Individualized HbA1c goals for adults with type 2 diabetes would be more cost-effective than having an intensive target of HbA1c < 7% for all patients, a new analysis suggests.
Specifically, treating patients with type 2 diabetes in the United States to an HbA1c goal of < 6%, < 7%, or < 8%, depending on their age, comorbidities, complications, and diabetes duration would save more than $13,000 over a person’s lifetime.
Moreover, although patients would live roughly 36 fewer days, they would gain 36 quality-adjusted life-days by using slightly fewer medications per year and having fewer lifetime hypoglycemic events.
These findings, based on model simulations using data from the 2011–2012 National Health and Nutrition Examination Survey (NHANES), by Neda Laiteerapong, MD, and colleagues, from the University of Chicago, Illinois, were published online December 11 in the Annals of Internal Medicine.
The study “complements other work that says patient preferences matter,” Dr Laiteerapong told Medscape Medical News.
Treating to Different Targets, Taking Quality of Life Into Consideration
“The prospect of reducing costs by using fewer medications (-0.6 per person per year) and not substantially worsening patient outcomes is appealing, especially given that many patients prefer to avoid diabetes medications if they can do so safely,” the researchers note.
Health systems may ask clinicians to treat all patients with diabetes to a target HbA1c below 7%, Dr Laiteerapong explained, but this study suggests that approach may not benefit all patients and may cost more.
In addition, other studies have shown that glycemic control is not aggressive enough among 40- to 59-year-olds in the United States (especially among certain ethnic minorities), but it may be too tight in adults aged 65 and older, she said.
“This study will hopefully raise more attention to those issues.”
“What I really like about this study is that the authors take into account not just length but also quality of life,” Richard W Grant, MD, a research scientist at Kaiser Permanente Northern California, in Oakland, who was not involved with this study, told Medscape Medical News in an email.
“It is unlikely that randomized controlled trials (which would cost tens of millions of dollars) will ever be conducted for fine-tuned questions about exactly how to deintensify therapy and to what targets,” he said, “so this analysis is one way to help understand the implications of treating to different targets.”
Cost-effectiveness of One HbA1c Target vs Three Tailored Targets
Uniform intensive glycemic control to a target HbA1c of < 7% is an established cost-effective standard of care, Dr Laiteerapong and colleagues write.
However, the ACCORD trial showed that patients at high risk of cardiovascular disease had increased mortality with achieved HbA1c of 6.4% vs 7.5%, and other studies have reported that older patients have a high incidence of hypoglycemia with tight glycemic control.
Thus, in 2012, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) published a position statement recommending individualized glycemic targets depending on a patient’s age, comorbidities, complications, and diabetes duration.
However, until now, the lifetime cost-effectiveness of the two strategies has not been compared.
The researchers identified 569 adults age 30 and older who had type 2 diabetes and were part of NHANES 2011–2012, representing 17.3 million people in the United States with this disease.
The patients had a mean age of 61, and 50% were female.
More than a third (36%) had a history of diabetic complications, defined as angina pectoris, myocardial infarction (MI), stroke, coronary heart disease, congestive heart failure, retinopathy, dialysis, or an albumin–creatinine ratio greater than 300 mg/g.
About two in five patients (42%) had a high Charlson Comorbidity Index score of 5 or more, based on self-report of MI, heart failure, stroke, lung disease, rheumatoid arthritis, liver disease, diabetes, or cancer.
The researchers input baseline data into a simulation model for diabetes, to compare the cost-effectiveness of two glycemic control strategies for each patient.
In the uniform intensive control strategy, all patients received medications as recommended by the ADA guidelines, to reach an HbA1c target of < 7%.
In the individualized glycemic control strategy, patients were treated to HbA1c < 7% or to a more or less stringent target (< 6.5% and < 8%, respectively) based on age, comorbidities, complications, and diabetes duration.
Individualized Glycemic Control HbA1c Targets
| Age | Complications | Comorbidities | Diabetes duration | Percentage of the population | HbA1c target |
|---|---|---|---|---|---|
| 30–44 | No | Low | — | 7% | < 6.5% |
| 30–44 | Yes | Low | — | 2% | < 7% |
| 45–64 | No | Low | — | 35% | |
| 65–75 | No | Low | <10 years | 5% | |
| 30–44 | Yes | High | — | 50% | < 8% |
| 45–64 | Yes | High | — | ||
| 65– 75 | Yes or no | High | — | ||
| >76 | Yes or no | High or low | — |
Reduction in Costs Mostly Due to Fewer Medications
The researchers ran 2500 simulations for each participant.
Patients received metformin, sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagonlike peptide 1 (GLP-1) receptor agonists, basal insulin, and bolus insulin — based on data from the National Ambulatory Medical Care Survey (NAMCS).
The model did not include sodium glucose cotransporter 2 (SGL2) inhibitors.
The most common medications were metformin (51%), sulfonylureas (33%), and insulin (18%).
The researchers assumed HbA1c levels would drift upward over time.
They assumed that a patient who no longer achieved their HbA1c target on metformin would be started on sulfonylureas (40.6% of the time), thiazolidinediones (13.4%), a DPP-4 inhibitor (27.0%), a GLP-1– receptor agonist (4.4%), or basal insulin (14.6%).
They calculated costs of medications and diabetes-related complications for the two glycemic-control strategies.
Individualized control increased the lifetime risk of MI by 1.4%, amputation by 1%, and stroke by 0.85% but decreased the rate of hypoglycemia.
Overall, lifetime healthcare costs were $118,854 for patients treated to a uniform intensive glycemic target vs $105,307 for patients treated to individualized targets.
Medications were assumed to be generic, where available, and costs were in 2015 US dollars.
The $13,547 lower lifetime healthcare cost per adult treated to individualized glycemic control targets was mainly driven by a $14,242 reduction in cost of medications per patient.
In the model, when the patients received individualized vs uniform glycemic control they had a slightly decreased life expectancy (20.63 vs 20.73 years), due to a higher rate of diabetic complications (7854 vs 7456 events per 10,000 patients).
However, the patients used fewer medications per year and had fewer hypoglycemic events, which translated into slightly more quality-adjusted life-years (16.68 vs 16.58).
“Additional research is needed,” the researchers conclude, “to understand how glycemic control affects outcomes differently over the disease course and the pleiotropic effects of newer diabetes agents in order to develop diabetes simulation models that can better inform future strategies in diabetes management and healthcare policy.”
The study was funded by a grant from the National Institute of diabetes and Digestive and Kidney Disease. The authors have no relevant financial relationships.
Ann Intern Med. Published online December 10, 2017. Abstract
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