The cost-effectiveness of treating all patients with type 2 diabetes with angiotensin-converting enzyme inhibitors

Background: Although guidelines recommend angiotensin-converting enzyme inh ibitors for diabetic patients with microalbuminuria, this strategy requires that providers adhere to screening recommendations. In addition, the benef it of angiotensin-converting enzyme inhibitors in normoalbuminuric patients was recently demonstrated. Objective: To evaluate the cost-effectiveness of treating all patients with type 2 diabetes. Design: Markov model simulating the progression of diabetic nephropathy. Data Sources: Randomized trials estimating the progression of diabetic neph ropathy with and without angiotensin-converting enzyme inhibitors. Target Population: Patients 50 years of age with newly diagnosed type 2 dia betes (fasting plasma glucose level greater than or equal to 7.8 mmol/L [14 0 mg/dL]). Time Horizon: Lifetime. Perspective: Societal. Interventions: Patients received angiotensin-converting enzyme inhibitors, screening for microalbuminuria, or screening for gross proteinuria. Outcome Measures: Lifetime cost, quality-adjusted life expectancy, and marg inal cost-effectiveness. Results of Base-Case Analysis: Screening for gross proteinuria had the high est cost and the lowest benefit. Compared with screening for microalbuminur ia, treating all patients was more expensive ($15 240 and $14 940 per patie nt) but was associated with increased quality-adjusted life expectancy (11. 82 and 11.78 quality-adjusted life-years). The marginal cost-effectiveness ratio was $7500 per quality-adjusted life-year gained. Results of Sensitivity Analysis: Results were sensitive to the cost, effect iveness, and quality of life associated with angiotensin-converting enzyme inhibitor therapy, as well as age at diagnosis. The model was relatively in sensitive to adherence with screening and costs of treating end-stage renal disease. Conclusions: Treating all middle-aged diabetic patients with angiotensin-co nverting enzyme inhibitors is a simple strategy that provides additional be nefit at modest additional cost. The strategy assumes that patients meet th e older diagnostic criteria for diabetes and makes sense only for those who are not bothered by treatment.