PracticeUpdate: Diabetes

EDITOR’S PICKS 6

30-Year Cost-Effectiveness Associated With Excellent Glycemic Control in

Type 1 Diabetes Journal of Diabetes and Its Complications

" Although maintaining excellent glycemic control can be costly, such cost is offset by cost savings from averting

Take-home message • The authors investigated the costs involved in intensive and conventional treat- ments of type 1 diabetes (T1D). Over a 30-year period, the following observations were reported. Diabetes Control and Complications Trial (DCCT) intensive therapy vs DCCT conventional therapy resulted in a cost of $127,500 to $181,600 more per patient. Modern intensive therapy vs modern basic therapy cost between $87,700 and as much as $409,000 more per patient. Approximately $90,900 was saved in costs through excellent glycemic control as a result of averting complications, and approximately 1.62 quality-adjusted life-years were added per patient over this period. • Value for money is apparent when utilizing the least expensive intensive therapy option that can achieve treatment goals in patients with T1D. T he current studies shed light on the benefits and costs of long-term intensive glycemic control for patients with type 1 diabetes mellitus (T1DM). 1,2 The authors conducted a post hoc analysis of DCCT/EDIC and demonstrated that 30 years of excellent (HbA1c ~ 7%) compared with poor (HbA1c ~ 9%) glycemic control substan- tially reduces the risk of end-stage renal disease, retinopathy, neuropathy, myocardial infarction, stroke, and death, as well as increases quality-adjusted life years. 1 A 30-year Monte Carlo simulation informed by DCCT/EDIC results revealed that achieving the HbA1c target of 7% using multiple daily injection therapy is cost-saving and using insu- lin pump therapy is cost-effective. 2 However, modern pump therapy with continuous glucose monitoring (CGM) may not be cost-effective. These results support the use of intensive therapy to achieve HbA1c ~ 7% for patients with T1DM. Although maintaining excellent glycemic control can be costly, such cost is offset by cost savings from averting downstream diabetes-related complications, comorbidities, and death. Also, current studies do not support pump therapy with CGM as first-line treatment for all T1DM patients due to its notably greater cost, although it can be an appropriate therapy for a subset of patients who are at increased risk of hypoglycemia or have poor glycemic control. References 1. Herman WH, Braffett BH, Kuo S, et al. What Are the Clinical, Quality-of-Life, and Cost Consequences of 30 Years of Excellent vs Poor Glycemic Control in Type 1 Diabetes? [Published online June 12, 2018]. J Diabetes Complicat Doi: 10.1016/j.jdiacomp.2018.05.007. 2. Herman WH, Braffett BH, Kuo S, et al. The 30-Year Cost-Effectiveness of Alternative Strategies to Achieve Excellent Glycemic Control in Type 1 Diabetes: An Economic Simulation Informed by the Results of the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) [published online June 12, 2018]. J Diabetes Complicat Doi: 10.1016/j. jdiacomp.2018.06.005. COMMENT By Pooyan Kazemian PhD

Abstract OBJECTIVE To simulate the cost-effectiveness of historical and modern treatment scenarios that achieve excellent vs. poor glycemic control in type 1 diabetes (T1DM). RESEARCH DESIGN ANDMETHODS We describe and compare the costs of intensive and conven- tional therapies for T1DM as performed during DCCT, and modern intensive and basic therapy scenarios using insulin analogs, pens, pumps, and continuous glucose monitoring (CGM) to achieve excellent or poor glycemic control. We then assess the differences in treatment costs and the costs of outcomes over 30 years and report incremental cost-effectiveness ratios. RESULTS Over 30 years, DCCT intensive therapy cost $127,500 to $181,600 more per participant than DCCT conventional therapy, and modern intensive therapy cost $87,700 to $409,000more per individual thanmodern basic therapy. Excellent glycemic control averted as much as $90,900 in costs from complications and added ~ 1.62 qual- ity-adjusted life-years (QALYs) per participant over 30 years. When costs and QALYs were dis- counted at 3% annually, DCCT intensive therapy and modern intensive therapies that use multiple daily injections (MDI) or pumps are cost-saving or cost-effective (<$100,000/QALY-gained). If applied to all patients with T1DM, modern intensive ther- apy using pumps and CGM is not cost-effective (>$250,000/QALY-gained) but would be more cost-effective if associated with less hypoglyce- mia, better glycemic control, fewer complications, or improved health-related quality-of-life. CONCLUSIONS Use of the least expensive inten- sive therapy needed to safely achieve treatment goals for patients with T1DM represents a good value for money. The 30-Year Cost-Effectiveness of Alternative Strategies to Achieve Excellent Glycemic Con- trol in Type 1 Diabetes: An Economic Simulation Informed by the Results of the Diabetes Control and Complications Trial/Epidemiology of Dia- betes Interventions and Complications (DCCT/ EDIC). J Diabetes Complicat 2018 Jun 12;[EPub Ahead of Print], WH Herman, BH Braffett, S Kuo, et al. www.practiceupdate.com/c/69637 downstream diabetes- related complications, comorbidities, and death. "

Dr. Kazemian is a Research Scientist at Medical Practice Evaluation Center of the Division of General Internal Medicine, Massachusetts General Hospital, and Instructor in Medicine at Harvard Medical School in Boston, Massachusetts.

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