Real world outcomes related to providing an annual supply of short-acting hormonal contraceptives.

OBJECTIVE: To compare pregnancy rates among women provided a 12-month supply or less than a 12-month supply of short-acting hormonal contraceptives. STUDY DESIGN: This retrospective cohort study examined data from an integrated health plan in California, collected about people aged 10-50 years, who filled at least one contraceptive prescription between January 2017 and September 2018. We examined outcomes following index contraceptive prescriptions for up to 15 months, end of membership, initiation of a long-acting contraceptive, or death, whichever occurred first. We compared rates per 100 person years of observation of: pregnancy, receipt of emergency contraception (EC), and contraceptive refills more than 12 months after the index prescription. We used multivariable logistic regression to control for demographics and baseline clinical variables when comparing provision of a 12-month to a smaller supply. RESULTS: We identified 1689 members who received a 12-month supply of short-acting hormonal contraception and 352,624 women who received less than a 12-month supply. Those who received a 12-month supply were less likely to receive EC (1.3 vs 2.1 per 100 person years, p = 0.04) or have documentation of pregnancy (1.7 vs 2.7 per 100 person-years, p = 0.02), and more likely to refill the contraceptive more than 1 year after the index prescription (99.4% vs 63.9%, p < 0.01). Among new starts, the adjusted odds ratio (OR) of pregnancy was 0.50 (95% CI 0.27-0.94) among women who received a 12-month supply vs. those were not. CONCLUSION: Members of an integrated healthcare system who received a 12-month supply of short-acting hormonal contraceptives are less likely to become pregnant within the following year. IMPLICATIONS: Offering a 12-month supply of short-acting hormonal contraceptives may reduce rates of undesired pregnancy.

Evaluation of Dipeptidyl Peptidase-4 Inhibitors versus Thiazolidinediones or Insulin in Patients with Type 2 Diabetes Uncontrolled with Metformin and a Sulfonylurea in a Real-World Setting.

BACKGROUND: Guidelines do not make clear recommendations for third add-on agents to metformin plus a sulfonylurea. This study compared the effectiveness and safety of dipeptidyl peptidase-4 inhibitors (DPP4is) to thiazolidinedione (TZD) or insulin as a third add-on agent to metformin plus a sulfonylurea in an integrated health care setting. METHODS: This retrospective database cohort study included adults with type 2 diabetes not at goal hemoglobin A1C (HbA1C) who initiated DPP4i, TZD, or insulin as a third add-on agent to metformin plus a sulfonylurea from January 2006 to June 2016. Primary outcomes were the proportion of patients who achieved goal HbA1C after starting the third add-on agent and change in HbA1C. Subgroup analysis was performed for patients with baseline HbA1C greater than 9%. RESULTS: In this study, 2080 patients started on a DPP4i were matched to 8320 patients started on TZD and to 8320 patients taking insulin. A significantly higher percentage of patients taking TZD reached goal HbA1C (31.0% versus 23.6%; p < 0.05) and had a significantly larger HbA1C reduction (-0.94% ± 1.34% versus -0.79% ± 1.23%; p < 0.01) compared to patients taking a DPP4i. No difference in the percentage of patients meeting goal HbA1C nor in change in HbA1C was demonstrated between insulin versus DPP4i regimens. For patients with baseline HbA1C greater than 9%, insulin or TZD resulted in a significantly higher proportion of patients achieving goal HbA1C compared to DPP4i (17.3% and 19.0% versus 12.4%, respectively; p < 0.01). CONCLUSION: TZD was more effective than DPP4i but DPP4i was as effective as insulin as a third add-on agent in the overall study population. Insulin was more effective than DPP4i only in the subgroup analysis of patients with baseline HbA1C greater than 9%.

Evaluation of Outcomes After Initiating Triple Antidiabetic Therapy with a GLP-1 RA in an Integrated Health Care System.

BACKGROUND: Type 2 diabetes (T2D) is characterized by chronic hyper-glycemia and can lead to life-threatening complications if not treated. A stepwise and patient-centered approach is recommended when managing patients with T2D. Metformin is the preferred first-line agent, while sulfonylureas (SU) are often chosen as second-line agents. If a patient's hemoglobin A1c (A1c) goal is not achieved despite 3 months of treatment with dual therapy, then triple therapy is recommended. However, due to the lack of head-to-head trials for different triple antidiabetic regimens, the recommendations are unclear for selection of an optimal third-line agent. OBJECTIVE: To evaluate the comparative effectiveness of a glucagon-like peptide-1 receptor agonist (GLP-1 RA) compared with a thiazolidinedione (TZD) or insulin as a third-line add-on therapy in patients who have not achieved A1c goals while receiving metformin and SU dual therapy in the real-world setting within an integrated health care system. METHODS: This is a retrospective cohort study of adult patients with T2D who were not at goal A1c while on dual therapy with metformin and an SU and initiated triple antidiabetic therapy. The primary outcome was the proportion of patients who achieved goal A1c within 3-7 months after starting triple therapy with a GLP-1 RA compared with a TZD or insulin. Goal A1c was defined as an A1c of < 7% for patients aged less than 65 years and A1c of < 8% for patients aged 65 years or older. Secondary outcomes included mean change in A1c, mean change in weight, and the proportion of patients with an emergent health care encounter due to a hypoglycemic event. Propensity score matching was used to select comparison groups from the insulin and TZD groups with similar baseline characteristics to the GLP-1 RA group in a 4:1 ratio. RESULTS: 274 patients initiated a GLP-1 RA in addition to dual therapy with metformin and an SU. A propensity matched group of 1,096 patients who initiated insulin and 1,096 patients who initiated a TZD were selected as the control groups. Addition of a GLP-1 RA resulted in a significantly lower proportion of patients achieving goal A1c (23.0%) compared with the addition of a TZD (30.8%, P = 0.011). There was no significant difference with the addition of a GLP-1 RA when compared with insulin (24.1%, P = 0.704). CONCLUSIONS: This study reflects data from real-world practice in a large integrated health care system. Significantly less patients achieved goal A1c with the addition of a GLP-1 RA as a third-line add-on option to dual therapy with metformin and an SU compared with the addition of a TZD. Providers and patients should carefully weigh the risks and benefits of different antidiabetic agents when choosing triple therapy regimens. DISCLOSURES: No outside funding supported this study. The authors have nothing to disclose. Part of this study was presented as a nonreviewed resident poster at the Academy of Managed Care & Specialty Pharmacy Annual Meeting 2017 in Denver, CO, on March 27-29, 2017.

Process-Based Treatment of Diabetes in Kaiser Permanente Southern California: How to Make Diabetes Care "Complete".

PURPOSE OF REVIEW: The purpose of this review was to provide an overview of the Kaiser Permanente Southern California (KPSC) Complete Care management strategy. RECENT FINDINGS: The KPSC Complete Care program allows members of care management teams to coordinate the administration of care for patients with diabetes. This program encompasses teams of physicians, physician assistants, pharmacists, nurse practitioners, registered nurse (RN) care managers, office-based RNs, health educators, and many others to contribute to the glycemic and overall health outcomes for our patients with diabetes. The 2016 Kaiser Permanente National Clinical Practice Guideline for Adult Diabetes Clinician Guide and the supplemental KPSC Treat-to-Target (TTT) Type 2 Diabetes A1c Control algorithm are used to assist KPSC clinicians by providing guidance for shared decision-making, as well as the selection and sequence of appropriate pharmacological treatment. Collaboration with pharmacy through the Formulary and the Drug Utilization Action Team (DUAT) allows the organization to manage member resources while consistently offering patients the highest quality and value health care possible. Recent technology integrations have also contributed to the success of the program.