Journal of General Internal Medicine

, Volume 33, Issue 4, pp 471–480 | Cite as

Trends in Diabetes Treatment and Monitoring among Medicare Beneficiaries

  • Bruce E. Landon
  • Alan M. Zaslavsky
  • Jeffrey Souza
  • John Z. Ayanian



Diabetes is a costly and common condition, but little is known about recent trends in diabetes management among Medicare beneficiaries.


To evaluate the use of diabetes medications and testing supplies among Medicare beneficiaries.


Retrospective cohort analysis of Medicare claims from 2007 to 2014.


Traditional Medicare beneficiaries with a diagnosis of diabetes in the current or any prior year.

Main Measures

We analyzed choices of first diabetes medication for those new to medication and patterns of adding medications. We also examined the use of testing supplies, use of statins and ACE inhibitors/angiotensin receptor blockers, and spending.

Key Results

Diagnosed diabetes increased from 28.7% to 30.2% of beneficiaries from 2007 to 2014. The use of metformin as the most commonly prescribed first medication increased from 50.2% in 2007 to 70.2% in 2014, whereas long-acting sulfonylureas decreased from 16.6% to 8.2%. The use of thiazolidinediones fell considerably, while the use of new diabetes medication classes increased. Among patients prescribed insulin, long-acting insulin as the first choice increased substantially, from 38.9% to 56.8%, but short-acting or combination regimens remained common, particularly among older or sicker beneficiaries. Prescriptions of testing supplies for more than once-daily testing were also common. The mean total cost of diabetes medications per patient increased over the period due to the increasing use of high-cost drugs, particularly by those patients with costs above the 90th percentile of spending, although the median costs decreased for both medications and testing supplies.


The use of metformin and long-acting insulin have increased substantially among elderly Medicare patients with diabetes, but a substantial subgroup continues to receive costly and complex treatment regimens.


Medicare elderly diabetes 



This work was supported by a grant from the National Institute on Aging (P01 AG032952, J. Newhouse, PI).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4310_MOESM1_ESM.docx (355 kb)
ESM 1 (DOCX 355 KB)


  1. 1.
    Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2014. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2014.Google Scholar
  2. 2.
    American Diabetes Association. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033–46.CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Centers for Disease Control and Prevention. Mean and Median Age at Diagnosis of Diabetes Among Adult Incident Cases Aged 18-79 Years, United States, 1997-2011. Atlanta, GA: US Department of Health and Human Services; 2015. Accessed Jan 25 2018.Google Scholar
  4. 4.
    Chronic Conditions Data Warehouse. Medicare – CCW Condition Period Prevalence, 2014. 2016.Google Scholar
  5. 5.
    Reusch JE, Manson JE. Management of type 2 diabetes in 2017: getting to goal. JAMA. 2017;317(10)1015–6.
  6. 6.
    Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2889-934.CrossRefPubMedGoogle Scholar
  7. 7.
    American Diabetes Association. Standards of medical care in diabetes-2016: Summary of revisions. Diabetes Care. 2016;39(Suppl 1):S4–5.Google Scholar
  8. 8.
    Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, et al. Diabetes in older adults: a consensus report. J Am Geriatr Soc. 2012;60(12):2342-56.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Sinclair AJ, Paolisso G, Castro M, Bourdel-Marchasson I, Gadsby R, Rodriguez Manas L. European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab. 2011;37(Suppl 3):S27–38.CrossRefPubMedGoogle Scholar
  10. 10.
  11. 11.
    Moreno G, Mangione CM, Kimbro L, Vaisberg E. Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 update. J Am Geriatr Soc. 2013;61(11):2020-6.CrossRefPubMedGoogle Scholar
  12. 12.
    Dunning T, Sinclair A, Colagiuri S. New IDF Guideline for managing type 2 diabetes in older people. Diabetes Res Clin Pract. 2014;103(3):538-40.CrossRefPubMedGoogle Scholar
  13. 13.
    American Diabetes Assocation. 10. Older Adults. Diabetes care. 2015;38(Suppl 1):S67-S9.Google Scholar
  14. 14.
    American Diabetes Assocation. 7. Approaches to Glycemic Treatment. Diabetes Care. 2015;38(Suppl 1):S41-S8.CrossRefGoogle Scholar
  15. 15.
    Zinman B, Wanner C, Lachin JM, Fitchett D, Bluhmki E, Hantel S, et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med. 2015;373(22):2117-28.CrossRefPubMedGoogle Scholar
  16. 16.
    Marso SP, Bain SC, Consoli A, Eliaschewitz FG, Jodar E, Leiter LA, et al. Semaglutide and Cardiovascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med. 2016;375:1834-1844.Google Scholar
  17. 17.
    Wanner C, Inzucchi SE, Lachin JM, Fitchett D, von Eynatten M, Mattheus M, et al. Empagliflozin and Progression of Kidney Disease in Type 2 Diabetes. N Engl J Med. 2016;375(4):323-34.CrossRefPubMedGoogle Scholar
  18. 18.
    Scirica BM, Bhatt DL, Braunwald E, Steg PG, Davidson J, Hirshberg B, et al. Saxagliptin and Cardiovascular Outcomes in Patients with Type 2 Diabetes Mellitus. N Engl J Med. 2013;369(14):1317-26.CrossRefPubMedGoogle Scholar
  19. 19.
    Green JB, Bethel MA, Armstrong PW, Buse JB, Engel SS, Garg J, et al. Effect of Sitagliptin on Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2015;373(3):232-42.CrossRefPubMedGoogle Scholar
  20. 20.
    Pfeffer MA, Claggett B, Diaz R, Dickstein K, Gerstein HC, Kober LV, et al. Lixisenatide in Patients with Type 2 Diabetes and Acute Coronary Syndrome. N Engl J Med. 2015;373(23):2247-57.CrossRefPubMedGoogle Scholar
  21. 21.
    White WB, Cannon CP, Heller SR, Nissen SE, Bergenstal RM, Bakris GL, et al. Alogliptin after Acute Coronary Syndrome in Patients with Type 2 Diabetes. N Engl J Med. 2013;369(14):1327-35.CrossRefPubMedGoogle Scholar
  22. 22.
    Marso SP, Daniels GH, Brown-Frandsen K, Kristensen P, Mann JF, Nauck MA, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2016;375(4):311-22.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Margolis DJ, Leonard CE, Razzaghi H, Hoffstad OJ, Freeman CP, de Nava KL, et al. Utilization of antidiabetic drugs among Medicare beneficiaries with diabetes, 2006-2009: Data Points #9. 2012. Accessed Jan 25 2018.
  24. 24.
    Landon BE, Zaslavsky AM, Saunders RC, Pawlson LG, Newhouse JP, Ayanian JZ. Analysis Of Medicare Advantage HMOs compared with traditional Medicare shows lower use of many services during 2003-09. Health Aff. 2012;31(12):2609-17.CrossRefGoogle Scholar
  25. 25.
    Landon BE, Zaslavsky AM, Saunders R, Pawlson LG, Newhouse JP, Ayanian JZ. A comparison of relative resource use and quality in Medicare Advantage health plans versus traditional Medicare. Am J Manag Care. 2015;21(8):559-66.PubMedGoogle Scholar
  26. 26.
    Ayanian JZ, Landon BE, Zaslavsky AM, Saunders RC, Pawlson LG, Newhouse JP. Medicare beneficiaries more likely to receive appropriate ambulatory services in HMOs than in traditional medicare. Health Aff. 2013;32(7):1228-35.CrossRefGoogle Scholar
  27. 27.
    Centers for Medicare and Medicaid Services. Chronic Conditions Data Warehouse.Google Scholar
  28. 28.
    Centers for Medicare and Medicaid Services DoHaHS. Chronic Conditions Data Warehouse home page. Accessed Jan 25 2018.
  29. 29.
    Approaches to Glycemic Treatment. Diabetes Care. 2016;39(Suppl 1):S52–S9.Google Scholar
  30. 30.
    Lipska KJ, Ross JS, Wang Y, Inzucchi SE, Minges K, Karter AJ, et al. National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011. JAMA Intern Med. 2014;174(7):1116-24.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227–46. Accessed Jan 25 2018.
  32. 32.
    American Diabetes Association. New Standards of Care Provide Guidelines for Statin Use for People with Diabetes to Prevent Heart Disease. 2014. Accessed Jan 25 2018.
  33. 33.
    Zaslavsky AM, Ayanian JZ, Zaborski LB. The validity of race and ethnicity in enrollment data for Medicare beneficiaries. Health Serv Res. 2012;47(3 Pt 2):1300-21.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Bonito A, Bann C, Eicheldinger C, Carpenter L. Creation of New Race-Ethnicity Codes and Socioeconomic Status (SES) Indicators for Medicare Beneficiaries Final Report. 2008. Accessed Jan 25 2018.
  35. 35.
    Porter ME, Lee TH. From Volume to Value in Health Care: The Work Begins. JAMA. 2016;316(10):1047-8.CrossRefPubMedGoogle Scholar
  36. 36.
    Lee VS, Kawamoto K, Hess R, Park C, Young J, Hunter C, et al. Implementation of a Value-Driven Outcomes Program to Identify High Variability in Clinical Costs and Outcomes and Association With Reduced Cost and Improved Quality. JAMA. 2016;316(10):1061-72.CrossRefPubMedGoogle Scholar
  37. 37.
    Cai JX, Campbell EJ, Richter JM. Concordance of Outpatient Esophagogastroduodenoscopy of the Upper Gastrointestinal Tract With Evidence-Based Guidelines. JAMA Intern Med. 2015;175(9):1563-4.CrossRefPubMedGoogle Scholar
  38. 38.
    Perry Undem Research/Communication. Unnecessary Tests and Procedures In the Health Care System. ABIM; 2014. Accessed Jan 25 2018.
  39. 39.
    Ingelfinger JR, Rosen CJ. Cardiac and Renovascular Complications in Type 2 Diabetes--Is There Hope? N Engl J Med. 2016;375(4):380-2.CrossRefPubMedGoogle Scholar
  40. 40.
    Scarpello JH. Improving survival with metformin: the evidence base today. Diabetes Metab. 2003;29(4 Pt 2):6S36–43.PubMedGoogle Scholar
  41. 41.
    Evans JM, Ogston SA, Emslie-Smith A, Morris AD. Risk of mortality and adverse cardiovascular outcomes in type 2 diabetes: a comparison of patients treated with sulfonylureas and metformin. Diabetologia. 2006;49(5):930-6.CrossRefPubMedGoogle Scholar
  42. 42.
    Berkowitz SA, Krumme AA, Avorn J, Brennan T, Matlin OS, Spettell CM, et al. Initial choice of oral glucose-lowering medication for diabetes mellitus: a patient-centered comparative effectiveness study. JAMA Intern Med. 2014;174(12):1955-62.CrossRefPubMedGoogle Scholar
  43. 43.
    Eurich DT, Majumdar SR, McAlister FA, Tsuyuki RT, Johnson JA. Improved clinical outcomes associated with metformin in patients with diabetes and heart failure. Diabetes Care. 2005;28(10):2345-51.CrossRefPubMedGoogle Scholar
  44. 44.
    Johnson JA, Majumdar SR, Simpson SH, Toth EL. Decreased mortality associated with the use of metformin compared with sulfonylurea monotherapy in type 2 diabetes. Diabetes Care. 2002;25(12):2244-8.CrossRefPubMedGoogle Scholar
  45. 45.
    Desai NR, Shrank WH, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, et al. Patterns of medication initiation in newly diagnosed diabetes mellitus: quality and cost implications. Am J Med. 2012;125(3):302 e1–7.CrossRefGoogle Scholar
  46. 46.
    Palmer SC, Mavridis D, Nicolucci A, Johnson DW, Tonelli M, Craig JC, et al. Comparison of Clinical Outcomes and Adverse Events Associated With Glucose-Lowering Drugs in Patients With Type 2 Diabetes: A Meta-analysis. JAMA. 2016;316(3):313-24.CrossRefPubMedGoogle Scholar
  47. 47.
    Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175(3):356-62.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Lipska KJ, Ross JS, Van Houten HK, Beran D, Yudkin JS, Shah ND. Use and out-of-pocket costs of insulin for type 2 diabetes mellitus from 2000 through 2010. JAMA. 2014;311(22):2331-3.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Hua X, Carvalho N, Tew M, Huang ES, Herman WH, Clarke P. Expenditures and Prices of Antihyperglycemic Medications in the United States: 2002-2013. JAMA. 2016;315(13):1400-2.CrossRefPubMedPubMedCentralGoogle Scholar
  50. 50.
    Gomes T, Martins D, Tadrous M, Paterson JM, Shah BR, Tu JV, et al. Association of a Blood Glucose Test Strip Quantity-Limit Policy With Patient Outcomes: A Population-Based Study. JAMA Intern Med. 2016;77(1):61-66.Google Scholar
  51. 51.
    Hahamian J. Blood Glucose Test Strip Utilization Within Medicare. J Diabetes Sci Technol. 2014;8(2):429-30.CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Centers for Medicare and Medicaid Services. Department of Health and Human Services. Contract suppliers selected under medicare competitive bidding program. 2013. Accessed Jan 25 2018.
  53. 53.
    Puckrein GA, Nunlee-Bland G, Zangeneh F, Davidson JA, Vigersky RA, Xu L, et al. Impact of CMS Competitive Bidding Program on Medicare Beneficiary Safety and Access to Diabetes Testing Supplies: A Retrospective, Longitudinal Analysis, Diabetes Care. 2016;39(4):563-71.CrossRefPubMedGoogle Scholar
  54. 54.
    Sussman JB, Kerr EA, Saini SD, Holleman RG, Klamerus ML, Min LC, et al. Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus. JAMA Intern Med. 2015;175(12):1942-9.CrossRefPubMedGoogle Scholar
  55. 55.
    O’Connor PJ, Bodkin NL, Fradkin J, Glasgow RE, Greenfield S, Gregg E, et al. Diabetes performance measures: current status and future directions. Diabetes Care. 2011;34(7):1651-9.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Bruce E. Landon
    • 1
    • 2
  • Alan M. Zaslavsky
    • 1
  • Jeffrey Souza
    • 1
  • John Z. Ayanian
    • 3
    • 4
    • 5
    • 6
  1. 1.Department of Health Care Policy Harvard Medical SchoolBostonUSA
  2. 2.Division of General Medicine and Primary CareBeth Israel Deaconess Medical Center and Harvard Medical SchoolBostonUSA
  3. 3.Institute for Healthcare Policy and InnovationUniversity of MichiganAnn ArborUSA
  4. 4.Division of General Medicine, Medical SchoolUniversity of MichiganAnn ArborUSA
  5. 5.Department of Health Management and Policy, School of Public HealthUniversity of MichiganAnn ArborUSA
  6. 6.Gerald R. Ford School of Public PolicyUniversity of MichiganAnn ArborUSA

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