Lubor Golan, MD, MS; John D. Birkmeyer, MD; H. Gilbert Welch, MD, MPH
Acknowledgments: The authors thank the members of the Veterans Affairs Outcomes Group for intellectual support and encouragement.
Grant Support: Dr. Golan was supported by the Veterans Affairs Fellowship in Ambulatory Care. Dr. Birkmeyer was supported by a Career Development Award from the Veterans Affairs Health Services Research and Development Program.
Requests for Reprints: H. Gilbert Welch, MD, MPH, Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009-0001. For reprint orders in quantities exceeding 100, please contact the Reprints Coordinator; phone, 215-351-2657; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Golan: Vondrousova 1156, 163000 Prague 6, Reply II, Czech Republic.
Drs. Birkmeyer and Welch: Veterans Affairs Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, VT 05009-0001.
Although guidelines recommend angiotensin-converting enzyme inhibitors for diabetic patients with microalbuminuria, this strategy requires that providers adhere to screening recommendations. In addition, the benefit of angiotensin-converting enzyme inhibitors in normoalbuminuric patients was recently demonstrated.
To evaluate the cost-effectiveness of treating all patients with type 2 diabetes.
Markov model simulating the progression of diabetic nephropathy.
Randomized trials estimating the progression of diabetic nephropathy with and without angiotensin-converting enzyme inhibitors.
Patients 50 years of age with newly diagnosed type 2 diabetes (fasting plasma glucose level ≥ 7.8 mmol/L [140 mg/dL]).
Patients received angiotensin-converting enzyme inhibitors, screening for microalbuminuria, or screening for gross proteinuria.
Lifetime cost, quality-adjusted life expectancy, and marginal cost-effectiveness.
Screening for gross proteinuria had the highest cost and the lowest benefit. Compared with screening for microalbuminuria, treating all patients was more expensive ($15 240 and $14 940 per patient) but was associated with increased quality-adjusted life expectancy (11.82 and 11.78 quality-adjusted life-years). The marginal cost-effectiveness ratio was $7500 per quality-adjusted life-year gained.
Results were sensitive to the cost, effectiveness, and quality of life associated with angiotensin-converting enzyme inhibitor therapy, as well as age at diagnosis. The model was relatively insensitive to adherence with screening and costs of treating end-stage renal disease.
Treating all middle-aged diabetic patients with angiotensin-converting enzyme inhibitors is a simple strategy that provides additional benefit at modest additional cost. The strategy assumes that patients meet the older diagnostic criteria for diabetes and makes sense only for those who are not bothered by treatment.
Health states and clinical strategies in the Markov model.
Table 1. Baseline Prevalence and Transition Probabilities in the Model
Table 2. Baseline Values in the Decision Analysis Model and Their Range in the Sensitivity Analysis
Distribution of health states after 10 years for each of the three strategies.
Table 3. Output from Decision Analysis Model
Table 4. Expected and Marginal Values Obtained from the Decision Analysis and Results of the Cost-Effectiveness Analysis
Cost-effectiveness of the “treat all” strategy relative to the “screen for microalbuminuria” strategy as a function of cost of angiotensin-converting enzyme (ACE) inhibitors (top) or relative risk for progression to microalbuminuria (bottom) and age at diagnosis.
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Golan L, Birkmeyer JD, Welch HG. The Cost-Effectiveness of Treating All Patients with Type 2 Diabetes with Angiotensin-Converting Enzyme Inhibitors. Ann Intern Med. ;131:660–667. doi: 10.7326/0003-4819-131-9-199911020-00005
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Published: Ann Intern Med. 1999;131(9):660-667.
Cardiology, Coronary Risk Factors, Diabetes, Endocrine and Metabolism, Hypertension.
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