Implementing ACP Diabetes Guidelines Could Be Cost-Effective

Miriam E. Tucker

June 08, 2019

SAN FRANCISCO — Following the 2018 American College of Physicians (ACP) glycemic control guidelines for US adults with type 2 diabetes would be cost-effective, according to new research. 

The data were presented June 7 here at the American Diabetes Association (ADA) 2019 Scientific Sessions by Hui Shao, MBBS, PhD, of the Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia.

The ACP recommendation for an HbA1c target of 7% to 8% for most nonpregnant adults with type 2 diabetes and de-intensification for those with an HbA1c < 6.5% have been a major source of controversy in the diabetes community.

Other groups, including the ADA and American Association of Clinical Endocrinologists (AACE), recommend lower targets overall — HbA1c < 7% or < 6.5% — with adjustments up or down depending on individual patient characteristics.

But Shao's new analysis shows that implementing the ACP recommendations would be cost-effective among the adult US population with type 2 diabetes, he said, noting that "if healthcare costs were taken into consideration, a combination of treatment de-intensification among some patients and treatment intensification among others may be an efficient strategy."

In addition, he explained, "Resources saved from treatment de-intensification can be shifted to individuals with HbA1c insufficiently controlled to achieve better health outcomes at a national level."

Asked to comment, session moderator Neda Laiteerapong, MD, a general internist and health services and outcomes researcher at the University of Chicago, Illinois, queried the models that Shao and colleagues used in their analysis.

"We can't predict the potential benefit of having a little bit higher blood sugar or the harms of having too low blood sugar. That's a problem when we try to simulate something like the ACP guidelines. You just can't do it with our models," she told Medscape Medical News in an interview.  

Laiteerapong also cited a JAMA clinical guidelines synopsis (JAMA. 2018;319:2430-2431) she co-authored, which voiced concern that the ACP guidelines could have unintended consequences for younger, relatively healthy people newly diagnosed with type 2 diabetes who stand to benefit more from intensive glycemic management than older individuals with longstanding diabetes and complications.

"I think there are benefits of early intensive blood glucose control...Any guideline is meant to make a large sweeping statement for the entire population. But we can also be a little more cautious and be more sophisticated and include clauses about younger groups," Laiteerapong stressed.

Applying ACP Guidelines Would Be Cost-Effective

Shao and colleagues' analysis modeled three different groups who would be affected by the ACP guidelines:

  1. Individuals with current HbA1c levels < 6.5% on glucose-lowering agents other than metformin, for whom ACP recommends treatment de-intensification.

  2. Individuals with current HbA1c 6.5%-8.0% and a life expectancy < 10 years, for whom ACP also recommends de-intensification.

  3. Individuals with current HbA1c levels > 8.0% and a life expectancy > 10 years, for whom ACP recommends intensification of treatment.

Data from the 2011-2016 National Health and Nutrition Examination Survey and 2017 census suggest approximately 11.3 million, or 45.5% of all people in the US with diagnosed type 2 diabetes, would fall into those three groups, including 2.7 million in group 1, 3.5 million in group 2, and 5.1 million in group 3.

Using an equation Shao and colleagues recently developed for estimating quality of life decrements due to diabetes complications, they determined that de-intensification in group 1 would lead to an incremental loss of 0.4 million quality-adjusted life-years (QALYs), but would also lead to a lifetime saving of $45.7 billion.

Similarly, in group 2, de-intensification would lead to a QALY loss of 0.2 million, but also saves $24.7 million.

In group 3, intensification would result in 2.0 million QALYs gained, at a cost of $88.3 billion.

Overall, the ACP recommendations would result in a gain of 1.4 million QALYs, at a cost of $17.9 billion.

That falls within the generally accepted cost-effectiveness threshold of < $50,000 per QALY gained, Shao said.

Implementing the new guideline would result in 243,524 fewer cardiovascular events, 1.38 million QALYs gained, and an increase of $3.6 billion in healthcare expenditure nationwide, he noted.

Further, they calculated that if the $70.4 billion saved from de-intensification in groups 1 and 2 were to be re-allocated to intensification in group 3 and applied to 80% of that population, the result would be a gain of 2.6 million life-years at no additional cost.

Shao also pointed out that, compared to individuals with an HbA1c < 6.5%, those with poorly controlled HbA1c (> 8.0%) are more likely to be nonwhite (31% vs 50%), Hispanic (6% vs 23%), and female (39% vs 49%).

"Resource allocation may, therefore, help to mitigate the racial/gender disparity in the context of glycemic control by improving the HbA1c levels in a larger proportion of vulnerable populations," he concluded.  

Shao and Laiteerapong have reported no relevant financial relationships.

ADA Scientific Sessions. Presented June 7, 2019. Abstract 9-OR

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