Implementing ACP Diabetes Guidelines Could Be Profitable

SAN FRANCISCO – According to the findings of a new study, the recommendations of the American College of Physicians (ACP) for American adults with type 2 diabetes would be cost-effective.

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

The ACP recommendation for an HbA_{1 C} Target of 7% to 8% for most non-pregnant adults with type 2 diabetes and de-intensification for those with HbA_{1 C} <6.5% have been a major source of controversy in the diabetes community.

Other groups, including ADA and the American Association of Clinical Endocrinologists (AACE), recommend lower overall targets – HbA_{1 C} <7% or <6.5% – with upward or downward adjustments based on patient characteristics.

But Shao's new badysis shows that implementation of the ACP recommendations would be cost-effective for the adult American population with type 2 diabetes, he said, noting that "if health care costs were taken into account , a combination of treatment desensitization in some treatment intensification, among others, may be an effective strategy. "

In addition, he explained, "the resources saved by the de-intensification of treatment can be transferred to people with HbA_{1 C} insufficiently controlled to achieve better health outcomes at the national level. "

Guest moderator, Neda Laiteerapong, MD, a general internist and health services researcher from the University of Chicago, Illinois, asked questions about the models used by Shao and her colleagues. in their badysis.

"We can not predict the potential benefits of a slightly higher blood sugar, nor the inconvenience of too low blood sugar, it's a problem when we try to simulate something like the ACP guidelines." You can not do it with our models, "she said Medscape Medical News in an interview.

Laiteerapong also cited a JAMA synopsis of clinical guidelines (JAMA. 2018; 319: 2430-2431), she co-wrote, fearing that the ACP guidelines could have unintended consequences for the relatively young and relatively healthy people newly diagnosed with type 2 diabetes and who would benefit more. Intensive glycemic management that older people and long-standing diabetes and complications.

"I think there are benefits to early early control of blood glucose levels … Any guideline is intended to make a broad and bulky statement to the general population, but we can also be a little more cautious and sophisticated. include clauses regarding younger groups, "Laiteerapong pointed out.

The application of ACP directives would be profitable

The badysis of Shao and his colleagues modeled three different groups that would be affected by the ACP guidelines:

1. People with a current HbA_{1 C} <6.5% on hypoglycemic agents other than metformin for which the ACP recommends de-treatment.

2. People with a current HbA_{1 C} 6.5% to 8.0% and a life expectancy <10 years, for which ACP also recommends de-densification.

3. People with a current HbA_{1 C} levels> 8.0% and life expectancy> 10 years, for which ACP recommends intensification of treatment.

Data from the 2011-2016 National Health and Nutrition Survey and the 2017 Census suggest that about 11.3 million, or 45.5% of all people with diabetes of type 2 diagnosed in the United States, belong to these three groups, of which 2.7 million in group 1, 3.5 million in group 2 and 5.1 million in group 3.

Using an equation recently developed by Shao to estimate decreases in quality of life due to diabetes complications, they determined that group 1 desintensification would result in an additional 0.4 million years of life adjusted for quality (QALY), but resulting in a lifetime savings of $ 45.7 billion.

Similarly, in Group 2, de-densification would result in a loss of 0.2 million QALY, but would also save $ 24.7 million.

In Group 3, the intensification would yield 2.0 million QALYs earned, at a cost of $ 88.3 billion.

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

This falls below the generally accepted break-even threshold of <$ 50,000 per QALY earned, Shao said.

The implementation of the new directive would result in 243,524 fewer cardiovascular events, 1.38 million QALYs earned and a $ 3.6 billion increase in health care spending nationwide. he noted.

In addition, they calculated that if the $ 70.4 billion saved from Group 1 and 2 de-densification were reallocated to Group 3 intensification and applied to 80% of this population, the result would be a gain of 2.6 millions of dollars alive. years without additional costs.

Shao also pointed out that, compared to individuals with an HbA_{1 C} <6.5%, those whose HbA is poorly controlled_{1 C} (> 8.0%) are more likely to be non-white (31% vs. 50%), Hispanic (6% vs. 23%), and female (39% vs. 49%).

"The allocation of resources can therefore help to mitigate gender disparities in the context of glycemic control by improving HbA levels._{1 C} levels in a greater proportion of vulnerable populations, "he concluded.

Shao and Laiteerapong have not reported any relevant financial relationship.

ADA scientific sessions. Presented June 7, 2019. Summary 9-OR

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