The topic today is some of the older diabetes treatments. I’ll cover some of the newer agents–jardiance, ozempic, trulicity, and so on–next month.
The cost-effectiveness literature covers individual drugs and overall goals such as “intensive glucose control” or “goal of normoglycemia.”
Before I get into the details, I will try to explain the overall findings this way. What is the most likely cause of death for a poorly controlled diabetic? A heart attack. What is the most likely cause of death for a well-controlled diabetic? A heart attack.
Our U.S. language on chronic disease and outcomes is at best imprecise, and at worst, just wrong. When common chronic diseases are appropriately treated, they don’t PREVENT death, they DELAY death. From a policy perspective, each healthcare system must decide how much it’s willing to pay for an extra number of weeks of life expectancy. If a new drug for diabetes or any other chronic disease costs too much, according to that country’s cut-offs, they don’t buy the drug. This is the main reason the U.S. has twice as many adults on statins as any European country.
The U.S. has no such cut-off. In fact, Medicare is prohibited from considering cost in its coverage determinations.
OK, let’s look at a couple of these cost-effectiveness studies in more detail.
A study from 1997 using 1994 dollars compared a goal of “normoglycemia,” defined as a hemoglobin A1c of 7.2% vs. 10%, using several medicines including insulin. Of course, they didn’t assume insulin would cost $300/vial. They assumed it would cost a little over $1,000 per year, but the other pills (metformin when it was new to the U.S. and glyburide) would be about $3,000/year. Of course, the costs have changed. There were other modest assumptions about cost such as a case of severe hypoglycemia costing $268.
They estimated that the life expectancy would increase by 1.3 years. They calculated that the incremental cost-effectiveness ratio (ICER) was ~$16,000/QALY. Not too bad, but not cost saving.
Here is a similar study:
Generic “intensive glucose control” — $78,000/QALY
As you might imagine, there is an extensive literature on single agents, almost always funded by the drug manufacturer. Meta-analyses of this literature has found what you probably expect: drug company-funded studies are more likely to calculate lower ICERs. Trying to find valid U.S.-based studies can actually be a little tedious. The literature is full of studies that sound like, “The cost-effectiveness of of thiazolidinedione added to metformin in poorly controlled patients with diabetes in Slovenia.” Of course, their cost estimates are, legitimately, much lower than the U.S. Here is a sampling of single agent studies using U.S. costs, if possible.
Thiazolidinedione in the UK — £16,000/QALY
Sitagliptin vs. glyburide as a second-line agent on top of metformin — $169,500/QALY (BTW, calculates an increase of 1 ½ months of life expectancy)
Insulin detemir — $4,000-$7,000/QALY
Insulin glargine vs. NPH in Canada — $8,000/QALY
For all of these treatments, the micro-economics of healthcare are most similar to everything else in micro-economics: better outcomes cost more. How much each country is willing to spend to squeeze out a few more weeks of life expectancy is up to each country. The U.S. is unwilling to set cost limits. That’s one of the main reasons why we have the exorbitantly expensive system we have.
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