The impact of diabetes and associated cardiometabolic risk factors on members: strategies for optimizing outcomes.

BACKGROUND In the past decade, the prevalence of obesity, diabetes, and metabolic syndrome has increased exponentially. Estimated national spending on direct costs related to these conditions exceeds $90 billion for overweight and obesity, $90 billion for diabetes, and $250 billion for cardiovascular disease (CVD). Spending on prescription drugs that are used to modify cardiometabolic risk (CMR) is both a major component of all spending on prescription drugs and a leading cause of the increase in such spending. Also, spending on antihyperglycemic agents is projected to become the largest single component of all spending on prescription drugs in the near future. As the use of antihyperglycemic agents continues to increase, there is a growing need to evaluate the relative and comparative cost-effectiveness of these products. As new antihyperglycemic agents appear, physicians and health plans may begin differentiating products in this category not only on the basis of their use in achieving glycemic control, but also in the context of their effect on global CMR factor modification. OBJECTIVE To describe the effect of overall CMR on clinical outcomes and costs in patients with diabetes. SUMMARY Metabolic syndrome is defined as a clustering of risk factors that identify those at increased risk of CVD and diabetes. Although the exact definition and clinical use of the term "metabolic syndrome" are debated, the clinical community is united in identifying its individual risk factors as important contributors to the development of cardiometabolic disease. Two of the most important points of consensus are that diabetes significantly increases the risk of CVD and that the CVD risk associated with metabolic syndrome is greater than the sum of its measured risk factors. Therefore, it is increasingly recognized that the risk of CVD is greater in patients with diabetes and other CMR factors than in those with diabetes alone. Diabetes treatment goals extend beyond glycemic control to include other risk factor modifications, such as blood pressure control, lipid management, weight management, and smoking cessation. However, a significant percentage of patients do not reach their treatment targets. To improve the quality of diabetes care, treatment algorithms have been developed to provide specific recommendations for each line of treatment and to suggest prompt reevaluation. Also, new antihyperglycemic agents, such as incretin-related therapies, have the potential to address the unmet needs associated with conventional antihyperglycemic agents, including the improvement of glycemic control with either weight maintenance or weight loss and the modification of CMR factors. Economic analyses demonstrate that CMR modification in patients with diabetes can reduce the costs of complications. Among chronic complications of diabetes, CVD treatment generates the greatest expenses, particularly in the early stages of disease progression. Health plan spending related to diabetes can be affected by a number of patient attributes, including age, glycemic control, complications, and CMR. It has also been shown that diabetes spending increases substantially in the presence of various CMR factors (e.g., obesity, hypertension, and dyslipidemia), independent of the presence of other chronic complications. Increasing differences among antihyperglycemic agents have made apparent the need for models in cost-effectiveness analysis. Pharmacoeconomic models have been developed and validated that simulate the treatment benefits not just of glycemic control, but of comprehensive diabetes management. These models can assist in demonstrating the importance of CMR modification in patients with diabetes. CONCLUSION Growing evidence indicates that the evaluation of diabetes treatment strategies should incorporate considerations of their effect on global CMR. Macrovascular disease is one of the major factors in diabetes costs and resource use, both medical and pharmaceutical. Various economic analyses indicate that global CMR should be reduced to control costs in this population. Newer antihyperglycemic agents with a favorable overall metabolic profile may offer a cost-effective approach to managing diabetes.