Cost-effectiveness of a national population-based screening program for type 2 diabetes: the Brazil experience

Cost-effectiveness and cost-utility analysis of type-2 diabetes screening in pharmacies in Iran

Background and purpose

Several studies have shown the effectiveness of screening programs in decreasing the costs and disutility of type-2 diabetes and related complications. As there is a growth in the incidence of type-2 diabetes amongst the Iranian population, the cost-effectiveness of performing type-2 diabetes screening tests in community pharmacies of Iran was evaluated in this study from the payer's perspective. The target population consisted of two hypothetical cohorts of 1000 people 40 years of age without a prior diagnosis of diabetes, for the intervention (screening test) and no-screening groups.

Experimental approach

A Markov model was developed to evaluate the cost-effectiveness and cost-utility of a type-2 diabetes screening test in community pharmacies in Iran. A 30-year time horizon was considered in the model. Three screening programs with 5-year intervals were considered for the intervention group. The evaluated outcomes were quality-adjusted life-years (QALYs) for cost-utility-analysis and life-years-gained (LYG) for cost-effectiveness-analysis. To examine the robustness of the results, one-way and probabilistic-sensitivity analyses were applied to the model.

Findings/Results

The screening test represented both more effects and higher costs. The incremental effects in the base-case scenario (no-discounting) were estimated to be 0.017 and 0.0004 (approximately 0) for QALYs and LYG, respectively. The incremental cost was estimated to be 2.87 USD/patient. The estimated incremental-cost-effectiveness ratio was 164.77 USD/QALY.

Conclusion and implications

This study indicated that screening for type-2 diabetes in community pharmacies of Iran could be considered highly cost-effective, as it meets the WHO criteria of the annual GDP per capita ($2757 in 2020).

Programmatic Cost-Effectiveness of a Second-Time Visit to Detect New Tuberculosis and Diabetes Mellitus in TB Contact Tracing in Myanmar

BACKGROUND

Integration of diabetes mellitus screening in home visits for contact tracing for tuberculosis could identify hidden patients with either tuberculosis or diabetes mellitus. However, poor compliance to the first home screening has been reported. A second time visit not only increases screening compliance but also the cost. This study aimed to determine if an additional second time visit was cost effective based on the health system perspective of the tuberculosis contact tracing program in Myanmar.

METHODS

This cross-sectional study was based on usual contact tracing activity in the Yangon Region, Myanmar, from April to December 2018 with integration of diabetes mellitus screening and an additional home visit to take blood glucose tests along with repeated health education and counseling to stress the need for a chest X-ray. New tuberculosis and diabetes mellitus cases detected were the main outcome variables. Programmatic operational costs were calculated based on a standardized framework for cost evaluation on tuberculosis screening. The effectiveness of an additional home visit was estimated using disability-adjusted life years averted. The willingness to pay threshold was taken as 1250.00 US dollars gross domestic product per capita of the country.

RESULTS

Single and additional home visits could lead to 42.5% and 65.0% full compliance and 27.2 and 9.3 additional years of disability-adjusted life years averted, respectively. The respective base costs and additional costs were 3280.95 US dollars and 1989.02 US dollars. The programmatic costs for an extra unit of disability-adjusted life years averted was 213.87 US dollars, which was lower than the willingness to pay threshold.

CONCLUSIONS

From the programmatic perspective, conducting the second time visit for tuberculosis contact tracing integrated with diabetes mellitus screening was found to be cost effective.

Cost-effectiveness of community diabetes screening: Application of Akaike information criterion in rural communities of Nigeria

Background

The prevalence of diabetes mellitus (DM) is increasing globally, and this requires several approaches to screening. There are reports of alternative indices for prediction of DM, besides fasting blood glucose (FBG) level. This study, investigated the ability of combination of biochemical and anthropometric parameters and orodental disease indicators (ODIs) to generate models for DM prediction, using Akaike information criterion (AIC) to substantiate health economics of diabetes screening.

Methods

Four hundred and thirty-three subjects were enrolled in the study in Ndokwa communities, Delta State, Nigeria, and their glycaemic status was determined, using the CardioChek analyser^® and previous data from the Prediabetes and Cardiovascular Complications Study were also used. The cost of screening for diabetes (NGN 300 = $0.72) in a not-for-profit organization/hospital was used as basis to calculate the health economics of number of individuals with DM in 1,000 participants. Data on the subjects' anthropometric, biochemical and ODI parameters were used to generate different models, using R statistical software (version 4.0.0). The different models were evaluated for their AIC values. Lowest AIC was considered as best model. Microsoft Excel software (version 2020) was used in preliminary analysis.

Result

The cost of identifying <2 new subjects with hyperglycemia, in 1,000 people was ≥NGN 300,000 ($ 716). A total of 4,125 models were generated. AIC modeling indicates FBG test as the best model (AIC = 4), and the least being combination of random blood sugar + waist circumference + hip circumference (AIC ≈ 34). Models containing ODI parameters had AIC values >34, hence considered as not recommendable.

Conclusion

The cost of general screening for diabetes in rural communities may appear high and burdensome in terms of health economics. However, the use of prediction models involving AIC is of value in terms of cost-benefit and cost-effectiveness to the healthcare consumers, which favors health economics.

Early prediction of diabetes by applying data mining techniques: A retrospective cohort study

BACKGROUND

Saudi Arabia ranks 7th globally in terms of diabetes prevalence, and its prevalence is expected to reach 45.36% by 2030. The cost of diabetes is expected to increase to 27 billion Saudi riyals in cases where undiagnosed individuals are also documented. Prevention and early detection can effectively address these challenges.

OBJECTIVE

To improve healthcare services and assist in building predictive models to estimate the probability of diabetes in patients.

METHODS

A chart review, which was a retrospective cohort study, was conducted at the National Guard Health Affairs in Riyadh, Saudi Arabia. Data were collected from 5 hospitals using National Guard Health Affairs databases. We used 38 attributes of 21431 patients between 2015 and 2019. The following phases were performed: (1) data collection, (2) data preparation, (3) data mining and model building, and (4) model evaluation and validation. Subsequently, 6 algorithms were compared with and without the synthetic minority oversampling technique.

RESULTS

The highest performance was found in the Bayesian network, which had an area under the curve of 0.75 and 0.71.

CONCLUSION

Although the results were acceptable, they could be improved. In this context, missing data owing to technical issues played a major role in affecting the performance of our model. Nevertheless, the model could be used in prevention, health monitoring programs, and as an automated mass population screening tool without the need for extra costs compared to traditional methods.

Cost-Effectiveness of Population Screening Programs for Cardiovascular Diseases and Diabetes in Low- and Middle-Income Countries: A Systematic Review

Almost all low- and middle-income countries (LMICs) have instated a program to control and manage non-communicable diseases (NCDs). Population screening is an integral component of this strategy and requires a substantial chunk of investment. Therefore, testing the screening program for economic along with clinical effectiveness is essential. There is significant proof of the benefits of incorporating economic evidence in health decision-making globally, although evidence from LMICs in NCD prevention is scanty. This systematic review aims to consolidate and synthesize economic evidence of screening programs for cardiovascular diseases (CVD) and diabetes from LMICs. The study protocol is registered on PROSPERO (CRD42021275806). The review includes articles from English and Chinese languages. An initial search retrieved a total of 2,644 potentially relevant publications. Finally, 15 articles (13 English and 2 Chinese reports) were included and scrutinized in detail. We found 6 economic evaluations of interventions targeting cardiovascular diseases, 5 evaluations of diabetes interventions, and 4 were combined interventions, i.e., screening of diabetes and cardiovascular diseases. The study showcases numerous innovative screening programs that have been piloted, such as using mobile technology for screening, integrating non-communicable disease screening with existing communicable disease screening programs, and using community health workers for screening. Our review reveals that context is of utmost importance while considering any intervention, i.e., depending on the available resources, cost-effectiveness may vary—screening programs can be made universal or targeted just for the high-risk population.

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 population-based screening for diabetes and hypertension in India: an economic modelling study

BACKGROUND

India faces a high burden of diabetes and hypertension. Currently, there is a dearth of economic evidence about screening programmes, affected age groups, and frequency of screening for these diseases in Indian settings. We assessed the cost effectiveness of population-based screening for diabetes and hypertension compared with current practice in India for different scenarios, according to type of screening test, population age group, and pattern of health-care use.

METHODS

We used a hybrid decision model (decision tree and Markov model) to estimate the lifetime costs and consequences from a societal perspective. A meta-analysis was done to assess the effectiveness of population-based screening. Primary data were collected from two Indian states (Haryana and Tamil Nadu) to assess the cost of screening. The data from the National Health System Cost Database and the Costing of Health Services in India study were used to determine the health system cost of diagnostic tests and cost of treating diabetes or hypertension and their complications. A total of 962 patients were recruited to assess out-of-pocket expenditure and quality of life. Parameter uncertainty was evaluated using univariate and multivariable probabilistic sensitivity analyses. Finally, we estimated the incremental cost per quality-adjusted life-year (QALY) gained with alternative scenarios of scaling up primary health care through a health and wellness centre programme for the treatment of diabetes and hypertension.

FINDINGS

The incremental cost per QALY gained across various strategies for population-based screening for diabetes and hypertension ranged from US$0·02 million to $0·03 million. At the current pattern of health services use, none of the screening strategies of annual screening, screening every 3 years, and screening every 5 years was cost-effective at a threshold of 1-time per capita gross domestic product in India. In the scenario in which health and wellness centres provided primary care to 20% of patients who were newly diagnosed with uncomplicated diabetes or hypertension, screening the group aged between 30 and 65 years every 5 years or 3 years for either diabetes, hypertension, or a comorbid state (both diabetes and hypertension) became cost-effective. If the share of treatment for patients with newly diagnosed uncomplicated diabetes or hypertension at health and wellness centres increases to 70%, from the existing 4% at subcentres and primary health centres, annual population-based screening becomes a cost saving strategy.

INTERPRETATION

Population-based screening for diabetes and hypertension in India could potentially reduce time to diagnosis and treatment and be cost-effective if it is linked to comprehensive primary health care through health and wellness centres for provision of treatment to patients who screen positive.

FUNDING

None.

Community-based interventions for detection and management of diabetes and hypertension in underserved communities: a mixed-methods evaluation in Brazil, India, South Africa and the USA

INTRODUCTION

As non-communicable disease (NCD) burden rises worldwide, community-based programmes are a promising strategy to bridge gaps in NCD care. The HealthRise programme sought to improve hypertension and diabetes management for underserved communities in nine sites across Brazil, India, South Africa and the USA between 2016 and 2018. This study presents findings from the programme's endline evaluation.

METHODS

The evaluation utilises a mixed-methods quasi-experimental design. Process indicators assess programme implementation; quantitative data examine patients' biometric measures and qualitative data characterise programme successes and challenges. Programme impact was assessed using the percentage of patients meeting blood pressure and A1c treatment targets and tracking changes in these measures over time.

RESULTS

Almost 60 000 screenings, most of them in India, resulted in 1464 new hypertension and 295 new diabetes cases across sites. In Brazil, patients exhibited statistically significant reductions in blood pressure and A1c. In Shimla, India, and in South Africa, country with the shortest implementation period, there were no differences between patients served by facilities in HealthRise areas relative to comparison areas. Among participating patients with diabetes in Hennepin and Ramsey counties and hypertension patients in Hennepin County, the percentage of HealthRise patients meeting treatment targets at endline was significantly higher relative to comparison group patients. Qualitative analysis identified linking different providers, services, communities and information systems as positive HealthRise attributes. Gaps in health system capacities and sociodemographic factors, including poverty, low levels of health education and limited access to nutritious food, are remaining challenges.

CONCLUSIONS

Findings from Brazil and the USA indicate that the HealthRise model has the potential to improve patient outcomes. Short implementation periods and strong emphasis on screening may have contributed to the lack of detectable differences in other sites. Community-based care cannot deliver its full potential if sociodemographic and health system barriers are not addressed in tandem.

Screening for chronic conditions with reproductive factors using a machine learning based approach

A large proportion of cases with chronic conditions including diabetes or pre-diabetes, hypertension and dyslipidemia remain undiagnosed. To include reproductive factors (RF) might be able to improve current screening guidelines by providing extra effectiveness. The objective is to study the relationships between RFs and chronic conditions' biomarkers. A cross-sectional study was conducted. Demographics, RFs and metabolic biomarkers were collected. The relationship of the metabolic biomarkers were shown by correlation analysis. Principal component analysis (PCA) and autoencoder were compared by cross-validation. The better one was adopted to extract a single marker, the general chronic condition (GCC), to represent the body's chronic conditions. Multivariate linear regression was performed to explore the relationship between GCC and RFs. In total, 1,656 postmenopausal females were included. A multi-layer autoencoder outperformed PCA in the dimensionality reduction performance. The extracted variable by autoencoder, GCC, was verified to be representative of three chronic conditions (AUC for patoglycemia, hypertension and dyslipidemia were 0.844, 0.824 and 0.805 respectively). Linear regression showed that earlier age at menarche (OR = 0.9976) and shorter reproductive life span (OR = 0.9895) were associated with higher GCC. Autoencoder performed well in the dimensionality reduction of clinical metabolic biomarkers. Due to high accessibility and effectiveness, RFs have potential to be included in screening tools for general chronic conditions and could enhance current screening guidelines.

Cost-utility Analysis of Opportunistic and Systematic Diabetic Retinopathy Screening Strategies from the Perspective of the Brazilian Public Healthcare System

OBJECTIVE

To perform a cost-utility analysis of diabetic retinopathy (DR) screening strategies from the perspective of the Brazilian Public Healthcare System.

METHODS

A model-based economic evaluation was performed to estimate the incremental costs per quality-adjusted life-year (QALY) gained between three DR screening strategies: (1) the opportunistic ophthalmology referral-based (usual practice), (2) the systematic ophthalmology referral-based, and (3) the systematic teleophthalmology-based. The target population included individuals with type 2 diabetes (T2D) aged 40 years, without retinopathy, followed over a 40-year time horizon. A Markov model was developed with five health states and a 1-year cycle. Model parameters were based on literature and country databases. One-way and probabilistic sensitivity analyses were performed to assess model parameters' uncertainty. WHO willingness-to-pay (WHO-WTP) thresholds were used as reference (i.e. one and three times the Brazilian per capita Gross Domestic Product of R$32747 in 2018).

RESULTS

Compared to usual practice, the systematic teleophthalmology-based screening was associated with an incremental cost of R$21445/QALY gained ($9792/QALY gained). The systematic ophthalmology referral-based screening was more expensive (incremental costs = R$4) and less effective (incremental QALY = -0.012) compared to the systematic teleophthalmology-based screening. The probability of systematic teleophthalmology-based screening being cost-effective compared to usual practice was 0.46 and 0.67 at the minimum and the maximum WHO-WTP thresholds, respectively.

CONCLUSION

Systematic teleophthalmology-based DR screening for the Brazilian population with T2D would be considered very cost effective compared to the opportunistic ophthalmology referral-based screening according to the WHO-WTP threshold. However, there is still a considerable amount of uncertainty around the results.

Disease and Economic Burden of Hospitalizations Attributable to Diabetes Mellitus and Its Complications: A Nationwide Study in Brazil

Diabetes is associated with a significant burden globally. The costs of diabetes-related hospitalizations are unknown in most developing countries. The aim of this study was to estimate the total number and economic burden of hospitalizations attributable to diabetes mellitus (DM) and its complications in adults from the perspective of the Brazilian Public Health System in 2014. Data sources included the National Health Survey (NHS) and National database of Hospitalizations (SIH). We considered diabetes, its microvascular (retinopathy, nephropathy, and neuropathy) and macrovascular complications (coronary heart disease, cerebrovascular disease, and peripheral arterial disease), respiratory and urinary tract infections, as well as selected cancers. Assuming that DM patients are hospitalized for these conditions more frequently that non-DM individuals, we estimated the etiological fraction of each condition related to DM, using the attributable risk methodology. We present number, average cost per case, and overall costs of hospitalizations attributable to DM in Brazil in 2014, stratified by condition, state of the country, gender and age group. In 2014, a total of 313,273 hospitalizations due to diabetes in adults were reported in Brazil (4.6% of total adult hospitalization), totaling (international dollar) Int$264.9 million. The average cost of an adult hospitalization due to diabetes was Int$845, 19% higher than hospitalization without DM. Hospitalizations due to cardiovascular diseases related to diabetes accounted for the higher proportion of costs (47.9%), followed by microvascular complications (25.4%) and DM per se (18.1%). Understanding the costs of diabetes and its major complications is crucial to raise awareness and to support the decision-making process on policy implementation, also allowing the assessment of prevention and control strategies.

Systematic literature review of the health economic implications of early detection by screening populations at risk for type 2 diabetes

BACKGROUND

Undetected/uncontrolled diabetes is associated with substantial morbidity and mortality and consequent costs. Early detection through screening identifies patients at risk, allowing for earlier treatment initiation.

OBJECTIVES

To determine the economic impact of screening for type 2 diabetes (T2DM).

DATA SOURCES

We systematically reviewed health economic analyses of screening programs for T2DM/pre-diabetes.

STUDY ELIGIBILITY CRITERIA

Published between 2000 and 2015 in any language. Articles must have reported costs of screening, test/patient outcomes and cost-effectiveness.

PARTICIPANTS AND INTERVENTIONS

Any type of screening (universal, targeted, opportunistic) was accepted.

METHODS

Data were extracted from Scopus/Medline/Embase, then tabulated.

RESULTS

There were 137 studies identified, 108 rejected; 29 were analyzed. Screening types included 18 universal, 8 targeted and 8 opportunistic. One study screened for pre-diabetes, 16 for T2DM and 12 examined both. Fourteen (48%) reported costs of screening only, 9 (31%) costs of screening combined with interventions and 6 (21%) presented all costs separately. Screening was compared to no screening in 13 studies (45%); screening was cost-effective in 8 (62%), not cost-effective in 4 (31%) and neither in 1 (8%). When comparing different screening methods, 6 found targeted screening was cost-effective compared with universal screening (none found the opposite), 2 found opportunistic superior to universal. Sensitivity analyses generally confirmed primary findings. Cost drivers included prevalence of T2DM/pre-diabetes, type of blood test used and uptake of testing. For optimal cost-effectiveness, screening for both T2DM and pre-diabetes should be initiated around age 45-50, with repeated testing every 5 years.

CONCLUSIONS/IMPLICATIONS

Targeted screening appears to be cost-effective compared to universal screening.