Cost-effectiveness of lower targets for blood pressure and low-density lipoprotein cholesterol in diabetes: the Stop Atherosclerosis in Native Diabetics Study (SANDS)

J Clin Lipidol. 2010 May-Jun;4(3):165-72. doi: 10.1016/j.jacl.2010.01.008.


Background: The Stop Atherosclerosis in Native Diabetics Study (SANDS) reported cardiovascular benefit of aggressive versus standard treatment targets for both low-density lipoprotein cholesterol (LDL-C) and blood pressure (BP) in diabetic individuals.

Objective: In this analysis, we examined within trial cost-effectiveness of aggressive targets of LDL-C ≤70 mg/dL and systolic BP ≤115 mmHg versus standard targets of LDL-C ≤100 mg/dL and systolic BP ≤130 mmHg.

Design: Randomized, open label blinded-to-endpoint 3-year trial.

Data sources: SANDS clinical trial database, Quality of Wellbeing survey, Centers for Medicare and Medicaid Services, Wholesale Drug Prices.

Target population: American Indians ≥ age 40 years with type 2 diabetes and no previous cardiovascular events.

Time horizon: April 2003 to July 2007.

Perspective: Health payer.

Interventions: Participants were randomized to aggressive versus standard groups with treatment algorithms defined for both.

Outcome measures: Incremental cost-effectiveness.

Results of base-case analysis: Compared with the standard group, the aggressive group had slightly lower costs of medical services (-$116) but a 54% greater cost for BP medication ($1,242) and a 116% greater cost for lipid-lowering medication ($2,863), resulting in an increased cost of $3,988 over 3 years. Those in the aggressively treated group gained 0.0480 quality-adjusted life-years (QALY) over the standard group. When a 3% discount rate for costs and outcomes was used, the resulting cost per QALY was $82,589.

Results of sensitivity analysis: The use of a 25%, 50%, and 75% reduction in drug costs resulted in a cost per QALY of $61,329, $40,070, and $18,810, respectively.

Limitations: This study was limited by use of a single ethnic group and by its 3-year duration.

Conclusions: Within this 3-year study, treatment to lower BP and LDL-C below standard targets was not cost-effective because of the cost of the additional medications required to meet the lower targets. With the anticipated availability of generic versions of the BP and lipid-lowering drugs used in SANDS, the cost-effectiveness of this intervention should improve. Published by Elsevier Inc on behalf of the National Lipid Association.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Antihypertensive Agents / economics*
  • Antihypertensive Agents / therapeutic use*
  • Blood Pressure / drug effects
  • Cardiovascular Diseases / prevention & control
  • Cholesterol, LDL / blood
  • Cost-Benefit Analysis
  • Diabetes Complications / prevention & control
  • Diabetes Mellitus, Type 2 / blood
  • Diabetes Mellitus, Type 2 / drug therapy*
  • Diabetes Mellitus, Type 2 / economics*
  • Diabetes Mellitus, Type 2 / physiopathology
  • Female
  • Humans
  • Hypolipidemic Agents / economics*
  • Hypolipidemic Agents / therapeutic use*
  • Indians, North American
  • Male
  • Middle Aged
  • Quality-Adjusted Life Years
  • United States


  • Antihypertensive Agents
  • Cholesterol, LDL
  • Hypolipidemic Agents