Cost-Effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?
Authors: Siegel Karen R. , Ali Mohammed K. , Zhou Xilin , Ng Boon Peng , Jawanda Shawn , Proia Krista , Zhang Xuanping , Gregg Edward W. , Albright Ann L. , Zhang Ping 
Published: June 2020

Objective:
To synthesize updated evidence on the cost-effectiveness (CE) of interventions
to manage diabetes, its complications, and comorbidities.

<p>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 January 2008 and July 2017. We also incorporated studies from a
previous CE review from 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 to $50,000 per LYG or QALY), marginally cost-effective
($50,001 to $100,000 per LYG or QALY), or not cost-effective (>$100,000 per
LYG or QALY). Costs were measured in 2017 U.S. dollars.</p>

<p>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: (I) Cost-saving: 1) Angiotensin-converting
enzyme 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 T2D and obesity (BMI≥30 kg/m<sup>2</sup>).
(II) Very cost-effective: 1) intensive glycemic management (targeting A1c
<7%) compared with conventional glycemic management (targeting A1c level of 8-10%)
for individuals with newly diagnosed type 2 diabetes (T2D); 2). multi-component
interventions (involving behavior change/education and pharmacological therapy
targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria,
nephropathy/retinopathy, secondary prevention of CVD 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. </p>

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.