# Comparative and cost effectiveness of diabetes medications

> **NIH VA I01** · VA BOSTON HEALTH CARE SYSTEM · 2024 · —

## Abstract

Background: Diabetes is a significant cause of cardiovascular disease (CVD), kidney and eye diseases, and
mortality. Diabetes and its complications also generate substantial healthcare utilization. Medications
contribute to both the benefits and costs of diabetes care. Newer diabetes medications have been developed
and marketed, but there remains a mismatch in our understanding of their net benefits, risks, and cost-
effectiveness. This is particularly relevant for older adults (≥65 years), where benefits and risks are more finely
balanced. Clinical practice guidelines recommend initial treatment with metformin across all age groups but are
unclear about next steps when metformin is ineffective. This is a frequent treatment transition. Medications
such as glucagon-like peptide-1 receptor agonists (GLP1) and sodium-glucose co-transporter-2 inhibitors
(SGLT2) have favorable effects on CVD and renal disease but also carry greater costs and side-effects. Within
VA, their usage is accelerating. It remains uncertain if these medications have specific advantages over the
frequently used generic medications, sulfonylureas (SU). Thus, we hypothesize that diabetes medication
usage is influenced by a complex interplay of patient factors and provider practice patterns. We further
hypothesize that when studied using real-world data, GLP1 and SGLT2 medications will reduce major adverse
outcomes and be cost-effective in comparison to SU when used as add-on treatment to metformin.
Significance: There are major gaps in the evidence base that informs clinical and cost-effective diabetes
treatment decisions among older Veterans (≥65 years), which comprise >70% of the VA diabetes cohort.
Innovation and Impact: We will employ a large nationwide sample of Veterans with diabetes who are dually
enrolled in VA/Medicare and apply advanced methods to reduce the impact of unmeasured factors. By using
real-world data, our study will add significant new information that informs the care of older Veterans, VA’s
diabetes and pharmacy programs, and clinical guidelines.
Specific Aims:
Aim 1. Determine prescribing patterns for SU, GLP1 and SGLT2. We will examine the extent to which patient
characteristics and clinician prescribing patterns influence initiating an SU, GLP1 or SGLT2 as add-on to
metformin.
Aim 2. Estimate the relationships between SU, GLP1, and SGLT2 usage as add-on to metformin with
healthcare utilization and adverse outcomes. Using clinician prescribing patterns as an instrumental variable,
we will measure the effects on emergency department (ED) visits, hospitalizations, healthcare costs,
hypoglycemia events, medication adherence, new diabetes complications and mortality.
Aim 3. Investigate the cost-effectiveness of initiating an SU, GLP1 or SGLT2 as add-on to metformin.
Methodology: This is a retrospective observational study of secondary data from patient-level administrative
and claims data from VA and Medicare, and uses a quasi-experimental design involving i...

## Key facts

- **NIH application ID:** 10923800
- **Project number:** 5I01HX003527-03
- **Recipient organization:** VA BOSTON HEALTH CARE SYSTEM
- **Principal Investigator:** PAUL R CONLIN
- **Activity code:** I01 (R01, R21, SBIR, etc.)
- **Funding institute:** VA
- **Fiscal year:** 2024
- **Award amount:** —
- **Award type:** 5
- **Project period:** 2022-07-01 → 2026-03-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10923800

## Citation

> US National Institutes of Health, RePORTER application 10923800, Comparative and cost effectiveness of diabetes medications (5I01HX003527-03). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10923800. Licensed CC0.

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