Influence of Diabetes Complications on HbA_1c Treatment Goals Among Older U.S. Adults: A Cost-effectiveness Analysis.

Abstract

Guidelines on the standard care of diabetes recommend that glycemic treatment goals for older adults consider the patient's complications and life expectancy. In this study, we examined the influence of diabetes complications and associated life expectancies on the cost-effectiveness (CE) of HbA_1c treatment goals. We used data from the 2011-2016 National Health and Nutrition Examination Survey (NHANES) to generate nationally representative subgroups of older individuals with diabetes with various health states. We used the Centers for Disease Control and Prevention-RTI International diabetes CE model to estimate the long-term consequences of two treatment goals-a stringent control goal (HbA_1c <7.5%) and a moderate control goal (HbA_1c <8.5%)-on health and cost. Our simulation population represented typical patients, and all individuals in each health subgroup had average characteristics, which did not account for person-level variations. The CE study was conducted from a health system perspective and followed the study samples over a lifetime. We used $50,000 per quality-adjusted life year (QALY) as the incremental CE threshold. A stringent goal was, on average, cost-effective for individuals with no complications ($10,007 per QALY) or only microvascular complications (excluding renal failure; $19,621 per QALY), but it was not cost-effective for individuals with one or more macrovascular complications (all >$82,413 per QALY). Further, a stringent goal was not cost-effective when an individual had less than 7 years of life remaining. Our findings support the guideline recommendation that glycemic goals for older adults should consider the complexity of their complications and their life expectancy from a CE perspective.