The cost-effectiveness of diabetes prevention: results from the Diabetes Prevention Program and the Diabetes Prevention Program Outcomes Study

Metformin in the Diabetes Prevention Program 3-year trial: The cost-effectiveness that never was

AIM

To highlight oversimplified quality-adjusted life year (QALY) calculations and incremental cost-effectiveness ratios (ICERs) regarding lifestyle metformin and placebo as flaws in the trial-based (Diabetes Prevention Program) cost-effectiveness analysis.

MATERIALS AND METHODS

We revised the QALY calculations to conform to convention and calculated appropriate ICERs using both original and revised QALYs results. We used several additional health economics tools to present results, showing the consistency of each method and the added value of each. We presented net monetary benefits, assessed decision uncertainty and calculated net losses. We also used graphics, making correct interpretation clearer and allowing illustration and calculation of technical and economic inefficiencies of treatments that were not cost-effective.

RESULTS

ICERs with either QALY calculation indicated that metformin was technically and economically inefficient and not cost-effective. There was virtually no decision uncertainty. All methods employed pointed to an identical conclusion.

CONCLUSIONS

In contrast to original claims, although lifestyle was cost-effective in diabetes prevention, metformin was not, and acting otherwise imposes significant monetary and health costs. Various available tools of economic evaluation would probably have prevented the original misinterpretation by the authors had they been used. The varied tools implemented here illustrate with a common example their consistency and value to the field, showing how to depict the results in various ways.

National health and economic impact of a lifestyle program to prevent type 2 diabetes mellitus in Germany: a simulation study

INTRODUCTION

To examine the long-term health and economic impact of a lifestyle diabetes prevention program in people with high risk of developing type 2 diabetes in Germany.

RESEARCH DESIGN AND METHODS

We assessed the lifetime cost-effectiveness of a 2-year pragmatic lifestyle program for preventing type 2 diabetes targeting German adults aged 35-54 and 55-74 years old with hemoglobin A1c (HbA1c) from 6.0% to 6.4%. We used the Centers for Disease Control and Prevention RTI Diabetes Cost-Effectiveness Model to run a simulation on the program effectiveness. We estimated incremental health benefits in quality-adjusted life years (QALYs) and costs using an established simulation model adapted to the German context, from a healthcare system and societal perspective. The cost-effectiveness of the program was measured by incremental cost-effectiveness ratios (ICERs) in cost per QALY. We projected the number of type 2 diabetes cases prevented by participation rate if the program was implemented nationwide.

RESULTS

The lifestyle program would result to more QALYs and higher costs. The lifetime ICERs were 14 690€ (35-54 years old) and 14 372€ (55-74 years old) from a healthcare system perspective and cost saving (ICER=-3805€) and cost-effective (ICER=4579€), respectively, from a societal perspective. A total of 10 527 diabetes cases would be prevented over lifetime if the program was offered to all eligible people nationwide and 25% of those would participate in the program.

CONCLUSIONS

Implementing the lifestyle intervention for people with HbA1c from 6.0% to 6.4% could be a cost-effective at standard willingness to pay level strategy for type 2 diabetes prevention. The intervention in the younger cohort could be cost saving from a societal perspective. The successful implementation of a lifestyle-based diabetes prevention program could be an important component of a successful National Diabetes Strategy in Germany.

The Final Frontier in Diabetes Care: Implementing Research in Real-World Practice

Despite extensive evidence related to the prevention and management of type 2 diabetes (T2D) and its complications, most people at risk for and people who have diabetes do not receive recommended guideline-based care. Clinical implementation of proven care strategies is of the utmost importance because without this, even the most impressive research findings will remain of purely academic interest. In this review, we discuss the promise and challenges of implementing effective approaches to diabetes prevention and care in the real-world setting. We describe successful implementation projects in three critical areas of diabetes care-diabetes prevention, glycemic control, and prevention of diabetes-related complications-which provide a basis for further clinical translation and an impetus to improve the prevention and control of T2D in the community. Advancing the clinical translation of evidence-based care must include recognition of and assessment of existing gaps in care, identification of barriers to the delivery of optimal care, and a locally appropriate plan to address and overcome these barriers. Care models that promote team-based approaches, rather than reliance on patient-provider interactions, will enhance the delivery of contemporary comprehensive diabetes care.

Current type 2 diabetes guidelines: Individualized treatment and how to make the most of metformin

Evidence-based guidelines provide the premise for the delivery of quality care to preserve health and prevent disabilities and premature death. The systematic gathering of observational, mechanistic and experimental data contributes to the hierarchy of evidence used to guide clinical practice. In the field of diabetes, metformin was discovered more than 100 years ago, and with 60 years of clinical use, it has stood the test of time regarding its value in the prevention and management of type 2 diabetes. Although some guidelines have challenged the role of metformin as the first-line glucose-lowering drug, it is important to point out that the cardiovascular-renal protective effects of sodium-glucose co-transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists were gathered from patients with type 2 diabetes, the majority of whom were treated with metformin. Most national, regional and international guidelines recommend metformin as a foundation therapy with emphasis on avoidance of therapeutic inertia and early attainment of multiple treatment goals. Moreover, real-world evidence has confirmed the glucose-lowering and cardiovascular-renal benefits of metformin accompanied by an extremely low risk of lactic acidosis. In patients with type 2 diabetes and advanced chronic kidney disease (estimated glomerular filtration rate 15-30 mL/min/1.73m2), metformin discontinuation was associated with an increased risk of cardiovascular-renal events compared with metformin persistence. Meanwhile, it is understood that microbiota, nutrients and metformin can interact through the gut-brain-kidney axis to modulate homeostasis of bioactive molecules, systemic inflammation and energy metabolism. While these biological changes contribute to the multisystem effects of metformin, they may also explain the gastrointestinal side effects and vitamin B12 deficiency associated with metformin intolerance. By understanding the interactions between metformin, foods and microbiota, healthcare professionals are in a better position to optimize the use of metformin and mitigate potential side effects. The United Kingdom Prospective Diabetes Study and the Da Qing Diabetes Prevention Program commenced 40 years ago provided the first evidence that type 2 diabetes is preventable and treatable. To drive real-world impact from this evidence, payors, practitioners and planners need to co-design and implement an integrated, data-driven, metformin-based programme to detect people with undiagnosed diabetes and prediabetes (intermediate hyperglycaemia), notably impaired glucose tolerance, for early intervention. The systematic data collection will create real-world evidence to bring out the best of metformin and make healthcare sustainable, affordable and accessible.

A low-glucose eating pattern is associated with improvements in glycemic variability among women at risk for postmenopausal breast cancer: an exploratory analysis

Background

High glycemic variability (GV) is a biomarker of cancer risk, even in the absence of diabetes. The emerging concept of chrononutrition suggests that modifying meal timing can favorably impact metabolic risk factors linked to diet-related chronic disease, including breast cancer. Here, we examined the potential of eating when glucose levels are near personalized fasting thresholds (low-glucose eating, LGE), a novel form of timed-eating, to reduce GV in women without diabetes, who are at risk for postmenopausal breast cancer.

Methods

In this exploratory analysis of our 16-week weight loss randomized controlled trial, we included 17 non-Hispanic, white, postmenopausal women (average age = 60.7 ± 5.8 years, BMI = 34.5 ± 6.1 kg/m2, HbA1c = 5.7 ± 0.3%). Participants were those who, as part of the parent study, provided 3-7 days of blinded, continuous glucose monitoring data and image-assisted, timestamped food records at weeks 0 and 16. Pearson's correlation and multivariate regression were used to assess associations between LGE and GV, controlling for concurrent weight changes.

Results

Increases in LGE were associated with multiple unfavorable measures of GV including reductions in CGM glucose mean, CONGA, LI, J-Index, HBGI, ADDR, and time spent in a severe GV pattern (r = -0.81 to -0.49; ps < 0.044) and with increases in favorable measures of GV including M-value and LBGI (r = 0.59, 0.62; ps < 0.013). These associations remained significant after adjusting for weight changes.

Conclusion

Low-glucose eating is associated with improvements in glycemic variability, independent of concurrent weight reductions, suggesting it may be beneficial for GV-related disease prevention. Further research in a larger, more diverse sample with poor metabolic health is warranted.Clinical trial registration: ClinicalTrials.gov, NCT03546972.

Young-Onset Diabetes in East Asians: From Epidemiology to Precision Medicine

Precision diagnosis is the keystone of clinical medicine. In East Asians, classical type 1 diabetes is uncommon in patients with youngonset diabetes diagnosed before age of 40, in whom a family history, obesity, and beta-cell and kidney dysfunction are key features. Young-onset diabetes affects one in five Asian adults with diabetes in clinic settings; however, it is often misclassified, resulting in delayed or non-targeted treatment. Complex aetiologies, long disease duration, aggressive clinical course, and a lack of evidence-based guidelines have contributed to variable care standards and premature death in these young patients. The high burden of comorbidities, notably mental illness, highlights the numerous knowledge gaps related to this silent killer. The majority of adult patients with youngonset diabetes are managed as part of a heterogeneous population of patients with various ages of diagnosis. A multidisciplinary care team led by physicians with special interest in young-onset diabetes will help improve the precision of diagnosis and address their physical, mental, and behavioral health. To this end, payors, planners, and providers need to align and re-design the practice environment to gather data systematically during routine practice to elucidate the multicausality of young-onset diabetes, treat to multiple targets, and improve outcomes in these vulnerable individuals.

The cost-effectiveness of metformin in the US diabetes prevention program trial: Simple interpretations need not apply

Based on previously published US Diabetes Prevention Program (DPP) cost-effectiveness analyses (CEAs) metformin continues to be promoted as "cost-effective." We review the DPP within-trial CEA to assess this claim. Treatment alternatives included placebo (plus standard lifestyle advice), branded metformin and individual lifestyle modification. We added generic metformin as an alternative. Original published CEA data were taken as given and re-analyzed according to accepted principles for calculating incremental cost-effectiveness ratios (ICERs) in the economic evaluation field. With more than two treatments as in the DPP, these require attention to the rankings of interventions according to cost or effect prior to stipulating appropriate ICERs to calculate. With proper ICERs neither branded nor generic metformin was cost-effective, regardless of the value assumed for the willingness to pay for the quality-adjusted life year outcome assessed. Metformin alternatives were technically inefficient compared to placebo or the lifestyle modification alternative. Net loss calculations indicated substantial costs/health losses to using metformin instead of the optimal lifestyle alternative in response to metformin having been inaccurately labelled "cost-effective" in the original CEA. That CEA and subsequent analyses and citations of such analyses continue to claim that both metformin and lifestyle modification are cost-effective in diabetes prevention based on DPP data. Using metformin implies substantial costs and health losses compared to the cost-effective lifestyle modification. It may be that metformin has a role in cost-effective diabetes prevention, but this has yet to be shown based on DPP data.

Weight loss and modeled cost savings in a digital diabetes prevention program

Background

Participation in the National Diabetes Prevention Program (DPP) can improve individual health through reduced risk of type 2 diabetes and save the healthcare system substantial medical costs associated with a diagnosis of type 2 diabetes and its associated complications. There is less evidence of outcomes and cost savings associated with a fully digital delivery of the DPP.

Methods

This study assessed 13,593 members who provided an initial digital weight and subsequently achieved various weight loss and engagement outcomes during their participation in a digital DPP. Analyzed data included both complete observations and missing observations imputed using maximum likelihood estimation. Findings include members' behavioral correlates of weight loss and a literature-based cost-savings estimate associated with achieving three mutually exclusive weight loss or engagement benchmarks: ≥5% weight loss, >2% but <5% weight loss, and completion of ≥4 educational lessons.

Results

11,976 members (88%) provided a weight after 2 months of participation, enabling calculation of their weight nadir. Considering complete data, 97% of members maintained or lost weight. Using the imputed data for these calculations, 32.0% of members achieved ≥5%, 32.4% achieved >2% but <5%, 32.0% maintained ±2%, and 3.6% gained weight. Members who lost the most weight achieved their weight nadir furthest into the program (mean day = 189, SE = 1.4) and had the longest active engagement (mean days = 268, SE = 1.4), particularly compared to members who gained weight (mean nadir day = 119, SE = 3.7; active engagement mean days = 199, SE = 4.9) (both p ≤ 0.0001). Modeled 1-year cost-savings estimates ranged from $11,229,160 to $12,960,875.

Conclusions

Members of a fully digital DPP achieved clinical and engagement outcomes during their participation in the program that confer important health benefits and cost savings.

Differences in the impact of impaired glucose status on clinical outcomes in younger and older adults: Over a decade of follow-up in the Tehran lipid and glucose study

Introduction

Studies found that the impact of dysglycemia on microvascular, macrovascular events and mortality outcomes were different between the younger vs. older population. We aimed to investigate the age-specific association of prediabetes with clinical outcomes including type 2 diabetes (T2DM), hypertension, chronic kidney disease (CKD), cardiovascular disease (CVD), and mortality.

Materials and methods

A total of 5,970 Iranians (3,829 women) aged ≥30 years, without T2DM, were included. The age-specific (<60 and ≥60 years; minimum p-value for interaction = 0.001) multivariable-adjusted Cox regression was done to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) of the impaired glucose status including impaired fasting glucose (IFG) vs. normal fasting glucose (NFG), impaired glucose tolerance (IGT) vs. normal glucose tolerance (NGT), and IFG&IGT vs. NFG/NGT with each outcome.

Results

Among individuals aged ≥60 years, the prevalence of impaired glucose status (IFG, IGT, or both) was about 2 times higher compared to those aged <60. Age-specific association between prediabetes and incident hypertension was found for those aged <60 years; [HR (95% CI); IFG: 1.38 (1.16-1.65), IGT: 1.51 (1.26-1.81), and IFG&IGT: 1.62 (1.21-2.12)]. For CVD, in all impaired glycemic states, those aged <60 were at higher significant risk [IFG: 1.39 (1.09-1.77), IGT: 1.53 (1.19-1.97), and IFG&IGT: 1.60 (1.14-2.25)]. Stratified analyses showed similar associations for IFG and IGT with non-CV mortality 1.71 (1.04-2.80) and 2.12 (1.30-3.46), respectively, and for all-cause mortality among those aged <60 years [IFG: 1.63 (1.08-2.45) and IGT: 1.82 (1.20-2.76)]. In both age groups, all glycemic status groups were significantly associated with T2DM but not with CKD and CV mortality.

Conclusions

The high prevalence of prediabetes particularly among the elderly population, limited resources, and the observed significant age differences in the impact of prediabetes states on different clinical outcomes calls for multicomponent intervention strategies by policy health makers, including lifestyle and possible pharmacological therapy, with the priority for the young Iranian population.

Prevention of Cardiorenal Complications with Sodium-Glucose Cotransporter Type 2 Inhibitors: A Narrative Review

Heart failure (HF) and chronic kidney disease (CKD) are the most frequent first cardiorenal conditions in patients with type 2 diabetes (T2D), which can be exacerbated by other comorbidities, such as hypertension, dyslipidemia, and obesity. To improve their clinical outcomes, patients with T2D need to achieve and maintain glycemic targets, as well as prevent cardiorenal disease onset and progression. Several clinical trials evaluating the sodium-glucose cotransporter type 2 inhibitors (SGLT2i) dapagliflozin, empagliflozin, canagliflozin, and ertugliflozin have shown consistent risk reduction in major adverse cardiovascular events and/or hospitalization for HF, together with lower risk of kidney disease progression. The benefits associated with SGLT2i in T2D are distinct from other antihyperglycemic drugs since they have been proposed to exert pleiotropic metabolic and direct effects on the kidney and the heart. In this review, we summarize and discuss the evidence regarding the mechanisms of action, the efficacy and safety profiles, and the clinical guidelines on the use of the therapeutic class of SGLT2i, highlighting their role in cardiorenal prevention beyond glycemic control.

Effects of a Digital Diabetes Prevention Program: An RCT

INTRODUCTION

In light of the need to expand the reach and access of clinically proven digital Diabetes Prevention Programs (d-DPPs) and the need for rigorous evidence of effectiveness, the purpose of this study was to determine the effectiveness of a digital Diabetes Prevention Program for improving weight, HbA1c, and cardiovascular risk factors among people with prediabetes compared to enhanced standard care plus waitlist control.

STUDY DESIGN

This was a single-blind RCT among participants at risk of developing type 2 diabetes and included 12 months of follow-up.

SETTING/PARTICIPANTS

A total of 599 volunteer patients with prediabetes were recruited primarily through electronic medical records and primary care practices.

INTERVENTION

Participants were randomized to either a d-DPP (n=299) or a single-session small-group diabetes-prevention education class (n=300) focused on action planning for weight loss. The d-DPPs consisted of 52 weekly sessions, lifestyle coaching, virtual peer support, and behavior tracking tools.

MAIN OUTCOME MEASURES

The primary outcome was a change in HbA1c from baseline to 12 months using intent-to-treat analyses. On the basis of multiple comparisons of endpoints, 95% CIs are presented and 2-sided p<0.025 was required for statistical significance. Secondary outcomes included body weight and cardiovascular disease risk factors.

RESULTS

Among 599 randomized participants (mean age=55.4 years, 61.4% women), 483 (80%) completed the study. The d-DPPs produced significantly greater reductions in HbA1c (0.08%, 95% CI= -0.12, -0.03) and percentage change in body weight (-5.5% vs -2.1%, p<0.001) at 12 months. A greater proportion of the d-DPPs group achieved a clinically significant weight loss ≥5% (43% vs 21%, p<0.001), and more participants shifted from prediabetes to normal HbA1c range (58% vs 48%, p=0.04). Engagement in d-DPPs was significantly related to improved HbA1c and weight loss.

CONCLUSIONS

This d-DPPs demonstrated clinical effectiveness and has significant potential for widespread dissemination and impact, particularly considering the growing demand for telemedicine in preventive healthcare services.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov (ClinicalTrials.gov Identifier: NCT03312764).

Evaluating the Implementation of Digital and In-Person Diabetes Prevention Program in a Large, Integrated Health System: Natural Experiment Study Design

INTRODUCTION

Implementation of a Diabetes Prevention Program (DPP) in both in-person and digital health-care settings has been increasing. The purpose of this article is to describe the protocol of a mixed-methods, natural experiment study designed to evaluate the implementation of DPP in a large, integrated health system.

METHODS

Kaiser Permanente Northwest patients who were 19 to 75 years with prediabetes (hemoglobin A1c or glycated hemoglobin, 5.7-6.4) and obesity (body mass index ≥ 30 kg/m2) were invited, via the Kaiser Permanente Northwest patient portal, to participate in the digital (n = 4124) and in-person (n = 2669) DPP during 2016 through 2018. Primary (weight) and secondary (hemoglobin A1c or glycated hemoglobin level) outcome data will be obtained from electronic health records. A cost-effectiveness analysis as well as qualitative interviews with patients (enrolled and not enrolled in the DPP) and stakeholders will be conducted to examine further implementation, acceptability, and sustainability.

CONCLUSION

The mixed-methods, natural experiment design we will use to evaluate Kaiser Permanente Northwest's implementation of the digital and in-person DPP builds on existing evidence related to the effectiveness of these two DPP delivery modes and will contribute new knowledge related to best practices for implementing and sustaining the DPP within large health systems over the long term.

Postpartum Use of Weight Loss and Metformin for the Prevention of Type 2 Diabetes Mellitus: a Review of the Evidence

PURPOSE OF REVIEW

As many as 70% of patients diagnosed with gestational diabetes mellitus (GDM) will go on to develop type 2 diabetes (T2DM) within their lifetimes. Implementing strategies to mitigate this progression in the postpartum period when patients are already connected to care is essential in optimizing lifelong health for our patients. Both lifestyle modification and metformin have been investigated as options to reduce type 2 diabetes risk in patients with a history of GDM.

RECENT FINDINGS

The current model for postpartum testing and care of patients with GDM has been shown to have poor uptake rates. Similarly, intervening with lifestyle modification postpartum has not resulted in significant diabetes risk reduction in prospective studies. Metformin is known to decrease insulin resistance and is also associated with weight loss. Data from large prospective studies has indicated that metformin may be a useful addition to lifestyle modifications to prevent progression to diabetes, but additional studies are needed specifically in postpartum individuals. Metformin is a safe in the postpartum period and may reduce diabetes risk if started soon after delivery in individuals with GDM, but additional studies are needed to determine which individuals with GDM are most likely to benefit from this medication.

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.

Management of Women with Polycystic Ovary Syndrome During Pregnancy

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among reproductive age women and is associated with subfertility and adverse perinatal outcomes, which may include early pregnancy loss, gestational diabetes mellitus, hypertensive spectrum disorder, preterm birth, fetal growth disorders, and cesarean deliveries. The phenotypic heterogeneity, different diagnostic criteria, and PCOS-related conditions that women enter pregnancy with have limited evidenced-based studies and guidelines to reduce pregnancy complications among this high-risk population. This review summarizes the available evidence on the approach and management of women with PCOS preconception, prenatal, and postpartum.

Simulating the Fiscal Impact of Anti-Obesity Medications as an Obesity Reduction Strategy

While substantial public health investment in anti-smoking initiatives has had demonstrated benefits on health and fiscal outcomes, similar investment in reducing obesity has not been undertaken, despite the substantial burden obesity places on society. Anti-obesity medications (AOMs) are poorly prescribed despite evidence that weight loss is not sustained using other strategies alone.

We used a simulation model to estimate the potential impact of 100% uptake of AOMs on Medicare and Medicaid spending, disability payments, and taxes collected relative to status quo with negligible AOM use. Relative to status quo, AOM use simulation would result in Medicare and Medicaid savings of $231.5 billion and $188.8 billion respectively over 75 years. Government tax revenues would increase by $452.8 billion. Overall, the net benefit would be $746.6 billion. Anti-smoking efforts have had substantial benefits for society. A similar investment in obesity reduction, including broad use of AOMs, should be considered.

Comparison of smartphone-based retinal imaging systems for diabetic retinopathy detection using deep learning

Background

Diabetic retinopathy (DR), the most common cause of vision loss, is caused by damage to the small blood vessels in the retina. If untreated, it may result in varying degrees of vision loss and even blindness. Since DR is a silent disease that may cause no symptoms or only mild vision problems, annual eye exams are crucial for early detection to improve chances of effective treatment where fundus cameras are used to capture retinal image. However, fundus cameras are too big and heavy to be transported easily and too costly to be purchased by every health clinic, so fundus cameras are an inconvenient tool for widespread screening. Recent technological developments have enabled to use of smartphones in designing small-sized, low-power, and affordable retinal imaging systems to perform DR screening and automated DR detection using image processing methods. In this paper, we investigate the smartphone-based portable retinal imaging systems available on the market and compare their image quality and the automatic DR detection accuracy using a deep learning framework.

Results

Based on the results, iNview retinal imaging system has the largest field of view and better image quality compared with iExaminer, D-Eye, and Peek Retina systems. The overall classification accuracy of smartphone-based systems are sorted as 61%, 62%, 69%, and 75% for iExaminer, D-Eye, Peek Retina, and iNview images, respectively. We observed that the network DR detection performance decreases as the field of view of the smartphone-based retinal systems get smaller where iNview is the largest and iExaminer is the smallest.

Conclusions

The smartphone-based retina imaging systems can be used as an alternative to the direct ophthalmoscope. However, the field of view of the smartphone-based retina imaging systems plays an important role in determining the automatic DR detection accuracy.

Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India

IMPORTANCE

A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective.

OBJECTIVE

To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India.

INTERVENTIONS

The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice.

MAIN OUTCOMES AND MEASURES

Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $).

RESULTS

The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.

Estimated Lifetime Economic Burden of Type 1 Diabetes

Background: The financial strain of type 1 diabetes on the United States health care system, patients, and employers underscores the importance of developing novel treatments for the disease. This study estimated the lifetime economic burden attributable to type 1 diabetes in the United States. Methods: A patient-level, Markov state/transition simulation model was developed to compare cumulative societal costs among patients with and without type 1 diabetes. For each patient type, 1 prevalent and 10 incident cohorts were constructed and followed annually over a lifetime horizon. The 1 prevalent cohort with type 1 diabetes entered in the first year of the model and at the current age of each patient, whereas the 10 incident cohorts entered in each of 10 subsequent years and at the age of diagnosis of each patient. Patients were assigned age-specific annual medical expenditures and lost wages. Model outputs included the total cumulative medical and lost productivity costs attributable to type 1 diabetes, defined as the difference in costs between patients with and without type 1 diabetes. Results: The model consisted of 1,630,317 patients with type 1 diabetes and an equal number of patients without type 1 diabetes. The difference in lifetime costs was $813 billion (95% confidence interval: $682-$1037 billion), representing a high burden of illness compared with patients without type 1 diabetes. Sensitivity analyses demonstrated robustness in model results. Conclusions: Our findings suggest significant investment in research and development of novel treatments for type 1 diabetes is justified, given the high burden of illness associated with the disease.

The Societal Value of Broader Access to Antiobesity Medications

OBJECTIVE

Obesity and its complications place an enormous burden on society. Yet antiobesity medications (AOM) are prescribed to only 2% of the eligible population, even though few individuals can sustain weight loss using other strategies alone. This study estimated the societal value of greater access to AOM.

METHODS

By using a well-established simulation model (The Health Economics Medical Innovation Simulation), the societal value of AOM for the cohort of Americans aged ≥ 25 years in 2019 was quantified. Four scenarios with differential uptake among the eligible population (15% and 30%) were modeled, with efficacy from current and next-generation AOM. Societal value was measured as monetized quality of life, productivity gains, and savings in medical spending, subtracting the costs of AOM.

RESULTS

For the 217 million Americans aged ≥ 25 years, AOM generated $1.2 trillion in lifetime societal value under a conservative scenario (15% annual uptake using currently available AOM). The introduction of next-generation AOM increased societal value to $1.9 to $2.5 trillion, depending on uptake. Finally, societal value was higher for younger individuals and Black and Hispanic individuals compared with White individuals.

CONCLUSIONS

This study suggests that AOM provide substantial gains to patients and society. Policies promoting broader clinical access to and use of AOM warrant consideration to reach national goals to reduce obesity.

Metformin for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus

BACKGROUND

The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether metformin can prevent or delay T2DM and its complications in people with increased risk of developing T2DM is unknown.

OBJECTIVES

To assess the effects of metformin for the prevention or delay of T2DM and its associated complications in persons at increased risk for the T2DM.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Scopus, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was March 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of one year or more comparing metformin with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or standard care in people with impaired glucose tolerance, impaired fasting glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or combinations of these.

DATA COLLECTION AND ANALYSIS

Two review authors read all abstracts and full-text articles and records, assessed risk of bias and extracted outcome data independently. We used a random-effects model to perform meta-analysis and calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 20 RCTs randomising 6774 participants. One trial contributed 48% of all participants. The duration of intervention in the trials varied from one to five years. We judged none of the trials to be at low risk of bias in all 'Risk of bias' domains. Our main outcome measures were all-cause mortality, incidence of T2DM, serious adverse events (SAEs), cardiovascular mortality, non-fatal myocardial infarction or stroke, health-related quality of life and socioeconomic effects.The following comparisons mostly reported only a fraction of our main outcome set. Fifteen RCTs compared metformin with diet and exercise with or without placebo: all-cause mortality was 7/1353 versus 7/1480 (RR 1.11, 95% CI 0.41 to 3.01; P = 0.83; 2833 participants, 5 trials; very low-quality evidence); incidence of T2DM was 324/1751 versus 529/1881 participants (RR 0.50, 95% CI 0.38 to 0.65; P < 0.001; 3632 participants, 12 trials; moderate-quality evidence); the reporting of SAEs was insufficient and diverse and meta-analysis could not be performed (reported numbers were 4/118 versus 2/191; 309 participants; 4 trials; very low-quality evidence); cardiovascular mortality was 1/1073 versus 4/1082 (2416 participants; 2 trials; very low-quality evidence). One trial reported no clear difference in health-related quality of life after 3.2 years of follow-up (very low-quality evidence). Two trials estimated the direct medical costs (DMC) per participant for metformin varying from $220 to $1177 versus $61 to $184 in the comparator group (2416 participants; 2 trials; low-quality evidence). Eight RCTs compared metformin with intensive diet and exercise: all-cause mortality was 7/1278 versus 4/1272 (RR 1.61, 95% CI 0.50 to 5.23; P = 0.43; 2550 participants, 4 trials; very low-quality evidence); incidence of T2DM was 304/1455 versus 251/1505 (RR 0.80, 95% CI 0.47 to 1.37; P = 0.42; 2960 participants, 7 trials; moderate-quality evidence); the reporting of SAEs was sparse and meta-analysis could not be performed (one trial reported 1/44 in the metformin group versus 0/36 in the intensive exercise and diet group with SAEs). One trial reported that 1/1073 participants in the metformin group compared with 2/1079 participants in the comparator group died from cardiovascular causes. One trial reported that no participant died due to cardiovascular causes (very low-quality evidence). Two trials estimated the DMC per participant for metformin varying from $220 to $1177 versus $225 to $3628 in the comparator group (2400 participants; 2 trials; very low-quality evidence). Three RCTs compared metformin with acarbose: all-cause mortality was 1/44 versus 0/45 (89 participants; 1 trial; very low-quality evidence); incidence of T2DM was 12/147 versus 7/148 (RR 1.72, 95% CI 0.72 to 4.14; P = 0.22; 295 participants; 3 trials; low-quality evidence); SAEs were 1/51 versus 2/50 (101 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin with thiazolidinediones: incidence of T2DM was 9/161 versus 9/159 (RR 0.99, 95% CI 0.41 to 2.40; P = 0.98; 320 participants; 3 trials; low-quality evidence). SAEs were 3/45 versus 0/41 (86 participants; 1 trial; very low-quality evidence). Three RCTs compared metformin plus intensive diet and exercise with identical intensive diet and exercise: all-cause mortality was 1/121 versus 1/120 participants (450 participants; 2 trials; very low-quality evidence); incidence of T2DM was 48/166 versus 53/166 (RR 0.55, 95% CI 0.10 to 2.92; P = 0.49; 332 participants; 2 trials; very low-quality evidence). One trial estimated the DMC of metformin plus intensive diet and exercise to be $270 per participant compared with $225 in the comparator group (94 participants; 1 trial; very-low quality evidence). One trial in 45 participants compared metformin with a sulphonylurea. The trial reported no patient-important outcomes. For all comparisons there were no data on non-fatal myocardial infarction, non-fatal stroke or microvascular complications. We identified 11 ongoing trials which potentially could provide data of interest for this review. These trials will add a total of 17,853 participants in future updates of this review.

AUTHORS' CONCLUSIONS

Metformin compared with placebo or diet and exercise reduced or delayed the risk of T2DM in people at increased risk for the development of T2DM (moderate-quality evidence). However, metformin compared to intensive diet and exercise did not reduce or delay the risk of T2DM (moderate-quality evidence). Likewise, the combination of metformin and intensive diet and exercise compared to intensive diet and exercise only neither showed an advantage or disadvantage regarding the development of T2DM (very low-quality evidence). Data on patient-important outcomes such as mortality, macrovascular and microvascular diabetic complications and health-related quality of life were sparse or missing.

Barriers and Facilitators to the Implementation of Evidence-Based Lifestyle Management in Polycystic Ovary Syndrome: A Narrative Review

Polycystic ovary syndrome (PCOS) is a complex condition that involves metabolic, psychological and reproductive complications. Insulin resistance underlies much of the pathophysiology and symptomatology of the condition and contributes to long term complications including cardiovascular disease and diabetes. Women with PCOS are at increased risk of obesity which further compounds metabolic, reproductive and psychological risks. Lifestyle interventions including diet, exercise and behavioural management have been shown to improve PCOS presentations across the reproductive, metabolic and psychological spectrum and are recommended as first line treatment for any presentation of PCOS in women with excess weight by the International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome 2018. However, there is a paucity of research on the implementation lifestyle management in women with PCOS by healthcare providers. Limited existing evidence indicates lifestyle management is not consistently provided and not meeting the needs of the patients. In this review, barriers and facilitators to the implementation of evidence-based lifestyle management in reference to PCOS are discussed in the context of a federally-funded health system. This review highlights the need for targeted research on the knowledge and practice of PCOS healthcare providers to best inform implementation strategies for the translation of the PCOS guidelines on lifestyle management in PCOS.

Economic Costs Attributable to Diabetes in Each U.S. State

OBJECTIVE

To estimate direct medical and indirect costs attributable to diabetes in each U.S. state in total and per person with diabetes.

RESEARCH DESIGN AND METHODS

We used an attributable fraction approach to estimate direct medical costs using data from the 2013 State Health Expenditure Accounts, 2013 Behavioral Risk Factor Surveillance System, and the Centers for Medicare & Medicaid Services' 2013-2014 Minimum Data Set. We used a human capital approach to estimate indirect costs measured by lost productivity from morbidity (absenteeism, presenteeism, lost household productivity, and inability to work) and premature mortality, using the 2008-2013 National Health Interview Survey, 2013 daily housework value data, 2013 mortality data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research, and mean wages from the 2014 Bureau of Labor Statistics. Costs were adjusted to 2017 U.S. dollars.

RESULTS

The estimated median state economic cost was $5.9 billion, ranging from $694 million to $55.5 billion, in total and $18,248, ranging from $15,418 to $30,915, per person with diabetes. The corresponding estimates for direct medical costs were $2.8 billion (range $0.3-22.9) and $8,544 (range $6,591-12,953) and for indirect costs were $3.0 billion (range $0.4-32.6) and $9,672 (range $7,133-17,962). In general, the estimated state median indirect costs resulting from morbidity were larger than costs from mortality both in total and per person with diabetes.

CONCLUSIONS

Economic costs attributable to diabetes were large and varied widely across states. Our comprehensive state-specific estimates provide essential information needed by state policymakers to monitor the economic burden of the disease and to better plan and evaluate interventions for preventing type 2 diabetes and managing diabetes in their states.

Practical Tips for Implementing the Diabetes Prevention Program in Clinical Practice

PURPOSE OF REVIEW

The Diabetes Prevention Program (DPP) is an evidence-based lifestyle change program for prediabetes that is associated with a 58% reduction in 3-year diabetes incidence, and it has been supported by the American Medical Association and the Centers for Disease Control and Prevention. However, 9 in 10 patients are unaware they have the condition.

RECENT FINDINGS

With the passage of the Affordable Care Act (ACA) and broadened coverage for preventive services, the DPP has emerged as an accessible intervention in patients at risk. In 2018, Medicare began to cover the DPP, making it widely available for the first time to any patient over the age of 65 meeting eligibility criteria. The DPP is an evidence-based, widely available, frequently covered benefit, for lifestyle change for patients with prediabetes. To take advantage of this intervention, providers need to develop prediabetes screening and DPP referral workflows.

Evolving Trends in the Epidemiology, Risk Factors, and Prevention of Type 2 Diabetes: A Review

Currently, the global prevalence of diabetes is 8.8%. This figure is expected to increase worldwide, with the largest changes projected to occur in low- and middle-income countries. The aging of the world's population and substantial increases in obesity have contributed to the rise in diabetes. Global shifts in lifestyles have led to the adoption of unhealthy behaviours such as physical inactivity and poorer-quality diets. Correspondingly, diabetes is a rapidly-increasing problem in higher- as well as lower-income countries. In Canada, the prevalence of diabetes increased approximately 70% in the past decade. Although diabetes-related mortality rates have decreased in Canada, the number of people affected by diabetes has continued to grow because of a surge in the number of new diabetes cases. Non-European ethnic groups and individuals of lower socioeconomic status have been disproportionately affected by diabetes and its risk factors. Clinical trials have proven efficacy in reducing the onset of diabetes in high-risk populations through diet and physical activity interventions. However, these findings have not been broadly implemented into the Canadian health care context. In this article we review the evolving epidemiology of type 2 diabetes, with regard to trends in occurrence rates and prevalence; the role of risk factors including those related to ethnicity, obesity, diet, physical activity, socioeconomic status, prediabetes, and pregnancy; and the identification of critical windows for lifestyle intervention. Identifying high-risk populations and addressing the upstream determinants and risk factors of diabetes might prove to be effective diabetes prevention strategies to curb the current diabetes epidemic.

Diet, physical activity or both for prevention or delay of type 2 diabetes mellitus and its associated complications in people at increased risk of developing type 2 diabetes mellitus

BACKGROUND

The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether diet, physical activity or both can prevent or delay T2DM and its associated complications in at-risk people is unknown.

OBJECTIVES

To assess the effects of diet, physical activity or both on the prevention or delay of T2DM and its associated complications in people at increased risk of developing T2DM.

SEARCH METHODS

This is an update of the Cochrane Review published in 2008. We searched the CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, ICTRP Search Portal and reference lists of systematic reviews, articles and health technology assessment reports. The date of the last search of all databases was January 2017. We continuously used a MEDLINE email alert service to identify newly published studies using the same search strategy as described for MEDLINE up to September 2017.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) with a duration of two years or more.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology for data collection and analysis. We assessed the overall quality of the evidence using GRADE.

MAIN RESULTS

We included 12 RCTs randomising 5238 people. One trial contributed 41% of all participants. The duration of the interventions varied from two to six years. We judged none of the included trials at low risk of bias for all 'Risk of bias' domains.Eleven trials compared diet plus physical activity with standard or no treatment. Nine RCTs included participants with impaired glucose tolerance (IGT), one RCT included participants with IGT, impaired fasting blood glucose (IFG) or both, and one RCT included people with fasting glucose levels between 5.3 to 6.9 mmol/L. A total of 12 deaths occurred in 2049 participants in the diet plus physical activity groups compared with 10 in 2050 participants in the comparator groups (RR 1.12, 95% CI 0.50 to 2.50; 95% prediction interval 0.44 to 2.88; 4099 participants, 10 trials; very low-quality evidence). The definition of T2DM incidence varied among the included trials. Altogether 315 of 2122 diet plus physical activity participants (14.8%) developed T2DM compared with 614 of 2389 comparator participants (25.7%) (RR 0.57, 95% CI 0.50 to 0.64; 95% prediction interval 0.50 to 0.65; 4511 participants, 11 trials; moderate-quality evidence). Two trials reported serious adverse events. In one trial no adverse events occurred. In the other trial one of 51 diet plus physical activity participants compared with none of 51 comparator participants experienced a serious adverse event (low-quality evidence). Cardiovascular mortality was rarely reported (four of 1626 diet plus physical activity participants and four of 1637 comparator participants (the RR ranged between 0.94 and 3.16; 3263 participants, 7 trials; very low-quality evidence). Only one trial reported that no non-fatal myocardial infarction or non-fatal stroke had occurred (low-quality evidence). Two trials reported that none of the participants had experienced hypoglycaemia. One trial investigated health-related quality of life in 2144 participants and noted that a minimal important difference between intervention groups was not reached (very low-quality evidence). Three trials evaluated costs of the interventions in 2755 participants. The largest trial of these reported an analysis of costs from the health system perspective and society perspective reflecting USD 31,500 and USD 51,600 per quality-adjusted life year (QALY) with diet plus physical activity, respectively (low-quality evidence). There were no data on blindness or end-stage renal disease.One trial compared a diet-only intervention with a physical-activity intervention or standard treatment. The participants had IGT. Three of 130 participants in the diet group compared with none of the 141 participants in the physical activity group died (very low-quality evidence). None of the participants died because of cardiovascular disease (very low-quality evidence). Altogether 57 of 130 diet participants (43.8%) compared with 58 of 141 physical activity participants (41.1%) group developed T2DM (very low-quality evidence). No adverse events were recorded (very low-quality evidence). There were no data on non-fatal myocardial infarction, non-fatal stroke, blindness, end-stage renal disease, health-related quality of life or socioeconomic effects.Two trials compared physical activity with standard treatment in 397 participants. One trial included participants with IGT, the other trial included participants with IGT, IFG or both. One trial reported that none of the 141 physical activity participants compared with three of 133 control participants died. The other trial reported that three of 84 physical activity participants and one of 39 control participants died (very low-quality evidence). In one trial T2DM developed in 58 of 141 physical activity participants (41.1%) compared with 90 of 133 control participants (67.7%). In the other trial 10 of 84 physical activity participants (11.9%) compared with seven of 39 control participants (18%) developed T2DM (very low-quality evidence). Serious adverse events were rarely reported (one trial noted no events, one trial described events in three of 66 physical activity participants compared with one of 39 control participants - very low-quality evidence). Only one trial reported on cardiovascular mortality (none of 274 participants died - very low-quality evidence). Non-fatal myocardial infarction or stroke were rarely observed in the one trial randomising 123 participants (very low-quality evidence). One trial reported that none of the participants in the trial experienced hypoglycaemia. One trial investigating health-related quality of life in 123 participants showed no substantial differences between intervention groups (very low-quality evidence). There were no data on blindness or socioeconomic effects.

AUTHORS' CONCLUSIONS

There is no firm evidence that diet alone or physical activity alone compared to standard treatment influences the risk of T2DM and especially its associated complications in people at increased risk of developing T2DM. However, diet plus physical activity reduces or delays the incidence of T2DM in people with IGT. Data are lacking for the effect of diet plus physical activity for people with intermediate hyperglycaemia defined by other glycaemic variables. Most RCTs did not investigate patient-important outcomes.

Favorable cardiovascular risk factor profile is associated with lower healthcare expenditure and resource utilization among adults with diabetes mellitus free of established cardiovascular disease: 2012 Medical Expenditure Panel Survey (MEPS)

BACKGROUND AND AIMS

Given the prevalence and economic burden of diabetes mellitus (DM), we studied the impact of a favorable cardiovascular risk factor (CRF) profile on healthcare expenditures and resource utilization among individuals without cardiovascular disease (CVD), by DM status.

METHODS

25,317 participants were categorized into 3 mutually-exclusive strata: "Poor", "Average" and "Optimal" CRF profiles (≥4, 2-3, 0-1 CRF, respectively). Two-part econometric models were utilized to study cost data.

RESULTS

Mean age was 45 (48% male), with 54% having optimal, 39% average, and 7% poor CRF profiles. Individuals with DM were more likely to have poor CRF profile vs. those without DM (OR 7.7, 95% CI 6.4, 9.2). Individuals with DM/poor CRF profile had a mean annual expenditure of $9,006, compared to $6,461 among those with DM/optimal CRF profile (p < 0.001).

CONCLUSIONS

A favorable CRF profile is associated with significantly lower healthcare expenditures and utilization in CVD-free individuals across DM status, suggesting that these individuals require aggressive individualized prescriptions targeting lifestyle modifications and therapeutic treatments.

Metformin: From Research to Clinical Practice

Metformin is the recommended first-line oral glucose-lowering drug initiated to control hyperglycemia in type 2 diabetes mellitus. It acts in the liver, small intestines, and skeletal muscles with its major effect on decreasing hepatic gluconeogenesis. It is safe, inexpensive, and weight neutral and can be associated with weight loss. It can reduce microvascular complication risk and its use is associated with a lower cardiovascular mortality compared with sulfonylurea therapy. It is also used to delay the onset of type 2 diabetes mellitus, in treating gestational diabetes, and in women with polycystic ovary syndrome.