Intense Multifactorial Treatment for Type 2 Diabetes Shown to be Cost Effective


Michelle Kirkwood

Orlando, Florida
June 24, 2018

Analysis of European Steno 2 study examines long-term economic implications of interventions targeting complications

When patients with type 2 diabetes (T2D) receive intensified, multifactorial treatment combining lifestyle modification and pharmacological therapy for modifiable risk factors, there is no significant increase in medical costs, compared to patients who receive conventional, multifactorial treatment, according to the study, “A Cost Analysis of Intensified vs. Conventional Multifactorial Therapy of Patients with Type 2 Diabetes—The Steno 2 Study,” presented today at the American Diabetes Association’s® (ADA’s) 78th Scientific Sessions® at the Orange County Convention Center. 

People with T2D have an increased risk of damage to the eyes, kidneys, nerves, legs, heart and brain, and many of these complications can ultimately affect mortality. The 1993 Steno 2 study investigated whether a targeted, intensified, multifactorial regimen would have an impact on the mortality rate of patients with T2D from any cause, including cardiovascular causes. The trial enrolled 160 Danish people with T2D with consistent microalbuminuria and an average age of 55 years. Very small amounts of albumin in the urine indicates generalized blood vessel damage and is a strong predictor of premature, multiple organ damage. 

The patients were randomly assigned to two groups: 80 patients received conventional multifactorial treatment, based upon recommendations of the Danish Medical Association at the time; and 80 patients received intensified multifactorial intervention. In the intensified treatment group, all modifiable risk factors were treated ambitiously, and the group’s target levels for blood glucose, HbA1c, blood pressure, total cholesterol, LDL cholesterol and triglycerides were lower than those for the conventional treatment group. Treatment focused on polypharmacological approaches to cardiovascular issues, as well as improved health behaviors via nutrition, exercise and smoking cessation. 

After 7.8 years of treatment, the people in the intensified treatment group had an approximate 50 percent reduction in diabetes-related damage to the heart, brain and legs, compared to the patients receiving conventional care. All patients were subsequently followed observationally for an average of 5.5 years in a post-trial setting in which all study participants received intensified, multifactorial treatment. At 13.3 years follow-up, the group originally allocated to intensified treatment had a 50 percent reduction in mortality, and at 21.2 years follow-up, a median of 7.9 years of gain of life was demonstrated. The increase in lifespan was matched by the amount of time the patients went without cardiovascular disease incidents.

The current analysis compared the long-term economic implications of the intensified multifactorial intervention to conventional treatment over the 21.2-year timeframe. Information on direct health costs was gathered from Danish health registers. Researchers found no difference in total direct medical costs between the intensified treatment group and the conventional treatment group over the 21.2 years of follow-up. The total costs in the intensified treatment group was approximately $13 million, and total costs in the conventional treatment group was $12.3 million (p=0.19). The data also indicated a statistically significant lower health cost per-patient, per-year in the intensified treatment group ($9,648 per patient), compared to the conventional treatment group ($10,681 per patient; p=0.13) during the entire follow-up period. Intensified treatment was, on average, more expensive in terms of medication costs, but less costly in terms of primary care visits and inpatient admission services related to cardiovascular issues.

“The Steno-2 trial was instrumental in establishing treatment standards for people with T2D, so it was important that we weighed the costs of the intensified multifactorial treatment recommended in the study,” said junior lead study author Joachim Gaede, a graduate student in the medicine program at the University of Copenhagen in Denmark. “We discovered that while intensified, multifactorial treatment may lead to an initial increase in health care costs, this investment is recouped over time by the impressive health benefits and increased longevity the patients experienced. Additionally, the total direct costs of intensified, multifactorial intervention, which leads to disease-free-life length improvement of about eight years, was neutral compared to conventional treatment. So, in terms of cost, investing in early-intensified intervention of all known modifiable risk factors in high-risk individuals with T2D will pay for itself over time due to a reduced cost of complications incurred by patients.”

To speak with Mr. Gaede, please contact the ADA Press Office on-site at the Orange County Convention Center on June 22 - 26, by phone at 407-685-4010 or by email at 

The American Diabetes Association’s 78th Scientific Sessions, to be held June 22-26, 2018, at the Orange County Convention Center in Orlando, is the world’s largest scientific meeting focused on diabetes research, prevention and care. During the five-day meeting, more than 16,000 health care professionals from around the world will have exclusive access to more than 3,000 original diabetes research presentations, participate in provocative and engaging exchanges with leading diabetes experts, and can earn Continuing Medical Education (CME) or Continuing Education (CE) credits for educational sessions. The program is grouped into eight theme areas: Acute and Chronic Complications; Behavioral Medicine, Clinical Nutrition, Education and Exercise; Clinical Diabetes/Therapeutics; Epidemiology/Genetics; Immunology/Transplantation; Insulin Action/Molecular Metabolism; Integrated Physiology/Obesity; and Islet Biology/Insulin Secretion. Felicia Hill-Briggs, PhD, ABPP, President of Health Care and Education, will deliver her address, “The American Diabetes Association in the Era of Health Care Transformation,” on Saturday, June 23, and Jane E.B. Reusch, MD, President of Medicine and Science, will present her address, “24/7/365 – Lifetime with Diabetes,” on Sunday, June 24. In total, the 2018 Scientific Sessions includes 375 oral presentations; 2,117 poster presentations, including 47 moderated poster discussions; and 297 published-only abstracts. Join the Scientific Sessions conversation on social media using #2018ADA.


162-OR - A Cost Analysis of Intensified vs. Conventional Multifactorial Therapy of Patients with Type 2 Diabetes—The Steno 2 Study

News Briefing: Diabetes & Cardiovascular Disease, Sunday, June 24, 9:00 a.m. ET

Presentation: Oral Presentations

Location: W203

Session Time: Sunday, June 24, 2018, 8:00 am - 10:00 am


Introduction: Follow-up at 21.2 years after the initiation of the Steno-2 study, demonstrated that intensified multifactorial intervention increases median life-span with 7.9 years and delays incident cardiovascular disease (CVD) with a median of 8.1 years compared to conventional multifactorial intervention. Here we aimed to analyze the direct medical costs in the two original treatment groups during 21.2 years of follow-up.

Methods: In 1993, 160 Danish patients with type 2 diabetes and microalbuminuria were randomized to receive either conventional or intensified and target-driven multifactorial intervention for 7.8 years. Information on direct health costs was gathered from health registers and any difference of costs in the two groups was assessed by non-parametric bootstrap t-test analysis.

Results: Intensified treatment was on average more expensive regarding drug prescriptions, but less expensive in primary health sector services (both p<0.0001) and in-patient admission costs (p=0.02), specifically related to CVD (p<0.0001) during the entire follow-up period. There was no significant difference in total costs between the intensified treatment group, $13.0M and the conventional treatment group, $12.3M (p=0.19). When further assessing the cost per patient year there was no significant difference between the intensified group, $9,648, and the conventional treatment group, $10,681 (p=0.13).

Conclusion: Over an average follow-up of 21.2 years we found no significant increase in total costs or in costs per person year associated with intensified multipronged treatment for 7.8 years when compared to conventional multipronged treatment. Considering the substantial gain of years of life and health benefits achieved with intensified treatment we conclude that intensified multifaceted intervention in high-risk patients with type 2 diabetes is highly cost-effective in a Danish health care setting.

Author Disclosures: J. Gaede: None. J. Oellgaard: None. R. Ibsen: None. P. Gaede: None. E. Noertoft: Employee; Self; Novo Nordisk A/S. J. Kjellberg: None. O. Pedersen: None.

About the American Diabetes Association

Nearly half of American adults have diabetes or prediabetes; more than 30 million adults and children have diabetes; and every 21 seconds, another individual is diagnosed with diabetes in the U.S. Founded in 1940, the American Diabetes Association (ADA) is the nation’s leading voluntary health organization whose mission is to prevent and cure diabetes, and to improve the lives of all people affected by diabetes. The ADA drives discovery by funding research to treat, manage and prevent all types of diabetes, as well as to search for cures; raises voice to the urgency of the diabetes epidemic; and works to safeguard policies and programs that protect people with diabetes. In addition, the ADA supports people living with diabetes, those at risk of developing diabetes, and the health care professionals who serve them through information and programs that can improve health outcomes and quality of life. For more information, please call the ADA at 1-800-DIABETES (1-800-342-2383) or visit Information from both of these sources is available in English and Spanish. Find us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn)