We thank Dr. Egede (1) for his letter in this issue of Diabetes Care and for taking the time to read our study (2) and provide us with his thoughtful comments. He raises several important points.

The first point concerns the choice of years of life saved rather than quality-adjusted life years in the cost-effectiveness analysis. Dr. Egede’s point that both diabetes and cardiovascular disease may have a significant impact on quality of life is well taken. We agree with him that it would be desirable to include quality-of-life issues in our analyses. We have recently completed a study evaluating the quality of life of individuals with and without cardiovascular disease, and we believe this study could provide utility measures suitable for part of the analysis.

Second, in our study, we compared the effects of simvastatin therapy for individuals with diabetes or cardiovascular disease based on the results of the Scandinavian Simvastatin Survival Study (4S) trial (3). Dr. Egede argues that the lipid targets currently recommended by the American Diabetes Association are lower than the mean LDL cholesterol levels obtained in the 4S study. We note that this is also true of the lipid targets recommended by the American Heart Association for individuals with cardiovascular disease. However, the focus of our analyses was on the benefits of lipid therapy among various groups of patients rather than on the benefits of following expert guidelines. As a first step, this approach allows for a level playing field so that the benefits of treatment and treatment alone are being compared. We also note that the currently recommended lipid targets represent levels that are not often achieved in current clinical practice. Finally, we are unaware of any data describing the costs of successfully treating groups of individuals to a specified target lipid level. Without such cost data, it is impossible to calculate the associated cost-effectiveness ratios. We chose the 4S study because it provided the necessary data on statin utilization and the largest reductions in LDL cholesterol associated with long-term clinical outcomes.

Third, the availability of results from the Heart Protection Study, which is expected later this year, should provide a wealth of additional information and finally help to resolve any remaining questions regarding the cost-effectiveness of lipid therapy in diabetic patients without coronary heart disease (4).

Dr. Egede has raised important research questions for future analyses. We believe that with the availability of results from ongoing studies, as well as the completion of additional research, the necessary pieces will eventually be available to adequately complete the puzzle.

1
Egede LE: How cost-effective is the treatment of dyslipidemia in patients with diabetes but without cardiovascular disease? A response to Grover et al.
Diabetes Care
24
:
1306
,
2001
2
Grover SA, Coupal L, Zowall H, Alexander CM, Weiss TW, Gomes DRJ: How cost-effective is the treatment of dyslipidemia in patients with diabetes but without cardiovascular disease?
Diabetes Care
24
:
45
–50,
2001
3
Haffner SM, Alexander CM, Cook TJ, Boccuzzi SJ, Musliner TA, Pedersen TR, Kjekshus J, Pyorala K: Reduced coronary events in simvastatin-treated subjects with coronary heart disease and diabetes or impaired fasting glucose: subgroup analyses in the Scandinavian Simvastatin Survival Study.
Arch Intern Med
159
:
2661
–2667,
1999
4
MRC/BHF Heart Protection Study of cholesterol-lowering therapy and of antioxidant vitamin supplementation in a wide range of patients at increased risk of coronary heart disease death: early safety and efficacy experience.
Eur Heart J
20
:
725
–741,
1999

Address correspondence to Steven A. Grover, MD, The Montreal General Hospital, McGill University Health Center, Division of Clinical Epidemiology, 1650 Cedar Ave., Montreal, PQ H3G 1A4, Canada. E-mail: [email protected].