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Systematic Literature Reviews Elucidate Cost-Effectiveness of Diabetes Interventions

Aug 4, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Melinda Rodriguez, PharmD Candidate 2021, Lake Erie College of Osteopathic Medicine – L|E|C|O|M School of Pharmacy

$327 billion are spent annually for the treatment and management of diabetes; how does the cost-effectiveness of diabetes treatments compare?

According to the American Diabetes Association (ADA), 1 in 7 healthcare dollars is spent in treating diabetes and its complications. This disease imposes an enormous burden in terms of higher medical costs, lost productivity, and premature mortality. It also results in a much lower quality of life (QOL) for the individuals affected. Over 34 million Americans have been diagnosed with diabetes, and over 88 million more have pre-diabetes. Given the high prevalence of this condition, is it surprising that the U.S. spends over $327 billion annually for this disease alone?


The most significant components of the total medical expenditures are hospital inpatient care (30%), prescription medications to treat complications of diabetes (30%), anti-diabetic agents and diabetic supplies (15%), and physician office visits (13%). The average medical costs for people with diabetes are approximately 2.3 times higher than for those without diabetes. Roughly 67% of the costs for diabetes care in the U.S. are provided by government insurance, including Medicare, Medicaid, and military plans. Two percent of the population is uninsured. However, these patients have 168% more emergency department visits. California, Texas, Florida, and New York represent the top four states in total annual costs. Various campaigns have pushed for cost-effective diabetic treatment options and guidelines to improve access to care, affordability, and outcomes. Recent studies have elucidated the cost-effectiveness of diabetes management and prevention interventions recommended by the ADA to allow both patients and physicians to make informed decisions regarding diabetes interventions.

One study published in the Diabetes Care journal evaluated the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbid conditions. The systematic literature review consisted of studies from high-income countries obtained from seven different databases and dated between June 2008 through July 2017. The data were screened to match specific search criteria, analyzed for the strength of evidence, and stratified by intervention categories. Upon review, the interventions were categorized using conventional CE tiers. These tiers classified the interventions as cost-saving, very cost-effective, cost-effective, marginally cost-effective, or not cost-effective based on the cost in U.S. Dollars per quality-adjusted life-year (QALY) or life-year gained (LYG). A total of 122 studies were included.

The review concluded that the vast majority of ADA recommendations were either cost-saving or very cost-effective. The least cost-effective option (universal opportunistic screening for undiagnosed T2DM) was classified as marginally cost-effective. Five interventions fell into the cost-savings category: 1) intensive hypertension management (targeting systolic blood pressure [SBP] <130) with angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) therapy versus standard hypertension management (targeting SBP <140); 2) ACEI/ARB therapy for renoprotection in people with albuminuria versus no ACEI/ARB therapy; 3) comprehensive foot care and patient education to prevent and treat foot ulcers in patients with moderate/high risk; 4) telemedicine for diabetic retinopathy screening versus office screening; and 5) bariatric surgery for individuals with type 2 diabetes (T2DM) and obesity. A few interventions in the very cost-effective category include screening for T2DM every three years beginning at age 45; intensive glycemic management for newly diagnosed T2DM patients; intensive glycemic management among patients aged ≥50 years with T2DM; statin therapy for individuals with T2DM and history of cardiovascular disease; smoking cessation; daily aspirin use for primary prevention of cardiovascular complications; and collaborative care for depression.

Researchers involved in this study published a similar systematic review in the same issue of Diabetes Care. This study, however, focused on the CE of interventions to prevent T2DM among high-risk populations. They analyzed data about screening, lifestyle modification recommendations, pharmacological interventions, and translational Diabetes Prevention Programs (DPP). Lifestyle interventions targeting high-risk individuals were grouped by delivery method and personnel type. The median incremental cost-effectiveness ratio (ICER), measured in cost per additional QALY gained or cost per additional disability-adjusted life year (DALY) prevented, was used to measure CE. To determine whether a given intervention was cost-effective, researchers selected a threshold of $50,000/QALY. Thirty-nine studies were included in the review. Results showed cost-effectiveness for all interventions. Comparing pharmacological and lifestyle modifications, the latter was considered the most cost-effective intervention. However, the degree of CE varied between the types of lifestyle interventions. For example, those that involved a Diabetes Prevention Program (DPP) proved to be twice as cost-effective as those not involving a DPP (median ICER of $6,121/QALY vs. $13,228/QALY, respectively). A hybrid of virtual and in-person intervention media was more cost-effective than either individual media. When comparing the setting of in-person lifestyle interventions, group delivery settings (those that involved a collaborative effort between health professionals and lay health workers) had significantly lower ICER values than one-on-one settings with health professionals alone. While prophylactic treatment with metformin was considered cost-effective, the ICER was much higher than that of lifestyle interventions (median ICER of $17,089/QALY vs. $12,510/QALY, respectively).

Interestingly, the review also looked at a population-based initiative that included taxation on sugar-sweetened beverages and subsidies on fruits and vegetables. The goal was to determine if this policy intervention could impact public health and whether it would be cost-effective. The results, however, were inconsistent.

With the rising prevalence of diabetes in the United States, affordable and effective interventions for both diabetes prevention and management are more relevant now than ever. The studies summarized in this article demonstrate the impact of early interventions, both lifestyle and pharmacological, on patient quality of life. Furthermore, with the knowledge of cost-effective diabetes prevention interventions, policies can be implemented to improve patient outcomes while reducing this disease’s economic burden on patients and society. It has been suggested that Diabetes Prevention Programs for patients at high risk can significantly improve quality of life while reducing costs. These programs may also have a role in reducing the prevalence of this disease. Early and aggressive interventions remain the most cost-effective options. By educating patients and providing the correct strategies, health care providers and diabetes educators can play an enormous role in reducing the prevalence of diabetes. With the proper understanding of the costs and effectiveness of interventions, governments, health systems, health professionals, and patients can work together to set priorities and allocate resources to improve patient outcomes and reduce healthcare costs. 

Practice Pearls:

  • A vast majority of ADA recommendations for the treatment and management of diabetes are either cost-saving or very cost-effective, according to two systematic literature reviews.
  • Intensive glycemic (targeting HbA1C <7%) and hypertensive (targeting SBP <120mmHg) management may be more cost-effective than standard treatment in patients with T2DM.
  • Lifestyle interventions may be more cost-effective than metformin interventions for the prevention of diabetes in high-risk patients, especially those provided by a combination of healthcare professionals and lay health workers as part of a Diabetic Prevention Program.  


American Diabetes Association. Economic costs of diabetes in the U.S. in 2017. Diabetes Care. 2018;41:917–928

Xilin Zhou, Karen R. Siegel, Boon Peng Ng, Shawn Jawanda, Krista K. Proia, Xuanping Zhang, Ann L. Albright, Ping Zhang. Cost-effectiveness of Diabetes Prevention Interventions Targeting High-risk Individuals and Whole Populations: A Systematic Review. Diabetes Care Jul 2020, 43 (7) 1593-1616; DOI: 10.2337/dci20-0018

Karen R. Siegel, Mohammed K. Ali, Xilin Zhou, Boon Peng Ng, Shawn Jawanda1, Krista Proia, Xuanping Zhang, Edward W. Gregg, Ann L. Albright, and Ping Zhang. Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008? Diabetes Care 2020 Jul; 43(7): 1557-1592. https://doi.org/10.2337/dci20-0017


Melinda Rodriguez, PharmD Candidate 2021, Lake Erie College of Osteopathic Medicine – L|E|C|O|M School of Pharmacy


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