN
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Introduction
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Based upon 2003-2004 estimates of the annual prevalence of diabetes mellitus in children, 32 out of every 1,000 children had the disease1 This is an increase from the estimated annual prevalence of 26 in 20022 An increase in the prevalence of type 2 diabetes is believed to be a contributing factor to the increase in diabetes overall Until recently, type 2 diabetes was considered a condition that affected adults only In fact, the condition was previously classified as adult-onset diabetes due to its typical presentation in middle-aged and older adults While nationally representative estimates of the prevalence of type 2 diabetes in children and adolescents do not currently exist, smaller regional studies suggest that type 2 diabetes is becoming more common among
children, particularly in certain ethnic groups such as Native Americans, African Americans and Hispanic/Latino Americans3,4,5,6 Summaries of these and other similar studies report that 8 to 45 of children in the US with diabetes have nonimmune-mediated diabetes predominately type 27 The goal in the treatment of diabetes is normalization of blood glucose, and reduction of the risk of acute and chronic complications associated with diabetes Type 1 diabetes is an autoimmune disorder where the bodys immune system destroys the insulin-producing beta cells in the pancreas, generally resulting in an absolute deficiency of insulin Type 2 diabetes is characterized by insulin resistance the bodys inability to use insulin efficiently and a relative lack of insulin production Patients with type 1 diabetes require insulin injections, while some patients with type 2 diabetes can control their condition by following a healthful diet and exercise program However, many patients with type 2 diabetes also require drug therapy for glycemic control, including agents that stimulate insulin production Patients with type 2 diabetes may also require insulin in addition to oral agents that stimulate
insulin production to maintain glycemic control A distinction between type 1 and type 2 diabetes can be made based upon the pattern of drug therapy Patients with type 1 disease would require insulin but would not be treated with agents that stimulate insulin production, since the pancreas no longer produces insulin Given that and the fact that prescription claims data have been shown to be a reliable, valid measure of actual drug exposure,8,9 these data could be used to better understand the usage patterns of type 1 versus type 2 diabetes in children Therefore, the purpose of this study is to add to the current understanding of diabetes in children by profiling the prevalence of and trends in antidiabetic prescription use, including distinction between type 1 and type 2 treatment, within a sample of commercially insured children from 2002 through 2005
The purpose of this study is to add to the current understanding of diabetes in children by profiling the prevalence of and trends in antidiabetic prescription use
1
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Methods
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Prevalence
of antidiabetic prescription use in children was estimated from 2002 to 2005 using a database containing ambulatory administrative pharmacy claims and eligibility information for children enrolled with Express Scripts through commercial health plans Express Scripts is one of the largest pharmacy benefit management PBM companies in North America, providing PBM services to more than 50 million members Express Scripts serves thousands of client groups, including managed care organizations, insurance carriers, employers, third-party administrators, public sector and union-sponsored benefit plans Plan sponsors selected for the study sample in each year were private-sector and public-sector employer groups, managed care organizations, third-party administrators and unions Clients included in the analysis offered integrated Home Delivery and retail pharmacy benefits within an employer-based market ie, no Medicare or Medicaid, and offered a subsidized prescription benefit ie, no 100 copayments Prevalence was calculated quarterly by dividing the number of children age 5 years to 19 years with at least one antidiabetic prescription claim by the number of enrolled children age 5 years to 19
years sum of months that children were eligible for prescription benefits during the quarter divided by 3 Estimates of prevalence were calculated overall and for three age categories: age 5 years to 9 years, age 10 years to 14 years, and age 15 years to 19 years Age was calculated as of the beginning of each quarter Overall prevalence of use was calculated in addition to prevalence categorized by type 1 or type 2 usage The following decision rules were used to designate type 1 and type 2 antidiabetic prescription use: Type 1 treatment — Patients receiving insulin monotherapy or insulin in combination with pramlintide were defined as having type 1 diabetes Insulin and pramlintide can be used by patients with either type 1 or type 2 diabetes; however, utilization of these agents in the absence of oral antidiabetics and exanatide is more suggestive of treatment for type 1 diabetes, particularly in a younger population Type 2 treatment — Patients receiving an oral antidiabetic agent or exanatide with or without insulin or pramlintide were categorized as having type 2 diabetes The oral antidiabetics and exanatide are indicated for patients with type 2 diabetes, and are not approved
for use by patients with type 1 diabetes The proportion of all children with an antidiabetic prescription claim indicative of type 2 treatment was also estimated overall and by age group
Estimates of prevalence were calculated overall and for three categories: age 5 years to 9 years, age 10 years to 14 years, and age 15 years to 19 years
2
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Methods Continued
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
The quarterly trend in antidiabetic prescription use from 2002 to 2005 was estimated using time series analysis controlling for first order autocorrelated errors using AREG in SPSS The total increase in prevalence over the four-year period was estimated by multiplying the slope coefficient for quarter in the regression equation by 16 four quarters per year x four years The percent change in prevalence of use from Q12002 through Q42005 was estimated by dividing the overall increase in prevalence from 2002 to 2005 by the intercept term from the regression equations The intercept term represents the base-line or beginning value
3
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Reserved
Results
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
The average number of children enrolled each year ranged from 37 million to 43 million Across all years, a slightly greater proportion of children were in the age 15 years to 19 years and age 10 years to 14 years groups, compared with the age 5 years to 9 years group Table 1 Table 1
Average Annual Enrollment by Age Group by Year: 2002-2005
Age Group 5 yrs-9 yrs 10 yrs-14 yrs 15 yrs-19 yrs Total
2002 1,153,258 1,305,804 1,268,826 3,727,888
2003 1,206,588 1,384,806 1,351,826 3,943,220
2004 1,291,247 1,492,070 1,490,606 4,273,922
2005 1,312,760 1,493,941 1,526,643 4,333,344
Overall Prevalence of Antidiabetic Use Quarterly prevalence of antidiabetic prescription use per 1,000 child beneficiaries is profiled in Figure 1 The highest overall prevalence of use from 2002 to 2005 occurred in children age 15 years to 19 years where quarterly prevalence of prescription use grew from approximately three per 1,000 15 to 19 year olds to four per 1,000 The prevalence of use among those age 15 years to 19 years was three times the rate seen in children age 5 years to 9 years,
and 15 times that of children age 10 years to 14 years Across all age groups, total prevalence of antidiabetic prescription use grew by 080 per 1,000 child beneficiaries or a 41 increase in antidiabetic prescription use over this four-year time period Table 2 Using 2004 US Census population estimates of the number of children age 5 years to 19 years10 and assuming 60 of children receive health coverage through the employer market or purchased individually,11 this equates to a growth of approximately 28,642 additional commercially insured children being treated with antidiabetic medication from 2002 to 2005 In addition to having the highest overall prevalence of use, older teens age 15 years to 19 years also had the highest rate of growth at 118 per 1,000 15 to 19 year olds — a 41 increase over the four-year study period
Across all age groups, total prevalence of antidiabetic prescription use grew by 080 per 1,000 child beneficiaries or a 41 increase in antidiabetic prescription use over this four-year time period
4
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Results Continued
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19
Years
Figure 1
Quarterly Prevalence of Any Drug Therapy per 1,000 Child Beneficiaries 5 years to 19 years: 2002 to 2005
450 400 350 300 250 200 150 100 050 000
0 20 1 2Q 0 20 2 2Q 0 20 3 2Q 0 20 4 2Q 0 20 1 3Q 0 20 2 3Q 0 20 3 3Q 0 20 4 3Q 0 20 1 4Q 0 20 2 4Q 0 20 3 4Q 0 20 4 4Q 0 20 1 5Q 0 20 2 5Q 0 20 3 5Q 0 20 4 5Q
5-9
10-14
15-19
Total
See Appendix A for actual number
Table 2
Growth in the Prevalence of Antidiabetic Use per 1,000 Commercially Insured Children and Percent Change in Prevalence of Use Among Children Age 5 Years to 19 Years From 2002 to 2005
Estimated growth in the prevalence of antidiabetic medication use from 2002 to 2005
5 yrs-9 yrs Total Type 1 Type 2 0320 0320 0000 10 yrs-14 yrs 0720 0496 0224 15 yrs-19 yrs 1184 0576 0656 Total 0800 0496 0320
Percent change in the prevalence of use from 2002 to 2005
5 yrs-9 yrs Total Type 1 Type 2 337 364 00 10 yrs-14 yrs 372 290 1062 15 yrs-19 yrs 406 257 1023 Total 410 305 1036
5
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Results Continued
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Type 1 Antidiabetic Prescription Use From 2002 to 2005, all age groups
showed increases in the prevalence of type 1 antidiabetic prescription use, ranging from 26 among age 15 years to 19 years, up to 36 among children age 5 years to 9 years Table 2 The overall rate of growth in type 1 usage was 31, or an increase of 050 per 1,000 child beneficiaries Extrapolated, this equates to an additional 17,990 commercially insured child beneficiaries being treated for type 1 diabetes from 2002 to 2005 Again, the rate of use is highest in the age 15 years to 19 years category, with rates of use over two times that seen in the age 5 years to 9 years group and rates approximately 13 times that of the age 10 years to 14 years group Figure 2
Figure 2
Quarterly Prevalence of Type 1 Antidiabetic Drug Therapy per 1,000 Child Beneficiaries 5 years to 19 years: 2002 to 2005
300 250 200 150 100 050 000
2Q 2 Q3 Q4 Q1 Q1 Q1 Q2 Q3 Q4 04 Q2 20 04 Q3 20 04 Q4 20 05 Q1 20 05 Q2 20 05 Q3 20 05 Q4 02 02 03 02 03 20 0 03 03 04 20 20 20 20 20 20 20 20 20
From 2002 to 2005, all age groups showed increases in the prevalence of type 1 antidiabetic prescription use, ranging from 26 among age 15 years to 19 years, up to 36 among children age 5 years to 9
years
5-9
10-14
15-19
Total
6
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Results Continued
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Type 2 Antidiabetic Prescription Use The prevalence of type 2 prescription use in children was lower overall compared to type 1 prevalence However, the prevalence of type 2 usage grew at a much greater rate The percent of children taking medication indicating type 2 diabetes increased more than 100 — an overall increase of 032 children per 1,000 child beneficiaries from 2002 to 2005 Table 2 Teenagers age 15 years to 19 years again had the highest overall prevalence of use, and children 5 years to 9 years had the lowest Figure 3 The increase in the prevalence of treatment of type 2 diabetes is much more pronounced among preteens and teens, where quarterly prevalence of use increased more than 100 from 2002 to 2005 The overall growth in prevalence of type 2 treatment, together with population estimates of children commercially insured, suggests that an estimated additional 11,512 children began therapy indica 
tive of type 2 treatment from 2002 to 2005
The increase in the prevalence of
treatment of type 2 diabetes is much more pronounced among preteens and teens, where quarterly prevalence of use increased more than 100 from 2002 to 2005
Figure 3
Quarterly Prevalence of Type 2 Antidiabetic Drug Therapy per 1,000 Child Beneficiaries 5 years to 19 years: 2002 to 2005
140 120 100 080 060 040 020 000
0 20 1 2Q 0 20 2 2Q 0 20 3 2Q 0 20 4 2Q 0 20 1 3Q 0 20 2 3Q 0 20 3 3Q 0 20 4 3Q 0 20 1 4Q 0 20 2 4Q 0 20 3 4Q 04 20 Q4 05 20 Q1 0 20 2 5Q 05 20 Q3 05 20 Q4
5-9
10-14
15-19
Total
7
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Results Continued
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Proportion of Use for Type 2 Treatment The overall percent of antidiabetic prescription use that was suggestive of type 2 diabetes is presented in Figure 4 The proportion of type 2 usage overall increased from approximately 17 in 2002 to 23 in 2005 In 2002, within the age group 15 years to 19 years, 24 of those taking antidiabetic medications appeared to be using it for the treatment of type 2 diabetes This proportion grew to 31 in 2005 For preteens age 10 years to 14 years, the growth in the proportion of usage indicating
type 2 treatment grew from 12 to 16, while the proportion of treatment indicative of type 2 for the age 5 years to 9 years group remained relatively steady at around 6
Figure 4
Percent of Total Antidiabetic Drug Use Indicative of Type 2 Usage 2002-2005: By Age Group
35 30 25 20 15 10 5 0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 04 Q2 04 Q3 04 Q4 05 Q1 05 Q2 05 Q3 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 05 Q4 02 02 02 02 03 03 03 03
Total
5-9
10-14
15-19
04
8
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Limitations
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Studies have found prescription claims data to be a reliable and valid source of data8,9 However, limitations in their use should be recognized As in any analysis involving the use of administrative claims data, a claim does not indicate whether the patient actually took the medication Conversely, members may receive a prescription without a claim being submitted, if the cost of the prescription is less than a members copayment, for example As a result, these findings may underestimate type 2 antidiabetic use in those situations where the cost of generic oral
antidiabetic medications may be less than the members per prescription copayment These data represent the prevalence of antidiabetic medication use among children receiving prescription-drug benefits through commercially insured health plans and, therefore, do not reflect prevalence of use or trends for children receiving prescription coverage through state Medicaid programs
These data represent the prevalence of antidiabetic medication use among children receiving prescription-drug benefits through commercially insured health plans
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Implications
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Over the past four years, the prevalence of use of antidiabetic drug therapy in children age 5 years to 19 years has grown by approximately 41 Particularly concerning is the dramatic increase in the prevalence of prescription use suggestive of type 2 diabetes among Americas preteens and teens, leading to the proportion of treatment for older teens indicative of type 2 diabetes approaching one-third It is important to note that these data are not intended to suggest an increase in the
prevalence of diabetes itself, but rather an increase in the treatment of the condition which may be brought about by a greater recognition or screening of the condition in children; or in the case of type 2 diabetes, a greater tendency to treat diabetic children with drug therapy rather than diet and exercise Further study should explore to what extent this growth in the use of antidiabetic agents is attributed to increased recognition and treatment of the condition, increased likelihood of using drug therapy over nondrug treatments, or the increased prevalence of diabetes One factor believed to be contributing to the rise in the prevalence of diabetes among children is obesity, one of the key risk factors for type 2 diabetes12,13,14 Research indicates that overweight and obese children are approximately twice as likely as normal weight children to develop type 2 diabetes15 National estimates have been documenting the rise in the number of overweight children in the US According to the 1999-2002 National Health and Nutrition Examination Survey NHANES, 16 of children age 6 years to 19 years were considered overweight, an increase from the estimated 11 reported in the 1988-1994
NHANES survey16 The trends seen in the use of antidiabetic drug therapy in children may be indicative of the growing recognition of obesity as a risk factor for diabetes and, therefore, earlier testing of children who are overweight The increase in the prevalence of drug use indicative of type 1 diabetes in children is also an interesting finding Previous research indicates that the prevalence of type 1 diabetes has increased in children over the last 100 years, though the reasons for this increase are not well understood at this time17 The overall rise in the treatment of diabetes among children has important implications for our healthcare system The total annual economic cost of diabetes was estimated to be 132 billion in 2002, with direct medical expenditures alone totaling 918 billion18 When adjusted for differences in age, sex and race/ethnicity, people with diabetes had medical expenditures approximately 24 times higher than people without diabetes18 When taken together, 1 of every 10 healthcare dollars spent in the US is spent on diabetes and its complications18
Particularly concerning is the dramatic increase in the prevalence of prescription use suggestive of type 2
diabetes among Americas preteens and teens
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Implications Continued
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Diabetes is also associated with an increased risk for a number of serious complications When compared to people without diabetes, diabetics are at higher risk for heart disease two to four times higher, stroke two to four times higher, erectile dysfunction two times higher, amputations 10 times higher, nervous system damage 60 to 70 of diabetics, high blood pressure 73 of adults with diabetes, blindness diabetic retinopathy is the leading cause of blindness, kidney disease diabetes is the leading cause of kidney failure, and complications with pregnancy19 In 2002, 246 billion was spent on chronic complications attributed to diabetes, and 441 billion was spent for an excess prevalence of general medical conditions18 Clearly, the growth in the treatment of type 2 diabetes could signal the beginning of a multitude of long-term healthcare needs for many of these children
Clearly, the growth in the treatment of type 2 diabetes could signal the beginning of a multitude
of long-term healthcare needs for many of these children
11
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Appendix
2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
Appendix A
Quarterly Prevalence of Antidiabetic Prescription Use Overall, By Age Group and Type 1 versus Type 2 Usage: 2002 to 2005
Type 1 Prevalence of Use Time Period 2002 Q1 2002 Q2 2002 Q3 2002 Q4 2003 Q1 2003 Q2 2003 Q3 2003 Q4 2004 Q1 2004 Q2 2004 Q3 2004 Q4 2005 Q1 2005 Q2 2005 Q3 2005 Q4 5-9 yrs 0838 0918 0960 0935 1043 1045 1107 1082 1079 1058 1109 1098 1036 1136 1152 1174 10-14 yrs 15-19 yrs 1639 1812 1869 1907 2006 2013 2062 2050 2061 2042 2053 2061 2163 2170 2146 2154 2071 2367 2436 2408 2549 2549 2630 2631 2671 2658 2665 2624 2752 2798 2708 2713 Total 1535 1723 1782 1790 1894 1899 1966 1957 1974 1958 1982 1969 2057 2077 2044 2057 5-9 yrs 0065 0079 0065 0070 0068 0064 0068 0075 0064 0065 0071 0065 0061 0072 0075 0077 Type 2 Prevalence of Use 10-14 yrs 15-19 yrs 0229 0240 0235 0262 0290 0280 0319 0343 0345 0363 0376 0379 0392 0412 0428 0427 0632 0747 0784 0782 0869 0874 0932 0949 0990 1030 1101 1134 1206 1216 1263 1222 Total 0315 0362 0370 0381 0419 0417
0453 0471 0483 0505 0538 0550 0576 0591 0616 0604 5-9 yrs 0903 0998 1025 1035 1111 1109 1175 1157 1143 1123 1180 1163 1197 1208 1227 1251 Total Prevalence of Use 10-14 yrs 15-19 yrs 1868 2052 2104 2169 2296 2293 2381 2393 2407 2405 2430 2440 2555 2582 2574 2581 2704 3114 3220 3191 3418 3423 3562 3581 3661 3688 3765 3758 3958 4014 3971 3934 Total 1850 2085 2152 2171 2313 2316 2419 2428 2457 2463 2520 2519 2633 2668 2660 2661
Appendix B
Time Series Regression Intercept Terms and Slope Coefficients for Relationship Between Time quarter and Prevalence of Prescription Use Per 1,000 Child Beneficiaries: 2002 to 2005
Overall Interception Total Type 1 Type 2 1952 1624 0309 Slope Coefficient 0050 0031 0020 Intercept 0950 0880 0068 5-9 yrs Slope Coefficient 0020 0020 0000 Intercept 1934 1712 0211 10-14 yrs Slope Coefficient 0045 0031 0014 Intercept 2917 2245 0641 15-19 yrs Slope Coefficient 0074 0036 0041
12
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2002-2005 Trends in the Prevalence of Antidiabetic Drug Therapy In Children Age 5 Years to 19 Years
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Source:ssfcm.org
