Model-based simulation to explore the cost-effectiveness of following practice guidelines for triglyceride and low-density lipoprotein cholesterol control among patients with diabetes mellitus and mixed dyslipidemia

A Systematic Review of Cost-Effectiveness of Non-Statin Lipid-Lowering Drugs for Primary and Secondary Prevention of Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus

Although studies of non-statin lipid-lowering therapies (NSLLTs) have demonstrated cardiovascular benefits; whether these benefits provide good value has not been evaluated in type 2 diabetes mellitus (T2DM) patients. A systematic review was performed to include studies on the cost-effectiveness of NSLLTs in T2DM patients with/without cardiovascular disease (CVD). Thirteen studies were included; ezetimibe (n=8), proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors (n=4), fenofibrate (n=2), nicotinic acid (n=1), extended-release niacin/laropiprant (ER- ERN/LRPT) (n=1), and icosapent ethyl (n=1). Six studies considered ezetimibe+statin to be a cost-effective compared to statins monotherapy, three studies suggested that PCSK9 inhibitors+statins were not cost-effective compared to statin+ezetimibe. Fenofibrate was a cost-effective either as monotherapy or combined with a statin compared to statin or fenofibrate monotherapy. Nicotinic acid and ER- ERN/LRPT compared to statin monotherapy were also cost-effective. Icosapent ethyl using the solid-state relay was cost-effective compared to standard care but not using the wholesale acquisition cost.

Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

OBJECTIVE

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

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

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: In the cost-saving category are 1) ACE 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 type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m²). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease 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.

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.

The impact of insulin pump therapy to oxidative stress in patients with diabetic nephropathy

Background

The oxidative stress resulting from increased production of ROS plays a crucial role in the development of diabetic complications. We aim to explore the relationships between oxidative stress, diabetic nephropathy (DN) and short-term insulin pump intensive therapy (insulin therapy).

Methods

Levels of 8-hydroxy-deoxyguanosine (8-OHdG), 3-nitrotyrosine (3-NT), glutathione (GSH), superoxide dismutase (SOD) and Interleukin-6 (IL-6) were estimated before and after 2 weeks of insulin therapy in normal group (NC) and type 2 diabetic (DM) with normal albuminuria (NA), microalbuminuria (MA) and clinical albuminuria (CA).

Results

In DM group, levels of 8-OHdG and 3-NT were higher than those in NC group (P < 0.05); GSH and SOD were lower (P < 0.05). And their levels changed with urine albumin–creatinine ratio (P < 0.05). After insulin therapy, these derangements were significantly ameliorated and the changes in NA and MA groups were more significant than CA group (P < 0.05). Correlation analysis showed glycated hemoglobin, the course of disease, the HOME-IR and fasting plasma glucose were positively correlated with 8-OHdG and 3-NT, but negatively correlated with GSH and SOD.

Conclusions

The oxidative stress gradually increased with the magnitude of DN, and insulin pump intensive therapy can significantly ameliorate the derangements in the early stage of DN.

Trial registration NCT03174821

New Metrics for Economic Evaluation in the Presence of Heterogeneity: Focusing on Evaluating Policy Alternatives Rather than Treatment Alternatives

BACKGROUND

Cost-effectiveness analysis (CEA) methods fail to acknowledge that where cost-effectiveness differs across subgroups, there may be differential adoption of technology. Also, current CEA methods are not amenable to incorporating the impact of policy alternatives that potentially influence the adoption behavior. Unless CEA methods are extended to allow for a comparison of policies rather than simply treatments, their usefulness to decision makers may be limited.

METHODS

We conceptualize new metrics, which estimate the realized value of technology from policy alternatives, through introducing subgroup-specific adoption parameters into existing metrics, incremental cost-effectiveness ratios (ICERs) and Incremental Net Monetary Benefits (NMBs). We also provide the Loss with respect to Efficient Diffusion (LED) metrics, which link with existing value of information metrics but take a policy evaluation perspective. We illustrate these metrics using policies on treatment with combination therapy with a statin plus a fibrate v. statin monotherapy for patients with diabetes and mixed dyslipidemia.

RESULTS

Under the traditional approach, the population-level ICER of combination v. monotherapy was $46,000/QALY. However, after accounting for differential rates of adoption of the combination therapy (7.2% among males and 4.3% among females), the modified ICER was $41,733/QALY, due to the higher rate of adoption in the more cost-effective subgroup (male). The LED metrics showed that an education program to increase the uptake of combination therapy among males would provide the largest economic returns due to the significant underutilization of the combination therapy among males under the current policy.

CONCLUSION

This framework may have the potential to improve the decision-making process by producing metrics that are better aligned with the specific policy decisions under consideration for a specific technology.

Clinical and economic benefits associated with the achievement of both HbA1c and LDL cholesterol goals in veterans with type 2 diabetes

OBJECTIVE

This study compared the clinical and economic benefits associated with dual-goal achievement, glycated hemoglobin (HbA1c)<7% (53 mmol/mol) and LDL cholesterol (LDL-C)<100 mg/dL, with achievement of only the LDL-C goal or only the HbA1c goal in veterans with type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

This retrospective cohort analysis evaluated electronic medical records (Veterans Integrated Service Network 16) in adult T2DM patients with two or more measurements of LDL-C and HbA1c between 1 January 2004 and 30 June 2010 (N=75,646). Cox proportional hazards models were used to compare microvascular and cardiovascular outcomes by goal achievement status; generalized linear regression models were used to assess diabetes-related resource utilization (hospitalization days and number of outpatient visits) and medical service costs.

RESULTS

Relative to achievement of only the LDL-C goal, dual-goal achievement was associated with lower risk of microvascular complications (adjusted hazard ratio [aHR] 0.79), acute coronary syndrome (0.88), percutaneous coronary intervention (0.78), and coronary artery bypass graft (CABG) (0.74); it was also associated with fewer hospitalization days (adjusted incidence rate ratio [aIRR] 0.93) and outpatient visits (0.88), as well as lower diabetes-related annual medical costs (-$130.89). Compared with achievement of only the HbA1c goal, dual-goal achievement was associated with lower risk of the composite cardiovascular-related end point (aHR 0.87) and CABG (aHR 0.62), as well as fewer outpatient visits (aIRR 0.98).

CONCLUSIONS

Achieving both HbA1c and LDL-C goals in diabetes care is associated with additional clinical and economic benefits, as compared with the achievement of either goal alone.

Early antiretroviral therapy for patients with acute aids-related opportunistic infections: a cost-effectiveness analysis of ACTG A5164

PURPOSE

ACTG A5164 demonstrated that early antiretroviral therapy (ART) in HIV-infected patients with acute opportunistic infections (OIs) reduced death and AIDS progression compared to ART initiation 1 month later. We project the life expectancies, costs, and incremental cost-effectiveness ratios (ICERs) of these strategies.

METHOD

using an HIV simulation model, we compared 2 strategies for patients with acute OIs: (1) an intervention to deliver early ART, and (2) deferred ART. Parameters from ACTG A5164 included initial mean CD4 count (47/microL), linkage to outpatient care (87%), and immune reconstitution inflammatory syndrome 1 month after ART initiation (7%). The estimated intervention cost was $1,650/patient.

RESULTS

early ART lowered projected 1-year mortality from 10.4% to 8.2% and increased life expectancy from 10.07 to 10.39 quality-adjusted life-years (QALYs). Lifetime costs increased from $385,220 with deferred ART to $397,500 with early ART, primarily because life expectancy increased, producing an ICER of $38,600/QALY. Results were most sensitive to increased intervention cost and decreased virologic efficacy in the early ART strategy.

CONCLUSIONS

an intervention to initiate ART early in patients with acute OIs improves survival and meets US cost-effectiveness thresholds. Programs should be developed to implement this strategy at sites where HIV-infected patients present with OIs.

Fibrate therapy in the management of dyslipidemias, alone and in combination with statins: role of delayed-release fenofibric acid

IMPORTANCE OF THE FIELD

Optimization of lipid management is a crucial aspect in the treatment of cardiovascular disease. Currently, HMG-CO reductase inhibitors (statins) are a mainstay of therapy. While this class of drugs has proven efficacy at lowering low-density lipoprotein cholesterol (LDL-C), their effects on other important lipid parameters, such as high-density lipoprotein cholesterol (HDL-C) and triglycerides, are less robust.

AREAS COVERED IN THIS REVIEW

The current paper will address the significance of these secondary targets and review currently available therapies, including a new formulation of delayed-release fenofibric acid. A comprehensive MEDLINE search (1966 to September 2009) was performed.

WHAT THE READER WILL GAIN

The reader will gain a comprehensive review of the importance of secondary cholesterol targets, as well as the effectiveness of currently available therapies to address non-LDL-C. The role of the newly released fenofibric acid will also be addressed, as well as its potential use in combination therapy with a statin.

TAKE HOME MESSAGE

Adequate treatment of lipid parameters beyond LDL-C is an essential component in the treatment of dyslipidemia. The fibrate class of drugs has proven efficacy in improving secondary targets; however, concerns regarding severe myopathy and rhabdomyolysis have limited their combination with statins. Recently, a new fibrate derivative, fenofibric acid, has become available. Studies to date reflect a positive safety and tolerability profile when combined with statins. This may offer a new tool to address the important secondary cholesterol targets that are becoming increasingly recognized as important contributors to cardiovascular outcomes.