The cost-effectiveness of treating all patients with type 2 diabetes with angiotensin-converting enzyme inhibitors.
BACKGROUND
Although guidelines recommend angiotensin-converting enzyme inhibitors for diabetic patients with microalbuminuria, this strategy requires that providers adhere to screening recommendations. In addition, the benefit of angiotensin-converting enzyme inhibitors in normoalbuminuric patients was recently demonstrated.


OBJECTIVE
To evaluate the cost-effectiveness of treating all patients with type 2 diabetes.


METHODS
Markov model simulating the progression of diabetic nephropathy.


METHODS
Randomized trials estimating the progression of diabetic nephropathy with and without angiotensin-converting enzyme inhibitors.


METHODS
Patients 50 years of age with newly diagnosed type 2 diabetes (fasting plasma glucose level > or = 7.8 mmol/L [140 mg/dL]).


METHODS
Lifetime.


CONCLUSIONS
Societal.


METHODS
Patients received angiotensin-converting enzyme inhibitors, screening for microalbuminuria, or screening for gross proteinuria.


METHODS
Lifetime cost, quality-adjusted life expectancy, and marginal cost-effectiveness.


RESULTS
Screening for gross proteinuria had the highest cost and the lowest benefit. Compared with screening for microalbuminuria, treating all patients was more expensive ($15240 and $14940 per patient) but was associated with increased quality-adjusted life expectancy (11.82 and 11.78 quality-adjusted life-years). The marginal cost-effectiveness ratio was $7500 per quality-adjusted life-year gained.


RESULTS
Results were sensitive to the cost, effectiveness, and quality of life associated with angiotensin-converting enzyme inhibitor therapy, as well as age at diagnosis. The model was relatively insensitive to adherence with screening and costs of treating end-stage renal disease.


CONCLUSIONS
Treating all middle-aged diabetic patients with angiotensin-converting enzyme inhibitors is a simple strategy that provides additional benefit at modest additional cost. The strategy assumes that patients meet the older diagnostic criteria for diabetes and makes sense only for those who are not bothered by treatment.
Golan
L
L
Department of Veterans Affairs Medical Center, White River Junction, Vermont 05009-0001, USA.
Birkmeyer
J D
JD
Welch
H G
HG
D000419:Albuminuria / Q000175:diagnosis; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000191:economics* / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy*; D003928:Diabetic Nephropathies / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control*; D006801:Humans; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000191:economics* / Q000517:prevention & control*; D008390:Markov Chains; D011507:Proteinuria / Q000175:diagnosis; D019057:Quality-Adjusted Life Years
D000806:Angiotensin-Converting Enzyme Inhibitors