Table 2

Summary of the cost-effectiveness studies by intervention*

InterventionComparisonIntervention populationNumber of studiesLevel of recommendation by ADAMedian of the cost-effectiveness ratiosRange of the cost-effectiveness ratios
Strong evidence
Cost saving
    ACEI therapy for intensive hypertension controlStandard hypertension controlType 24BCost savingCost saving-$1,200/LYG $230/QALY
    Addition of ACEI or ARB therapy to prevent ESRDNo ACEI or ARB therapyType 27ACost savingCost saving
    Irbesartan therapy at the stage of microalbuminuriaIrbestartan therapy at the stage of macroalbuminuriaType 23ACost savingCost saving
    Comprehensive foot care to prevent ulcerUsual careMixed population of type 1 and type 21BCost savingCost saving
    Multi-component interventions (conventional insulin control, ACEI treatment, eye screening, and treatment)Conventional insulin controlType 11A: ACEI treatment
B: eye screening and ensuing treatment
Cost savingCost saving
    Multi-component interventions (standard antidiabetic care plus education, nephropathy screening, ACEI treatment, retinopathy screening)Standard antidiabetic careType 21B: education
E: nephropathy screening
B: ACEI therapy
B: retinopathy screening
Cost savingCost saving
Very cost-effective
    Intensive lifestyle modificationStandard lifestyle recommendation or no interventionIGT8B: medical nutritional therapy$1,500/QALYCost saving-$84,700/QALY
A: physical activity
    Universal opportunistic screening for undiagnosed type 2 diabetes in African Americans between 45 and 54 years oldNo screeningAfrican Americans aged 45–54 years1B$19,600/QALY$19,600/QALY
    Intensive glycemic control as in UKPDS settingConventional glycemic controlType 2 newly diagnosed6A, B
$3,400/QALYCost saving-$12,400/QALY
    Statin therapyNo statin therapyType 2, with hyperlipidemia, with CVD history3A$2,800/LYGCost saving-$12,300/LYG
    Smoking cessationNo smoking cessationType 21A, B<$25,000/QALY<$25,000/QALY-$89,800/QALY (aged 85–94 years)
    Annual screening for diabetic retinopathyNo screeningType 12B$2,150/QALYCost saving-$4,300/QALY
    Annual screening for diabetic retinopathyNo screeningType 23B$6,900/QALYCost saving-$39,500/QALY
    Immediate vitrectomy to treat diabetic retinopathyDeferral of vitrectomyMixed population of type 1 and type 21Mentioned but not explicitly provided level, supported by trials$2,900/QALY$2,900/QALY
Cost-effective
    Targeted screening for undiagnosed type 2 diabetesNo screeningU.S. population with hypertension 45 years and older1B: in adults of any age who are overweight or obese and who have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45$49,200/QALY$46,800–$70,500/QALY starting at different age
    Intensive insulin treatmentConventional glycemic controlType 14A, B$28,900/QALY$10,200–$50,800/QALY
    Intensive glycemic control as in the U.S. settingConventional glycemic controlType 2 newly diagnosed at 25–54 years old1A, B$27,500/QALY$14,400-$56,000/QALY
    Intensive glycemic control through lifestyle modificationConventional glycemic controlType 2 newly diagnosed1A, B$33,100/QALY$33,100/QALY
    Statin therapyNo statin therapyType 2, with hyperlipidemia, without CVD history3A: statin therapy for diabetic patients without CVD who are older than 40 years and have one or more other CVD risk factors$38,200/LYG§$6,100/LYG–$61,300/LYG $77,800/QALY
    Multi-component interventions (intensive insulin control, ACEI treatment, eye screening and ensuing treatment)Intensive insulin controlType 11A, B: intensive insulin control
A: ACEI therapy
B: eye screening
$49,800/LYG (non U.S.)$46,500-$50,600/LYG
Marginally cost-effective
    Intensive glycemic control as in the U.S. settingConventional glycemic controlType 2 newly diagnosed All age group diagnosed of diabetes at 25 years and older1A, B$62,000/QALY$14,400–$3 million/QALY
    Eye screening every 2 yearsEye screening every 3 yearsType 21B: annual eye screening recommended, less frequent exams (every 2–3 years) may be considered following one or more normal eye exams$54,000/QALY$54,000/QALY
Not cost-effective
    Universal opportunistic screening for undiagnosed type 2 diabetesTargeted screening in persons with hypertensionU.S. population 45 years and older1B>$100,000/QALY$70,100-$928,000/QALY
    Universal opportunistic screening for undiagnosed type 2 diabetes and ensuing treatmentNo screeningU.S. population 45 years and older2B>$100,000/QALY$70,100-$1 million
    Intensive glycemic control as in the U.S. settingConventional glycemic controlType 2 Newly diagnosed at 55–94 years1A, B>$100,000/QALY>$100,000–$3 million/QALY
    Eye screening every yearEye screening every 2 yearsType 21B$116,800/QALY$116,800/QALY
Supportive evidence
Cost saving
    Screening for GDM with sequential methodNo screening30-year-old pregnant women between 24–28 weeks' gestation1CCost savingCost saving
    Screening for GDM with 100-g GTTNo screening30-year-old pregnant women between 24–28 weeks' gestation1CCost savingCost saving
    Screening for GDM with sequential method75-g GTT30-year-old pregnant women between 24–28 weeks' gestation1CCost savingCost saving
    Screening for GDM with 100-g GTT75-g GTT30-year-old pregnant women between 24–28 weeks' gestation1CCost savingCost saving
    Diabetes self-management educationNo educationType 11BCost savingCost saving
    Reimbursement for ACEI by public insurancePaying out-of-pocketType 11ECost savingCost saving
    Reimbursement for ACEI by public insurancePaying out-of-pocketType 21ECost savingCost saving
    Screening using mobile camera and electronically transmitted to a data reading center and read by trained personnelRetina-specialists visitMixed population of type 1 and type 2 at a remote area1Recommended but not leveled, assume level ECost savingCost saving
    Screening for diabetic nephropathy and ensuing ACEI or ARB therapyTreat until macroalbuminuriaType 13E: screening A: ACEI treatmentCost savingCost saving-$58,400/QALY
    Intensified foot ulcer treatmentStandard treatmentA mixed population of type 1 and type 21BCost savingCost saving
Very cost-effective
    Intensive diet and educationStandard antidiabetic careWomen with GDM history, currently IGT1A, B$2,500/LYG$2,500/LYG
    Universal opportunistic screening for type 2 diabetes in younger and certain ethnic groupsNo screeningAfrican Americans, aged 25–44 years1B: if overweight or obese$3,100/QALY$1,300–$19,600/QALY
    Screening for GDM 100-g GTTSequential method30-year-old pregnant women between 24–28 weeks' gestation1E$35,200/QALY for maternal outcomes, $9,000/QALY for neonatal outcomes$9,000–$35,200/QALY
    Diabetes self-management educationNo educationType 21B$4,000/LYG$4,000/LYG
    Disease managementNo disease management programType 2 or mixed types2Mentioned but not provided level, assume level E$23,350/QALY$4,800–$68,400/QALY for groups with different insurance
    SMBG 3 times/dayNo SMBGType 2 treated with oral agents in a large HMO1E$6,900/QALY$540–$30,300/QALY for different time horizon
    SMBG 1 time/dayNo SMBG1E$9,700/QALY$8,200–$24,200/QALY for different time horizon
Cost-effective
    MetforminPlaceboIGT6E$26,600/QALYCost saving-$47,900/QALY
Marginally cost-effective
        NA
Not cost-effective
        NA
Uncertain
    Optimal screening for type 2 diabetes starting ageU.S. population 45 years and older2B: recommend starting screening for type 2 diabetes at age 45 years if no other risk factors
  • ACEI, angiotensin converting enzyme inhibitors; ARB, angiotensin receptor blocker; CVD, cardiovascular disease; ESRD, end stage renal disease; GDM, gestational diabetes; GTT, glucose tolerance test; IGT, impaired glucose tolerance; LYG, life year gained; NA, not available; QALY, quality adjusted life years; SMBG, self-monitoring blood glucose. A, as defined in Standards of Medical Care in Diabetes—2008: clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered; compelling non-experimental evidence, i.e., “all or none” rule developed by the Centre for Evidence-Based Medicine at Oxford; supportive evidence from well-conducted randomized controlled trials that are adequately powered. B, as defined in Standards of Medical Care in Diabetes–2008: supportive evidence from well-conducted cohort studies; supportive evidence from a well-conducted case-control study. C, as defined in Standards of Medical Care in Diabetes–2008: supportive evidence from poorly controlled or uncontrolled studies; conflicting evidence with the weight of evidence supporting the recommendation. E, as defined in Standards of Medical Care in Diabetes–2008: expert consensus or clinical experience.

  • *, the same interventions applied to different populations or compared with different comparison interventions were treated as different specific interventions.

  • †, including foot exams, appropriate footwear, treatment, and education.

  • ‡, the study for within trial and the results from health plan perspective are not used for determining the cost-effectiveness of the intervention.

  • §, get this number by taking the median for women in one study (conservative, women > men) as the results for that study, then take the median of the three study.

  • ‖, 50-g GTT + 100-g GTT.

  • ¶, the evidence was very weak: there was an over 40% probability that the intervention would cost more than $50,000/QALY in a long-term.