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In type 2 diabetes, intensive therapy increases lifespan with no additional health care cost
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ORLANDO, Fla. — A new cost analysis of the long-term STENO-2 study suggests that patients with type 2 diabetes who received intensive, multifactorial treatment lived on average 8 years longer compared with similar patients assigned to conventional care, with no additional health care costs over 21 years of follow-up.
“There was no difference in total cost between the two groups, but a reduction in cost per patient year in the intensified patient group,” Joachim Gaede, a graduate student in the Center for Metabolic Research at the University of Copenhagen in Denmark, said during a press conference at the American Diabetes Association Scientific Sessions. “The key point is that an intensified, multifactorial approach to treatment of type 2 diabetes increased the lifespan of patients by a median of 7.9 years without any additional total health care costs over 21.1 years of follow-up.”
Lifespan increased
In the STENO-2 study, which was initiated in 1993, 160 Danish patients with type 2 diabetes and persistent microalbuminuria (mean age, 55 years) were randomly assigned to standard treatment with a family physician (n = 80) or intensive therapy with medication and behavior modification at a specialized diabetes clinic (n = 80) for a mean of 8 years. Intensive treatment was a structured risk factor intervention with predefined, strict targets resembling current ADA guidelines, Gaede said, focusing on intensive pharmaceutical intervention but also lifestyle modification, including smoking cessation and dietary modifications.
The study continued as an observational follow-up after 7.8 years, and all patients then received intensive therapy. All patients completed up to six study visits at the Steno Diabetes Center at baseline and after an average of 1.9, 3.8, 7.8, 13.3 and 21.2 years. Primary outcome was the difference in median survival time between the original treatment groups with and without CVD.
Follow-up data at 21 years after randomization, published in 2016 in Diabetologia, revealed that patients assigned to intensive intervention experienced a 45% reduction in both the composite CV endpoint and death from any cause. That study also revealed patients assigned to intensive therapy gained 7.9 years of life vs. patients assigned to usual care, Gaede said.
“It is also worth noting that in the end of the 21 years of follow-up, there were 24 patients still alive in the original conventional-treatment group vs. 42 patients in the originally intensified group,” Gaede said.
Cost analysis
When analyzing total cost, Gaede said there were no between-group differences over the first 8 years of the study; however, a marked increase in treatment costs for the conventional-therapy group was observed after 8 years. A similar increase was observed in the intensive-therapy group at 15 years, mirroring the later event curve for these patients, Gaede said.
At 18 years, researchers observed declining health care costs in the conventional-therapy group; however, Gaede noted that this was caused by a reduced number of patients in that arm of the study over time, Gaede said.
“This flattening [in the curve] is actually a result of patients in that group dying,” Gaede said.
In analyzing the cumulative health care costs for both the intensive vs. conventional groups, researchers found no between-group difference in total costs over 21.2 years ($13 million vs. $12.3 million, respectively; P = .19); however, data indicated a lower health cost per patient per year in the intensified vs. conventional group (mean, $9,648 per patient vs. $10,681 per patient; P = .13) over follow-up, Gaede said. Sensitivity analyses excluding the first 3 years of the study did not change the findings, Gaede said.
Gaede said that, on average, intensive treatment was more expensive in terms of medication costs, but less costly in terms of primary care visits and inpatient hospital admissions related to CV events. – by Regina Schaffer
References:
Gaede J, et al. 162-OR. Presented at: American Diabetes Association 78th Scientific Sessions; June 22-26, 2018; Orlando, Fla.
Gaede P, et al. Diabetologia. 2016;doi:10.1007/s00125-016-4065-6.
Disclosures: The STENO-2 study was funded by unrestricted grants from Novo Nordisk. Gaede reports no relevant financial disclosures.
Perspective
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Nathan D. Wong, MD
The findings from this latest report from STENO-2 underscore the long-term or legacy effect of multifactorial risk factor control for both the prevention of cardiovascular disease events and overall mortality, which continues long after the initial 8-year randomization to intensive therapy. The results are consistent with our findings from a large pooling project of more than 2,000 patients with diabetes in three U.S. prospective studies (Wong ND, et al. Diabetes Care. 2016; doi:10.2337/dc15-2439.) Our study demonstrated approximately 60% lower cardiovascular disease risk over 11 years of follow-up in those at target for HbA1c, LDL cholesterol and blood pressure vs. not being at target for any of the factors. Unfortunately, one-quarter or fewer persons with diabetes are at target for even just these three factors, emphasizing the urgent need to advocate for comprehensive risk factor control in patients with diabetes.
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