gms | German Medical Science

Background: Type 2 diabetes is the main cause of end-stage renal disease (ESRD) in the Netherlands as well as in other European countries and the US [1]. In 2010, about 15 000 patients underwent renal-replacement therapy [2]. In the Netherlands, the costs of ESRD treatment amount to €42 000 per patient year [3], [4]. Hence, prevention of ESRD is not only important from a medical, but also from an economic viewpoint. Angiotensin-converting enzyme (ACE) inhibitors have a potential to slow down the progression of renal disease and therefore provide a renal-protective effect.

Material/Methods: Three strategies were compared: treating all patients at the time of diagnosing type 2 diabetes, screening for microalbuminuria, and screening for macroalbuminuria. A lifetime Markov decision model with simulated 50-year-old patients with newly diagnosed diabetes mellitus was developed using published data on costs and health outcomes and simulating the progression of renal disease. A health insurance perspective was adopted.

Figure 1 [Fig. 1] shows our model which contains the following 5 health states that represent the occurrence of events after model entry.

Results: In the base-case analysis, the treat-all strategy is associated with the lowest costs and highest benefit and therefore dominates screening both for macroalbuminuria and microalbuminuria.

In the univariate sensitivity analysis, variables with the largest impact on incremental costs and effectiveness are the absolute risk for progression from micro- to macroalbuminuria without ACE inhibition as well as the relative risk for progression from normo- to microalbuminuria with ACE inhibitor therapy and the discount rate (see supplementary table 3 for details). When assuming a low progression rate from micro- to macroalbuminuria without ACE inhibition, screening for microalbuminuria dominates the treat-all strategy. A threshold sensitivity analysis shows that at an annual drug cost of €362.80 (base case: €62.70) the breakeven point is reached. Figure 2 [Fig. 2] shows the cost-effectiveness acceptability curve, which considers uncertainty in cost-effectiveness. The probability of savings of the “treat all” strategy compared to screening for microalbuminuria is 70%, as could be seen in the multivariate sensitivity analysis. The scatterplot (Figure 3 [Fig. 3]) shows 1000 replications from a distribution of cost and quality-adjusted life year (QALY) differences (angiotensin-converting enzyme inhibitor vs microalbuminuria screening).

Conclusions: Patients with type 2 diabetes should receive an ACE inhibitor immediately after diagnosis if they do not have contraindications. An ARB should be considered for those patients developing a dry cough under ACE inhibitor therapy. The potential for cost savings would be even larger if the prevention of cardiovascular events were considered.