Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

Abstract

OBJECTIVE To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985–2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001–$50,000 per LYG or QALY), marginally cost-effective ($50,001–$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985–2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8–10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

Cost-effectiveness of financial incentives to improve glycemic control in adults with diabetes: A pilot randomized controlled trial

“…Results of this study align with findings from a recent systematic review on cost-effectiveness of interventions to manage diabetes, that multiple component interventions focused on managing diabetes and risk factors for developing complications is very cost effective [22]. Though the evidence that interventions to manage diabetes are cost-effective grew between a review conducted in 2010 and the most recent review, no financial incentive interventions were included in either systematic review [22,30]. The finding that multicomponent interventions were very cost effective compared to usual care, combined with these findings that multi-component financial incentive structures had less variation in cost-effectiveness and resulted in larger drops in HbA1c, suggest that adding small financial incentives that match to the different components of previously tested interventions may offer an additional factor to initiate behavior change.…”

“…This will be particularly useful to understand in the field of diabetes, given possible long-term cost savings by preventing complications resulting from uncontrolled blood sugar [ 1 ]. Systematic reviews conducted to understand the most cost-effective interventions for managing diabetes, its complications, and comorbidities found strong evidence that diabetes self-monitoring (DSME), compared with usual care, is very cost-effective ($5,047/Quality Adjusted Life Year, QALY) [ 22 ]. Multi-component interventions were also on average very cost-effective ($2,315/QALY) for individuals with diabetes compared with usual care [ 22 ].…”

Cost-Effectiveness Analysis of Type 2 Diabetes Mellitus (T2DM) Treatment in Patients with Complications of Kidney and Peripheral Vascular Diseases in Indonesia

“…To gain more cost-effective T2DM treatment with complications, it is necessary for the government of Indonesia to intensify prevention strategies. A systematic review study by Siegel et al on the cost-effectiveness of interventions to manage DM highlighted that there were several interventions with strong evidence to prevent T2DM complications, such as through screening for undiagnosed T2DM, managing risk factors, and early treatment interventions [ 41 ]. Screening for T2DM has been proven to be a cost-effective intervention.…”

“…A randomized-controlled trial study on the cost-effectiveness of DSME highlighted that DSME was a promising investment and had a potential to be a cost-saving intervention [ 43 ]. Regarding early treatment interventions, we found strong evidence that early T2DM treatment with the use of telemedicine could be cost-effective [ 41 , 44 ]. Learning from the experience of other countries on managing risk factors to prevent T2DM complications, these interventions are promising to be included in the benefit package of social insurance in Indonesia.…”

Cost-effectiveness of GLP-1 receptor agonists versus insulin for the treatment of type 2 diabetes: a real-world study and systematic review

“…All costs and ICERs (expressed as dollars per quality-adjusted life year [QALY] gained) were adjusted to 2019 US dollars using the overall CPI [ 45 ]. We calculated a range and median ICER for all CEAs of GLP-1RAs versus insulin and by individual GLP-1RA drugs, and then used the US [ 44 ] and Taiwan’s WTP norms to determine whether a GLP-1RA versus insulin is: (1) cost-saving (when ICER < 0), (2) cost-effective (ICER < US$50,000 [US norm] or US$25,893 [one time Taiwan’s GDP]), (3) marginally cost-effective (ICER between US$50,000 and US$100,000 [US norm] or between US$25,893 and US$77,679 [one and three times Taiwan’s GDP]), or (4) not cost-effective (ICER > US$100,000 [US norm] or US$77,679 [three times Taiwan’s GDP]).…”