Comparative effectiveness and cost-effectiveness of target- versus benefit-based treatment of type 2 diabetes in low- and middle-income countries

BACKGROUND: How to optimally prescribe blood pressure, lipid and glucose-lowering treatments to adults with type 2 diabetes in low- and middle-income countries (LMICs) remains unclear. METHODS: We developed a microsimulation model to compare: (i) a “treat to target” (TTT) strategy, aiming to achieve target levels of biomarkers (blood pressure <130/80 mmHg, low-density lipoprotein <2.59 mmol/L, haemoglobin A1c <7%); with (ii) a “benefit-based tailored treatment” (BTT) strategy, aiming to lower estimated risk for complications (to a 10-year cardiovascular disease [CVD] risk <10%, and lifetime microvascular risk <5%) based on age, sex, and biomarker values. Data were obtained from cohorts in China, Ghana, India, Mexico, and South Africa, to span a spectrum of risk profiles. FINDINGS: TTT recommended treatment to many people at lower risk of diabetes complications, while BTT recommended treatment to fewer people at higher risk. BTT would be expected to avert 24% to 31% more complications than TTT, and be more cost-effective from a societal perspective (saving between $4 and $300 per DALY averted among the different countries simulated). Alternative treatment thresholds, matched by total cost or population size treated, did not change the comparative superiority of BTT, nor did titrating treatment using fasting plasma glucose (for areas without A1c testing). If insulin were unavailable, however, BTT was no longer significantly superior for preventing microvascular events, only for preventing CVD events. INTERPRETATION: A BTT strategy would be more effective and cost-effective than a TTT strategy in LMICs for prevention of both CVD and microvascular complications of type 2 diabetes. The superiority of the BTT strategy for averting microvascular complications, however, would be contingent on insulin availability. FUNDING: Rosenkranz Prize for Healthcare Research in Developing Countries; U.S. National Institutes of Health (U54 MD010724, DP2 MD010478).