title: Long-term outcomes of analogue insulin compared with NPH for patients with type 2 diabetes mellitus.
abstract: BACKGROUND
  Long-acting insulin analogues (eg, insulin glargine and insulin detemir) are an alternative to neutral protamine Hagedorn (NPH) insulin for maintaining glycemic control in patients with diabetes. Clinical trials comparing analogue insulin and NPH have neither been adequately powered nor had sufficient follow-up to examine long-term health outcomes.
  
  
  OBJECTIVE
  To compare the effects of NPH and long-acting insulin analogues on long-term outcomes.
  
  
  METHODS
  This retrospective observational study relied on administrative data from the Veterans Health Administration and Medicare from 2000 to 2010. Local variations in analogue insulin prescribing rates were used in instrumental variable models to control for confounding. Outcomes were assessed using survival models.
  
  
  METHODS
  The study population included US veterans dually enrolled in Medicare who received at least 1 prescription for oral diabetes medication and then initiated long-acting insulin between 2001 and 2009. Outcomes included ambulatory care-sensitive condition (ACSC) hospitalizations and mortality.
  
  
  RESULTS
  There was no significant relationship between type of insulin and ACSC hospitalization or mortality. The hazard ratio for mortality of individuals starting a long-acting analogue insulin was 0.97 (95% CI, 0.85-1.11), and was 1.05 (95% CI, 0.95-1.16) for ACSC hospitalization. Differences in risk remained insignificant when predicting diabetes-specific ACSC hospitalizations, but starting on long-acting analogue insulin significantly increased the risk of a cardiovascular-specific ACSC hospitalization.
  
  
  CONCLUSIONS
  We found no consistent difference in long-term health outcomes when comparing use of long-acting insulin analogues and NPH insulin. The higher cost of analogue insulin without demonstrable clinical benefit raises questions of its cost-effectiveness in the treatment of patients with diabetes.
authors.affiliation: Health Care Financing and Economics, VA Boston Healthcare System, 150 So Hunting-ton Ave (152H), Boston, MA 02130. E-mail: jprentic@bu.edu.
authors.forename: Julia C
authors.initials: JC
authors.lastname: Prentice
authors.forename: Paul R
authors.initials: PR
authors.lastname: Conlin
authors.forename: Walid F
authors.initials: WF
authors.lastname: Gellad
authors.forename: David
authors.initials: D
authors.lastname: Edelman
authors.forename: Todd A
authors.initials: TA
authors.lastname: Lee
authors.forename: Steven D
authors.initials: SD
authors.lastname: Pizer
mesh_terms: D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007336:Insulin, Isophane / Q000627:therapeutic use*; D049528:Insulin, Long-Acting / Q000627:therapeutic use*; D008297:Male; D006278:Medicare; D012189:Retrospective Studies; D014481:United States
chemical_list: D007004:Hypoglycemic Agents; D049528:Insulin, Long-Acting; D007336:Insulin, Isophane