The impact of patient preferences on the cost-effectiveness of intensive glucose control in older patients with new-onset diabetes.

摘要

OBJECTIVE: Cost-effectiveness analyses have reported that intensive glucose control is not cost-effective in older patients with new-onset diabetes. However, these analyses have had limited data on patient preferences concerning diabetic health states. We examined how the cost- effectiveness of intensive glucose control changes with the incorporation of patient preferences. RESEARCH DESIGN AND METHODS: We collected health state preferences/utilities from 519 older diabetic patients. We incorporated these utilities into an established cost-effectiveness model of intensive glucose control and compared incremental cost-effectiveness analyses ratios (ICERs) (cost divided by quality-adjusted life-year [QALY]) when using the original and patient-derived utilities for complications and treatments. RESULTS: The mean utilities were approximately 0.40 for major complications, 0.76 (95% CI 0.74-0.78) for conventional glucose control, 0.77 (0.75-0.80) for intensive therapy with oral medications, and 0.64 (0.61-0.67) for intensive therapy with insulin. Incorporating our patient-derived complication utilities alone improved ICERs for intensive glucose control (e.g., patients aged 60-65 years at diagnosis, 136,000 dollars/QALY-->78,000 dollars/QALY), but intensive therapy was still not cost-effective at older ages. When patient-derived treatment utilities were also incorporated, the cost-effectiveness of intensive treatment depended on the method of glucose control. Intensive control with insulin generated fewer QALYs than conventional control. However, intensive control with oral medications was beneficial on average at all ages and had an ICER < or =100,000 dollars to age 70. CONCLUSIONS: The cost-effectiveness of intensive glucose control in older patients with new-onset diabetes is highly sensitive to assumptions regarding quality of life with treatments. Cost-effectiveness analyses of diabetes care should consider the sensitivity of results to alternative utility assumptions.