OBJECTIVES: Substantial opportunity exists to enhance primary prevention of stroke in type 2 diabetes (T2D) patients. We aimed to evaluate the cost-effectiveness of improved implementation of seven current guideline-recommended strategies for primary stroke prevention in U.S. adults with T2D.

METHODS: Based on National Health and Nutrition Examination Survey (NHANES) data from 2015-2018, we identified individuals with T2D aged ≥45 years without stroke history. We simulated stroke events, stroke-related quality-adjusted life years (QALYs), and healthcare costs for this population over a 10-year horizon using a microsimulation model, the Michigan Model for Diabetes, comparing seven scenarios each with full implementation of one of the seven primary prevention strategies versus a status-quo scenario. The status-quo scenario assumed that the level of implementation of each of the seven prevention strategies was the average national implementation level in 2015-2018. The enhanced scenarios assumed all individuals implemented particular strategy as soon as they became eligible. Analyses were performed from a health system/payer perspective.

RESULTS: Full implementation of the well-controlled blood pressure (BP) strategy would result in approximately 237,200 fewer stroke events, 95,000 fewer stroke-related deaths, a gain of 0.05 QALYs, and savings of $24.6 billion (2014 US dollar) nationally. In contrast, fully-enhanced implementation of the well-control HbA1c level strategy cost $279 billion more nationally at a slight loss of 0.005 QALYs. Full implementation of guidelines related to statins, aspirin, warfarin treatment for atrial fibrillation, or smoking cessation would be cost-effective or cost-saving. The strategy of losing 5% weight for all overweight or obese individuals would not be cost-effective.

CONCLUSIONS: Enhancing implementation of guideline-recommended strategies for BP control, and statins, aspirin, warfarin treatment, and smoking cessation for the U.S. adult T2D population without stroke history could potentially avert a large number of stroke events, improve quality-of-life stroke-related deaths, and be cost-saving.