Small reductions in HbA1C could equal big cost savings

If patients with type 1 or type 2 diabetes were able to achieve small improvements in their glycemic control there could be a significant financial benefit to the national healthcare system, according to a U.K. study published recently in Diabetic Medicine.

Using a population-based intervention based on a sustained, incremental improvement in glycemic control by everyone with type 1 or type 2 diabetes there could be significant reductions in microvascular complications incurred, translating into a cost avoidance of about £340 million (~$500 million) over 5 years and as much as £5.5 billion (~$8 billion) after 25 years, the study showed.

“Improved glycemia improves the outcomes from microvascular complications. In type 1 diabetes, this is mostly related to kidney disease. In type 2, it is mostly driven by the avoidance of foot complications,” Mike Baxter, of Sanofi, Guildford, United Kingdom, told Medical Economics. “The results were unexpected, and do point to a different intervention strategy (focus) ‘to incrementally improve everyone’ and, for the first time, give some idea of the quantitative impact of improved glycemia on the patients and the system.”

According to Baxter, the United Kingdom currently has about 3.1 million people with diabetes, many of whom are predisposed to complications in the eyes, kidneys, and feet that are related to glucose control.

“The cost of treating and managing these avoidable complications is 80% of the monies spent of diabetes and adds up to £8 billion (~$11.5 billion) in the U.K. per annum,” Baxter said.

With this study, Baxter and colleagues wanted to determine if a small improvement in glycemic control could be effective in generating meaningful improvements in outcomes, and, if so, if they could estimate the financial effects of this type of reduction.

The researchers used the IMS Core Diabetes Model to look at the effect of a modest, but achievable reduction in HbA1c in a representative cohort of adults with type 1 or type 2 diabetes. They then modeled the incidence of microvascular and macrovascular complications across 5-year periods for 25 years.

For patients with type 1 diabetes, the researchers assumed that better management would equate to a 0.4% lower HbA1c (decrease in 4 mmol/mol). With this reduction, they estimated that the cost reduction from avoided complications per person after 25 years would be between £2,057 (HbA1c about 7.5%) to £4,136 (HbA1c >about 9%). Calculated out to the entire population of people with type 1 diabetes in the United Kindgom, that would mean a cost reduction of £39 million (~$56 million) over 5 years and as much as £995 million (~$1.4 billion) after 25 years.

In people with type 2 diabetes, the researchers assumed that people “might receive up to five treatment modifications at the levels of HbA1c recommended in NICE guidance.” The per person cost avoidance over 25 years would be between £1,280 (~$1,846) per person (with an HbA1c of 7.5%) to £2,223 (~$3,200) per person (HbA1c of 8.0% to 9.0%). Calculated out to the entire population, that would equate to a cost reduction of about £299 million (~$431 million) over 5 years and £4.506 billion (~$6.5 billion) over 25 years.

“People don’t all have to be perfect (as defined by an HbA1c of 7%) they just need to be better than they currently are,” Baxter said. “[The study] also highlighted that people with lower HbA1c, who previously would be considered to be OK, and at target, where in fact not without risk of developing diabetic complications (low risk is not no risk) and in fact in population terms were very important to the overall clinical and financial picture.”

Baxter and colleagues used this analysis to calculate the cost reductions for individual disease complications as well. In type 1 diabetes, a population-wide 0.4% improvement in HbA1c over 25 years would result in cost reductions of £12 million (~$17 million) for eye disease, £740 million (~$1.1 billion) for renal disease and £240 million (~$346 million) for foot and ulcer amputations. In type 2 diabetes, treatment to NICE guidelines over 25 years would result in cost savings of £637 million (~$919 million) for eye disease, £1.29 billion (~$1.9 billion) for renal disease, £2.57 billion (~$3.7 billion) for foot ulcers and amputations and £2 million (~$2.8 million) for cardiovascular disease.

“The study would need to be repeated using U.S. data but, in theory, these observations are absolutely transferable,” Baxter said. “In fact, because the U.S. problem is so much bigger-29.1 million people (10 times the United Kingdom) -and current spending on diabetes care is over $200 billion, this suggests that the actual magnitude of cost avoidance and clinical benefit could be massive.”