ACP Guideline for A1c Levels Provide Cost-Effectiveness for Diabetics

Hui Shao, MBBS, PhD

Whether it’s ideal as a standard of care depends on various factors, but at least the recent American College of Physicians (ACP) guideline for blood sugar control (A1c) targets in patients with type 2 diabetes (T2D) is cost-effective.

In a new study presented at the American Diabetes Association (ADA) 2019 Annual Scientific Sessions in San Francisco, CA, investigator Hui Shao, MBBS, PhD, of the Centers for Disease Control and Prevention (CDC) Division of Diabetes Translation, presented findings showing that the 3-tier effect of the ACP 2018 A1c guideline would be an overall saving of treatment costs for patients.

In March 2018, the ACP released a guideline stating that patients with T2D should be treated to achieve A1C levels between 7% and 8%, an increase from the previous standard of 6.5% to 7%. At the time, the organization argued that clinical evidence was lacking for the microvascular benefit of pursuing A1c levels between the diabetes diagnosis benchmark of 6.5%.

The new guideline also recommends treat de-intensification in patients with A1c < 6.5%, and minimizing symptoms associated with hyperglycemia while avoiding HbA1c levels in patients with a life expectancy < 10 years.

As such, Shao and colleagues saw the effect reaching 3 subgroups of patients:

• Those whose A1c levels were < 6.5% due to nonmetformin anti-diabetes care, who would have to de-intensify therapy to reach 7% to 8%
• Those whose A1c levels were between the recommended 7% to 8%, but with life expectancies < 10 years which would require deintensification
• Those whose A1c levels were > 8% and life expectancy > 10 years which would require intensification

Shao noted a national-based guideline change would carry great implications for patient status and costs of care. Factor in the epidemic-level of diabetes and pre-diabetes prevalence in the US, and the ACP guideline requires critical, definite assessment.

In order to compare the cost-effectiveness of newly recommended treatment standards versus status quo, the team used a diabetes stimulation model from the CDC and San Francisco-based RTI research institute. The model estimated long-term healthcare and cost consequences due to the change in A1c targets. The team used data from the 2011-2016 National Health and Nutrition Examination Survey (NHANES) and the 2017 Census to estimate each of the 3 patient populations.

Shao and colleagues also used previous trials to estimate patient life expectancy for patients without previous diabetes-related cardiovascular complications. Patterns of therapy use were extracted from NHANES data.

Cost-effectiveness per 2017 USD was measured by cost per quality adjusted life year (QALY).

Investigators found the new guideline would result in 243,524 fewer cardiovascular events, approximately 1.38 million QALYs added to patients, and an increase of 3.6 billion USD in national healthcare expenditure—indicating an incremental cost-effective ratio (ICER) of $2367 per QALY.

Each of the 3 subgroups achieved cost-effectiveness versus status quo when simulated through progression with ACP A1c recommendations. Using a $50,000 threshold, the following savings were estimated to each of the subgroups:

• $8656 at a cost of .122 QALY for patients with life expectancy < 10 years (n= 3.4 million)
• $8169 at a cost of .058 QALY for patients with A1c < 6.5% (n= 3.17 million)
• $11,454 at with a .38 QALY gain for patients with A1c > 8% (n= 5.16 million)

Though Shao cited the results as robust, he noted limitations including the lack of representation for individual-level variations among patients with T2D, as well as there being no account made for the potential increased risk of hypoglycemia with the clinical pursuit of lower A1c targets.

That said, the findings were conclusive the new ACP guideline is at least cost-effective among the affected T2D patient populations in the US.

The study, "Cost Effectiveness of the New 2018 ACP Glycemic Control Guideline among U.S. Adults with Type 2 Diabetes," was presented at ADA 2019.