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DIABETES

Pharmacoeconomic Analysis of Angiotensin-Converting Enzyme Inhibitors in Type 2 Diabetes: A Markov Model

Research Associate, Health Economics, Veterans Affairs Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM

Kathy D Boardman, BSPharm

Assistant Center Director, Veterans Affairs Cooperative Studies Program Clinical Research Pharmacy Coordinating Center

Melanie A Dodd, PharmD

Research Assistant Professor of Geriatrics, College of Pharmacy, University of New Mexico, Albuquerque

Dennis W Raisch, PhD

Associate Center Director, Scientific Affairs, Veterans Affairs Cooperative Studies Program Clinical Research Pharmacy Coordinating Center; Research Associate Professor of Pharmacy Administration, College of Pharmacy, University of New Mexico

Reprints: Dr. Campbell, VA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, 2401 Centre Ave. SE, Albuquerque, NM 87106, fax 505/248-3205, heather.campbell{at}csp.research.med.va.gov

BACKGROUND: Prevention of cardiovascular disease (CVD) events by initiating an angiotensin-converting enzyme (ACE) inhibitor on diagnosis of type 2 diabetes may increase survival and decrease costs.

OBJECTIVE: To determine the incremental cost-effectiveness ratios of ACE inhibitor initiation in normoalbuminuric, microalbuminuric, and macroalbuminuric patients with newly diagnosed type 2 diabetes.

METHODS: A cohort of patients with newly diagnosed type 2 diabetes was followed for 8 years in a Markov model. Clinical outcomes included CVD events, dialysis, all-cause mortality, and the composite endpoints of the 3 events. Probabilities and costs were obtained from the literature. One-way and two-way sensitivity analyses were conducted to test the robustness of the model.

RESULTS: Implementation of ACE inhibitor therapy on diagnosis of type 2 diabetes in normoalbuminuric and microalbuminuric patients is a dominant strategy (ie, more effective and less costly) across all outcomes. In macroalbuminuric patients, an additional $4.10 and $4.58 saves one life and avoids one composite endpoint, respectively; however, in these patients, not giving an ACE inhibitor is dominant for prevention of CVD events and dialysis. This is due to a 28.62% higher mortality rate in patients not receiving an ACE inhibitor. Thus, analysis of the composite endpoint shows that not giving an ACE inhibitor does not remain dominant. A limitation of our study is the inability to determine causality.

CONCLUSIONS: If every newly diagnosed patient with type 2 diabetes in the US was prescribed an ACE inhibitor, our model shows that 68 314 CVD events would be averted, 46 410 lives would be saved, and 48 people would be prevented from needing dialysis over 8 years. These findings suggest that ACE inhibitors prevent numerous events in patients with type 2 diabetes who are normoalbuminuric at diagnosis, in addition to those already identified as being at risk for CVD events.

Key Words: angiotensin-converting enzyme inhibitors, cardiovascular disease, cost, type 2 diabetes mellitus

Published Online, July 3, 2007. www.theannals.com, DOI 10.1345/aph.1K074