Background

Given the increasing prevalence of diabetes in low-income and middle-income countries (LMICs), we aimed to estimate the health and cost implications of achieving different targets for diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among LMICs.

Methods

We constructed a microsimulation model to estimate disability-adjusted life-years (DALYs) lost and health-care costs of diagnosis, treatment, and control of blood pressure, dyslipidaemia, and glycaemia among people with diabetes in LMICs. We used individual participant data—specifically from the subset of people who were defined as having any type of diabetes by WHO standards—from nationally representative, cross-sectional surveys (2006–18) spanning 15 world regions to estimate the baseline 10-year risk of atherosclerotic cardiovascular disease (defined as fatal and non-fatal myocardial infarction and stroke), heart failure (ejection fraction of <40%, with New York Heart Association class III or IV functional limitations), end-stage renal disease (defined as an estimated glomerular filtration rate <15 mL/min per 1·73 m² or needing dialysis or transplant), retinopathy with severe vision loss (<20/200 visual acuity as measured by the Snellen chart), and neuropathy with pressure sensation loss (assessed by the Semmes-Weinstein 5·07/10 g monofilament exam). We then used data from meta-analyses of randomised controlled trials to estimate the reduction in risk and the WHO OneHealth tool to estimate costs in reaching either 60% or 80% of diagnosis, treatment initiation, and control targets for blood pressure, dyslipidaemia, and glycaemia recommended by WHO guidelines. Costs were updated to 2020 International Dollars, and both costs and DALYs were computed over a 10-year policy planning time horizon at a 3% annual discount rate.

Findings

We obtained data from 23 678 people with diabetes from 67 countries. The median estimated 10-year risk was 10·0% (IQR 4·0–18·0) for cardiovascular events, 7·8% (5·1–11·8) for neuropathy with pressure sensation loss, 7·2% (5·6–9·4) for end-stage renal disease, 6·0% (4·2–8·6) for retinopathy with severe vision loss, and 2·6% (1·2–5·3) for congestive heart failure. A target of 80% diagnosis, 80% treatment, and 80% control would be expected to reduce DALYs lost from diabetes complications from a median population-weighted loss to 1097 DALYs per 1000 population over 10 years (IQR 1051–1155), relative to a baseline of 1161 DALYs, primarily from reduced cardiovascular events (down from a median of 143 to 117 DALYs per 1000 population) due to blood pressure and statin treatment, with comparatively little effect from glycaemic control. The target of 80% diagnosis, 80% treatment, and 80% control would be expected to produce an overall incremental cost-effectiveness ratio of US$1362 per DALY averted (IQR 1304–1409), with the majority of decreased costs from reduced cardiovascular event management, counterbalanced by increased costs for blood pressure and statin treatment, producing an overall incremental cost-effectiveness ratio of $1362 per DALY averted (IQR 1304–1409).

Interpretation

Reducing complications from diabetes in LMICs is likely to require a focus on scaling up blood pressure and statin medication treatment initiation and blood pressure medication titration rather than focusing on increasing screening to increase diabetes diagnosis, or a glycaemic treatment and control among people with diabetes.

Funding

None.

中文翻译：

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在低收入和中等收入国家中增加糖尿病及其相关心血管危险因素的诊断、治疗和控制的估计效果：微观模拟模型

背景

鉴于低收入和中等收入国家 (LMIC) 糖尿病患病率的增加，我们旨在估计在 LMIC 中实现糖尿病及其相关心血管危险因素的不同诊断、治疗和控制目标对健康和成本的影响。

方法

我们构建了一个微观模拟模型来估计中低收入国家糖尿病患者在诊断、治疗和控制血压、血脂异常和血糖方面的残疾调整生命年 (DALY) 损失和医疗保健成本。我们使用来自全国 15 个世界区域的具有代表性的横断面调查 (2006-18) 的个体参与者数据——特别是来自按照 WHO 标准被定义为患有任何类型糖尿病的人的子集——来估计基线 10 年风险动脉粥样硬化性心血管疾病（定义为致命性和非致命性心肌梗塞和中风）、心力衰竭（射血分数 <40%，纽约心脏协会 III 级或 IV 级功能受限）、终末期肾病（定义为估计肾小球滤过率 <15 mL/min/1·73 m ²或需要透析或移植）、具有严重视力丧失的视网膜病变（根据 Snellen 图测量的视力<20/200），以及伴有压力感觉丧失的神经病变（通过 Semmes-Weinstein 5·07/10 g 单丝检查评估）。然后，我们使用来自随机对照试验的荟萃分析的数据来估计风险的降低，并使用 WHO OneHealth 工具来估计达到诊断、治疗开始和血压、血脂异常和控制目标的 60% 或 80% 的成本。 WHO指南推荐的血糖。成本更新为 2020 国际美元，成本和 DALYs 都是在 10 年政策规划时间范围内以 3% 的年贴现率计算的。

发现

我们获得了来自 67 个国家的 23678 名糖尿病患者的数据。心血管事件的中位估计 10 年风险为 10·0% (IQR 4·0–18·0)，伴有压力觉丧失的神经病变为 7·8% (5·1-11·8)，7·2% (5·6-9·4) 用于终末期肾病，6·0% (4·2-8·6) 用于伴有严重视力丧失的视网膜病变，以及 2·6% (1·2-5·3)用于充血性心力衰竭。预计 80% 诊断、80% 治疗和 80% 控制的目标将使糖尿病并发症造成的 DALYs 损失从人口加权损失中位数减少到 10 年内每 1000 人 1097 DALYs（IQR 1051-1155），相对于基线为 1161 个 DALY，主要是由于血压和他汀类药物治疗导致心血管事件减少（从每 1000 人的中位数 143 到 117 个 DALY），而血糖控制的影响相对较小。

解释

在中低收入国家减少糖尿病并发症可能需要重点关注扩大血压和他汀类药物治疗的启动和血压药物滴定，而不是重点关注增加筛查以增加糖尿病诊断，或对糖尿病患者进行血糖治疗和控制。

资金

没有任何。