Practical considerations

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Implementation of an intensive and multifactorial treatment strategy requires extensive resources including a multidisciplinary team and a greater time commitment per patient. Other factors to consider in the equation are patient characteristics and behaviors that may affect adherence to treatment and cost issues related to multiple medications needed to meet the stringent treatment targets. The cost-effectiveness analysis done by



Relative Risk

Automatic neuropathy

Peripheral neuropathy

Intensive Therapy Better

Conventional Therapy Better

Fig. 8. Relative risk of the development or progression of nephropathy, retinopathy, and autonomic and peripheral neuropathy during the average follow-up of 7.8 years in the intensive therapy group, as compared with the conventional therapy group. (From Gaede P, Vedel P, Larsen N, et al. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 2003;348:383-93; with permission. Copyright © 2003 Massachusetts Medical Society.)

the Diabetes Cost-effectiveness Group of the Centers for Disease Control provides some insights into these issues [43]. A hypothetical cohort of individuals with newly diagnosed type 2 diabetes in the United States was used. A Markov model of type 2 diabetes disease progression was used to calculate incremental cost-effectiveness ratios for the interventions. Interventions considered were sulfonylurea or insulin for intensive glycemic control, ACE inhibitors or beta-blockers for intensified hypertension control, and pravastatin for reducing the serum cholesterol level. Intensified hypertension control was found to reduce costs and improve health outcomes as compared with moderate hypertension control. Although intensive glycemic control and reduction in serum cholesterol level also improved health outcomes, these goals were achieved at increased costs. This analysis raises questions regarding the most appropriate and economically feasible guidelines from the perspective of public health. Although more studies evaluating the cost-benefit analysis of various targeted interventions are certainly needed to determine whether comprehensive risk reduction is the most appropriate and cost-effective strategy in the diabetic patient, the clinician must now rely on the available data and good clinical judgment. The clinician should consider the specific risk profile for the given patient and institute the appropriate risk-reduction strategy to achieve the greatest benefit. For example, in the case of a diabetic patient with microalbuminuria or a strong family history of premature coronary artery disease, the predictable high risk of CV events makes it mandatory to institute aggressive management of all the modifiable risk factors at the earliest possible time.

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