Effectiveness and Cost-effectiveness of Benefit-based Treatment vs. Treat-to-target Treatment in Type-2 Diabetes

21 Nov, 16

Introduction

Optimal treatment of type-2 diabetes mellitus (T2DM) includes effective management of three principal coexisting risk factors namely high blood pressure (BP), dyslipidemia and poor glycemic control. Traditionally, management has been guided by a treat-to-target (TTT) approach (e.g. achieving target levels of individual risk factors). However, recent guidelines have started shifting towards benefit-based treatment approach {e.g. prescribing statins on the basis of cardiovascular risk rather than low density lipoprotein (LDL) cholesterol levels}. Whether and under what circumstances, one approach is more beneficial than the other is currently unclear.

Aim

To compare the effectiveness and cost-effectiveness of two treatment approaches: TTT and benefit-based-tailored strategy (BTT) for the management of T2DM in five low-income and middle-income countries (India, China, Ghana, Mexico, South Africa).

Patient Profile

Type 2 diabetes mellitus patients selected from five ‘low’ or ‘middle’ income countries (China, Ghana, India, Mexico, and South Africa)
Age 20-79 years

Methods

Study Design

A microsimulation model to simulate T2DM adults and their risks of 5 diabetes complications: myocardial infarction (MI), stroke, end-stage renal disease (ESRD), blindness and diabetic ulcer.

Treatment Strategy

Following treatment strategies were simulated for the subjects to estimate probability of the 5 diabetes complications (mentioned above)

Cost effectiveness analysis was also conducted by using the simulation model

Outcomes

Probability of MI, stroke, blindness, ESRD and ulcer
Cost effectiveness of the two treatment strategies

Results

The TTT strategy recommended treatment to a larger number of people who were generally at lower risk of diabetes complications (10 year cardiovascular risk ranging from 16.1 – 17.3% vs. 19.7 – 21.1%, respectively). The BTT strategy recommended treatment to fewer people at higher risk.
As per the estimates, BTT strategy as compared to the TTT strategy, would avert around 24·4–30·5% more complications (MI, stroke, blindness, and ESRD, with the exception of diabetic ulcers)
Although the BTT strategy had equivalent costs when compared to TTT strategy, it was significantly more effective that TTT (BTT averted significantly more DALYs [disability-adjusted life years]) in all the participant countries.
The incremental cost-effectiveness ratio due to shift from TTT to BTT strategy ranged from -$ 4.0 to -$300 per incremental DALY averted, thus indicating cost savings due to implementation of the BTT strategy.
The comparative superiority of the BTT strategy remained unaltered with the use of alternative treatment thresholds, matched by total cost or population size treated or due to altering the treatment on the basis of fasting plasma glucose values (in areas where the facility of HbA1c testing was unavailable)
Importantly, the BTT strategy remained more effective than TTT strategy to prevent CV outcomes but not for microvascular outcomes
Biomarkers that could predict the patients in whom a complication would be averted by TTT strategy rather than the BTT strategy and vice versa could not be identified

Conclusion

BTT strategy was more effective and cost-effective than TTT strategy in low-income and middle-income countries for prevention of both CV and microvascular complications associated with T2DM
The superior prevention of CV and microvascular complications was a consequence of primarily concentrating effective therapy in patients with a high risk of CV and microvascular complications
BTT can therefore be considered as a cost-effective alternative to TTT strategy in low-income and middle-income countries for prevention of complications associated with T2DM

Lancet Diabetes Endocrinol Oct 4, 2016 (Published online); http: //dx.doi.org/10.1016/S2213-8587(16)30270-4