Different strategies for screening and prevention of type 2 diabetes in adults: cost effectiveness analysis

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Impact of different types of hypertensive disorders of pregnancy and their duration on incident post-partum risk of diabetes mellitus: Results from the French nationwide study CONCEPTION

AIMS

To evaluate the impact of onset time, duration, and severity of various types of hypertensive disorders of pregnancy (HDP) on the risk of incident DM.

METHODS

We used data from the ongoing French nationwide prospective cohort study CONCEPTION. We included all primiparous women in CONCEPTION who delivered between 2010 and 2018 (n = 2,816,793 women). Follow-up spanned from childbirth to 31 December 2021. HDP and incident DM onset during follow-up were identified using algorithms combining ICD-10 coded diagnoses during hospitalization and/or medication dispensing. We used Cox models to assess the associations between incident DM and preexisting chronic hypertension, gestational hypertension (GH), and various phenotypes of pre-eclampsia.

RESULTS

Pre-eclampsia and GH alone occurred in 2.6 % and 4.6 % of the population, respectively. During follow-up (mean = 4.5 years), 16,670 women had incident DM. The cumulative incidences of DM were 15.8 % and 1.8 % in women who had pre-eclampsia during pregnancy with and without concomitant gestational diabetes, respectively. The risk of DM was higher after HDP (all types) irrespective of gestational diabetes status during pregnancy. In women without gestational diabetes, compared with those who had no HDP, the risk of incident DM was higher in women who had GH (adjusted hazard ratio, aHR = 1.97 [1.81-2.16]), pre-eclampsia (aHR = 2.42 [2.21-2.65]), and preexisting chronic hypertension prior to pregnancy (aHR = 3.35 [3.03-3.70]). Pre-eclampsia duration was significantly associated with a higher risk of DM.

CONCLUSION

Women who experienced an HDP had twice the risk of developing DM. Early blood glucose assessment and blood pressure monitoring should be more widely recommended after HDP diagnosis.

Evaluating the Long-Term Cost-Effectiveness of the English NHS Diabetes Prevention Programme using a Markov Model

BACKGROUND

In 2016, England launched the largest nationwide diabetes mellitus prevention programme, the NHS Diabetes Prevention Programme (NHS DPP). This paper seeks to evaluate the long-term cost-effectiveness of this programme.

METHODS

A Markov cohort state transition model was developed with a 35-year time horizon and yearly cycles to compare referral to the NHS DPP to usual care for individuals with non-diabetic hyperglycaemia. The modelled cohort of individuals mirrored the age profile of referrals received by the programme by April 2020. A health system perspective was taken, with costs in UK £ Sterling (price year 2020) and outcomes in terms of quality-adjusted life-years (QALYs). Probabilistic analysis with 10,000 Monte Carlo simulations was used. Several sensitivity analyses were conducted to explore the uncertainty surrounding the base case results, particularly varying the length of time for which the effectiveness of the programme was expected to last.

RESULTS

In the base case, using only the observed effectiveness of the NHS DPP at 3 years, it was found that the programme is likely to dominate usual care, by generating on average 40.8 incremental QALYs whilst saving £135,755 in costs for a cohort of 1000. At a willingness to pay of £20,000 per QALY, 98.1% of simulations were on or under the willingness-to-pay threshold. Scaling this up to the number of referrals actually received by the NHS DPP prior to April 2020, cost savings of £71.4 million were estimated over the 35-year time horizon and an additional 21,472 QALYs generated. These results are robust to several sensitivity analyses.

CONCLUSION

The NHS DPP is likely to be cost-effective. Indeed, in the majority of the simulations, the NHS DPP was cost-saving and generated greater QALYs, dominating usual care. This research should serve as evidence to support the continued investment or recommissioning of diabetes prevention programmes.

Cost-effectiveness analysis of two interventions to promote physical activity in a multiethnic population at high risk of diabetes: an economic evaluation of the 48-month PROPELS randomized controlled trial

INTRODUCTION

Physical activity (PA) is protective against type 2 diabetes (T2D). However, data on pragmatic long-term interventions to reduce the risk of developing T2D via increased PA are lacking. This study investigated the cost-effectiveness of a pragmatic PA intervention in a multiethnic population at high risk of T2D.

MATERIALS AND METHODS

We adapted the School for Public Health Research diabetes prevention model, using the PROPELS trial data and analyses of the NAVIGATOR trial. Lifetime costs, lifetime quality-adjusted life years (QALYs), and incremental cost-effectiveness ratios (ICERs) were calculated for each intervention (Walking Away (WA) and Walking Away Plus (WA+)) versus usual care and compared with National Institute for Health and Care Excellence's willingness-to-pay of £20 000-£30 000 per QALY gained. We conducted scenario analyses on the outcomes of the PROPELS trial data and a threshold analysis to determine the change in step count that would be needed for the interventions to be cost-effective.

RESULTS

Estimated lifetime costs for usual care, WA, and WA+ were £22 598, £23 018, and £22 945, respectively. Estimated QALYs were 9.323, 9.312, and 9.330, respectively. WA+ was estimated to be more effective and cheaper than WA. WA+ had an ICER of £49 273 per QALY gained versus usual care. In none of our scenario analyses did either WA or WA+ have an ICER below £20 000 per QALY gained. Our threshold analysis suggested that a PA intervention costing the same as WA+ would have an ICER below £20 000/QALY if it were to achieve an increase in step count of 500 steps per day which was 100% maintained at 4 years.

CONCLUSIONS

We found that neither WA nor WA+ was cost-effective at a limit of £20 000 per QALY gained. Our threshold analysis showed that interventions to increase step count can be cost-effective at this limit if they achieve greater long-term maintenance of effect.

TRIAL REGISTRATION NUMBER

ISRCTN registration: ISRCTN83465245: The PRomotion Of Physical activity through structuredEducation with differing Levels of ongoing Support for those with pre-diabetes (PROPELS)https://doi.org/10.1186/ISRCTN83465245.

The Cost-Effectiveness of Pertuzumab for the Treatment of Metastatic HER2+ Breast Cancer in Czechia: A Semi-Markov Model Using Cost States

OBJECTIVES

This article estimates the cost-effectiveness of adding pertuzumab to the combination of trastuzumab and docetaxel within the first-line treatment for metastatic breast cancer with the amplification of HER2+.

METHODS

Data from Czech clinical practice recorded in the BREAST register are used. A semi-Markov model with states derived based on the treatment phases (first-line medication, no medication, next-line medication, death) is defined to estimate costs from the healthcare payers' perspective. The benefits are estimated as patient survival until death. The Kaplan-Meier estimates are supplemented by the Cox proportional hazard and the accelerated failure time models to control for patient characteristics. Health-related quality-of-life indicators are derived from relevant literature.

RESULTS

Based on the used data, adding pertuzumab does not result in statistically significantly longer survival while inducing higher treatment costs (€163 360 compared with €90 112 per patient in 2018 prices). Statistically longer survival was not supported by the log-rank test (P = .97), the Cox proportional hazard model, or the accelerated failure time model using the Gompertz distribution. The incremental cost-effectiveness ratio (€87 200) substantially exceeds the willingness to pay for 1 quality-adjusted life-year (€46 500).

CONCLUSIONS

This analysis indicates that adding pertuzumab cannot be considered cost-effective in Czechia. However, the observed phenomenon may be attributed to the limited duration of patient follow-up periods at the time of the study's execution (mean of 20-21 months). Importantly, we find that using states connected to specific treatment phases is appropriate for a retrospective analysis of patient-level clinical data.

Revised Case Finding Protocol for Dysglycemia in Chile: A Call for Action in Other Populations

OBJECTIVE

Guidelines recommend case finding for dysglycemia (prediabetes and type 2 diabetes [T2D]) in adults or youth older than 10 years with overweight/obesity, but increased adiposity has not been associated with dysglycemia in some Hispanic populations. This study aims to determine the prevalence of dysglycemia in this population using simplified criteria independent of BMI and age to request an oral glucose tolerance test (OGTT).

METHODS

Cross-sectional retrospective analysis of medical records from a clinical center in Chile (2000-2007). OGTT was obtained from any patient with one cardiometabolic risk factor (CMRF) independent of age and BMI.

RESULTS

In total, 4,969 adults (mean age ± SD) 45.7 ± 15.9 years and 509 youths 16.6 ± 3.0 years were included. The prevalence (%, 95%CI) of prediabetes doubled that of T2D in youths (14.1%, 1.4-17.4 vs. 6.3%, 4.5-8.7) and tripled it in adults (36.0%, 34.7-37.4 vs. 10.7%, 9.8-11.5). In underweight and normal-weight adults, 22% (12.0-36.7) and 29.2% (26.4-32.1) had prediabetes, whereas 4.9% (1.3-16.1) and 8.8% (7.2-10.7) had T2D, respectively. In normal-weight youths, 10.5% (6.7-15.9) and 2.9% (1.2-6.6) had prediabetes and T2D, respectively. In adults, but not in youths, most dysglycemia categories were related to overweight/obesity.

CONCLUSION

This study supports a public health policy to identify more people at risk for cardiovascular disease by implementing a revised case-finding protocol for dysglycemia using OGTT in even normal-weight patients over 6 years of age when there is at least one CMRF. Re-analysis of case-finding protocols for cardiometabolic risk in other populations is warranted.

Factores asociados al cribado de Diabetes Mellitus en población Peruana ¿problema para la salud pública?

Highlights: El ser varón es un factor relevante asociado al no tamizaje de diabetes mellitus tipo 2 (DM2). Un mayor nivel de educación y socioeconómico se asocian positivamente con la posibilidad de realizarse tamizaje para DM2 El fortalecimiento de los servicios de atención primaria es crucial en la prevención primaria de DM2 a través del tamizaje. Introducción: La Diabetes Mellitus tipo 2 es una enfermedad que representa un reto para la salud pública por su tendencia al crecimiento e impacto sobre todo en países en desarrollo. Objetivo: determinar los factores asociados a la no realización del cribado de diabetes mellitus tipo 2 según la encuesta demográfica y de salud familiar del año 2020 (ENDES-2020). Materiales y métodos: Estudio analítico transversal secundario de la ENDES-2020. Resultados: Las variables que mostraron asociación estadísticamente significativa para cribado de DM2 fueron: sexo masculino (PR=1,06, IC95% 1,02–1,10; p<0,001), edad entre 30 a 59 años (0,92; IC95% 0,89–0,95; p<0,001) y 60 años a más (PR=0,72; IC95% 0,65–0,79; p<0,001), educación primaria (PR=0,94, IC 95% 0,92 - 0,99; p<0,020), secundaria (PR=0,93; IC 95% 0,88–0,97; p=0,008) y superior (PR=0,86, IC 95% 0,85–0,94; p<0,001), ser pobre (PR=0,96, IC95% 0,92–0,99; p=0,016), medio (PR=0,93; IC95% 0,88 – 0,96; p=0,001), rico (PR=0,89; IC95% 0,84 – 0,94; p<0,001), muy rico (PR=0,81; IC95% 0,75–0,86; p<0,001), e hipertensión (PR=0,91; IC 95% 0,867–0,969; p=0,002). Discusión: El sexo masculino fue el único factor asociado a la no realización del cribado de diabetes mellitus tipo 2, mientras que, pertenecer a un grupo de edad mayor, tener hipertensión arterial, mayor nivel educativo y socioeconómico aumentó la posibilidad de realizarlo. Conclusión: Es imprescindible reforzar las estrategias de cribado en el primer nivel de atención, mediante la implementación de medidas de prevención. Como citar este artículo: Fiorella Trujillo Minaya, Vera-Ponce Victor Juan, Torres-Malca Jenny Raquel, Zuzunaga-Montoya Fiorella E, Guerra Valencia Jamee, De la Cruz-Vargas Jhony A, Cruz Ausejo Liliana. Factores asociados al cribado de diabetes mellitus en población peruana ¿problema para la salud pública?. Revista Cuidarte. 2023;14(1):e2792. http://dx.doi.org/10.15649/cuidarte.2792

Usefulness of Home Screening for Promoting Awareness of Impaired Glycemic Status and Utilization of Primary Care in a Low Socio-Economic Setting: A Follow-Up Study in Reunion Island

BACKGROUND

Low socio-economic settings are characterized by high prevalence of diabetes and difficulty in accessing healthcare. In these contexts, proximity health services could improve healthcare access for diabetes prevention. Our primary objective was to evaluate the usefulness of home screening for promoting awareness of impaired glycemic status and utilization of primary care among adults aged 18-79 in a low socio-economic setting.

METHODS

This follow-up study was conducted in 2015-2016 in Reunion Island, a French overseas department in the Indian Ocean. Enrollment and screening occurred on the same day at the home of participants (N=907). Impaired glycemic status was defined as [glycated hemoglobin (HbA1c) ≥5.7%] OR [fasting capillary blood glucose (FCBG) ≥1.10 g/L] OR [HbA1c=5.5-5.6% and FCBG=1.00-1.09 g/L]. Medical, socio-cultural, and socio-economic characteristics were collected via a face-to-face questionnaire. A one-month telephone follow-up survey was conducted to determine whether participants had consulted a general practitioner (GP) for confirmation of screening results. A multinomial polytomous logistic regression model was used to identify factors independently associated with non-use of GP consultation for confirmation of screening results and nonresponse to the telephone follow-up survey.

RESULTS

Prevalence of glycemic abnormalities was 46.0% (95% CI = 42.7-49.2%). Among participants with impaired glycemic status (N=417), 77.7% (95% CI=73.7-81.7%) consulted a GP for confirmation of screening results, 12.5% (95% CI=9.3-15.6%) did not, and 9.8% failed to respond to the follow-up survey. Factors independently associated with non-use of GP consultation for confirmation of screening results were self-reported unwillingness to consult a GP (adjusted odds ratio [OR]: 4.86, 95% CI=1.70-13.84), usual GP consultation frequency of less than once a year (adjusted OR: 4.13, 95% CI=1.56-10.97), and age 18-39 years (adjusted OR: 3.09, 95% CI=1.46-6.57).

CONCLUSION

Home screening for glycemic abnormalities is a useful proximity health service for diabetes prevention in low socio-economic settings. Further efforts, including health literacy interventions, are needed to increase utilization of primary care.

Use of the new guidelines on an earlier age threshold of 35 years for diabetes screening can identify an additional 6.3 million undiagnosed individuals with diabetes and 72.3 million individuals with prediabetes among Chinese adults: An analysis of a nationally representative survey

BACKGROUND

Young-onset diabetes has been increasingly prevalent in China and most of the young patients with diabetes remain undiagnosed. Recently, the American Diabetes Association (ADA) updated their screening criteria and turned down the age threshold of diabetes screening from 45 years to 35 years, which highlighted the importance of identifying young individuals with diabetes. Herein, we aimed to evaluate the clinical relevance of updated ADA screening recommendations in Chinese adults and the metabolic features and risk factor profiles of these newly diagnosed individuals.

STUDY DESIGN AND METHODS

Using a complex, multistage, probability sampling design, we analyzed data from a nationally representative sample of 98,658 Chinese adults in 2010. Participants without previously diagnosed diabetes were included into the present study. We calculated the proportion of individuals with diabetes eligible for screening and the number needed to screen (NNS) to identify one patient with diabetes by age groups.

RESULTS

Setting an earlier age threshold of diabetes screening can identify additional 6.3 million patients with diabetes and 72.3 million individuals with prediabetes, and the proportion of identified individuals increased more in rural, underdeveloped, and central areas. The NNS in Chinese adults dropped significantly from 28 in 30-34 age group to 15 in 35-45 years of age and remained low afterwards. The undiagnosed patients with diabetes who met the new screening age threshold of ADA recommendation were characterized by younger age, lower blood pressure and blood lipids, but higher proportion of overweight and higher level of insulin resistance, and tended to have an unhealthy diet habit, including low intake of fruits and vegetables and high intake of sugar-sweetened beverages, compared to those aged over 45 years.

CONCLUSIONS

The new age threshold of 35 years for diabetes screening would reduce the proportion of undiagnosed diabetes with high cost-effectiveness, given the NNS for a positive test result was much lower in 35-45 age group comparing to the lower age group in Chinese adults.

[Effectiveness of different screening strategies for type 2 diabete on preventing cardiovascular diseases in a community-based Chinese population using a decision-analytic Markov model]

OBJECTIVE

To evaluate the effectiveness of different screening strategies for type 2 diabetes to prevent cardiovascular disease in a community-based Chinese population from economically developed areas based on the Chinese electronic health records research in Yinzhou (CHERRY) study.

METHODS

A Markov model was used to simulate different systematic diabetes screening strategies, including: (1) screening among Chinese adults aged 40-70 years recommended by the 2020 Chinese Guideline for the prevention and Treatment of Type 2 Diabetes (Strategy 1); (2) screening among Chinese adults aged 35 to 70 years recommended by the 2022 American Diabetes Association Standard of Medical Care in Diabetes (Strategy 2); and (3) screening among Chinese adults aged 35-70 years with overweight or obesity recommended by the 2021 United States Preventive Services Task Force Recommendation Statement on Screening for Prediabetes and Type 2 Diabetes (Strategy 3). According to the guidelines, individuals who were screened positively (fasting plasma glucose ≥ 7.0 mmol/L) would be introduced to intensive glycemic targets management (glycated hemoglobin < 7.0%).The Markov model simulated different screening scenarios for ten years (cycles) with parameters mainly from the CHERRY study or published literature. Number of cardiovascular disease events or deaths could be prevented and number needed to screen (NNS) were calculated to compare the effectiveness of the different strategies. One-way sensitivity analysis on the sensitivity of screening methods and probabilistic sensitivity analysis on uncertainties of diabetes incidence, the sensitivity of screening methods, and intensive glycemic management effects were conducted.

RESULTS

Totally 289 245 Chinese adults aged 35-70 years without cardiovascular diseases or diagnosed diabetes at baseline were enrolled. In terms of the number of cardiovascular disease events could be prevented, Strategy 1 for systematic diabetes screening among the adults aged 35-70 years was 222 (95%UI: 180-264), Strategy 2 for systematic diabetes screening among the adults aged 40-70 years was 227 (95%UI: 185-271), and Strategy 3 for systematic diabetes screening among the adults aged 35-70 years with obesity or overweight (body mass index ≥ 24 kg/m²) was 131 (95%UI: 98-164), compared with opportunistic screening. NNS per cardiovascular disease event for the strategies 1, 2 and 3 were 1 184 (95%UI: 994-1 456), 1 274 (95%UI: 1 067-1 564) and 814 (95%UI: 649-1 091), respectively. Compared with Strategy 1, NNS per cardiovascular disease event for Strategy 2 increased by 90 (95%UI: -197-381) with similar effectiveness of cardiovascular prevention; however, NNS per cardiovascular disease event for Strategy 3 was reduced by 460 (95%UI: 185-724) in contrast to the Strategy 2, suggesting that the Strategy 3 was more efficient. The results were consistent in multiple sensitivity analyses.

CONCLUSION

Systematic screening for diabetes based on the latest guidelines in economically developed areas of China can reduce cardiovascular events and deaths. However, merely lowering the starting age of screening from 40 to 35 years seems ineffective for preventing cardiovascular disease, while screening strategy for Chinese adults aged 35-70 years with overweight or obesity is recommended to improve efficiency.

Productivity Losses Due to Diabetes in Urban Rural China

BACKGROUND

Productivity losses due to diabetes are increasing in China, but research about the impact of diabetes on productivity in urban and rural areas requires further in-depth study. This article provides the first estimate of the cost of productivity losses attributed to diabetes in individuals 20-69 years old in urban and rural areas of China.

METHODS

The human capital approach is employed to measure the productivity losses attributed to absenteeism, presenteeism, labor force dropout, and premature deaths due to diabetes of the 20-69-year-old population of males and females in urban and rural areas of China. Based on the life table modelling, we calculate the years of potential life lost and working years of life lost of people with diabetes.

RESULTS

In 2017, we estimated that there were 100.46 million people with diabetes, with the total cost of productivity losses being USD 613.60 billion, comprising USD 326.40 billion from labor force dropout, USD 186.34 billion from premature death, USD 97.71 billion from absenteeism, and USD 27.04 billion from presenteeism. Productivity loss was greater in urban (USD 490.79 billion) than rural areas (USD 122.81 billion), with urban presenteeism (USD 2.54 billion) greater than rural presenteeism (USD 608.55 million); urban absenteeism (USD 79.10 billion) greater than rural absenteeism (USD 18.61 billion); urban labor force dropout (USD 261.24 billion) greater than rural labor force dropout (USD 65.15 billion); and urban premature death (USD 147.90 billion) greater than rural premature death (USD 38.44 billion).

CONCLUSIONS

Diabetes has a large and significant negative impact on productivity in urban and rural China. Productivity loss is significantly higher in urban versus rural regions. Further investment is required in the prevention, diagnosis, and control of diabetes in under-resourced health services in rural locations as well as in urban areas, where most diabetes cases reside. Specifically, targeted and effective diabetes prevention and management actions are urgently required.

Simulating lifestyle and medical interventions to prevent type-2 diabetes: an economic evaluation for Belgium

By 2040, over half a billion people globally are expected to have diabetes. This disease implies a loss in life quality and comes with a significant financial impact. To avoid prevalence increases in the main category of diabetes-type-2 diabetes (T-2D)-, preventive action among high-risk groups is necessary. Lifestyle and medical interventions with metformin among prediabetic individuals show strong potential to decrease or delay T-2D. The aim of this paper is to evaluate the cost-effectiveness and budget impact of a nation-wide implementation of these interventions, between 2020 and 2040, in Belgium. This is done through a dynamic, non-homogeneous, semi-Markov model which simulates prevalence and costs of a type of prediabetes (impaired glucose tolerance or IGT) and T-2D in Belgium. High-risk individuals are first screened; individuals with IGT then enroll in a lifestyle or metformin program. Compared to no intervention, both programs are very cost effective from the perspective of the health care system and cost-saving from a broader societal perspective. Both interventions require an initial, affordable government investment and later yield government savings. The lifestyle program is a cost-effective alternative to the metformin intervention and may yield additional benefits through, for example, improvements in mental health.

Behavioural interventions to promote physical activity in a multiethnic population at high risk of diabetes: PROPELS three-arm RCT

BACKGROUND

Type 2 diabetes is a leading cause of mortality globally and accounts for significant health resource expenditure. Increased physical activity can reduce the risk of diabetes. However, the longer-term clinical effectiveness and cost-effectiveness of physical activity interventions in those at high risk of type 2 diabetes is unknown.

OBJECTIVES

To investigate whether or not Walking Away from Diabetes (Walking Away) - a low-resource, 3-hour group-based behavioural intervention designed to promote physical activity through pedometer use in those with prediabetes - leads to sustained increases in physical activity when delivered with and without an integrated mobile health intervention compared with control.

DESIGN

Three-arm, parallel-group, pragmatic, superiority randomised controlled trial with follow-up conducted at 12 and 48 months.

SETTING

Primary care and the community.

PARTICIPANTS

Adults whose primary care record included a prediabetic blood glucose measurement recorded within the past 5 years [HbA_1c ≥ 42 mmol/mol (6.0%), < 48 mmol/mol (6.5%) mmol/mol; fasting glucose ≥ 5.5 mmol/l, < 7.0 mmol/l; or 2-hour post-challenge glucose ≥ 7.8 mmol/l, < 11.1 mmol/l] were recruited between December 2013 and February 2015. Data collection was completed in July 2019.

INTERVENTIONS

Participants were randomised (1 : 1 : 1) using a web-based tool to (1) control (information leaflet), (2) Walking Away with annual group-based support or (3) Walking Away Plus (comprising Walking Away, annual group-based support and a mobile health intervention that provided automated, individually tailored text messages to prompt pedometer use and goal-setting and provide feedback, in addition to biannual telephone calls). Participants and data collectors were not blinded; however, the staff who processed the accelerometer data were blinded to allocation.

MAIN OUTCOME MEASURES

The primary outcome was accelerometer-measured ambulatory activity (steps per day) at 48 months. Other objective and self-reported measures of physical activity were also assessed.

RESULTS

A total of 1366 individuals were randomised (median age 61 years, median body mass index 28.4 kg/m², median ambulatory activity 6638 steps per day, women 49%, black and minority ethnicity 28%). Accelerometer data were available for 1017 (74%) and 993 (73%) individuals at 12 and 48 months, respectively. The primary outcome assessment at 48 months found no differences in ambulatory activity compared with control in either group (Walking Away Plus: 121 steps per day, 97.5% confidence interval -290 to 532 steps per day; Walking Away: 91 steps per day, 97.5% confidence interval -282 to 463). This was consistent across ethnic groups. At the intermediate 12-month assessment, the Walking Away Plus group had increased their ambulatory activity by 547 (97.5% confidence interval 211 to 882) steps per day compared with control and were 1.61 (97.5% confidence interval 1.05 to 2.45) times more likely to achieve 150 minutes per week of objectively assessed unbouted moderate to vigorous physical activity. In the Walking Away group, there were no differences compared with control at 12 months. Secondary anthropometric, biomechanical and mental health outcomes were unaltered in either intervention study arm compared with control at 12 or 48 months, with the exception of small, but sustained, reductions in body weight in the Walking Away study arm (≈ 1 kg) at the 12- and 48-month follow-ups. Lifetime cost-effectiveness modelling suggested that usual care had the highest probability of being cost-effective at a threshold of £20,000 per quality-adjusted life-year. Of 50 serious adverse events, only one (myocardial infarction) was deemed possibly related to the intervention and led to the withdrawal of the participant from the study.

LIMITATIONS

Loss to follow-up, although the results were unaltered when missing data were replaced using multiple imputation.

CONCLUSIONS

Combining a physical activity intervention with text messaging and telephone support resulted in modest, but clinically meaningful, changes in physical activity at 12 months, but the changes were not sustained at 48 months.

FUTURE WORK

Future research is needed to investigate which intervention types, components and features can help to maintain physical activity behaviour change over the longer term.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN83465245.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 77. See the NIHR Journals Library website for further project information.

Economic evaluation of population-based type 2 diabetes mellitus screening at different healthcare settings in Vietnam

Introduction

Few economic evaluations have assessed the cost-effectiveness of screening type-2 diabetes mellitus (T2DM) in different healthcare settings. This study aims to evaluate the value for money of various T2DM screening strategies in Vietnam.

Methods

A decision analytical model was constructed to compare costs and quality-adjusted life years (QALYs) of T2DM screening in different health care settings, including (1) screening at commune health station (CHS) and (2) screening at district health center (DHC), with no screening as the current practice. We further explored the costs and QALYs of different initial screening ages and different screening intervals. Cost and utility data were obtained by primary data collection in Vietnam. Incremental cost-effectiveness ratios were calculated from societal and payer perspectives, while uncertainty analysis was performed to explore parameter uncertainties.

Results

Annual T2DM screening at either CHS or DHC was cost-effective in Vietnam, from both societal and payer perspectives. Annual screening at CHS was found as the best screening strategy in terms of value for money. From a societal perspective, annual screening at CHS from initial age of 40 years was associated with 0.40 QALYs gained while saving US$ 186.21. Meanwhile, one-off screening was not cost-effective when screening for people younger than 35 years old at both CHS and DHC.

Conclusions

T2DM screening should be included in the Vietnamese health benefits package, and annual screening at either CHS or DHC is recommended.

Cost-Effectiveness of Peer-Educator-Delivered Lifestyle Modification for Type 2 Diabetes Prevention in a Young Healthy Population in Sri Lanka: A Trial-Based Economic Evaluation and Economic Model

BACKGROUND

This study evaluated the cost effectiveness of an intensive lifestyle modification (LSM) intervention delivered by peer educators for the prevention of type 2 diabetes mellitus in a young at-risk population in a low healthcare resource setting.

OBJECTIVE

The aim of this study was to evaluate the short-term and long-term cost effectiveness of an intensive lifestyle modification intervention for type 2 diabetes prevention in a young urban at-risk population in Sri Lanka.

METHODS

This was an economic evaluation using cost and outcome data from a randomized controlled trial. We randomized 3539 healthy individuals aged 5-40 years with risk factors for type 2 diabetes to either 3-monthly (P-LSM n = 1727) or 12-monthly (C-LSM n = 1812) peer-educator advice aimed at reducing weight, improving diet, reducing psychological stress and increasing physical activity. A cost-effectiveness analysis was conducted from a health system perspective with outcomes expressed as disability-adjusted life-years (DALYs). Intervention costs and outcomes were collected during a median clinical trial period of 3 years and extrapolated to a lifetime horizon using economic modelling. Uncertainty in the lifetime model was explored by structural and probabilistic sensitivity analyses.

RESULTS

The costs of the more intensive peer support programme were partially offset by reduced costs of type 2 diabetes complications recorded over the trial period and completely offset by lifetime cost savings of 6000 LKR. The more intensive P-LSM also averted more DALYs, estimated at 0.456 DALYs over the lifetime of participants.

CONCLUSIONS

In a young at-risk Sri Lanka population, an intensive LSM programme was cost effective, averting more DALYs at an acceptable additional cost than a much less intensive LSM programme. Early intervention in young at-risk people represents good value for money from the Sri Lankan health care payer perspective.

Trends in type 2 diabetes mellitus disease burden in European Union countries between 1990 and 2019

This observational study aimed to assess trends in type 2 diabetes mellitus (T2DM) disease burden in European Union countries for the years 1990–2019. Sex specific T2DM age-standardised prevalence (ASPRs), mortality (ASMRs) and disability-adjusted life-year rates (DALYs) per 100,000 population were extracted from the Global Burden of Disease (GBD) Study online results tool for each EU country (inclusive of the United Kingdom), for the years 1990–2019. Trends were analysed using Joinpoint regression analysis. Between 1990 and 2019, increases in T2DM ASPRs were observed for all EU countries. The highest relative increases in ASPRs were observed in Luxembourg (males + 269.1%, females + 219.2%), Ireland (males + 191.9%, females + 165.7%) and the UK (males + 128.6%, females + 114.6%). Mortality trends were less uniform across EU countries, however a general trend towards reducing T2DM mortality was observed, with ASMRs decreasing over the 30-year period studied in 16/28 countries for males and in 24/28 countries for females. The UK observed the highest relative decrease in ASMRs for males (− 46.9%). For females, the largest relative decrease in ASMRs was in Cyprus (− 67.6%). DALYs increased in 25/28 countries for males and in 17/28 countries for females between 1990 and 2019. DALYs were higher in males than females in all EU countries in 2019. T2DM prevalence rates have increased across EU countries over the last 30 years. Mortality from T2DM has generally decreased in EU countries, however trends were more variable than those observed for prevalence. Primary prevention strategies should continue to be a focus for preventing T2DM in at risk groups in EU countries.

Prediabetes: how pathophysiology drives potential intervention on a subclinical disease with feared clinical consequences

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder whose rising incidence suggests the epidemic proportions of the disease. Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT) - alone or combined - represent two intermediate metabolic condition between Normal Glucose Tolerance (NGT) and overt T2DM. Several studies have demonstrated that insulin resistance and beta-cell impairment can be identified even in normoglycemic prediabetic individuals. Worsening of these two conditions may lead to progression of IGT and/or IFG status to overt diabetes. Starting from these assumptions, it seems logical to suppose that interventions aimed at improving metabolic conditions, even in prediabetes, could represent an effective target to halt transition from IGT/IFG to manifest T2DM. Starting from pathophysiological knowledge, in this review we evaluate two possible interventions (lifestyle modifications and pharmacological agents) eligible as prediabetes therapy since they have been demonstrated to improve insulin resistance and beta-cell impairment. Detecting high-risk people and treating them could represent an effective strategy to slow down progression to overt diabetes, normalize glucose tolerance, and even prevent micro- and macrovascular complications.

Reducing Fall-related Revisits for Elderly Diabetes Patients in Emergency Departments: A Transition Flow Model

This paper introduces a transition flow model to study fall-related emergency department (ED) revisits for elderly patients with diabetes. Five diabetes classes are used to classify patients at discharge, within 7-day revisits, and between 8 and 30-day revisits. Analytical formulas to evaluate patient revisiting risks are derived. To reduce revisits, sensitivity analysis is introduced to identify the most critical, i.e., dominant, factors whose changes can lead to the largest reduction in revisits. In addition, a case study at University of Wisconsin (UW) Hospital ED is described to illustrate the applicability of the model.

Targeting of the diabetes prevention program leads to substantial benefits when capacity is constrained

OBJECTIVE

Approximately 84 million people in the USA have pre-diabetes, but only a fraction of them receive proven effective therapies to prevent type 2 diabetes. We estimated the value of prioritizing individuals at highest risk of progression to diabetes for treatment, compared to non-targeted treatment of individuals meeting inclusion criteria for the Diabetes Prevention Program (DPP).

METHODS

Using microsimulation to project outcomes in the DPP trial population, we compared two interventions to usual care: (1) lifestyle modification and (2) metformin administration. For each intervention, we compared targeted and non-targeted strategies, assuming either limited or unlimited program capacity. We modeled the individualized risk of developing diabetes and projected diabetic outcomes to yield lifetime costs and quality-adjusted life expectancy, from which we estimated net monetary benefits (NMB) for both lifestyle and metformin versus usual care.

RESULTS

Compared to usual care, lifestyle modification conferred positive benefits and reduced lifetime costs for all eligible individuals. Metformin's NMB was negative for the lowest population risk quintile. By avoiding use when costs outweighed benefits, targeted administration of metformin conferred a benefit of $500 per person. If only 20% of the population could receive treatment, when prioritizing individuals based on diabetes risk, rather than treating a 20% random sample, the difference in NMB ranged from $14,000 to $20,000 per person.

CONCLUSIONS

Targeting active diabetes prevention to patients at highest risk could improve health outcomes and reduce costs compared to providing the same intervention to a similar number of patients with pre-diabetes without targeted selection.

Applying latent class analysis to risk stratification of incident diabetes among Chinese adults

OBJECTIVE

To use latent class analysis to identify unobservable subpopulations amongst the heterogeneous population and explore the relationship between subpopulations and incident diabetes among Chinese adults.

METHODS

The retrospective study included 32,312 Chinese adults without diabetes at baseline. Latent class indicators included demographic and clinical variables. The outcome was incident diabetes. The relationship between latent class and outcome was evaluated with Cox proportional hazard regression analysis.

RESULTS

After screening, the two-class latent class model best fits the population. Participants in class 2 are characterized by higher age, body mass index, systolic and diastolic blood pressure, fasting plasma glucose, total cholesterol, triglyceride, low-density lipoprotein cholesterol, serum creatinine, serum urea nitrogen, alanine aminotransferase, and a higher proportion of males, ever/current smokers and drinkers, but lower high-density lipoprotein cholesterol and a lower proportion of family history of diabetes. The risk of diabetes in class 2 was 5.451 times (HR: 6.451, 95%CI: 4.179-9.960, P < 0.00001) and 5.264 times (HR: 6.264, 95%CI: 4.680-8.385, P < 0.00001) higher than that in class 1 during 3-year and 5-year follow-up, respectively.

CONCLUSIONS

We used latent class analysis to identify two distinct subpopulations with differential risk of diabetes during 3-year and 5-year follow-up.

Early economic evaluation of an intervention to improve uptake of the NHS England Diabetes Prevention Programme

BACKGROUND

Despite reported increases in referral numbers, a large proportion of those with prediabetes still decline participation in the NHS England Diabetes Prevention Programme (NDPP). The aim of this study was to explore whether investment in interventions to improve uptake of the programme has the potential to be cost-effective.

METHODS

An early cost-utility analysis was conducted using a Markov model parameterized based on secondary data sources. We explored different uptake scenarios and the impact that this had on the maximum allowable intervention price based on cost-effectiveness at the UK NICE willingness to pay threshold of £20,000 (US$ 25,913). Value of information analyses were conducted to explore the potential value of further research to resolve uncertainty at each uptake level.

RESULTS

As uptake levels increase, the maximum allowable intervention price and overall expected value of removing decision uncertainty increases. For 5 percentage and 50 percentage points increase in uptake levels, the maximum allowable intervention price is £41.86 (US$ 54.23) and £418.59 (US$ 542.34) per person, and the overall expected value of removing decision uncertainty are £361,818,839 (US$ 468,786,625) and £1,468,712,316 (US$ 1,902,921,063) respectively.

CONCLUSION

There is headroom for investment in interventions that improve uptake to the NDPP, thereby allowing the programme itself to be delivered in a manner that remains cost-effective.

Awareness and risk burden of diabetes mellitus in a rural community of Ekiti State, South-Western Nigeria

Objective

In recent times, Diabetes Mellitus (DM) has had a rapid increase in developing countries as a result of changing lifestyles among the people. This study was therefore aimed to investigate the level of awareness of DM and its associated risk factors in Afao: a rural community located in Irepodun/Ifelodun Local Government Ekiti State, Nigeria.

Design

The study was descriptive cross-sectional in design. A multi-stage sampling technique was applied to recruit respondents who are residents in the community. Two hundred and one individuals were involved in this community-based study. Information was obtained using a modified WHO STEPwise approach to chronic disease risk surveillance. The questionnaire included questions that assessed socio-demographic characteristics, diabetic risk factors and anthropometric measures of respondents.

Result

Of the 134 (66.7%) respondents aware of DM, only an average of 43.9% had knowledge of its risk factors. Respondent’s body mass index was significantly associated (P < 0.01) with knowledge of overweight/obesity as overweight (52.9%), grade 1 obese (62.5%) and morbid obese (100%) respondents had no knowledge of their status as risk factors for DM. Also, respondent’s blood pressure status showed a significant association (P = 0.099) with respondent’s knowledge of high blood pressure, 62.5% of those unaware of their blood pressure status had no knowledge of high blood pressure as a diabetes risk factor. Respondent’s age (P = 0.024) and diet; daily vegetable servings (P = 0.015) and cooking oil (P = 0.05) showed significant association with the occurrence of the disease in 14.4% respondents previously diagnosed.

Conclusion

This study shows a need to improve on the level of awareness of diabetes risk factors in Afao. Routine measurement of blood glucose levels for adults, community health education and enlightenment strategies through the ministry of health on the awareness of diabetes are highly recommended for the Afao community.

Assessment of simple strategies for identifying undiagnosed diabetes and prediabetes in the general population

BACKGROUND AND AIMS

The rising tide of diabetes mellitus (DM) and prediabetes (PDM) is urgently calling for strategies easily applicable to anticipate diagnosis. We assessed the effectiveness of random capillary blood glucose (RCBG), administration of a validated DM risk questionnaire, or the combination of both.

MATERIALS AND METHODS

RCBG measurement and/or questionnaire administration were offered to all individuals presenting at gazebos organized during the World Diabetes Day or similar public initiatives on diabetes awareness. Subjects with suspicious DM or PDM were invited to the Diabetes Center (DC) for laboratory confirmation (fasting plasma glucose and HbA1c).

RESULTS

Among 8563 individuals without known diabetes undergoing RCBG measurement, 341 (4%) had suspicious values. Diagnosis of DM was confirmed in 36 (41.9%) of the 86 subjects who came to the DC and PDM was found in 40 (46.5%). Among 3351 subjects to whom the questionnaire was administered, 480 (14.3%) had suspicious scores. Diagnosis of DM was confirmed in 40 (10.1%) of the 397 who came to the DC and PDM was found in 214 (53.9%). These 3351 subjects also had RCBG measurement and 30 out of them had both tests positive. Among them, 27 subjects came to DC and DM was diagnosed in 17 (63.0%) and PDM was found in 9 (33.3%).

CONCLUSIONS

These data suggest that RCBG definitely outperforms the questionnaire to identify unknown DM and PDM. RCBG measurement, with questionnaire as an adjunctive tool, appears to be a simple, fast, and feasible opportunistic strategy in detecting undiagnosed DM and PDM.

Early detection of type 2 diabetes in socioeconomically disadvantaged areas in Stockholm - comparing reach of community and facility-based screening

BACKGROUND

Type 2 diabetes and its high-risk stage, prediabetes, are often undiagnosed. Early detection of these conditions is of importance to avoid organ complications due to the metabolic disturbances associated with diabetes. Diabetes screening can detect persons unaware of diabetes risk and the elevated glucose levels can potentially be reversed through lifestyle modification and medication. There are mainly two approaches to diabetes screening: opportunistic facility-based screening at health facilities and community screening.

OBJECTIVE

To determine the difference in population reach and participant characteristics between community- and facility-based screening for detection of type 2 diabetes and persons at high risk of developing diabetes.

METHODS

Finnish diabetes risk score (FINDRISC) is a risk assessment tool used by two diabetes projects to conduct community- and facility-based screenings in disadvantaged suburbs of Stockholm. In this study, descriptive and limited inferential statistics were carried out analyzing data from 2,564 FINDRISC forms from four study areas. Community- and facility-based screening was compared in terms of participant characteristics and with population data from the respective areas to determine their reach.

RESULTS

Our study found that persons born in Africa and Asia were reached through community screening to a higher extent than with facility-based screening, while persons born in Sweden and other European countries were reached more often by facility-based screening. Also, younger persons were reached more frequently through community screening compared with facility-based screening. Both types of screening reached more women than men.

CONCLUSION

Community-based screening and facility-based screening were complementary methods in reaching different population groups at high risk of developing type 2 diabetes. Community screening in particular reached more hard-to-reach groups with unfavorable risk profiles, making it a critical strategy for T2D prevention. More men should be recruited to intervention studies and screening initiatives to achieve a gender balance.

'I could have made those changes years earlier': experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes

BACKGROUND

Prediabetes increases the risk of developing type 2 diabetes (T2D). Improving diet quality is key in preventing this progression, yet little is known about the characteristics of individuals with prediabetes or the nutrition care they receive.

OBJECTIVES

This study aims to identify characteristics and experiences associated with receiving a prediabetes diagnosis prior to developing T2D.

METHODS

A mixed methods study encompassed a quantitative subanalysis of participants with newly diagnosed T2D from The 3D Study, and semi-structured telephone interviews with a subsample of participants who were previously diagnosed with prediabetes. Interviews were thematically analysed and survey data synthesized using SPSS statistical software.

RESULTS

Of the 225 study participants, 100 individuals were previously diagnosed with prediabetes and 120 participants were not. Those with prediabetes were less likely to be smokers (P = 0.022) and more likely to be satisfied with seeing a dietitian (P = 0.031) than those without a previous prediabetes diagnosis. A total of 20 participants completed semi-structured interviews. Thematic analysis revealed three themes: (i) experiencing a prediabetes diagnosis; (ii) receiving nutrition care during prediabetes and (iii) reflecting on the experience of receiving care for prediabetes versus T2D.

CONCLUSIONS

There are gaps in the current management of prediabetes in Australia. Low rates of prediabetes diagnosis and an ambiguous experience of receiving this diagnosis suggest an area of health service improvement. With no difference in diet quality between individuals with and without a previous prediabetes diagnosis, the nutrition care during prediabetes may be more important than the diagnosis itself in delaying the onset of T2D.

Cost-effectiveness of Diabetes Prevention Interventions Targeting High-risk Individuals and Whole Populations: A Systematic Review

OBJECTIVE

We conducted a systematic review of studies evaluating the cost-effectiveness (CE) of interventions to prevent type 2 diabetes (T2D) among high-risk individuals and whole populations.

RESEARCH DESIGN AND METHODS

Interventions targeting high-risk individuals are those that identify people at high risk of developing T2D and then treat them with either lifestyle or metformin interventions. Population-based prevention strategies are those that focus on the whole population regardless of the level of risk, creating public health impact through policy implementation, campaigns, and other environmental strategies. We systematically searched seven electronic databases for studies published in English between 2008 and 2017. We grouped lifestyle interventions targeting high-risk individuals by delivery method and personnel type. We used the median incremental cost-effectiveness ratio (ICER), measured in cost per quality-adjusted life year (QALY) or cost saved to measure the CE of interventions. We used the $50,000/QALY threshold to determine whether an intervention was cost-effective or not. ICERs are reported in 2017 U.S. dollars.

RESULTS

Our review included 39 studies: 28 on interventions targeting high-risk individuals and 11 targeting whole populations. Both lifestyle and metformin interventions in high-risk individuals were cost-effective from a health care system or a societal perspective, with median ICERs of $12,510/QALY and $17,089/QALY, respectively, compared with no intervention. Among lifestyle interventions, those that followed a Diabetes Prevention Program (DPP) curriculum had a median ICER of $6,212/QALY, while those that did not follow a DPP curriculum had a median ICER of $13,228/QALY. Compared with lifestyle interventions delivered one-on-one or by a health professional, those offered in a group setting or provided by a combination of health professionals and lay health workers had lower ICERs. Among population-based interventions, taxing sugar-sweetened beverages was cost-saving from both the health care system and governmental perspectives. Evaluations of other population-based interventions-including fruit and vegetable subsidies, community-based education programs, and modifications to the built environment-showed inconsistent results.

CONCLUSIONS

Most of the T2D prevention interventions included in our review were found to be either cost-effective or cost-saving. Our findings may help decision makers set priorities and allocate resources for T2D prevention in real-world settings.

How valid are projections of the future prevalence of diabetes? Rapid reviews of prevalence-based and Markov chain models and comparisons of different models' projections for England

OBJECTIVES

To examine validity of prevalence-based models giving projections of prevalence of diabetes in adults, in England and the UK, and of Markov chain models giving estimates of economic impacts of interventions to prevent type 2 diabetes (T2D).

METHODS

Rapid reviews of both types of models. Estimation of the future prevalence of T2D in England by Markov chain models; and from the trend in the prevalence of diabetes, as reported in the Quality and Outcomes Framework (QOF), estimated by ordinary least squares regression analysis.

SETTING

Adult population in England and UK.

MAIN OUTCOME MEASURE

Prevalence of T2D in England and UK in 2025.

RESULTS

The prevalence-based models reviewed use sample estimates of past prevalence rates by age and sex and projected population changes. Three most recent models, including that of Public Health England (PHE), neither take account of increases in obesity, nor report Confidence Intervals (CIs). The Markov chain models reviewed use transition probabilities between states of risk and death, estimated from various sources. None of their accounts give the full matrix of transition probabilities, and only a minority report tests of validation. Their primary focus is on estimating the ratio of costs to benefits of preventive interventions in those with hyperglycaemia, only one reported estimates of those developing T2D in the absence of a preventive intervention in the general population.Projections of the prevalence of T2D in England in 2025 were (in millions) by PHE, 3.95; from the QOF trend, 4.91 and by two Markov chain models, based on our review, 5.64 and 9.07.

CONCLUSIONS

To inform national policies on preventing T2D, governments need validated models, designed to use available data, which estimate the scale of incidence of T2D and survival in the general population, with and without preventive interventions.

Evaluation of the Diabetes Screening Component of a National Cardiovascular Risk Assessment Programme in England: a Retrospective Cohort Study

Type 2 Diabetes (T2D) is increasing but the effectiveness of large-scale diabetes screening programmes is debated. We assessed associations between coverage of a national cardiovascular and diabetes risk assessment programme in England (NHS Health Check) and detection and management of incident cases of non-diabetic hyperglycaemia (NDH) and T2D. Retrospective analysis employing propensity score covariate adjustment method of prospectively collected data of 348,987 individuals aged 40-74 years and registered with 455 general practices in England (January 2009-May 2016). We examined differences in diagnosis of NDH and T2D, and changes in blood glucose levels and cardiovascular risk score between individuals registered with general practices with different levels (tertiles) of programme coverage. Over the study period 7,126 cases of NDH and 12,171 cases of T2D were detected. Compared with low coverage practices, incidence rate of detection in medium and high coverage practices were 15% and 19% higher for NDH and 10% and 9% higher for T2D, respectively. Individuals with NDH in high coverage practices had 0.2 mmol/L lower mean fasting plasma glucose and 0.9% lower cardiovascular risk score at follow-up. General practices actively participating in the programme had higher detection of NDH and T2D and improved management of blood glucose and cardiovascular risk factors.

The community-based prevention of diabetes (ComPoD) study: a randomised, waiting list controlled trial of a voluntary sector-led diabetes prevention programme

Objective

This two-site randomised trial compared the effectiveness of a voluntary sector-led, community-based diabetes prevention programme to a waiting-list control group at 6 months, and included an observational follow-up of the intervention arm to 12 months.

Methods

Adults aged 18–75 years at increased risk of developing type 2 diabetes due to elevated blood glucose and being overweight were recruited from primary care practices at two UK sites, with data collected in participants’ homes or community venues. Participants were randomised using an online central allocation service. The intervention, comprising the prototype “Living Well, Taking Control” (LWTC) programme, involved four weekly two-hour group sessions held in local community venues to promote changes in diet and physical activity, plus planned follow-up contacts at two, three, six, nine and 12 months alongside 5 hours of additional activities/classes. Waiting list controls received usual care for 6 months before accessing the programme. The primary outcome was weight loss at 6 months. Secondary outcomes included glycated haemoglobin (HbA1c), blood pressure, physical activity, diet, health status and well-being. Only researchers conducting analyses were blinded.

Results

The target sample of 314 participants (157 each arm) was largely representative of local populations, including 44% men, 26% from ethnic minorities and 33% living in deprived areas. Primary outcome data were available for 285 (91%) participants (141 intervention, 144 control). Between baseline and 6 months, intervention participants on average lost more weight than controls (− 1.7 kg, 95% CI − 2.59 to − 0.85). Higher attendance was associated with greater weight loss (− 3.0 kg, 95% CI − 4.5 to − 1.5). The prototype LWTC programme more than doubled the proportion of participants losing > 5% of their body weight (21% intervention vs. 8% control, OR 2.83, 95% CI 1.36 to 5.90) and improved self-reported dietary behaviour and health status. There were no impacts on HbA1c, blood pressure, physical activity and well-being at 6 months and, amongst intervention participants, few further changes from six to 12-months (e.g. average weight re-gain 0.36 kg, 95% CI − 0.20 to 0.91). There were no serious adverse events but four exercise-related injuries were reported in the intervention arm.

Conclusions

This voluntary sector-led diabetes prevention programme reached a broad spectrum of the population and had modest effects on weight-related outcomes, but limited impacts on other diabetes risk factors.

Trial registration

Trial registration number: ISRCTN70221670, 5 September 2014

Funder (National Institute for Health Research School for Public Health Research) project reference number: SPHR-EXE-PES-COM.

Machine Learning For Tuning, Selection, And Ensemble Of Multiple Risk Scores For Predicting Type 2 Diabetes

Background

This study proposes the use of machine learning algorithms to improve the accuracy of type 2 diabetes predictions using non-invasive risk score systems.

Methods

We evaluated and compared the prediction accuracies of existing non-invasive risk score systems using the data from the REACTION study (Risk Evaluation of Cancers in Chinese Diabetic Individuals: A Longitudinal Study). Two simple risk scores were established on the bases of logistic regression. Machine learning techniques (ensemble methods) were used to improve prediction accuracies by combining the individual score systems.

Results

Existing score systems from Western populations performed worse than the scores from Eastern populations in general. The two newly established score systems performed better than most existing scores systems but a little worse than the Chinese score system. Using ensemble methods with model selection algorithms yielded better prediction accuracy than all the simple score systems.

Conclusion

Our proposed machine learning methods can be used to improve the accuracy of screening the undiagnosed type 2 diabetes and identifying the high-risk patients.

Prognostic Modeling and Prevention of Diabetes Using Machine Learning Technique

Stratifying individuals at risk for developing diabetes could enable targeted delivery of interventional programs to those at highest risk, while avoiding the effort and costs of prevention and treatment in those at low risk. The objective of this study was to explore the potential role of a Hidden Markov Model (HMM), a machine learning technique, in validating the performance of the Framingham Diabetes Risk Scoring Model (FDRSM), a well-respected prognostic model. Can HMM predict 8-year risk of developing diabetes in an individual effectively? To our knowledge, no study has attempted use of HMM to validate the performance of FDRSM. We used Electronic Medical Record (EMR) data, of 172,168 primary care patients to derive the 8-year risk of developing diabetes in an individual using HMM. The Area Under Receiver Operating Characteristic Curve (AROC) in our study sample of 911 individuals for whom all risk factors and follow up data were available is 86.9% compared to AROCs of 78.6% and 85% reported in a previously conducted validation study of FDRSM in the same Canadian population and the Framingham study respectively. These results demonstrate that the discrimination capability of our proposed HMM is superior to the validation study conducted using the FDRSM in a Canadian population and in the Framingham population. We conclude that HMM is capable of identifying patients at increased risk of developing diabetes within the next 8-years.

The community pharmacy setting for diabetes prevention: Views and perceptions of stakeholders

Background

Diabetes prevention programmes delay or prevent the onset of type 2 diabetes in people with pre-diabetes. To increase accessibility, national guidelines recommend delivering diabetes prevention programmes in primary care settings, including community pharmacy. This study aimed to explore the English community pharmacy setting as an option for delivering diabetes prevention services.

Methods

Two focus groups and nine semi-structured interviews were conducted with stakeholders including, community pharmacists, general practitioners and commissioners. The topic guide was framed using the COM-B theoretical model for behaviour change to elicit practitioners’ capability, opportunity and motivation to engage with providing or referring to community pharmacy diabetes prevention services. Data were analysed thematically, and barriers/facilitators mapped to the COM-B framework.

Results

Five themes were identified: ‘Pre-diabetes management and associated challenges’, ‘The community pharmacy setting’, ‘Awareness of community pharmacy services’, ‘Relationships and communication’ and ‘Delivery of community pharmacy services’. Community pharmacy was highlighted as an accessible setting for delivering screening and follow-on lifestyle interventions. Key factors for enhancing the capability of community pharmacy teams to deliver the interventions included training and appropriate use of skill mix. Delivering diabetes prevention services in collaboration with general practices was identified as key to the provision of integrated primary care services. Whilst financial incentives were identified as a motivating factor for delivery, service promotion to patients, public and healthcare professionals was perceived as crucial for enhancing engagement.

Conclusions

This research highlights a role for community pharmacy in diabetes prevention. New service models should seek to integrate community pharmacy services in primary care to facilitate patient engagement and better communication with general practices.

Decision models of prediabetes populations: A systematic review

AIMS

With evidence supporting the use of preventive interventions for prediabetes populations and the use of novel biomarkers to stratify the risk of progression, there is a need to evaluate their cost-effectiveness across jurisdictions. Our aim is to summarize and assess the quality and validity of decision models and model-based economic evaluations of populations with prediabetes, to evaluate their potential use for the assessment of novel prevention strategies and to discuss the knowledge gaps, challenges and opportunities.

MATERIALS AND METHODS

We searched Medline, Embase, EconLit and NHS EED between 2000 and 2018 for studies reporting computer simulation models of the natural history of individuals with prediabetes and/or we used decision models to evaluate the impact of treatment strategies on these populations. Data were extracted following PRISMA guidelines and assessed using modelling checklists. Two reviewers independently assessed 50% of the titles and abstracts to determine whether a full text review was needed. Of these, 10% was assessed by each reviewer to cross-reference the decision to proceed to full review. Using a standardized form and double extraction, each of four reviewers extracted 50% of the identified studies.

RESULTS

A total of 29 published decision models that simulate prediabetes populations were identified. Studies showed large variations in the definition of prediabetes and model structure. The inclusion of complications in prediabetes (n = 8) and type 2 diabetes (n = 17) health states also varied. A minority of studies simulated annual changes in risk factors (glycaemia, HbA1c, blood pressure, BMI, lipids) as individuals progressed in the models (n = 7) and accounted for heterogeneity among individuals with prediabetes (n = 7).

CONCLUSIONS

Current prediabetes decision models have considerable limitations in terms of their quality and validity and do not allow evaluation of stratified strategies using novel biomarkers, highlighting a clear need for more comprehensive prediabetes decision models.

The Community Health Assessment Program in the Philippines (CHAP-P) diabetes health promotion program for low- to middle-income countries: study protocol for a cluster randomized controlled trial

Background

Type 2 diabetes is increasing globally, with the highest burden in low- to middle-income countries (LMICs) such as the Philippines. Developing effective interventions could improve detection, prevention, and treatment of diabetes. The Cardiovascular Health Awareness Program (CHAP), an evidence-based Canadian intervention, may be an appropriate model for LMICs due to its low cost, ease of implementation, and focus on health promotion and disease prevention. The primary aim of this study is to adapt the CHAP model to a Philippine context as the Community Health Assessment Program in the Philippines (CHAP-P) and evaluate the effect of CHAP-P on glycated hemoglobin (HbA1c) compared to a random sample of community residents in control communities.

Methods

Six-month, 26-community (13 intervention, 13 control) parallel cluster randomized controlled trial in Zamboanga Peninsula, an Administrative Region in the southern Philippines. Criteria for community selection include: adequate political stability, connection with local champions, travel feasibility, and refrigerated space for materials. The community-based intervention, CHAP-P sessions, are volunteer-led group sessions with chronic condition assessment, blood pressure monitoring, and health education. Three participant groups will be involved: 1) Random sample of community participants aged 40 or older, 100 per community (1300 control, 1300 intervention participants total); 2) Community members aged 40 years or older who attended at least one CHAP-P session; 3) Community health workers and staff facilitating sessions. Primary outcome: mean difference in HbA1c at 6 months in intervention group individuals compared to control. Secondary outcomes: modifiable risk factors, health utilization and access (individual); diabetes detection and management (cluster). Evaluation also includes community process evaluation and cost-effectiveness analysis.

Discussion

CHAP has been shown to be effective in a Canadian setting. Individual components of CHAP-P have been piloted locally and shown to be acceptable and feasible. This study will improve understanding of how best to adapt this model to an LMIC setting, in order to maximize prevention, detection, and management of diabetes. Results may inform policy and practice in the Philippines and have the potential to be applied to other LMICs.

Trial registration

ClinicalTrials.gov (NCT03481335), registered March 29, 2018.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6974-z) contains supplementary material, which is available to authorized users.

Economic Impact of Diabetes in South Asia: the Magnitude of the Problem

PURPOSE OF REVIEW

To critically assess and identify gaps in the current literature on the economic impact of diabetes in South Asia.

RECENT FINDINGS

The total annual (direct medical and non-medical and indirect) costs for diabetes care in South Asia range from $483-$2637 per patient, and on an average 5.8% of patients with diabetes suffer catastrophic spending i.e. when households reduce basic expenditure by 40% to cope with healthcare costs. The mean direct costs per patient are positively associated with a country's gross domestic product (GDP) per capita, although there is wide heterogeneity across South Asian countries. With an estimated 84 million people suffering from diabetes in South Asia, diabetes imposes a substantial economic burden on individuals, families, and society. Since the disease burden increasingly occurs in the most productive midlife period, it adversely affects workforce productivity and macroeconomic development. Diabetes-related complications lead to markedly higher treatment costs, causing catastrophic medical spending for many households, thus underscoring the importance of preventing diabetes-related complications.

Targeted screening for prediabetes and undiagnosed diabetes in a community setting in India

BACKGROUND AND OBJECTIVES

Data to support the use of risk scores in screening programs to detect people with prediabetes and undiagnosed diabetes in low- and middle-income countries are limited. We evaluated a targeted screening program involving a diabetes risk score in a community setting in India in terms of its uptake, yield, and costs.

METHODS

In the Kerala Diabetes Prevention Program, 2586 individuals (age 30-60 years) without known diabetes were screened using a two-step procedure. Step 1: screening with the Indian Diabetes Risk Score at participants' homes by trained non-medical staff. Step 2: oral glucose tolerance test (OGTT) among those with IDRS score ≥60 ("screen-positive") at community-based clinics. Screening costs were expressed in 2013 US dollars.

RESULTS

96.3% of those invited for the IDRS screening consented and 79.1% of screen-positives attended clinics for an OGTT. Older age and male gender were associated with higher IDRS uptake. Female gender, higher monthly household expenditure, and higher IDRS score were associated with higher OGTT uptake. The number needed to screen (yield) to detect one person with prediabetes and undiagnosed diabetes was two and six, respectively. The average screening cost of identifying one person with prediabetes and undiagnosed diabetes was $33.8 and $116.5, respectively.

CONCLUSION

This targeted screening program had a high uptake and high yield for prediabetes and undiagnosed diabetes in a community setting in India. Alternative strategies are likely required to enhance the uptake of screening in certain groups.

Increased risk of diabetes mellitus five years after an episode of Staphylococcus aureus bacteraemia

Background: Diabetes mellitus is a risk factor for infection with Staphylococcus aureus, but it is unclear whether S. aureus infection is a prediabetic condition. Methods: Nationwide population-based matched cohort study. Incidence rate and ratio with 95% confidence interval of diabetes were estimated by negative binomial regression. Results: Of 19,988 individuals with S. aureus bacteraemia and 185,579 population comparators, 667 and 4974 had a primary diagnose of diabetes within five years after discharge of S. aureus bacteraemia corresponding to a more than double risk of diabetes (adjusted incidence rate ratio 2.28 (95% confidence interval: 2.10-2.46)). Other factors associated with an increased risk of diabetes during follow-up were male sex, increasing age and level of comorbidity. Of the S. aureus bacteraemia and population cohort, 422 (2.11%) and 4048 (2.18%), respectively, developed diabetes without complications, while 245 (1.23%) and 926 (0.50%), respectively, developed diabetes with complications. Rates of diabetes without complication were increased for individuals in the S. aureus bacteraemia cohort compared to the population cohort within the first two years after which rates were comparable while rates of diabetes with complications remained higher throughout the five year follow-up period compared to the population cohort. Conclusions: The risk of diabetes was markedly increased up to five years after S. aureus bacteraemia compared to a population cohort. In addition to screening for diabetes during hospital admittance, screening cases of S. aureus bacteraemia for diabetes in the years following S. aureus bacteraemia may allow for earlier detection of diabetes.

Diabetes Screening Through Community Pharmacies in England: A Cost-Effectiveness Study

Community pharmacies are commonly used to screen for patients with diabetes. The aim of this paper is to estimate the cost per test and cost per appropriately referred patient from a pharmacy perspective using a one-year decision tree model. One-way sensitivity analysis was performed to estimate the effect of geographical location and patient self-referral rate. Data was used from 164 patients screened and located in an area with average social deprivation and largely white European inhabitants and 172 patients in an area with higher social deprivation (lower than average ability to access society’s resources) and a mixed ethnicity population in England. The diabetes screening consisted of initial risk assessment via questionnaire followed by HbA1c test for those identified as high risk. The cost per person screened was estimated as £28.65. The cost per appropriately referred patient with type 2 diabetes was estimated to range from £7638 to £11,297 in deprived mixed ethnicity and non-deprived areas respectively. This increased to £12,730 and £18,828, respectively, if only 60% of patients referred chose to inform their general practitioner (GP). The cost per test and identification rates through community pharmacies was similar to that reported through medical practices. Locating services in areas of suspected greater diabetes prevalence and increasing the proportion of patients who follow pharmacist advice to attend their medical practice improves cost-effectiveness.

High prevalence of prediabetes among the family members of individuals with diabetes. Findings from targeted screening program from south India

AIM

We aimed to screen for prediabetes, diabetes and other cardiovascular risk factors among family members of people with diabetes registered for care in a primary health centre in South India.

METHODS

During 2017-2018, we screened eligible family members of individuals with diabetes at their homes. We measured fasting capillary blood glucose (FCBG); for those with FCBG≥126 mg/dl, we confirmed the diagnosis of diabetes with fasting plasma glucose (FPG). We defined prediabetes as FCBG between 100 and 125 mg/dl; diabetes as both FCBG and FPG ≥126 mg/dl. We assessed non-communicable disease risk factors using WHO STEPS questionnaire.

RESULTS

Of total 884 participants, 873 (99%) underwent screening; 280 (32%) had prediabetes, and 19 (2.2%) were confirmed with diabetes. Of newly diagnosed, 17 (90%) were initiated on treatment. Of 873 participants, 180 (20.6%) were newly diagnosed with hypertension. Of the total, 7.3%, 5.2% and 16% reported tobacco use, alcohol use and high salt intake respectively. Nearly half (48%) had overweight.

CONCLUSION

Though the yield for diabetes is modest (3%), the house to house approach was able to screen 99% of eligible population. High prevalence of prediabetes and undiagnosed hypertension emphasize the need for screening and life style modifications.

FINDRISC Modified for Latin America as a Screening Tool for Persons with Impaired Glucose Metabolism in Ciudad Bolívar, Venezuela

OBJECTIVE

The Finnish Diabetes Risk Score (FINDRISC) includes anthropometric, metabolic, and lifestyle factors that predict type 2 diabetes mellitus. The objective of this study was to evaluate the FINDRISC modified for Latin America (LA-FINDRISC) as a screening tool for persons with impaired glucose metabolism in Ciudad Bolívar, Venezuela.

METHODS

Subjects aged between 18 and 70 years of both sexes without known diabetes were invited to participate. After informed consent, they were screened with the LA-FINDRISC questionnaire and then given an oral glucose tolerance test, using the American Diabetes Association criteria for diagnosis. To obtain the cutoff point of LA-FINDRISC for predicting impaired glucose regulation, a receiver operating characteristic curve was constructed.

RESULTS

A total of 200 subjects were evaluated, 64.5% female, with a mean age of 35.20 ± 13.84 years. Of these, 158 (79%) did not present with carbohydrate metabolism disorder, while 42 (21%) did. Age (p = 0.0001), body mass index (p = 0.011), and waist circumference (p = 0.031) were significantly higher in subjects with impaired glucose regulation when compared to those without it. There were a significantly greater number of sedentary (p = 0.039) and hypertensive subjects (p = 0.0001), as well as those with a history of glucose >100 mg/dL (p = 0.0001), in the impaired glucose metabolism group. A cutoff LA-FINDRISC of 14 points predicted a high risk of impaired glucose regulation with a sensitivity of 45.2% and a specificity of 89.9%.

CONCLUSION

A LA-FINDRISC >14 points had low sensitivity but high specificity for predicting carbohydrate metabolism disorders in this group of patients from Ciudad Bolívar.

A systematic review on costs and cost-effectiveness of screening and prevention of type 2 diabetes in women with prior gestational diabetes: Exploring uncharted territory

AIMS

Women with gestational diabetes mellitus (GDM) are more likely to develop type 2 diabetes mellitus (T2DM) as compared to women with normoglycemic pregnancies. This study aims to explore the literature on cost(-effectiveness) of screening and prevention of T2DM in women with prior GDM.

METHODS

Five databases were systematically searched, inclusion criteria were: (1) women with (prior) GDM; (2) post-partum screening or prevention of T2DM; and (3) health-economic evaluations. No year limits were applied. English, Dutch, French or German publications were included. Quality was assessed using the Consensus Health Economic Criteria checklist.

RESULTS

Two cost-effectiveness analyses and two cost analyses were found. One study evaluated nine screening strategies. Three studies evaluated one prevention strategy each: intensive diet and behavioural modification; annual counseling; and an annual dietary consultation. Methodological quality was poor. Perspectives were unclear, time horizons were too short, and no incremental analyses were performed.

CONCLUSION

An oral glucose tolerance test per three years leads to the lowest cost per case detected, and prevention is potentially cost-effective or cost-saving. More health economic evaluations are needed that compare all relevant alternatives, including 'doing nothing'.

Descriptive analysis of pharmacy services provided after community pharmacy screening

Background Community pharmacies are promising locations for opportunistic screening due to pharmacist accessibility and ability to perform various health and medication management services. Little is known as to the provision of pharmacy services following screening initiatives. Objective To describe provision of pharmacy services for participants following a community pharmacy stroke screening initiative. Setting The Program for the Identification of "Actionable Atrial" Fibrillation Pharmacy initiative took place in 30 pharmacies in Alberta and Ontario, Canada. 1149 participants ≥ 65 were screened for atrial fibrillation, type 2 diabetes, and hypertension. Method Retrospective, secondary analysis of data using participant case-report forms, pharmacy data, and pharmacy claims to describe pharmacy services received by participants post-screening. Main Outcome Measure Number and types of remunerated pharmacy services received by participants post-screening. Results A total of 535/1149 (46.6%) participants screened at their regular pharmacy were included in this analysis. Of these, 165 (30.8%) participants received 229 pharmacy services within 3 months post-screening, including 146 medication reviews, 57 influenza vaccinations, and 21 pharmaceutical opinions. A median (interquartile range, IQR) of 6 (2-11) pharmacy services were delivered, and median (IQR) reimbursement was $187.50 ($67.50-$342.50). Conclusions Approximately one-third of participants received a pharmacy service within 3 months post-screening. Relatively large numbers of annual and follow-up medication reviews were delivered despite low eligibility for annual-only reviews and despite many missed opportunities for pharmacy service provision in at-risk patients. In-pharmacy screening may facilitate provision of some services, namely medication reviews, by providing opportunities to identify patients at-risk.

Prevention of type 2 diabetes: what is the right target population?

INTRODUCTION

Prevention of type 2 diabetes (T2D) is important to reduce suffering and health care costs. A precursor to T2D is impaired glucose regulation (IGR), a condition of elevated plasma glucose that is associated with insulin resistance and increased risk of cardiovascular disease. Prevention of T2D is determined by preservation of pancreatic β cell function which can be achieved by the use of anti-hyperglycemic medications or intensive lifestyle interventions (ILIs) to modify dietary and physical activity habits that induce modest weight loss (≥5%). Both interventions have beneficial effects on normal glucose regulation (NGR), but ILI is preferred due to its safety, efficacy, and cost.

AREAS COVERED

Traditional approaches to the prevention of T2D have used a variety of screening methods to identify those who are at high risk for developing T2D (prediabetes). People designated with prediabetes are then treated with ILI. An alternative approach for preventing T2D is to offer ILI to all overweight/obese adults who volunteer for weight loss treatment.

EXPERT COMMENTARY

This new alternative has several potential advantages: more rapid recruitment of participants with lower burden of care and early, aggressive treatment of potential β cell dysfunction. Cost-effectiveness studies of this alternative approach are needed.

The diabetes pandemic and associated infections: suggestions for clinical microbiology

There are 425 million people with diabetes mellitus in the world. By 2045, this figure will grow to over 600 million. Diabetes mellitus is classified among noncommunicable diseases. Evidence points to a key role of microbes in diabetes mellitus, both as infectious agents associated with the diabetic status and as possible causative factors of diabetes mellitus. This review takes into account the different forms of diabetes mellitus, the genetic determinants that predispose to type 1 and type 2 diabetes mellitus (especially those with possible immunologic impact), the immune dysfunctions that have been documented in diabetes mellitus. Common infections occurring more frequently in diabetic vs. nondiabetic individuals are reviewed. Infectious agents that are suspected of playing an etiologic/triggering role in diabetes mellitus are presented, with emphasis on enteroviruses, the hygiene hypothesis, and the environment. Among biological agents possibly linked to diabetes mellitus, the gut microbiome, hepatitis C virus, and prion-like protein aggregates are discussed. Finally, preventive vaccines recommended in the management of diabetic patients are considered, including the bacillus calmette-Guerin vaccine that is being tested for type 1 diabetes mellitus. Evidence supports the notion that attenuation of immune defenses (both congenital and secondary to metabolic disturbances as well as to microangiopathy and neuropathy) makes diabetic people more prone to certain infections. Attentive microbiologic monitoring of diabetic patients is thus recommendable. As genetic predisposition cannot be changed, research needs to identify the biological agents that may have an etiologic role in diabetes mellitus, and to envisage curative and preventive ways to limit the diabetes pandemic.

Five-year effectiveness of short messaging service (SMS) for pre-diabetes

Objective

An observational post-randomized controlled trial (RCT) design was adopted to evaluate the long-term sustainability and maintenance of improved glycemic control, lipid profile, reduced progression to diabetes at 3-year following a 2-year short messaging service (SMS). We performed a naturalistic follow-up to the 104 participants of SMS intervention, a 2-year randomized controlled trial comparing the SMS to non-SMS for pre-diabetes. All participants were arranged screening for diabetes at 5-year assessment. Primary outcome of this post-RCT study was cumulative incidence of diabetes whereas secondary outcomes were the change in biometric data over a 5-year period.

Results

After a mean 57-month follow-up, 19 (18.3%) were lost to follow-up after the RCT period. Progression to diabetes occurred in 20 and 16 patients among the intervention and control group respectively, with no significant between-group difference (8.06 and 7.31 cases per 100 person years, respectively; Hazard Ratio in the intervention group, 1.184; 95% confidence interval, 0.612 to 2.288; p-value = 0.616). No significant effect of SMS on reduction in diabetes was observed in overall and pre-defined subgroups. The SMS intervention preserved the clinical benefits within the trial period but failed to transform from treatment efficacy to long-term effectiveness beyond 2 years after intervention.

Trail registration ClinicalTrials.gov Identifier NCT01556880, retrospectively registered on March 16, 2012

Modeling of Diabetes and Its Clinical Impact

Understanding all aspects of diabetes treatment is hindered by the complexity of this chronic disease and its multifaceted complications and comorbidities, including social and financial impacts. In vivo studies as well as clinical trials provided invaluable information for unraveling not only metabolic processes but also risk estimations of, for example, complications. These approaches are often time- and cost-consuming and have frequently been supported by simulation models. Simulation models provide the opportunity to investigate diabetes treatment from additional viewpoints and with alternative objectives. This review presents selected models focusing either on metabolic processes or risk estimations and financial outcomes to provide a basic insight into this complex subject. It also discusses opportunities and challenges of modeling diabetes.

Undiagnosed Diabetes Mellitus in Community-Acquired Pneumonia: A Prospective Cohort Study

Background

Diabetes mellitus is an important risk factor for community-acquired pneumonia, whereas the prevalence of undiagnosed diabetes mellitus and prediabetes in patients with community-acquired pneumonia is largely unknown. We aimed to determine the prevalence of prediabetes, undiagnosed diabetes mellitus, and risk factors associated with undiagnosed diabetes mellitus in a large European community-acquired pneumonia cohort.

Methods

This was a multicenter prospective cohort study of hospitals and private practices in Germany and Austria encompassing 1961 adults with community-acquired pneumonia included in the German Community-Acquired Pneumonia Competence Network (CAPNETZ) study between 2007 and 2014. The prevalence of undiagnosed diabetes mellitus and prediabetes was estimated based on hemoglobin A1c measurements. Logistic regression was used to assess risk factors for undiagnosed diabetes mellitus.

Results

Fifteen percent of patients had known diabetes mellitus. Among patients without known diabetes mellitus, 5.0% had undiagnosed diabetes mellitus and 37.5% had prediabetes. Male sex (odds ratio [OR], 2.45 [95% confidence interval {CI}, 1.35-4.45]), body mass index ≥25 kg/m2 (OR, 2.64 [95% CI, 1.48-4.72]), and hyperglycemia at admission (6-11 mM: OR, 2.93 [95% CI, 1.54-5.60] and ≥11 mM: OR, 44.76 [95% CI, 17.58-113.98]) were associated with undiagnosed diabetes mellitus. Patients with undiagnosed diabetes mellitus had a higher 180-day mortality rate compared to patients without diabetes mellitus (12.1% vs 3.8%, respectively; P = .001).

Conclusions

Undiagnosed diabetes mellitus was prevalent among community-acquired pneumonia. Male sex, overweight, and hyperglycemia at admission were associated with undiagnosed diabetes mellitus. The long-term mortality among patients with undiagnosed diabetes mellitus was high compared to patients without diabetes mellitus.

A systematic review of economic evaluations of screening programmes for cardiometabolic diseases

Background

The early detection and adequate management of cardiometabolic diseases (CMD) is becoming a priority to prevent future health problems and related healthcare costs.

Aim

This study systematically reviewed the economic evaluations of screening programmes for the early detection of persons at risk for CMD.

Methods

A systematic review was conducted using MEDLINE, Web of Science, NHSEED and the CEA registry to identify relevant articles published between 1 January 2005 and 1 May 2015. Two reviewers independently selected articles, systematically extracted data and critically appraised the study quality using the Extended Consensus on Health Economic Criteria (CHEC) List.

Results

From the initial 2820 studies identified, 17 were included. Six studies assessed whether screening would be cost-effective, seven aimed to determine the most efficient screening programme and four assessed the cost-effectiveness of existing programmes. There were 11 cost-utility analyses using quality-adjusted life years (QALYs) or disability-adjusted life years. Decision-analytic modelling (e.g. Markov model) was most frequently used (n = 10), followed by simulation models (n = 4), observational (n = 2) and trial-based (n = 1) studies. All studies assessing the cost per QALY gained of screening for cardiovascular diseases and diabetes mellitus (n = 8) were below a threshold of £30 000, while those assessing chronic kidney diseases (n = 2) were above the threshold. Conclusions: In view of the heterogeneity in study objectives, country setting, screening programmes, comparators, methodology and outcomes, it is not possible to make clear recommendations about the economic value of screening programmes for CMD. Developing further screening programmes and conducting thorough economic analysis, including usual care, is needed.