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Estimated Benefits of Glycemic Control in Microvascular Complications in Type 2 Diabetes

Sandeep Vijan, MD, MS; Timothy P. Hofer, MD, MS; and Rodney A. Hayward, MD
[+] Article and Author Information

From the Veterans Affairs Center for Practice Management and Outcomes Research and the University of Michigan School of Medicine, Ann Arbor, Michigan. Grant Support: In part by grant HSO 6665-01 from the Agency for Health Care Policy and Research. Dr. Vijan is an Agency for Health Care Policy and Research Health Services Research Fellow, and Dr. Hofer is a Veterans Affairs Health Services Research and Development Career Development Awardee. Requests for Reprints: Sandeep Vijan, MD, Veterans Affairs Health Services Research and Development, PO Box 130170, Ann Arbor, MI 48113-0170. Current Author Addresses: Drs. Vijan, Hofer, and Hayward: Veterans Affairs Health Services Research and Development, PO Box 130170, Ann Arbor, MI 48113-0170.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;127(9):788-795. doi:10.7326/0003-4819-127-9-199711010-00003
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Background: The benefits of intensive glycemic control in patients with type 2 diabetes are not well quantified. It is therefore not clear which patients will benefit most from aggressive glycemic control.

Objective: To evaluate the efficacy of glycemic control in type 2 diabetes.

Design: Markov decision model.

Patients: Diabetic patients at a health maintenance organization.

Main Outcome Measures: Risks for developing blindness and end-stage renal disease; number of patients and patient-years needed to treat to prevent complications.

Results: For a patient in whom diabetes developed before 50 years of age, reducing hemoglobin A1c levels from 9% to 7% results in an estimated 2.3-percentage point decrease (from 2.6% to 0.3%) in lifetime risk for blindness due to retinopathy. The same change in a patient with diabetes onset at 65 years of age would be expected to decrease the risk for blindness by 0.5 percentage points (from 0.5% to <0.1%). However, the Markov model predicts substantially greater benefit when moving from poor to moderate glycemic control than when moving from moderate to almost-normal glycemic control. Targeting less than 20% of the patients at one health maintenance organization for intensified therapy may prevent more than 80% of the preventable patient-time spent blind. The risks for end-stage renal disease and the risk reduction provided by improved glycemic control are lower than those for blindness.

Conclusions: This probability model, based on extrapolation from the experience with type 1 diabetes, suggests that patients with early onset of type 2 diabetes will accrue substantial benefit from almost-normal glycemic control. In patients with later onset, moderate glycemic control prevents most end-stage complications caused by microvascular disease. These results have important implications for informing patients and allocating health care resources.

Figures

Grahic Jump Location
Figure 1.
Structure of the model.

Each circular node represents a chance node. Each node was encountered yearly, and the probabilities of remaining at the same level, advancing to the next complication, or dying were encountered. ESRD = end-stage renal disease.

Grahic Jump Location

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