National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010

Abstract Objective Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents. Design and setting Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs. Participants A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse. Measurements Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation. Results We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs −1.5 to −0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs −0.4 to −0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%–18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%–2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9–1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs −0.1 to 1.3). Conclusions Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.