The American College of Physicians (ACP) issued a new guideline on A1c targets for adults with type 2 diabetes in 2018, with potential implications for the long-term health and economic outcomes. We evaluated the cost-effectiveness (CE) of the new ACP guideline. Based on the ACP recommendation, 3 groups of patients would be affected by the new guidelines: (1) persons with A1c level <6.5% under antidiabetes medication other than metformin would de-intensify to a target level of 7.0%-8.0%, (2) those with A1c levels of 7.0%-8.0% and life expectancy <10 years would de-intensify to targets level of >8.0%; and 3) persons with a A1c level of >8.0% and life expectancy > 10 years would intensify to a A1c target level of 7.0%~8.0%. The CDC-RTI diabetes simulation model was used to estimate the long-term health/cost consequence of changes in A1c targets, compared with a status of quo. Data from the 2011-2016 National Health and Nutrition Examination Survey and the 2017 Census were used to estimate the numbers of persons in each of the three group. The incremental cost-effectiveness ratio (ICER), measured in cost per quality adjusted life year (QALY), was used to measure the CE in 2017 USD. Implementing the new guideline would result in 243,524 fewer cardiovascular events, 1.38 million QALYs gained and an increase of 3.6 billion dollars in healthcare expenditure nationwide (ICER: $2,367 per QALY). ACP recommendations were cost-effective over status quo in all 3 subgroups using $50,000 threshold: treatment de-intensification saves $8,656 at a cost of 0.122 QALY for individuals with life expectancy <10 years (3.4 million persons), and saves $8,169 at a cost of 0.058 QALY for individuals with A1c <6.5% (3.17 million persons). Intensifying treatment for those with an A1c >8.0% (5.16 million persons) costs additional $11,454 with 0.38 QALY gain. Results are robust according to multiple sensitivity analysis. We conclude that the new ACP glycemic guideline is cost-effective among adult U.S. population with diabetes.


H. Shao: None. M. Laxy: None. E. Gregg: None. P. Zhang: None.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at