Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes

Laiteerapong, Neda; Cooper, Jennifer; Skandari, M. Reza; Clarke, Philip; Winn, Aaron N.; Naylor, Rochelle N.; Huang, Elbert S.

doi:10.7326/m17-0537

Cited by 29 publications

(31 citation statements)

References 58 publications

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“…These utility changes were similarly applied to CV outcomes in the GCK-MODY model. Utility changes associated with complications for type 2 diabetes patients were similar to those reported elsewhere (25).…”

Section: Quality Of Life Effectssupporting

confidence: 84%

The Impact of Biomarker Screening and Cascade Genetic Testing on the Cost-Effectiveness of MODY Genetic Testing

et al. 2019

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In the US, genetic testing for MODY is frequently delayed due to difficulty with insurance coverage. Understanding the economic implications of clinical genetic testing is imperative to advance precision medicine for diabetes. The objective of this paper is to assess the cost-effectiveness of genetic testing, preceded by biomarker screening and followed by cascade genetic testing of first-degree relatives, for subtypes of MODY in US pediatric patients with diabetes. Research Design and Methods: We used simulation models of distinct forms of diabetes to forecast the clinical and economic consequences of a systematic genetic testing strategy compared to usual care over a 30-year time horizon. In the genetic testing arm, patients with MODY received treatment changes (sulfonylureas for HNF1A-/HNF4A-MODY associated with a 1.0% reduction in HbA1c; no treatment for GCK-MODY). Study outcomes included costs, life expectancy (LE), and quality-adjusted life years (QALY). Results: The strategy of biomarker screening and genetic testing was cost-saving as it increased average quality of life (+0.0052 QALY) and decreased costs (-$191) per simulated patient relative to the control arm. Adding cascade genetic testing increased quality of life benefits (+0.0081 QALY) and lowered costs further (-$735). Conclusions: A combined strategy of biomarker screening and genetic testing for MODY in the US pediatric diabetes population is cost-saving compared to usual care, and the addition of cascade genetic testing accentuates the strategy's benefits. Widespread implementation of this strategy could improve the lives of patients with MODY while saving the health system money, illustrating the potential population health benefits of personalized medicine.

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Section: Quality Of Life Effectssupporting

confidence: 84%

The Impact of Biomarker Screening and Cascade Genetic Testing on the Cost-Effectiveness of MODY Genetic Testing

et al. 2019

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“…Our study thus highlights the need for personalizing treatment targets in adults with type 2 diabetes and implementing diabetes quality improvement strategies [ 41 ] that are flexible enough to focus on both the potential over-treatment of multimorbid patients as well as potential under-treatment of healthier patients and to consider both blood pressure as well as glycemic targets. To that end, it is worth noting that a recent Monte Carlo-based Markov Model decision analysis confirmed that care to achieve individualized treatment targets was cost-saving and associated with a small improvement in quality of life [ 42 ].…”

Section: Discussionmentioning

confidence: 99%

Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: a comparison across health states

McAlister

Lethebe

Lambe

et al. 2018

Cardiovasc Diabetol

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BackgroundTo examine the intensity of glycemic and blood pressure control in British adults with diabetes mellitus and whether control levels or treatment deintensification rates differ across health states.MethodsRetrospective cohort study using primary care electronic medical records (the United Kingdom Health Improvement Network Database) for adults with diabetes diagnosed at least 6 months before the index HbA1C and systolic blood pressure (SBP) measurements (to give their primary care physicians time to achieve treatment goals). We used prescribing records for 6 months pre/post the index measurements to determine who had therapy subsequently deintensified (based on “glycemic therapy score” and “antihypertensive therapy score” derived from number and dosage of medications).ResultsOf 292,170 individuals with diabetes, HbA1C < 6% or SBP < 120 mmHg after at least 6 months of management was less common in otherwise fit patients (15.0 and 12.7%) than in those who were mildly frail (16.6 and 13.2%) or moderately–severely frail (20.2 and 17.0%, both p < 0.0001). In the next 6 months, only 44.7% of those with HbA1C < 6% had glycemic therapy reduced (44.4% of fit, 47.1% of mildly frail, and 41.5% of moderate-severely frail patients) and 39.8% of those with SBP < 120 had their antihypertensives decreased (39.3% of fit, 43.0% of mildly frail, and 46.7% of moderate-severely frail patients). On the other hand, more individuals exhibited higher than recommended levels for HbA1C or SBP after the first 6 months of therapy (37.3, 33.4, and 31.3% of fit, mildly frail, and moderately–severely frail patients had HbA1C > 7.5% and 46.6, 51.4, and 48.5% had SBP > 140 mmHg). The proportions of patients with HbA1C or SBP out of recommended treatment ranges changed little 6 months later despite frequent (median 14 per year) primary care visits.ConclusionsGlycemic and hypertensive control exhibited statistically significant but small magnitude differences across frailty states. Medication deintensification was uncommon, even in frail patients below SBP and HbA1C targets. SBP levels were more likely to be outside recommended treatment ranges than glycemic levels.Trial registration As this study is a retrospective secondary analysis of electronic medical record data and not a health care intervention trial it was not registeredElectronic supplementary materialThe online version of this article (10.1186/s12933-018-0673-4) contains supplementary material, which is available to authorized users.

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“…For people with type 2 diabetes, we modelled lifetime outcomes using the U.S. Type 2 Diabetes Policy Model [22][23][24], an individual population-level, Monte Carlo-based Markov model ( Fig. 1) (see Appendix S1 for details).…”

Section: Simulation Modelsmentioning

confidence: 99%

Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes

et al. 2020

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Aim To evaluate the U.S. population-level impact of two alternatives for initial type 2 diabetes screening [opportunistic random plasma glucose (RPG) > 6.7 mmol/l and a 1-h 50-g glucose challenge test (GCT) > 8.9 mmol/l] compared with American Diabetes Association (ADA)-recommended tests. Methods Using a sample (n = 1471) from the National Health and Nutrition Examination Survey (NHANES) 2013-2014 that represented 145 million U.S. adults at high risk for developing type 2 diabetes, we simulated a two-test screening process. We compared ADA-recommended screening tests [fasting plasma glucose (FPG), 2-h 75-g oral glucose tolerance test (OGTT), HbA 1c ] vs. initial screening with opportunistic RPG or GCT (followed by FPG, OGTT or HbA 1c). After simulation, participants were entered into an individual-level Monte Carlo-based Markov lifetime outcomes model. Primary outcomes were representative number of U.S. adults correctly identified with type 2 diabetes, societal lifetime costs and quality-adjusted life years (QALYs). Results In NHANES 2013-2014, 100 individuals had undiagnosed diabetes [weighted estimate: 8.4 million, standard error (SE): 1.1 million]. Among ADA-recommended screening tests, FPG followed by OGTT (FPG-OGTT) was most sensitive, identifying 35 individuals with undiagnosed diabetes (weighted estimate: 3.2 million, SE: 0.9 million). Four alternative screening strategies performed superior to FPG-OGTT, with RPG followed by OGTT being the most sensitive overall, identifying 72 individuals with undiagnosed diabetes (weighted estimate: 6.1 million, SE: 1.0 million). There was no increase in average lifetime costs and comparable QALYs. Conclusions Initial screening using opportunistic RPG or a GCT may identify more U.S. adults with type 2 diabetes without increasing societal costs.

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Individualized Glycemic Control for U.S. Adults With Type 2 Diabetes

Cited by 29 publications

References 58 publications

The Impact of Biomarker Screening and Cascade Genetic Testing on the Cost-Effectiveness of MODY Genetic Testing

The Impact of Biomarker Screening and Cascade Genetic Testing on the Cost-Effectiveness of MODY Genetic Testing

Control of glycemia and blood pressure in British adults with diabetes mellitus and subsequent therapy choices: a comparison across health states

Alternative type 2 diabetes screening tests may reduce the number of U.S. adults with undiagnosed diabetes

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