BMJ 1998;317:720-726 ( 12 September )

Papers

Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40

Editorials by Orchard and Mogensen Papers pp   703 , 713 This paper was prepared for publication by Maria Raikou, Alastair Gray, Andrew Briggs, Richard Stevens, Carole Cull, Alistair McGuire, Paul Fenn, Irene Stratton, Rury Holman, and Robert Turner.

UK Prospective Diabetes Study Group. 

Correspondence to: Dr Alastair Gray, Health Economics Research Centre, Institute of Health Sciences, Oxford University, Oxford OX3 7LF alastair.gray{at}ihs.ox.ac.uk

Reprint requests to: UK Prospective Diabetes Study Group, Diabetes Research Laboratories, Radcliffe Infirmary, Oxford OX2 6HE

Objectives: To estimate the economic efficiency of tight blood pressure control, with angiotensin converting enzyme inhibitors or beta  blockers, compared with less tight control in hypertensive patients with type 2 diabetes.
Design: Cost effectiveness analysis incorporating within trial analysis and estimation of impact on life expectancy through use of the within trial hazards of reaching a defined clinical end point. Use of resources driven by trial protocol and use of resources in standard clinical practice were both considered.
Setting: 20 hospital based clinics in England, Scotland, and Northern Ireland.
Subjects: 1148 hypertensive patients with type 2 diabetes from UK prospective diabetes study randomised to tight control of blood pressure (n=758) or less tight control (n=390).
Main outcome measure: Cost effectiveness ratios based on (a) use of healthcare resources associated with tight control and less tight control and treatment of complications and (b) within trial time free from diabetes related end points, and life years gained.
Results: Based on use of resources driven by trial protocol, the incremental cost effectiveness of tight control compared with less tight control was cost saving. Based on use of resources in standard clinical practice, incremental cost per extra year free from end points amounted to £1049 (costs and effects discounted at 6% per year) and £434 (costs discounted at 6% per year and effects not discounted). The incremental cost per life year gained was £720 (costs and effects discounted at 6% per year) and £291 (costs discounted at 6% per year and effects not discounted).
Conclusions: Tight control of blood pressure in hypertensive patients with type 2 diabetes substantially reduced the cost of complications, increased the interval without complications and survival, and had a cost effectiveness ratio that compares favourably with many accepted healthcare programmes.

Key messages

  • Analysis of hypertensive patients with type 2 diabetes from the UK prospective diabetes study has shown that a policy of tight control of blood pressure substantially reduced both microvascular and macrovascular complications, conferring health benefit

  • This economic analysis, conducted in conjunction with the clinical trial, shows that tight control of blood pressure in these patients substantially reduced the cost of complications, increased survival and the interval without complications, and had a cost effectiveness ratio that compares favourably with many accepted healthcare programmes

  • On both clinical and economic grounds the use of a policy of tight control of blood pressure in hypertensive patients with type 2 diabetes is justified



© BMJ 1998
Add to CiteULike CiteULike   Add to Complore Complore   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Reddit Reddit   Add to StumbleUpon StumbleUpon   Add to Technorati Technorati    What's this?

This article has been cited by other articles:

  • Shea, S., Weinstock, R. S., Teresi, J. A., Palmas, W., Starren, J., Cimino, J. J., Lai, A. M., Field, L., Morin, P. C., Goland, R., Izquierdo, R. E., Ebner, S., Silver, S., Petkova, E., Kong, J., Eimicke, J. P., IDEATel Consortium, (2009). A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study. J. Am. Med. Inform. Assoc. 16: 446-456 [Abstract] [Full text]  
  • Heart Protection Study Collaborative Group, (2009). Statin Cost-Effectiveness in the United States for People at Different Vascular Risk Levels. Circ Cardiovasc Qual Outcomes 2: 65-72 [Abstract] [Full text]  
  • Charlton, J., Latinovic, R., Gulliford, M. C. (2008). Explaining the Decline in Early Mortality in Men and Women With Type 2 Diabetes: A population-based cohort study. Diabetes Care 31: 1761-1766 [Abstract] [Full text]  
  • Gaede, P., Valentine, W. J., Palmer, A. J., Tucker, D. M.D., Lammert, M., Parving, H.-H., Pedersen, O. (2008). Cost-Effectiveness of Intensified Versus Conventional Multifactorial Intervention in Type 2 Diabetes: Results and projections from the Steno-2 study. Diabetes Care 31: 1510-1515 [Abstract] [Full text]  
  • Turchin, A., Shubina, M., Chodos, A. H., Einbinder, J. S., Pendergrass, M. L. (2008). Effect of Board Certification on Antihypertensive Treatment Intensification in Patients With Diabetes Mellitus. Circulation 117: 623-628 [Abstract] [Full text]  
  • Murray, E. (2007). Improving management of chronic illness in the National Health Service: are better incentives really the key?. Chronic Illness 3: 197-199  
  • Naik, A. D., Issac, T. T., Street, R. L. Jr, Kunik, M. E. (2007). Understanding the Quality Chasm for Hypertension Control in Diabetes: A Structured Review of "Co-maneuvers" Used in Clinical Trials. J Am Board Fam Med 20: 469-478 [Abstract] [Full text]  
  • Tunceli, K., Bradley, C. J., Lafata, J. E., Pladevall, M., Divine, G. W., Goodman, A. C., Vijan, S. (2007). Glycemic Control and Absenteeism Among Individuals With Diabetes. Diabetes Care 30: 1283-1285 [Full text]  
  • Groot Koerkamp, B., Hunink, M.G. M., Stijnen, T., Hammitt, J. K., Kuntz, K. M., Weinstein, M. C. (2007). Limitations of Acceptability Curves for Presenting Uncertainty in Cost-Effectiveness Analysis. Med Decis Making 27: 101-111 [Abstract]  
  • Heart Protection Study Collaborative, (2006). Lifetime cost effectiveness of simvastatin in a range of risk groups and age groups derived from a randomised trial of 20 536 people. BMJ 333: 1145-1145 [Abstract] [Full text]  
  • Ackermann, R. T., Thompson, T. J., Selby, J. V., Safford, M. M., Stevens, M., Brown, A. F., Narayan, K.M. V. (2006). Is the Number of Documented Diabetes Process-of-Care Indicators Associated With Cardiometabolic Risk Factor Levels, Patient Satisfaction, or Self-Rated Quality of Diabetes Care?: The Translating Research into Action for Diabetes (TRIAD) study.. Diabetes Care 29: 2108-2113 [Abstract] [Full text]  
  • Dobesh, P. P. (2006). Managing hypertension in patients with type 2 diabetes mellitus.. Am J Health Syst Pharm 63: 1140-1149 [Abstract] [Full text]  
  • Tobe, S. W., Pylypchuk, G., Wentworth, J., Kiss, A., Szalai, J. P., Perkins, N., Hartman, S., Ironstand, L., Hoppe, J. (2006). Effect of nurse-directed hypertension treatment among First Nations people with existing hypertension and diabetes mellitus: the Diabetes Risk Evaluation and Microalbuminuria (DREAM 3) randomized controlled trial. CMAJ 174: 1267-1271 [Abstract] [Full text]  
  • Saaddine, J. B., Cadwell, B., Gregg, E. W., Engelgau, M. M., Vinicor, F., Imperatore, G., Narayan, K. M. V. (2006). Improvements in Diabetes Processes of Care and Intermediate Outcomes: United States, 1988-2002. ANN INTERN MED 144: 465-474 [Abstract] [Full text]  
  • Bottomley, J., Palmer, A. J, Williams, R., Dormandy, J., Massi-Benedetti, M. (2006). Review: PROactive 03: Pioglitazone, type 2 diabetes and reducing macrovascular events -- economic implications?. British Journal of Diabetes & Vascular Disease 6: 63-70 [Abstract]  
  • Shea, S., Weinstock, R. S., Starren, J., Teresi, J., Palmas, W., Field, L., Morin, P., Goland, R., Izquierdo, R. E., Wolff, L. T., Ashraf, M., Hilliman, C., Silver, S., Meyer, S., Holmes, D., Petkova, E., Capps, L., Lantigua, R. A., for the IDEATel Consortium, (2006). A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus. J. Am. Med. Inform. Assoc. 13: 40-51 [Abstract] [Full text]  
  • Brouwer, W. B F, Niessen, L. W, Postma, M. J, Rutten, F. F H (2005). Need for differential discounting of costs and health effects in cost effectiveness analyses. BMJ 331: 446-448 [Full text]  
  • Herman, W. H., Hoerger, T. J., Brandle, M., Hicks, K., Sorensen, S., Zhang, P., Hamman, R. F., Ackermann, R. T., Engelgau, M. M., Ratner, R. E., for the Diabetes Prevention Program Research Group, (2005). The Cost-Effectiveness of Lifestyle Modification or Metformin in Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance. ANN INTERN MED 142: 323-332 [Abstract] [Full text]  
  • Young, R. J., Taylor, J., Friede, T., Hollis, S., Mason, J. M., Lee, P., Burns, E., Long, A. F., Gambling, T., New, J. P., Gibson, J. M. (2005). Pro-Active Call Center Treatment Support (PACCTS) to Improve Glucose Control in Type 2 Diabetes: A randomized controlled trial. Diabetes Care 28: 278-282 [Abstract] [Full text]  
  • Mason, J. M., Freemantle, N., Gibson, J. M., New, J. P. (2005). Specialist Nurse-Led Clinics to Improve Control of Hypertension and Hyperlipidemia in Diabetes: Economic analysis of the SPLINT trial. Diabetes Care 28: 40-46 [Abstract] [Full text]  
  • Gilmer, T. P., O'Connor, P. J., Rush, W. A., Crain, A. L., Whitebird, R. R., Hanson, A. M., Solberg, L. I. (2005). Predictors of Health Care Costs in Adults With Diabetes. Diabetes Care 28: 59-64 [Abstract] [Full text]  
  • MacLean, C. D, Littenberg, B., Gagnon, M., Reardon, M., Turner, P. D, Jordan, C. (2004). The Vermont Diabetes Information System (VDIS): study design and subject recruitment for a cluster randomized trial of a decision support system in a regional sample of primary care practices. Clin Trials 1: 532-544 [Abstract]  
  • Gaede, P., Pedersen, O. (2004). Intensive Integrated Therapy of Type 2 Diabetes: Implications for Long-Term Prognosis. Diabetes 53: S39-S47 [Abstract] [Full text]  
  • Marshall, D. A., Levy, A. R., Vidaillet, H., Fenwick, E., Slee, A., Blackhouse, G., Greene, H. L., Wyse, D. G., Nichol, G., O'Brien, B. J., and the AFFIRM and CORE Investigators*, (2004). Cost-Effectiveness of Rhythm versus Rate Control in Atrial Fibrillation. ANN INTERN MED 141: 653-661 [Abstract] [Full text]  
  • Rocchiccioli, J. T., O'Donoghue, C. R. (2004). Diabetes Mellitus: Toward a Federal Policy. Policy Politics Nursing Practice 5: 237-242 [Abstract]  
  • Johnson-Masotti, A. P., Laud, P. W., Hoffmann, R. G., Hayat, M. J., Pinkerton, S. D. (2004). A Bayesian Approach to Net Health Benefits: An Illustration and Application to Modeling HIV Prevention. Med Decis Making 24: 634-653 [Abstract]  
  • Hoerger, T. J., Harris, R., Hicks, K. A., Donahue, K., Sorensen, S., Engelgau, M. (2004). Screening for Type 2 Diabetes Mellitus: A Cost-Effectiveness Analysis. ANN INTERN MED 140: 689-699 [Abstract] [Full text]  
  • Petrou, S, Edwards, L (2004). Cost effectiveness analysis of neonatal extracorporeal membrane oxygenation based on four year results from the UK Collaborative ECMO Trial. Arch. Dis. Child. Fetal Neonatal Ed. 89: F263-F268 [Abstract] [Full text]  
  • HADDOCK, G., BARROWCLOUGH, C., TARRIER, N., MORING, J., O'BRIEN, R., SCHOFIELD, N., QUINN, J., PALMER, S., DAVIES, L., LOWENS, I., McGOVERN, J., LEWIS, S. (2003). Cognitive-behavioural therapy and motivational intervention for schizophrenia and substance misuse: 18-month outcomes of a randomised controlled trial. Br. J. Psychiatry 183: 418-426 [Abstract] [Full text]  
  • Ilag, L. L., Martin, C. L., Tabaei, B. P., Isaman, D. J. M., Burke, R., Greene, D. A., Herman, W. H. (2003). Improving Diabetes Processes of Care in Managed Care. Diabetes Care 26: 2722-2727 [Abstract] [Full text]  
  • New, J. P., Mason, J. M., Freemantle, N., Teasdale, S., Wong, L. M., Bruce, N. J., Burns, J. A., Gibson, J. M. (2003). Specialist Nurse-Led Intervention to Treat and Control Hypertension and Hyperlipidemia in Diabetes (SPLINT): A randomized controlled trial. Diabetes Care 26: 2250-2255 [Abstract] [Full text]  
  • Denver, E. A., Barnard, M., Woolfson, R. G., Earle, K. A. (2003). Management of Uncontrolled Hypertension in a Nurse-Led Clinic Compared With Conventional Care for Patients with Type 2 Diabetes. Diabetes Care 26: 2256-2260 [Abstract] [Full text]  
  • SCOTT, J., PALMER, S., PAYKEL, E., TEASDALE, J., HAYHURST, H. (2003). Use of cognitive therapy for relapse prevention in chronic depression: Cost-effectiveness study. Br. J. Psychiatry 182: 221-227 [Abstract] [Full text]  
  • O'Hagan, A, Stevens, J W (2002). Bayesian methods for design and analysis of cost-effectiveness trials in the evaluation of health care technologies. Stat Methods Med Res 11: 469-490 [Abstract]  
  • Sowers, J. R., Haffner, S. (2002). Treatment of Cardiovascular and Renal Risk Factors in the Diabetic Hypertensive. Hypertension 40: 781-788 [Full text]  
  • Gray, A., Clarke, P., Farmer, A., Holman, R. (2002). Implementing intensive control of blood glucose concentration and blood pressure in type 2 diabetes in England: cost analysis (UKPDS 63). BMJ 325: 860-860 [Abstract] [Full text]  
  • Krumholz, H. M., Weintraub, W. S., Bradford, W. D., Heidenreich, P. A., Mark, D. B., Paltiel, A. D. (2002). Task Force #2--the cost of prevention: can we afford it? Can we afford not to do it?. J Am Coll Cardiol 40: 603-615 [Full text]  
  • Clarke, P., Gray, A., Holman, R. (2002). Estimating Utility Values for Health States of Type 2 Diabetic Patients Using the EQ-5D (UKPDS 62). Med Decis Making 22: 340-349 [Abstract]  
  • Saaddine, J. B., Engelgau, M. M., Beckles, G. L., Gregg, E. W., Thompson, T. J., Narayan, K.M. V. (2002). A Diabetes Report Card for the United States: Quality of Care in the 1990s. ANN INTERN MED 136: 565-574 [Abstract] [Full text]  
  • Egede, L. E., Zheng, D. (2002). Modifiable Cardiovascular Risk Factors in Adults With Diabetes: Prevalence and Missed Opportunities for Physician Counseling. Arch Intern Med 162: 427-433 [Abstract] [Full text]  
  • Shea, S., Starren, J., Weinstock, R. S., Knudson, P. E., Teresi, J., Holmes, D., Palmas, W., Field, L., Goland, R., Tuck, C., Hripcsak, G., Capps, L., Liss, D. (2002). Columbia University's Informatics for Diabetes Education and Telemedicine (IDEATel) Project: Rationale and Design. J. Am. Med. Inform. Assoc. 9: 49-62 [Abstract] [Full text]  
  • Arauz-Pacheco, C., Parrott, M. A., Raskin, P. (2002). The Treatment of Hypertension in Adult Patients With Diabetes. Diabetes Care 25: 134-147 [Full text]  
  • Griffiths, T L, Phillips, C J, Davies, S, Burr, M L, Campbell, I A (2001). Cost effectiveness of an outpatient multidisciplinary pulmonary rehabilitation programme. Thorax 56: 779-784 [Abstract] [Full text]  
  • Egede, L. E., Miohel, Y. (2001). Perceived Difficulty of Diabetes Treatment in Primary Care: Does it Differ by Patient Ethnicity?. The Diabetes Educator 27: 678-684 [Abstract]  
  • Levy, J. C (2001). Review: UKPDS odyssey -- 2001. British Journal of Diabetes & Vascular Disease 1: 14-21 [Abstract]  
  • Campbell, H.E., Tait, S., Buxton, M.J., Sharples, L.D., Caine, N., Schofield, P.M., Wallwork, J. (2001). A UK trial-based cost-utility analysis of transmyocardial laser revascularization compared to continued medical therapy for treatment of refractory angina pectoris. Eur. J. Cardiothorac. Surg. 20: 312-318 [Abstract] [Full text]  
  • O'Hagan, A., Stevens, J. W. (2001). Bayesian Assessment of Sample Size for Clinical Trials of Cost-Effectiveness. Med Decis Making 21: 219-230 [Abstract]  
  • Morris, S, James-Roberts, I S., Sleep, J, Gillham, P (2001). Economic evaluation of strategies for managing crying and sleeping problems. Arch. Dis. Child. 84: 15-19 [Abstract] [Full text]  
  • Melville, A, Richardson, R, Lister-Sharp, D, McIntosh, A (2000). Complications of diabetes: renal disease and promotion of self-management. Qual Saf Health Care 9: 257-263 [Full text]  
  • Sculpher, M. J., Poole, L., Cleland, J., Drummond, M., Armstrong, P. W., Horowitz, J. D., Massie, B. M., Poole-Wilson, P. A., Ryden, L. (2000). Low doses vs. high doses of the angiotensin converting-enzyme inhibitor lisinopril in chronic heart failure: a cost-effectiveness analysis based on the Assessment of Treatment with Lisinopril and Survival (ATLAS) study. Eur J Heart Fail 2: 447-454 [Abstract] [Full text]  
  • Moayyedi, P., Soo, S., Deeks, J., Forman, D., Mason, J., Innes, M., Delaney, B. (2000). Systematic review and economic evaluation of Helicobacter pylori eradication treatment for non-ulcer dyspepsia. BMJ 321: 659-664 [Abstract] [Full text]  
  • Mulgirigama, A., Illangasekera, U. (2000). Study of the quality of care at a diabetic clinic in Sri Lanka. The Journal of the Royal Society for the Promotion of Health 120: 164-169 [Abstract]  
  • Adler, A. I, Stratton, I. M, Neil, H A. W, Yudkin, J. S, Matthews, D. R, Cull, C. A, Wright, A. D, Turner, R. C, Holman, R. R (2000). Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 321: 412-419 [Abstract] [Full text]  
  • Elliott, W. J., Weir, D. R., Black, H. R. (2000). Cost-effectiveness of the Lower Treatment Goal (of JNC VI) for Diabetic Hypertensive Patients. Arch Intern Med 160: 1277-1283 [Abstract] [Full text]  
  • (1999). Other Articles Noted. Evid. Based Nurs. 2: 105-112 [Full text]  
  • Narayan, K M V., Beckles, G. L A, Gregg, E. W, Williamson, D. F, Saaddine, J, Engelgau, M. M, Vinicor, F., Christiansen, E. H, Groetsch, S. M, LaVan, J. T, Epling, J. W, Richards, J., Turner, R., Holman, R. (1999). Treating type 2 diabetes. BMJ 318: 666a-666 [Full text]  
  • Orchard, T. (1998). Diabetes: a time for excitement---and concern. BMJ 317: 691-692 [Full text]  
  • Mogensen, C. E. (1998). Combined high blood pressure and glucose in type 2 diabetes: double jeopardy. BMJ 317: 693-694 [Full text]  
Access jobs at BMJ Careers
Whats new online at Student BMJ