Insulin Utilisation Review in a Public Primary Care Clinic: Analysis of Dose and Adherence
Abstract
Introduction: Diabetes is a leading cause of morbidity and mortality in Malaysia. Ensuring proper insulin prescribing and usage early on in the treatment period is important to ensure good glycaemic control and improved prognosis. The study aims to review the insulin utilisation patterns in a primary health care facility and estimate insulin adherence based on patient medication refills.
Methods: This is a retrospective database analysis of data Pharmacy Information System (PhIS). Dispensing data from January until 31 December 2019 were extracted and analysed using R Studio. Patient refill adherence for the study period was estimated using their medication refill information. The persistence rate among new insulin users was calculated. Insulin dose was calculated and compared between different types of insulin.
Results: Data was collected from 2,430 patients with 8,313 prescriptions. Insulin users were most predominant in 50-70 years old, accounting for 67.4% of insulin users. Use of basal human insulin was the most prevalent (n=1745), followed by regular human insulin (n=1058), premixed human insulin (n=827), basal analogue (n=28), and premixed analogue (n=15). The overall mean refill compliance was 0.27, with only 39.3% exhibiting good adherence (refill compliance >0.8). Analogue insulin users were most adherent, but the small population size of analogue users limit the generalizability of the result. In this cohort, 8.3% of patients stopped collecting their insulin after their first insulin dispensing. The lowest total daily dose was four units/day, and the highest was 178 units/day. The dose was significantly higher among female patients. No correlation was found between age and refill compliance, as well as between dose and refill compliance.
Conclusion: Insulin use was most prevalent among the elderly. Despite being free of charge, there was a high rate of non-adherence and exploring the possible associations between drug utilisation and treatment outcome.
References
Alison, C. & Anselm, S. (2020). The effectiveness of diabetes medication therapy adherence clinic to improve glycaemic control among patients with type 2 diabetes mellitus: a randomised controlled trial. Medical Journal Malaysia, 75(3), 246–253
Basu, R., Breda, E., Oberg, A.L., Powell, C.C., Dalla Man, C., Basu, A., Vittone, J.L., Klee, G.G., Arora, P., Jensen, M.D., Toffolo, G., Cobelli, C. & Rizza, R.A. (2003). Mechanisms of the age-associated deterioration in glucose tolerance: contribution of alterations in insulin secretion, action, and clearance. Diabetes 52(7), 1738–1748. https://doi.org/10.2337/diabetes.52.7.1738
Bonafede, M.M., Kalsekar, A., Pawaskar, M., Ruiz, K.M., Torres, A.M., Kelly, K.R. & Curkendall, S.M. (2011). Insulin use and persistence in patients with type 2 diabetes adding mealtime insulin to a basal regimen: a retrospective database analysis. BMC Endocrine Disorders, volume 11, 3. https://doi.org/10.1186/1472-6823-11-3
Capoccia, K., Odegard, P.S. & Letassy, N. (2016). Medication Adherence With Diabetes Medication: A Systematic Review of the Literature. The Diabetes Educator, 42(1), 34–71. https://doi.org/10.1177/0145721715619038
Cooke, C.E., Lee, H.Y., Tong, Y.P. & Haines, S.T. (2010). Persistence with injectable antidiabetic agents in members with type 2 diabetes in a commercial managed care organization. Current Medical Research and Opinion, 26(1), 231–238. https://doi.org/10.1185/03007990903421994
Donnelly, L.A., Morris, A.D., Evans, J.M.M. & DARTS/MEMO collaboration. (2007). Adherence to insulin and its association with glycaemic control in patients with type 2 diabetes. QJM: monthly journal of the Association of Physicians, 100(6), 345–350. https://doi.org/10.1093/qjmed/hcm031
Hassali, M., Supian, A., Mohamed Ibrahim, M.I., Al-Qazaz, H., Haddad, M., Salee, F. & Palaian, S. (2012). The characteristics of drug wastage at the hospital, Tuanku Jaafar Seremban, Malaysia: A descriptive study. Journal of Clinical and Diagnostic Research 6, 787–790
Hertz, R.P., Unger, A.N. & Lustik, M.B. (2005). Adherence with pharmacotherapy for type 2 diabetes: a retrospective cohort study of adults with employer-sponsored health insurance. Clinical Therapeutics, 27(7), 1064–1073. https://doi.org/10.1016/j.clinthera.2005.07.009
Hussein, Z., Foo, S.H., Lim, S.C., Md, M., Long Bidin, M.B., Yong, S.L., Adam, N.L., Nurain, M.N. & Sharma, S. (2011). Practical Guide to Insulin Therapy in Type 2 Diabetes. Malaysian Endocrine & Metabolic Society (MEMS).
Kamarudin, G., Penm, J., Chaar, B. & Moles, R., (2013). Educational interventions to improve prescribing competency: a systematic review. BMJ Open, 3(8), e003291. https://doi.org/10.1136/bmjopen-2013-003291
Karve, S., Cleves, M.A., Helm, M., Hudson, T.J., West, D.S. & Martin, B.C. (2009). Good and poor adherence: optimal cut-point for adherence measures using administrative claims data. Current Medical Research and Opinion, 25(9), 2303–2310. https://doi.org/10.1185/03007990903126833
Kleinman, N.L., Schaneman, J.L. & Lynch, W.D. (2008). The association of insulin medication possession ratio, use of insulin glargine, and health benefit costs in employees and spouses with type 2 diabetes. Journal of Occupational and Environmental Medicine, 50(12), 1386–1393. https://doi.org/10.1097/JOM.0b013e3181875e9b
Lam, W.Y. & Fresco, P. (2015). Medication Adherence Measures: An Overview. BioMed Research International, volume 2015, 217047. https://doi.org/10.1155/2015/217047
Lehmann, C.E.R., Anderson, T.M., Sankaran, M., Higgins, S.I., Archibald, S., Hoffmann, W.A., Hanan, N.P., Williams, R.J., Fensham, R.J., Felfili, J., Hutley, L.B., Ratnam, J., Jose, J.S., Montes, R., Franklin, D., Russell-Smith, J., Ryan, C.M., Durigan, G., Hiernaux, P., Haidar, R., Bowman, D.M.J.S. & Bond, W.J. (2014). Savanna Vegetation-Fire-Climate Relationships Differ Among Continents. Science, 343(6170), 548–552. https://doi.org/10.1126/science.1247355
Lerman, I., Díaz, J.P.M., Ibarguengoitia, M.E.R., Pérez, F.J.G., Villa, A.R., Velasco, M.L., Cruz, R.G. & Rodrigo, J.A.R. (2009). Nonadherence to insulin therapy in low-income, type 2 diabetic patients. Endocrine Practice: Official Journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 15(1), 41–46. https://doi.org/10.4158/EP.15.1.41
Lim, P.C. & Lim, K. (2010). Evaluation of a pharmacist-managed diabetes medication therapy adherence clinic. Pharmacy Practice, 8(4), 250–254. https://doi.org/10.4321/s1886-36552010000400008
McGovern, A., Tippu, Z., Hinton, W., Munro, N., Whyte, M. & de Lusignan, S. (2018). Comparison of medication adherence and persistence in type 2 diabetes: A systematic review and meta-analysis. Diabetes, Obesity & Metabolism, 20(4), 1040–1043. https://doi.org/10.1111/dom.13160
Ministry of Health Malaysia. (2020). Clinical Practice Guidelines (CPG): Management of Type 2 Diabetes Mellitus 6th Edition. Putrajaya: Ministry of Health Malaysia.
National Institute of Health Malaysia. (2020). National Health and Morbidity Survey 2019: Non-communicable disease, healthcare demand, and health literacy. Shah Alam: National Institute of Health (NIH), Ministry of Health Malaysia.
Ng, C.J., Lai, P.S.M., Lee, Y.K., Azmi, S.A. & Teo, C.H. (2015). Barriers and facilitators to starting insulin in patients with type 2 diabetes: a systematic review. International Journal of Clinical Practice, 69(10), 1050–1070. https://doi.org/10.1111/ijcp.12691
Pawaskar, M., Bonafede, M., Johnson, B., Fowler, R., Lenhart, G. & Hoogwerf, B. (2013). Medication utilization patterns among type 2 diabetes patients initiating Exenatide BID or insulin glargine: a retrospective database study. BMC Endocrine Disorders, 13(1), 20. https://doi.org/10.1186/1472-6823-13-20
Pharmaceutical Services Programme. (2017). Malaysian National Medicines Policy 3rd edition 2017-2021, 3rd ed. Putrajaya: Pharmaceutical Services Programme, Ministry of Health Malaysia.
Ryan, A.S. (2000). Insulin resistance with aging: effects of diet and exercise. Sports Medicine (Auckland, N.Z.), 30(5), 327–346. https://doi.org/10.2165/00007256-200030050-00002
Stuart, B.C., Simoni-Wastila, L., Zhao, L., Lloyd, J.T. & Doshi, J.A. (2009). Increased Persistency in Medication Use by U.S. Medicare Beneficiaries With Diabetes Is Associated with Lower Hospitalization Rates and Cost Savings. Diabetes Care, 32(4), 647–649. https://doi.org/10.2337/dc08-1311
The Diabetes Control and Complications Trial Research Group. (1993). The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus. New England Journal of Medicine, 329(14), 977–986. https://doi.org/10.1056/NEJM199309303291401
Trethewey, S.P. (2020). Strategies to combat medical misinformation on social media. Postgraduate Medical Journal, 96(1131), 4–6. https://doi.org/10.1136/postgradmedj-2019-137201
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work.
Copyright Transfer
It is our policy that all authors need to sign and submit the completed Copyright Transfer Agreement Form during the manuscript submission.
Institute for Health Management
