Valuing health-related quality of life in diabetes

An Exploratory Cost-Effectiveness Analysis of Immune Therapy in Delaying the Initiation of Automated Insulin Delivery Systems in Type 1 Diabetes

Objective: Immune therapies such as teplizumab and antithymocyte globulin (ATG) offer promise in delaying type 1 diabetes (T1D). However, growing availability of automated insulin delivery (AID) systems for insulin management may alter the cost-effectiveness of these therapies. Immune therapies may become more cost-effective when paired with AID instead of conventional insulin management. Meanwhile, as immune therapies delay T1D for only a short period, effective AID may reduce the economic value of prevention. This study provides the first cost-effectiveness analysis of the interplay between immune therapies and AID systems. Methods: Using microsimulation modeling, we examined the cost-effectiveness of six alternative prevention-treatment strategies defined by a combination of three preventive immune therapies (teplizumab, ATG, or no therapy) and two insulin management strategies (AID or conventional insulin management). Effectiveness was measured by quality-adjusted life years (QALYs). Costs were estimated from a payer perspective. Results: Among the six strategies considered, preventive ATG therapy followed by AID was the most cost-effective. It entailed $394,250 in lifetime costs and yielded 19.13 QALYs. These costs were lower and QALY gains higher than those with strategies that did not involve immune therapy or AID. Preventive teplizumab therapy followed by AID generated 0.25 more QALYs than ATG therapy followed by AID, albeit at an additional cost of $153,670, resulting in an incremental cost-effectiveness ratio of $369,890/QALY. Conclusions: Preventive ATG therapy followed by AID after T1D onset can be a potentially cost-effective approach. In the absence of randomized clinical trials for ATG in the prevention space, findings in this study assume that ATG is at least half as efficacious as teplizumab. The optimal prevention-treatment strategy will ultimately depend on payers' ability to negotiate prices for teplizumab and further evidence on efficacy of ATG in preventing T1D.

Domain-Specific and Domain-General Functional Brain Alterations in Type 2 Diabetes Mellitus: A Task-Based and Functional Connectivity Meta-Analysis

INTRODUCTION

Patients with Type 2 diabetes experience cognitive and affective deficits linked to widespread functional brain alterations. However, previous meta-analyses of functional neuroimaging have primarily focused on the resting-state studies. While valuable, this approach may have overlooked the key neuronal mechanisms underlying these deficits.

METHODS

To address this, we conducted a coordinate-level task-based meta-analysis of functional neuroimaging via a systematic search of Embase, PubMed, Medline, and Web of Science (December 2023), alongside task-based and task-free connectivity analyses using the BrainMap database. Activation likelihood estimations were applied to two task categories: that are, cognitive and affective. To control for biased results, we also conducted jackknife sensitivity analysis and within-paper combined experiments analysis as validation analyses.

RESULTS

We identified a cluster of activation in cognitive paradigm (18 contrasts, 153 foci, 767 subjects), with the middle frontal gyrus, part of the medial frontal cortex, as the peak region. For the affective paradigm (18 contrasts, 181 foci, 951 subjects), we observed both increased and decreased activities. Two increased clusters peak in the amygdala and middle temporal gyrus, while the three decreased clusters were inferior frontal gyrus, insula, and putamen. Follow-up connectivity analyses showed that these brain alterations were both task-specific and task-generic.

CONCLUSION

Despite the lack of uniformity across task, such domain-specific and domain-general patterns of alterations provide a more nuanced understanding of the cognitive and affective deficits in Type 2 diabetes patients. This highlights the varied neuronal mechanisms underlying these deficits.

The effect of diabetes education given to children with type 1 diabetes mellitus with digital games and video animation on quality of life

PURPOSE

The aim of the study was to examine the effects of diabetes education given to children with Type 1 Diabetes Mellitus with digital game and video animation on quality of life and metabolic control.

DESIGN AND METHODS

The study was an experimental single-blind, randomized controlled design. It was conducted with a total of 55 children with Type 1 Diabetes Mellitus, consisting of a study (n = 27) and a control group (n = 28). Data were collected by the "Introductory Information Form", "Pediatric Quality of Life 3.0 Diabetes Mellitus Module (PedsQL 3.0)" and "Metabolic Control Parameters Monitoring Form". Data were analyzed with Mann Whitney U, Chi square, Friedman and Bonferroni Dunn tests.

RESULTS

The descriptive characteristics of children with type 1 diabetes mellitus were homogeneous. The total mean quality of life scores of children with Type 1 Diabetes Mellitus in the study group were significantly higher than those in the control group (p < 0,05). The average HbA1c scores of the children in the study group decreased (p < 0,05), while the average HbA1c scores of the control group increased (p < 0,05).

CONCLUSIONS

Digital game and video animation based education was found to be effective in improving the quality of life of children with Type 1 Diabetes Mellitus and reducing HbA1c.

PRACTICE IMPLICATIONS

Providing diabetes education to children with Type 1 Diabetes Mellitus with digital games and video animations can facilitate diabetes management.

Examining the association of psychosocial and health behaviors with life satisfaction among canadians: a nationally representative study

BACKGROUND

Given life satisfaction is a key component or indicator of Quality of Life (QoL), previous studies in Canada have made some attempt to analyze its main determinants at population level. However, our knowledge of the association between psychosocial factors (e.g., sense of belongingness) and health behaviors (e.g., smoking, alcohol intake, and physical activity) and life satisfaction is limited. Understanding the associations between these key variables and life satisfaction is vital for informing interventions and improving well-being. This study aims to address this research gap by examining the relationships between psychosocial factors, health behaviors, and life satisfaction among Canadians aged 12 and above.

METHODS

Data from the 2017-2018 Canadian Community Health Survey (CCHS) were utilized for this study, encompassing information from a large sample of 113,000 Canadians aged 12 and above. Generalized Ordered logistic regression models were employed to assess the association of psychosocial and physical health behaviors with life satisfaction.

RESULTS

The study revealed significant associations between psychosocial factors, health behaviors, and life dissatisfaction among Canadians. Respondents living in moderately and severely food insecure households have 2.239 times (95% CI: 1.799-2.786) and 5.093 times (95% CI: 4.097-6.332) higher incidences of experiencing life dissatisfaction, respectively, compared to food-secured households. Respondents with a somewhat weak and very weak sense of belongingness had 2.635 times (95% CI: 2.048-3.391) and 6.740 times (95% CI: 5.210-8.717) higher chances, respectively, of falling into the life dissatisfaction category compared to being satisfied. Higher BMI and obesity were linked to increased life dissatisfaction, while physical activity exhibited a positive relationship with life satisfaction. Smoking was associated with higher levels of life dissatisfaction.

CONCLUSION

These findings underscore the importance of considering both psychosocial factors and physical health behaviors in understanding life dissatisfaction among Canadians. The results suggest that interventions targeting social factors, such as promoting a sense of belongingness and addressing socioeconomic disparities, alongside efforts to promote healthy lifestyle behaviors, may contribute to improving subjective well-being and life satisfaction.

Picking the low-hanging fruit: the cost-effectiveness of opportunistic diabetes screening during tuberculosis contact investigations on the Texas-Mexico border

Objective

There is a known association between type 2 diabetes (diabetes) and tuberculosis (TB), and TB clinics have become hubs for new diabetes diagnosis among active patients with TB. However, despite the potential to identify diabetes patients, resources limit diabetes screening opportunities to close TB contacts. We assessed the cost-effectiveness of adding opportunistic screening for diabetes during the routine TB contact investigations conducted at TB clinics.

Research design and methods

We used a Markov-based model to simulate the costs of diabetes screening, management and health outcomes, including the incidence of complications and death. All costs were considered from a health system perspective. One-way sensitivity analyses were conducted to assess the robustness of the results to various assumptions. Interventions that fall below US$50 000 per quality-adjusted life years (QALYs) are commonly considered very cost-effective, while those between $50 000 and $100 000 are considered moderately cost-effective.

Results

Simulation of diabetes screening among TB contacts resulted in not only increased survival and reduced complications but also increased costs of diabetes management. The resulting incremental cost-effectiveness ratio was $32 642 per QALY added, which is well within commonly used willingness-to-pay thresholds for cost-effectiveness. Compared with no screening, screening increased the costs by $8633 and resulted in an increase in QALYs by 0.26 per patient.

Conclusions

In the base case analysis, screening was very cost-effective given that none of the sensitivity analyses resulted in a cost-effectiveness ratio above $50 000 per QALY. Our results indicate that the expansion of diabetes screening in TB clinics is a cost-effective strategy to improve health outcomes.

Health state utility values of type 2 diabetes mellitus and related complications: a systematic review and meta-regression

BACKGROUND

This study aimed to synthesize and quantitatively examine Health State Utility Values (HSUVs) for Type 2 Diabetes Mellitus (T2DM) and its complications, providing a robust meta-regression framework for selecting appropriate HSUV estimates.

METHOD

We conducted a systematic review to extract HSUVs for T2DM and its complications, encompassing various influencing factors. Relevant literature was sourced from a review spanning 2000-2020, supplemented by literature from PubMed, Embase, and the Web of Science (up to March 2024). Multivariate meta-regression was performed to evaluate the impact of measurement tools, tariffs, health status, and clinical and demographic variables on HSUVs.

RESULTS

Our search yielded 118 studies, contributing 1044 HSUVs. The HSUVs for T2DM with complications varied, from 0.65 for cerebrovascular disease to 0.77 for neuropathy. The EQ-5D-3L emerged as the most frequently employed valuation method. HSUV differences across instruments were observed; 15-D had the highest (0.89), while HUI-3 had the lowest (0.70) values. Regression analysis elucidated the significant effects of instrument and tariff choice on HSUVs. Complication-related utility decrement, especially in diabetic foot, was quantified. Age <70 was linked to increased HSUVs, while longer illness duration, hypertension, overweight and obesity correlated with reduced HSUVs.

CONCLUSION

Accurate HSUVs are vital for the optimization of T2DM management strategies. This study provided a comprehensive data pool for HSUVs selection, and quantified the influence of various factors on HSUVs, informing analysts and policymakers in understanding the utility variations associated with T2DM and its complications.

Economic burden of type-2 diabetes in Peru: a cost-of-illness study valuing cost differences associated with the level of glycemic control

OBJECTIVES

Type 2 diabetes mellitus (T2DM) represents an increasing public health problem in Peru. This study aims to estimate the national economic burden of this disease for the public funder, the social security, and private sector insurers.

METHODS

Direct healthcare costs were estimated for a cohort of 45-to-75-year-old adults diagnosed with T2DM in 2019, over a 20-year period. Disease progression was modeled using PROSIT Models and literature, including acute and chronic microvascular and macrovascular complications. Three scenarios of glycemic control were considered: current levels of 35.8% of the population controlled (HbA1c < 7%) (S1); 100% controlled (S2) and; 100% uncontrolled (S3). The impact of diabetes prevalence on overall costs was evaluated in sensitivity analysis.

RESULTS

Total national economic burden was estimated at $15,405,448,731; an annual average per patient of $2,158. Total costs would decrease to $12,853,113,596 (-16.6%) in S2 and increase to $16,828,713,495 (+9.2%) in S3. Treating patients with complications and risk factors could cost 6.5 times more, being stroke the complication with the highest impact. Up to a 67.6% increase in total costs was found when increasing T2DM prevalence.

CONCLUSIONS

T2DM places a heavy burden on the Peruvian healthcare budget that will be even greater if poor glycemic control is maintained.

Health state utility values ranges across varying stages and severity of type 2 diabetes-related complications: A systematic review

INTRODUCTION

Health state utility values (HSUV) for Type 2 diabetes mellitus (T2DM) complications are useful in economic evaluations to determine cost effectiveness of an intervention. However, there is a lack of reference ranges for different severity and stages of individual complications. This study aimed to provide an overview of HSUV decrement ranges for common T2DM complications focusing on different severity and stages of complications.

METHOD

A systematic search was conducted in MEDLINE, SCOPUS, WEB OF SCIENCE. (Jan 2000 to April 2022). Included studies for HSUV estimates were from outpatient setting, regardless of treatment types, complication stages, regions and HRQoL instruments. Health Related Quality of Life (HRQoL) outcomes was to be presented as HSUV decrement values, adjusted according to social demographics and comorbidities. Adjusted HSUV decrements were extracted and compiled according to individual complications. After which, subsequently grouped into mild or severe category for comparison.

RESULTS

Searches identified 35 studies. The size of the study population ranged from 160 to 14,826. The HSUV decrement range was widest for cerebrovascular disease (stroke): -0.0060 to -0.0780 for mild stroke and -0.035 to -0.266 for severe stroke; retinopathy: mild (-0.005 to -0.0862), moderate (-0.0030 to -0.1845) and severe retinopathy (-0.023 to -0.2434); amputation: (-0.1050 to -0.2880). Different nature of complication severity defined in studies could be categorized into: those with acute nature, chronic with lasting effects, those with symptoms at early stage or those with repetitive frequency or episodes.

DISCUSSION

Overview of HSUV decrement ranges across different stages of each T2DM diabetes-related complications shows that chronic complications with lasting impact such as amputation, severe stroke with sequelae and severe retinopathy with blindness were generally associated with larger HSUV decrement range. Considerable heterogeneities exist across the studies. Promoting standardized complication definitions and identifying the most influential health state stages on HSUV decrements may assist researchers for future cost-effectiveness studies.

Major adverse foot events and functional mobility deficits associated with diabetic neuropathy and nephropathy

Aim

The purpose is to determine the risk ratios (RR) for both major adverse foot events (MAFEs) and the presence of moderate and severe functional mobility deficits in participants with diabetic peripheral neuropathy across the stages of chronic kidney disease (CKD).

Methods

We studied 284 participants with diabetes mellitus, peripheral neuropathy, and CKD. MAFEs including foot fracture, ulcerations, Charcot neuropathic arthropathy (CN), osteomyelitis, and minor foot amputations were collected from foot x-ray reports in the medical records of 152 participants; functional mobility deficits were assessed in 132 participants using the modified physical performance test (mPPT). Moderate mobility deficit was categorized as mPPT scores 22-29 and severe mobility deficit as < 22. Unadjusted and adjusted (age, body weight, race, HbA1c) RR were calculated across each stage of CKD, with stage 1 CKD used as the reference group.

Results

The RR for neuropathic foot fracture, CN, and diabetic foot ulceration remained consistent across CKD stages. The RR of minor amputation is greater in CKD stages 4 and 5. The RR of moderate or severe mobility deficit is greater in CKD stages 3 and 5 and in CKD stages 3, 4, and 5, respectively. An inverse association was observed between MAFE prevalence and mPPT scores across CKD stages.

Conclusion

Major adverse foot events and functional mobility deficits are prevalent in individuals with DPN and diabetic kidney disease. The risks for minor foot amputation and functional mobility deficits increase as early as stage 3 CKD and increase further in stages 4 and 5.

Medication adherence in patients with type 2 diabetes after disability onset: a difference-in-differences analysis using nationwide data

BACKGROUND

Effectively managing the coexistence of both diabetes and disability necessitates substantial effort. Whether disability onset affects adherence to type 2 diabetes medication remains unclear. This study investigated whether disability onset reduces such adherence and whether any reduction varies by disability type.

METHODS

This study used the National Disability Registry and National Health Insurance Research Database from Taiwan to identify patients with type 2 diabetes who subsequently developed a disability from 2013 to 2020; these patients were matched with patients with type 2 diabetes without disability onset during the study period. Type 2 diabetes medication adherence was measured using the medication possession ratio (MPR). A difference-in-differences analysis was performed to determine the effect of disability onset on the MPR.

RESULTS

The difference-in-differences analysis revealed that disability onset caused a reduction of 5.76% in the 1-year MPR (P < 0.001) and 13.21% in the 2-year MPR (P < 0.001). Among all disability types, organ disabilities, multiple disabilities, rare diseases, and a persistent vegetative state exhibited the largest reductions in 2-year MPR.

CONCLUSIONS

Policies aimed at improving medication adherence in individuals with disabilities should consider not only the specific disability type but also the distinct challenges and barriers these patients encounter in maintaining medication adherence.

Person-reported outcomes in diabetes care: What are they and why are they so important?

In this review, we aim to show how person-reported outcomes (PROs) and person-reported experiences (PREs) can significantly contribute to the way diabetes care is delivered, the involvement of people with diabetes in diabetes care, and the collaboration between health care professionals and people with diabetes. This review focuses on the definition and measurement of PROs and PREs, the importance of PROs and PREs for person-centred diabetes care, and integrating the perspectives of people with diabetes in the evaluation of medical, psychological and technological interventions. PROs have been increasingly accepted by Health Technology Assessment bodies and are therefore valued in the context of reimbursement decisions and consequently by regulators and other health care stakeholders for the allocation of health care resources. Furthermore, the review identified current challenges to the assessment and use of PROs and PREs in clinical care and research. These challenges relate to the combination of questionnaires and ecological momentary assessment for measuring PROs and PREs, lack of consensus on a core outcome set, limited sensitivity to change within many measures and insufficient standardization of what can be considered a minimal clinically important difference. Another issue that has not been sufficiently addressed is the involvement of people with diabetes in the design and development of measures to assess PROs and PREs.

Oral health-related quality of life among diabetic patients: A cross-sectional controlled study

Introduction

Diabetes is a widespread chronic metabolic condition that has a significant negative influence on a person's sociopsychological, physical, and economic well-being. This study was designed to (1) measure the impact of oral health on quality of life (QoL) using the Oral Health Impact Profile-14 (OHIP-14) in association with other factors (age, gender, years of diabetes, level of education, smoking, presence of other conditions, oral complaints, and glycemic control) and (2) validate the Arabic version of the OHIP-14.

Materials and Methods

Diabetic and healthy participants completed a two-part survey including demographic characteristics OHIP-14 questionnaire.

Results

The sample consisted of 121 patients with type 2 diabetes mellitus and 146 healthy controls. Sociodemographic data, OHIP-14 questionnaires, and glycemic control data were collected. The data were statistically analyzed. The results showed that OHIP-14 was found to have sufficient reliability and validity in measuring life quality. Our study documented the effects of oral health complications on QoL among diabetics compared to controls. The type of diabetes had no effect on life quality. The highest OHIP-14 domain affected was functional limitation, while the lowest one was social handicap.

Conclusion

It was concluded that diabetes has a negative effect on life quality. Diabetic patients have unsatisfactory oral health, which affects their QoL. The OHIP-14 is a reliable and valuable instrument to measure life quality.

A cost-effectiveness analysis of linagliptin add-on to insulin treatment for patients with type 2 diabetes mellitus and chronic kidney disease in Iran

Purpose

With the high prevalence of chronic kidney disease (CKD) in patients with type 2 diabetes mellitus (T2DM), determining optimal treatment strategies has become a major concern. Linagliptin is aDPP-4 inhibitor that does not require dose adjustment in patients with renal impairment. This study evaluates the cost-effectiveness of adding linagliptin to insulin therapy in patients with T2DM and mild (stage 2) or moderate (stage 3) CKD from a health system perspective in Iran.

Methods

We developed a cost-utility model using a decision tree and ran it separately for T2DM patients with mild or moderate CKD. Clinical outcomes and health-state utility values were extracted from published studies. Direct medical costs were obtained from national tariffs in Iran in 2021. We adopted an annual time horizon and calculated the difference in costs and quality-adjusted life-years (QALYs) to obtain the incremental cost-effectiveness ratios (ICER). To capture parameter uncertainties, one-way sensitivity analyses were also performed.

Results

In T2DM patients with mild CKD, the linagliptin add-on strategy was associated with an additional $23.69 cost and 0.0148 QALYs per patient, resulting in an ICER of 1600.37 USD/QALY. In moderate CKD, the strategy was associated with $22.59 more costs and 0.0191 more QALYs, and the ICER was estimated at 1182.72 USD/QALY. In both populations, the ICER was mainly driven by the impact of HbA1c on utility, cost of linagliptin, and the reduction in insulin usage by adding linagliptin to the treatment.

Conclusion

With a cost-effectiveness threshold of $1550 USD/QALY in Iran, adding linagliptin to insulin is cost-effective in patients with T2DM and moderate CKD. However, for those with mild CKD, it seems that the associated costs outweigh the expected benefits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01243-z.

Health-related Quality of Life of Patients With Diabetes Mellitus Measured With the Bahasa Indonesia Version of EQ-5D in Primary Care Settings in Indonesia

OBJECTIVES

Diabetes mellitus (DM) is a serious public health issue that places a heavy financial, social, and health-related burden on individuals, families, and healthcare systems. Self-reported health-related quality of life (HRQoL) is extensively used for monitoring the general population's health conditions and measuring the effectiveness of interventions. Therefore, this study investigated HRQoL and associated factors among patients with type 2 DM at a primary healthcare center in Indonesia.

METHODS

A cross-sectional study was conducted in Klaten District, Central Java, Indonesia, from May 2019 to July 2019. In total, 260 patients with DM registered with National Health Insurance were interviewed. HRQoL was measured with the EuroQol Group's validated Bahasa Indonesia version of the EuroQoL 5-Dimension 5-Level (EQ-5D-5L) with the Indonesian value set. Multivariate regression models were used to identify factors influencing HRQoL.

RESULTS

Data from 24 patients were excluded due to incomplete information. Most participants were men (60.6%), were aged above 50 years (91.5%), had less than a senior high school education (75.0%), and were unemployed (85.6%). The most frequent health problems were reported for the pain/discomfort dimension (64.0%) followed by anxiety (28.4%), mobility (17.8%), usual activities (10.6%), and self-care (6.8%). The average EuroQoL 5-Dimension (EQ-5D) index score was 0.86 (95% confidence interval [CI], 0.83 to 0.88). In the multivariate ordinal regression model, a higher education level (coefficient, 0.08; 95% CI, 0.02 to 0.14) was a significant predictor of the EQ-5D-5L utility score.

CONCLUSIONS

Patients with diabetes had poorer EQ-5D-5L utility values than the general population. DM patients experienced pain/discomfort and anxiety. There was a substantial positive relationship between education level and HRQoL.

Incorporating Prior Beliefs Into Meta-Analyses of Health-State Utility Values Using the Bayesian Power Prior

OBJECTIVES

Health-state utility values (HSUVs) directly affect estimates of Quality-Adjusted Life-Years and thus the cost-utility estimates. In practice a single preferred value (SPV) is often selected for HSUVs, despite meta-analysis being an option when multiple (credible) HSUVs are available. Nevertheless, the SPV approach is often reasonable because meta-analysis implicitly considers all HSUVs as equally relevant. This article presents a method for the incorporation of weights to HSUV synthesis, allowing more relevant studies to have greater influence.

METHODS

Using 4 case studies in lung cancer, hemodialysis, compensated liver cirrhosis, and diabetic retinopathy blindness, a Bayesian Power Prior (BPP) approach is used to incorporate beliefs on study applicability, reflecting the authors' perceived suitability for UK decision making. Older studies, non-UK value sets, and vignette studies are thus downweighted (but not disregarded). BPP HSUV estimates were compared with a SPV, random effects meta-analysis, and fixed effects meta-analysis. Sensitivity analyses were conducted iteratively updating the case studies, using alternative weighting methods, and simulated data.

RESULTS

Across all case studies, SPVs did not accord with meta-analyzed values, and fixed effects meta-analysis produced unrealistically narrow CIs. Point estimates from random effects meta-analysis and BPP models were similar in the final models, although BPP reflected additional uncertainty as wider credible intervals, particularly when fewer studies were available. Differences in point estimates were seen in iterative updating, weighting approaches, and simulated data.

CONCLUSIONS

The concept of the BPP can be adapted for synthesizing HSUVs, incorporating expert opinion on relevance. Because of the downweighting of studies, the BPP reflected structural uncertainty as wider credible intervals, with all forms of synthesis showing meaningful differences compared with SPVs. These differences would have implications for both cost-utility point estimates and probabilistic analyses.

Cost-effectiveness analysis of once-daily insulin glargine 300 U/mL versus insulin degludec 100 U/mL using the BRAVO diabetes model

AIMS

A cost-effectiveness analysis was conducted to compare insulin glargine 300 U/mL (Gla-300) versus insulin degludec 100 U/mL (IDeg-100) in insulin-naïve adults with type 2 diabetes (T2D) sub-optimally controlled with oral anti-diabetic drugs (OADs).

METHODS

The BRAVO diabetes model was used to assess costs and outcomes for once-daily Gla-300 versus once-daily IDeg-100 from a US healthcare sector perspective. Baseline clinical data were based on BRIGHT, a 24-week, non-inferiority, randomised control trial comparing Gla-300 and IDeg-100 in adults with T2D sub-optimally controlled with OADs (with or without glucagon-like peptide-1 receptor agonists). Treatment costs were based on doses observed in BRIGHT as well as net prices. Costs associated with complications were based on published literature. Lifetime costs (US$) and quality-adjusted life-years (QALYs) were predicted and used to calculate incremental cost-effectiveness ratio estimates; extensive scenario and sensitivity analyses were conducted.

RESULTS

Overall lifetime medical costs were estimated to be $327,904 and $330,154 for people receiving Gla-300 and IDeg-100, respectively; insulin costs were $43,477 and $44,367, respectively. People receiving Gla-300 gained 8.024 QALYs and 18.55 life-years, while people receiving IDeg-100 gained 7.997 QALYs and 18.52 life-years. Because Gla-300 was associated with a cost-saving of $2250 and 0.027 additional QALYs, it was considered to be dominant compared with IDeg-100. Results of the scenario and sensitivity analyses confirmed the robustness of the base case results.

CONCLUSION

Gla-300 was the dominant treatment option compared with IDeg-100 based on the willingness-to-pay threshold of $50,000/QALY. Results remained robust against a wide range of alternative assumptions on key parameters.

Health-Related Quality of Life Assessment in Older Patients with Type 1 and Type 2 Diabetes

Type 1 (T1D) and type 2 diabetes (T2D) are determinants of health-related outcomes including health-related quality of life (HRQOL). We aimed to determine differences in HRQOL between older adults with T1D and T2D and specific factors influencing HRQOL in this age group. This study used a cross-sectional design with 56 age- and HbA1c-matched T1D and T2D patients (aged 68.9 ± 7.8 years; 55% had T2D). We employed several validated questionnaires (Short Form-36 (SF-36) and the EuroQol-5 Dimensions/Visual Analog Scale (VAS)) to investigate the relationships between HRQOL domains and diabetes type, glycemic control, complications, and comorbidities. T1D was associated with better self-reported general health (assessed with the SF-36 general health domain (p = 0.048) and the EuroQol-5 VAS (p = 0.002), whereas no significant differences in the other SF-36 domains, self-reported diabetes distress, anxiety, or depression were found. Most HRQOL domains were not associated with HbA1c or the presence of diabetes complications. The most significant reduction in HRQOL was experienced by patients with higher BMIs, irrespective of the diabetes type. The obtained HRQOL data could be used in clinical settings for evidence-based patient education focused on specific subgroups of patients, as well as in national healthcare policies, e.g., interventions designed to alleviate obesity.

Guardians For Health: A Practical Approach to Improving Quality of Life and Longevity in People with Type 2 Diabetes

Type 2 diabetes is one of the fastest-growing health emergencies of the twenty-first century, in part due to its association with cardiovascular and renal disease. Successful implementation of evidence-based guidelines for the management of patients with diabetes and pre-diabetes has been shown to improve patient outcomes by controlling risk factors for cardiovascular and renal disease. Recommendations include the early introduction of lifestyle adjustments, supported by pharmacological tools. Despite the availability of regularly updated, evidence-based guidelines, guideline implementation in clinical practice is low. As a result, people living with type 2 diabetes are not consistently receiving ideal clinical care. Improving guideline adherence has the potential to improve quality of life and longevity in patients with type 2 diabetes. This article introduces Guardians For Health, a global initiative that aims to improve guideline adherence by simplifying patient management and encouraging patient participation in the implementation of guidelines for type 2 diabetes. Guardians For Health is supported by a global community of implementers, with tools to support decision-making and quality assurance. Through achieving better guideline adherence, Guardians For Health hopes to achieve its vision to "stop early mortality by reducing cardiovascular and kidney complications in people with type 2 diabetes".

Quality of life assessment in diabetic patients: validity of the creole version of the EQ-5D-5L in Reunion Island

Introduction

Due to the high prevalence of diabetes and its complications, evaluating the patient's quality of life is critical. EQ-5D-5L is a valid tool for assessing health-related quality of life (HRQOL) in chronic diseases, including diabetes. However, no psychometric measures have been validated in a Creole-speaking population. Therefore, this study aimed for the first time to validate and cross-culturally adapt Creole and French versions of EQ-5D-5L on Type II diabetes patients in Reunion Island.

Materials and methods

The Creole translation and cross-cultural adaptation process were based on the EUROQOL methods. Internal consistency and construct validity were determined using confirmatory factor analysis (CFA) of EQ-5D-5L for both versions. CFA model for HRQOL and global fit measures were calculated based on the EQ-5D-5L items using the maximum likelihood (ML) method.

Results

From November 2016 to October 2017, 148 patients were included in the Creole group and 152 in the French group. EQ-5D-5L measures were unidimensional for both versions. Cronbach's coefficient alpha was 0.76 for the Creole version and 0.81 for the French version in CFA models. The root mean square error of approximation (RMSEA) was 0.06 for the Creole version and 0.02 for the French version. The Comparative Fit Index (CFI) was closer to 1 for both versions. CFA models for both the Creole and French versions fit the data adequately.

Discussion

Overall, our findings provided evidence that both the Creole and French versions of EQ-5D-5L are suitable for assessing HRQOL in diabetes patients in Reunion Island. However, further research could be done to investigate French-Creole differences concerning the perception of health status, and a cultural adaptation of the French version will be considered.

Diabetes-Related Quality of Life: Learning From Individuals Making Lifestyle Changes to Improve Type 2 Diabetes Control

PURPOSE

The purpose of this study was to explore how treatment adherence and lifestyle changes required for glycemic control in type 2 diabetes (T2D) are related to quality of life (QoL) among predominantly ethnic minority and socioeconomically disadvantaged adults engaged in making changes to improve T2D self-management.

METHODS

Adults with T2D in New York City were recruited for the parent study based on recent A1C (≥7.5%) and randomly assigned to 1 of 2 arms, receiving educational materials and additional self-management support calls, respectively. Substudy participants were recruited from both arms after study completion. Participants (N = 50; 62% Spanish speaking) were interviewed by phone using a semistructured guide and were asked to define QoL and share ways that T2D, treatment, self-management, and study participation influenced their QoL. Interviews were analyzed using thematic analysis.

RESULTS

QoL was described as a multidimensional health-related construct with detracting and enhancing factors related to T2D. Detracting factors included financial strain, symptom progression and burden, perceived necessity to change cultural and lifestyle traditions, and dietary and medical limitations. Enhancing factors included social support, diabetes education, health behavior change, sociocultural connection.

CONCLUSION

QoL for diverse and socioeconomically disadvantaged adults with T2D is multifaceted and includes aspects of health, independence, social support, culture, and lifestyle, which may not be captured by existing QoL measures. Findings may inform the development of a novel QoL measure for T2D.

Quality of life in elderly people with type 2 diabetes using EQ-5D-5L tool: a case control study

Background

According to the World Health Organization (WHO), quality of life is “an individual’s perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns. Researchers have conceptualized quality of life on many levels, and there are multiple views on how it should be defined and measured. Chronic diseases like diabetes mellitus are known to compromise the HRQoL. Type 2 diabetes mellitus (DM) is a chronic metabolic disease known to affect HRQoL adversely. Two types of tools have been developed to measure HRQoL. Generic tools are general purpose measures used to assess HRQoL of communities and also for comparison between populations. The EQ-5D-5L consists of two pages—the EQ-5D-5L descriptive system and the EQ visual analog scale (EQ VAS). The descriptive system comprises the five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression).

Objectives

Assess of quality of life in elderly patients of type 2 diabetes mellitus as well as determine effects of factors related to diabetes and diabetic control on the quality of life of type 2 diabetes.

Methods

- Population of study and disease condition:

◦ A total of 60 participants were enrolled in this study, and all of the participants were among the geriatric group of people (age ≥ 60 years old).

◦ Thirty of them self-reported to have diabetes mellitus type 2, while the other 30 subjects were a control group (self-reported no to have diabetes mellitus).

◦ All participants were subjected to careful history taking, full clinical examination, in addition to laboratory investigation in the form of HBA1C.

◦ All participants had to fill in self-reported questionnaire which is used as a tool for the assessment of HRQOL named EQ-5D-5L (some patients were illiterate so the questionnaire was interviewed to them).

◦ All participants underwent interview questionnaires of the following HRQOL scales: geriatrics depression scale, ADL (activities of daily living scale), and IADL (instrumental activities of daily living scale).

Results

EQ-5D-5L score is significantly higher in diabetic patients than non-diabetics (p value < 0.001).

EQ VAS score is significantly lower in diabetic patients than non-diabetics (p value < 0.001).

ADL (activities of daily living) functional assessment impairment is higher in diabetics than non-diabetics (p value < 0.001). 

IADL (independence in activities of daily living) functional assessment impairment is higher in diabetics than non-diabetics (p value < 0.001).

Visual prop is impaired in diabetics more than non-diabetics (p value < 0.001).

Pain severity is mainly affected in diabetics more than non-diabetics.

Conclusion

Type 2 diabetes mellitus in elderly patients affects their health-related quality of life and their daily activities.

In our study, the HRQOL of uncontrolled diabetic patients were more negatively affected than that of the controlled diabetic patients.

Moreover, some of our diabetic patients were found to suffer from cognitive disorders (insomnia and depression) as a complication of diabetes.

We also found that the EQ-5D-5L of diabetic patients with comorbidities was higher than those without comorbidities and EQ-VAS was lower in comorbid diabetic patients.

An evaluation of lower urinary tract symptoms in diabetic patients: a cross-sectional study

BACKGROUND

Lower urinary tract symptoms (LUTS) are common among diabetic patients and represent hidden and mysterious morbidity. The pathophysiology of LUTS among diabetes mellitus (DM) patients is multifactorial. Importantly, LUTS is known to cause physical and psychological distress. Thus, this study describes LUTS among DM patients, investigates factors that may associate with it, and assesses the possible relationship between LUTS and the quality of life of diabetics.

METHODS

Over 6 months, data were collected from 378 diabetic patients in primary health care clinics. Demographic and clinical characteristics, Urogenital Distress Inventory-6 (UDI-6), and Incontinence Impact Questionnaire-7 (IIQ-7) were used to collect data. Univariate and multivariate analyses were performed.

RESULTS

Three hundred seventy-eight participants were included in this study. (29.9%) were (58-67) years old. 49% were female. Half of the cohort was overweight, and a third were obese. 81% were Type 2 DM. Almost all of them are on medical treatment. A median score of 5.50 (2.00-8.00) for the UDI-6 scale and a median score of 5 (0.00-10.00) for the IIQ-7 scale were reported. Multiple linear regression models showed that residency (p = 0.038) and regular exercise (p = 0.001) were significantly and negatively correlated with the UDI-6 score, while female gender (p = 0.042), insulin use (p = 0.009) and the presence of comorbidities (p = 0.007) were positively correlated with this score. Furthermore, age (p = 0.040) and body mass index (BMI) (p < 0.001) were significantly and positively associated with the IIQ-7 score.

CONCLUSION

LUTS is significant morbidity among DM patients. Factors such as age, BMI, and co-morbidities exacerbate LUTS, which can be modified and controlled. On the other hand, regular exercise and weight loss strategies help diabetic patients to improve LUTS.

First-Line Therapy for Type 2 Diabetes With Sodium-Glucose Cotransporter-2 Inhibitors and Glucagon-Like Peptide-1 Receptor Agonists : A Cost-Effectiveness Study

BACKGROUND

Guidelines recommend sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP1) receptor agonists as second-line therapy for patients with type 2 diabetes. Expanding their use as first-line therapy has been proposed but the clinical benefits may not outweigh their costs.

OBJECTIVE

To evaluate the lifetime cost-effectiveness of a strategy of first-line SGLT2 inhibitors or GLP1 receptor agonists.

DESIGN

Individual-level Monte Carlo-based Markov model.

DATA SOURCES

Randomized trials, Centers for Disease Control and Prevention databases, RED BOOK, and the National Health and Nutrition Examination Survey.

TARGET POPULATION

Drug-naive U.S. patients with type 2 diabetes.

TIME HORIZON

Lifetime.

PERSPECTIVE

Health care sector.

INTERVENTION

First-line SGLT2 inhibitors or GLP1 receptor agonists.

OUTCOME MEASURES

Life expectancy, lifetime costs, incremental cost-effectiveness ratios (ICERs).

RESULTS OF BASE-CASE ANALYSIS

First-line SGLT2 inhibitors and GLP1 receptor agonists had lower lifetime rates of congestive heart failure, ischemic heart disease, myocardial infarction, and stroke compared with metformin. First-line SGLT2 inhibitors cost $43 000 more and added 1.8 quality-adjusted months versus first-line metformin ($478 000 per quality-adjusted life-year [QALY]). First-line injectable GLP1 receptor agonists cost more and reduced QALYs compared with metformin.

RESULTS OF SENSITIVITY ANALYSIS

By removing injection disutility, first-line GLP1 receptor agonists were no longer dominated (ICER, $327 000 per QALY). Oral GLP1 receptor agonists were not cost-effective (ICER, $823 000 per QALY). To be cost-effective at under $150 000 per QALY, costs for SGLT2 inhibitors would need to be under $5 per day and under $6 per day for oral GLP1 receptor agonists.

LIMITATION

U.S. population and costs not generalizable internationally.

CONCLUSION

As first-line agents, SGLT2 inhibitors and GLP1 receptor agonists would improve type 2 diabetes outcomes, but their costs would need to fall by at least 70% to be cost-effective.

PRIMARY FUNDING SOURCE

American Diabetes Association.

Low aspartate aminotransferase/alanine aminotransferase ratio is a predictor of diabetes incidence in Japanese people: Population-based Panasonic cohort study 5

AIMS

The aim of this study was to calculate the cut-off values of liver enzymes to identify the risk of incident type 2 diabetes (DM) and to investigate the association between liver enzymes and incident DM in participants with or without obesity.

MATERIALS AND METHODS

The long-term cohort study included 70,688 subjects who underwent medical health checkups in 2008. The cut-off values of alanine aminotransferase (ALT) and the aminotransferase (AST)/ALT ratio for incident DM were evaluated using the time-dependent receiver operating characteristic curves. The risk of incident type 2 DM was examined according to cut-off values of liver enzymes and the group with body mass index (BMI) ≥25 kg/m² using Cox regression analyses.

RESULTS

In total, 4181 of 70,688 subjects developed DM within 10 years. The area under the curve and cut-off values for the ALT and the AST/ALT ratio for incident type 2 DM at 10 years were 0.707 and 23 IU/L and 0.694 and 0.875, respectively. The risk of incident DM was higher in subjects with ALT ≥23 or AST/ALT ≤0.875 and BMI <25 kg/m² than in those with ALT <23 IU/L or AST/ALT >0.875 and BMI ≥25 kg/m² , respectively.

CONCLUSIONS

The cut-off values of ALT and the AST/ALT ratio associated with the risk of incident type 2 DM were determined. Non-obese individuals with AST/ALT ≤0.875 had a higher risk of incident type 2 DM than obese individuals with AST/ALT >0.875.

Estimated Life-Years Gained Free of New or Recurrent Major Cardiovascular Events With the Addition of Semaglutide to Standard of Care in People With Type 2 Diabetes and High Cardiovascular Risk

OBJECTIVE

Semaglutide, a glucagon-like peptide 1 receptor agonist, reduced major adverse cardiovascular events (MACE) in people with type 2 diabetes (T2D) at high risk of cardiovascular disease (CVD) in a post hoc analysis of pooled data from Trial to Evaluate Cardiovascular and Other Long-term Outcomes with Semaglutide in Subjects With Type 2 Diabetes (SUSTAIN) 6 and Peptide Innovation for Early Diabetes Treatment (PIONEER) 6. We estimated the benefit of adding semaglutide to standard of care (SoC) on life-years free of new/recurrent CVD events in people with T2D at high risk of CVD.

RESEARCH DESIGN AND METHODS

The Diabetes Lifetime-perspective prediction (DIAL) competing risk-adjusted lifetime CVD risk model for people with T2D was developed previously. Baseline characteristics of the pooled cohort from SUSTAIN 6 and PIONEER 6 (POOLED cohort) (N = 6,480) were used to estimate individual life expectancy free of CVD for patients in the POOLED cohort. The hazard ratio of MACE from adding semaglutide to SoC was derived from the POOLED cohort (hazard ratio [HR] 0.76 [95% CI 0.62-0.92]) and combined with an individual's risk to estimate their CVD benefit.

RESULTS

Adding semaglutide to SoC was associated with a wide distribution in life-years free of CVD gained, with a mean increase of 1.7 (95% CI 0.5-2.9) life-years. Estimated life-years free of CVD gained with semaglutide was dependent on baseline risk (life-years free of CVD gained in individuals with established CVD vs. those with cardiovascular risk factors only: 2.0 vs. 0.2) and age at treatment initiation.

CONCLUSIONS

Adding semaglutide to SoC was associated with a gain in life-years free of CVD events that was dependent on baseline CVD risk and age at treatment initiation. This study helps contextualize the results of semaglutide clinical trials.

Cost-Effectiveness of Low-Dose Antithymocyte Globulin Versus Other Immunotherapies for Treatment of New-Onset Type 1 Diabetes

Objective: Several immunotherapies have shown efficacy in slowing C-peptide decline in new-onset type 1 diabetes. Although most of these biologic drugs are expensive, they offer the opportunity to reduce downstream disease management costs and risk of complications. The objective of this study is to examine the cost-effectiveness of immunotherapies versus no treatment for patients with new-onset type 1 diabetes. Methods: Using Markov microsimulation modeling and efficacy data from immunotherapy trials, we examined the cost-effectiveness of six immunotherapies for new-onset type 1 diabetes, namely, low-dose (2.5 mg/kg) antithymocyte globulin (ATG), high-dose (6.5 mg/kg) ATG, abatacept, alefacept, rituximab, and teplizumab, versus no treatment. Effectiveness was measured by quality-adjusted life-years (QALYs). Costs were estimated from a health system perspective. Results: Low-dose ATG treatment saves US$10,270, on average, over a patient's lifetime and generates 0.09 additional QALYs compared with no treatment. These cost savings arise as low-dose ATG generates downstream savings in disease management costs that more than offset its cost. In contrast, treatment with other immunotherapies yields smaller QALY gains (0.02-0.05 additional QALYs) and increases lifetime costs by US$9500-US$168,380 relative to no treatment, with incremental cost-effectiveness ratios that exceed the willingness-to-pay threshold of US$100,000 per QALY. Conclusions: Low-dose ATG treatment is both less costly and more effective relative to other immunotherapies and no treatment for new-onset type 1 diabetes.

Economic evaluation of a national vitamin D supplementation program among Iranian adolescents for the prevention of adulthood type 2 diabetes mellitus

BACKGROUND

This study aimed to evaluate the cost-effectiveness of vitamin D supplementation in preventing type 2 diabetes mellitus (T2DM) among Iranian adolescents.

METHODS

This analytical observational study was conducted, using the decision tree model constructed in TreeAge Pro to assess the cost per quality-adjusted life-year (QALY) of monthly intake vitamin D supplements to prevent T2DM compared to no intervention from the viewpoint of Iran's Ministry of Health and through an one-year horizon. In the national program of vitamin D supplementation, 1,185,211 Iranian high-school students received 50,000 IU vitamin D supplements monthly for nine months. The costs-related data were modified to 2018. The average cost and effectiveness were compared based on the Incremental Cost-Effectiveness Ratio (ICER).

RESULTS

Our analytical analysis estimated the 4071.25 (USD / QALY) cost per AQALY gained of the monthly intake of 50,000 IU vitamin D for nine months among adolescents over a one-year horizon. Based on the ICER threshold of 1032-2666, vitamin D supplementation was cost-effective for adolescents to prevent adulthood T2DM. It means that vitamin D supplementation costs were substantially less than the costs of T2DM treatments than the no intervention.

CONCLUSIONS

Based on the findings, the national vitamin D supplementation program for Iranian adolescents could be a cost-effective strategy to reduce the risk of diabetes in adulthood. From an economic perspective, vitamin D supplementation, especially in adolescents with vitamin D deficiency, would be administrated.

Health Utilities in Patients with Type 2 Diabetes in Taiwan

We aimed to measure health utilities in patients with diabetes mellitus (DM) in Taiwan and to estimate the impact of common DM-related complications and adverse effects (AEs) on health utilities. The present study was a cross-sectional survey of DM patients at a metropolitan hospital. Respondents’ health-related quality of life (HRQoL) was assessed by the EQ-5D-5L, and ordinary least-squares (OLS) regression was used to estimate the impact of self-reported DM-related complications and AEs on health utilities after controlling for age, gender, and duration of DM. A total of 506 eligible adults with type 2 DM (T2DM) were enrolled. The EQ-5D index values in our study sample ranged from −0.13 to 1, with a mean ± standard deviation of 0.88 ± 0.20. As indicated by the negative regression coefficients, the presence of any complication or AE was associated with lower EQ-5D index values, and the greatest impact on the score was made by amputation (−0.276), followed by stroke (−0.211), and blindness (−0.203). In conclusion, the present study elicited health utilities in patients with T2DM in Taiwan using the EQ-5D-5L. These estimated utility decrements provided essential data for future DM cost–utility analyses that are needed as a result of the increasing prevalence and health expenditures of DM.

Estimation of Utility Values for Computing Quality-adjusted Life Years Associated With Homelessness

BACKGROUND

There is a lack of data-driven evidence about the burden of homelessness, and lack of a holistic measure of effectiveness for evaluating interventions targeting homelessness. Quality-adjusted life years (QALYs) can help holistically capture the burden of homelessness, and facilitate the valuation and comparison of interventions designed to address homelessness.

OBJECTIVE

This study estimated utility values required to compute the QALYs associated with homelessness, and also examined individual-level characteristics that affect these values.

RESEARCH DESIGN

The study is cross-sectional and derived from a large national survey conducted during the coronavirus disease 2019 pandemic.

SUBJECTS

A sample of 6607 middle- and low-income adults in the United States.

MEASURES

A self-completion standard gamble survey was used to estimate utility values associated with homelessness. Linear regression was used to analyze the association between individual-level characteristics and these utility values.

RESULTS

The study estimated the average utility value associated with homelessness as 43.4% among the study participants. This implies that 1 year of life as a homeless individual is perceived to be equivalent to less than half a year of life as a stably housed individual in good health. The study also found that individuals who have experienced homelessness and financial distress value life as a homeless person considerably less than those who have not had these experiences.

CONCLUSIONS

The method developed in this study can be used to estimate QALYs in studies evaluating homelessness interventions, thereby establishing the societal value of these interventions and informing policy and budgetary decision-making. Future studies estimating the utility values associated with homelessness in the general population, as well as specific homeless groups, are required to provide more generalizable evidence.

The effect of aerobic exercise on the expression of mir-126 and related target genes in the endothelial tissue of the cardiac muscle of diabetic rats

BACKGROUND

The aim of this study was to investigate the effect of 8 weeks of aerobic exercise on the expression of mir-126 and some angiogenesis factors in the endothelial tissue of the cardiac muscle of type 2 diabetic rats.

METHODS

Sixteen male Wistar rats were divided into two groups: diabetic control and diabetic training. Nicotinamide and streptozotocin injections were used to induce type 2 diabetes. After familiarization, the training group participated in an 8-week exercise protocol on a treadmill with an intensity of 25 m per minute, a slope of 5% and 30 min per session. RT-PCR was used to evaluate the expression of mir-126 and PI3K genes. Expression of raf1, VEGF, blood glucose and insulin was determined by ELISA and insulin resistance was assessed by HOMA-IR homeostasis model. Immunohistochemistry was used to measure the capillary density of the cardiac muscle. Data were analyzed by t-test for independent groups with a significance level of p < 0.05.

RESULTS

Diabetes reduces angiogenesis in cardiac tissue, which is associated with a significant reduction in the expression of mir-126, raf1, VEGF and PI3K; while aerobic exercise increased the expression of mir-126, raf1, PI3K, VEGF. Exercise also decreased blood glucose levels and insulin resistance.

CONCLUSION

It seems that aerobic exercise can prevent the destructive effects of diabetes by activating the angiogenic pathway of cardiac tissue. Therefore, regulatory processes through mir-126, which are influenced by aerobic exercise, can be a valuable strategy in developing new treatments for diabetes.

Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review

BACKGROUND

For people with diabetes mellitus to achieve optimal glycaemic control, motivation to perform self-management is important. The research team wanted to determine whether or not psychological interventions are clinically effective and cost-effective in increasing self-management and improving glycaemic control.

OBJECTIVES

The first objective was to determine the clinical effectiveness of psychological interventions for people with type 1 diabetes mellitus and people with type 2 diabetes mellitus so that they have improved (1) glycated haemoglobin levels, (2) diabetes self-management and (3) quality of life, and fewer depressive symptoms. The second objective was to determine the cost-effectiveness of psychological interventions.

DATA SOURCES

The following databases were accessed (searches took place between 2003 and 2016): MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO, EMBASE, Cochrane Controlled Trials Register, Web of Science, and Dissertation Abstracts International. Diabetes conference abstracts, reference lists of included studies and Clinicaltrials.gov trial registry were also searched.

REVIEW METHODS

Systematic review, aggregate meta-analysis, network meta-analysis, individual patient data meta-analysis and cost-effectiveness modelling were all used. Risk of bias of randomised and non-randomised controlled trials was assessed using the Cochrane Handbook (Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928).

DESIGN

Systematic review, meta-analysis, cost-effectiveness analysis and patient and public consultation were all used.

SETTING

Settings in primary or secondary care were included.

PARTICIPANTS

Adolescents and children with type 1 diabetes mellitus and adults with types 1 and 2 diabetes mellitus were included.

INTERVENTIONS

The interventions used were psychological treatments, including and not restricted to cognitive-behavioural therapy, counselling, family therapy and psychotherapy.

MAIN OUTCOME MEASURES

Glycated haemoglobin levels, self-management behaviours, body mass index, blood pressure levels, depressive symptoms and quality of life were all used as outcome measures.

RESULTS

A total of 96 studies were included in the systematic review (n = 18,659 participants). In random-effects meta-analysis, data on glycated haemoglobin levels were available for seven studies conducted in adults with type 1 diabetes mellitus (n = 851 participants) that demonstrated a pooled mean difference of -0.13 (95% confidence interval -0.33 to 0.07), a non-significant decrease in favour of psychological treatment; 18 studies conducted in adolescents/children with type 1 diabetes mellitus (n = 2583 participants) that demonstrated a pooled mean difference of 0.00 (95% confidence interval -0.18 to 0.18), indicating no change; and 49 studies conducted in adults with type 2 diabetes mellitus (n = 12,009 participants) that demonstrated a pooled mean difference of -0.21 (95% confidence interval -0.31 to -0.10), equivalent to reduction in glycated haemoglobin levels of -0.33% or ≈3.5 mmol/mol. For type 2 diabetes mellitus, there was evidence that psychological interventions improved dietary behaviour and quality of life but not blood pressure, body mass index or depressive symptoms. The results of the network meta-analysis, which considers direct and indirect effects of multiple treatment comparisons, suggest that, for adults with type 1 diabetes mellitus (7 studies; 968 participants), attention control and cognitive-behavioural therapy are clinically effective and cognitive-behavioural therapy is cost-effective. For adults with type 2 diabetes mellitus (49 studies; 12,409 participants), cognitive-behavioural therapy and counselling are effective and cognitive-behavioural therapy is potentially cost-effective. The results of the individual patient data meta-analysis for adolescents/children with type 1 diabetes mellitus (9 studies; 1392 participants) suggest that there were main effects for age and diabetes duration. For adults with type 2 diabetes mellitus (19 studies; 3639 participants), baseline glycated haemoglobin levels moderated treatment outcome.

LIMITATIONS

Aggregate meta-analysis was limited to glycaemic control for type 1 diabetes mellitus. It was not possible to model cost-effectiveness for adolescents/children with type 1 diabetes mellitus and modelling for type 2 diabetes mellitus involved substantial uncertainty. The individual patient data meta-analysis included only 40-50% of studies.

CONCLUSIONS

This review suggests that psychological treatments offer minimal clinical benefit in improving glycated haemoglobin levels for adults with type 2 diabetes mellitus. However, there was no evidence of benefit compared with control interventions in improving glycated haemoglobin levels for people with type 1 diabetes mellitus.

FUTURE WORK

Future work should consider the competency of the interventionists delivering a therapy and psychological approaches that are matched to a person and their life course.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016033619.

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. 24, No. 28. See the NIHR Journals Library website for further project information.

Valuing health states of people with type 2 diabetes: Analyses of the nationwide representative linked databases

AIMS/INTRODUCTION

To estimate preference-based measures of health-related quality of life associated with sociodemographic and clinical characteristics in type 2 diabetes patients.

MATERIALS AND METHODS

Individuals with EuroQol-5 dimensions-3 levels data were identified from Taiwan's National Health Interview Survey in 2009 and 2013. Status of diabetes, comorbidities, complications and treatments were ascertained through data linkage to Taiwan's National Health Insurance Research Database. Multivariable ordinary least squares, Tobit and median regression analyses were used to estimate the coefficients that represented independent impacts of patients' characteristics on health-related quality of life.

RESULTS

The mean health utility score for 2,104 participants was 0.838. Being female, aging, divorced/widowed, never worked or underweight, or having a lower monthly household income, injectable glucose-lowering therapy, comorbid connective tissue disease or depression were associated with lower health utilities. Having an amputation led to the largest reduction by 0.288 in health utilities, followed by debilitating stroke (0.266), heart failure (0.237), other coronary heart disease (0.185), kidney dialysis/transplant (0.148), coronary revascularizations (0.093), transient ischemic attack/stroke (0.078), diabetic neuropathy (0.062), polyneuropathy (0.055) and other neuropathy (0.043).

CONCLUSIONS

Major vascular complications, connective tissue disease and depression are associated with considerably worse health-related quality of life. These health utility estimates can facilitate health economic evaluations to determine cost-effective strategies for diabetes management.

Health-Related Quality of Life in Patients with Health Conditions in Lebanese Community Setting

Background: The measurement of health-related quality of life (HRQoL) provides utility scores that could be used for health economics assessment. The aim of this study was to measure HRQoL in Lebanese patients with certain medical conditions, and to determine demographic and medical factors affecting such health utility scores. Method: This was a prospective cross-sectional pilot study conducted to gather information on the socioeconomic status, health condition and quality of life of participants with common diseases during their community pharmacy visit. The EuroQol-5-Dimension instrument was used to measure utility scores and SPSS v26 was used to perform the statistical analysis. Results: Participants (n = 102) gave an average of 6.8 and 7.4 out of 10 for their current health and for their satisfaction with their treatment, respectively. The mean utility score was 0.762 (SD 0.202). The number of prescribed medications per respondent indicated a significant impact on HRQoL (p = 0.002). On average, the utility scores were low for participants who were 75 years or older (0.15, p < 0.001), and those who were hospitalized in the past 12 months (0.111, p < 0.001). For every unit increase in treatment satisfaction, the quality-of-life score increased by 0.036 unit (p = 0.001). Conclusion: This pilot study measured health utility scores and factors influencing HRQoL in the Lebanese population. Further studies are needed to confirm our findings and to develop and validate tools helping to measure health related quality of life in the population in Lebanon.

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.

Effectiveness of a Multicomponent Intervention in Primary Care That Addresses Patients with Diabetes Mellitus with Two or More Unhealthy Habits, Such as Diet, Physical Activity or Smoking: Multicenter Randomized Cluster Trial (EIRA Study)

Introduction: We evaluated the effectiveness of an individual, group and community intervention to improve the glycemic control of patients with diabetes mellitus aged 45-75 years with two or three unhealthy life habits. As secondary endpoints, we evaluated the inverventions' effectiveness on adhering to Mediterranean diet, physical activity, sedentary lifestyle, smoking and quality of life. Method: A randomized clinical cluster (health centers) trial with two parallel groups in Spain from January 2016 to December 2019 was used. Patients with diabetes mellitus aged 45-75 years with two unhealthy life habits or more (smoking, not adhering to Mediterranean diet or little physical activity) participated. Centers were randomly assigned. The sample size was estimated to be 420 people for the main outcome variable. Educational intervention was done to improve adherence to Mediterranean diet, physical activity and smoking cessation by individual, group and community interventions for 12 months. Controls received the usual health care. The outcome variables were: HbA1c (main), the Mediterranean diet adherence score (MEDAS), the international diet quality index (DQI-I), the international physical activity questionnaire (IPAQ), sedentary lifestyle, smoking ≥1 cigarette/day and the EuroQuol questionnaire (EVA-EuroQol5D5L). Results: In total, 13 control centers (n = 356) and 12 intervention centers (n = 338) were included with similar baseline conditions. An analysis for intention-to-treat was done by applying multilevel mixed models fitted by basal values and the health center: the HbA1c adjusted mean difference = -0.09 (95% CI: -0.29-0.10), the DQI-I adjusted mean difference = 0.25 (95% CI: -0.32-0.82), the MEDAS adjusted mean difference = 0.45 (95% CI: 0.01-0.89), moderate/high physical activity OR = 1.09 (95% CI: 0.64-1.86), not living a sedentary lifestyle OR = 0.97 (95% CI: 0.55-1.73), no smoking OR = 0.61 (95% CI: 0.54-1.06), EVA adjusted mean difference = -1.26 (95% CI: -4.98-2.45). Conclusions: No statistically significant changes were found for either glycemic control or physical activity, sedentary lifestyle, smoking and quality of life. The multicomponent individual, group and community interventions only showed a statistically significant improvement in adhering to Mediterranean diet. Such innovative interventions need further research to demonstrate their effectiveness in patients with poor glycemic control.

Cost-Effectiveness of a Diabetes Self-Management Education and Support Intervention Led by Community Health Workers and Peer Leaders: Projections From the Racial and Ethnic Approaches to Community Health Detroit Trial

OBJECTIVE

To simulate the long-term cost-effectiveness of a peer leader (PL)-led diabetes self-management support (DSMS) program following a structured community health worker (CHW)-led diabetes self-management education (DSME) program in reducing risks of complications in people with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

The trial randomized 222 Latino adults with T2D to 1) enhanced usual care (EUC); 2) a CHW-led, 6-month DSME program and 6 months of CHW-delivered monthly telephone outreach (CHW only); or 3) a CHW-led, 6-month DSME program and 12 months of PL-delivered weekly group sessions with telephone outreach to those unable to attend (CHW + PL). Empirical data from the trial and the validated Michigan Model for Diabetes were used to estimate cost and health outcomes over a 20-year time horizon from a health care sector perspective, discounting both costs and benefits at 3% annually. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS

Over 20 years, the CHW + PL intervention had an ICER of $28,800 and $5,900 per quality-adjusted life-year (QALY) gained compared with the EUC and CHW-only interventions, respectively. The CHW-only intervention had an ICER of $430,600 per QALY gained compared with the EUC intervention. In sensitivity analyses, the results comparing the CHW + PL with EUC and CHW-only interventions were robust to changes in intervention effects and costs.

CONCLUSIONS

The CHW + PL-led DSME/DSMS intervention improved health and provided good value compared with the EUC intervention. The 6-month CHW-led DSME intervention without further postintervention CHW support was not cost effective in Latino adults with T2D.

Cost-effectiveness of Community-Based Depression Interventions for Rural and Urban Adults With Type 2 Diabetes: Projections From Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II

OBJECTIVE

We estimated the cost-effectiveness of the Program ACTIVE (Adults Coming Together to Increase Vital Exercise) II community-based exercise (EXER), cognitive behavioral therapy (CBT), and EXER+CBT interventions in adults with type 2 diabetes and depression relative to usual care (UC) and each other.

RESEARCH DESIGN AND METHODS

Data were integrated into the Michigan Model for Diabetes to estimate cost and health outcomes over a 10-year simulation time horizon from the health care sector and societal perspectives, discounting costs and benefits at 3% annually. Primary outcome was cost per quality-adjusted life-year (QALY) gained.

RESULTS

From the health care sector perspective, the EXER intervention strategy saved $313 (USD) per patient and produced 0.38 more QALY (cost saving), the CBT intervention strategy cost $596 more and gained 0.29 more QALY ($2,058/QALY), and the EXER+CBT intervention strategy cost $403 more and gained 0.69 more QALY ($585/QALY) compared with UC. Both EXER and EXER+CBT interventions dominated the CBT intervention. Compared with EXER, the EXER+CBT intervention strategy cost $716 more and gained 0.31 more QALY ($2,323/QALY). From the societal perspective, compared with UC, the EXER intervention strategy saved $126 (cost saving), the CBT intervention strategy cost $2,838/QALY, and the EXER+CBT intervention strategy cost $1,167/QALY. Both EXER and EXER+CBT interventions still dominated the CBT intervention. In comparison with EXER, the EXER+CBT intervention strategy cost $3,021/QALY. Results were robust in sensitivity analyses.

CONCLUSIONS

All three Program ACTIVE II interventions represented a good value for money compared with UC. The EXER+CBT intervention was highly cost-effective or cost saving compared with the CBT or EXER interventions.

Simplified Mathematical Modelling of Uncertainty: Cost-Effectiveness of COVID-19 Vaccines in Spain

When exceptional situations, such as the COVID-19 pandemic, arise and reliable data is not available at decision-making times, estimation using mathematical models can provide a reasonable reckoning for health planning. We present a simplified model (static but with two-time references) for estimating the cost-effectiveness of the COVID-19 vaccine. A simplified model provides a quick assessment of the upper bound of cost-effectiveness, as we illustrate with data from Spain, and allows for easy comparisons between countries. It may also provide useful comparisons among different vaccines at the marketplace, from the perspective of the buyer. From the analysis of this information, key epidemiological figures, and costs of the disease for Spain have been estimated, based on mortality. The fatality rate is robust data that can alternatively be obtained from death registers, funeral homes, cemeteries, and crematoria. Our model estimates the incremental cost-effectiveness ratio (ICER) to be 5132 € (4926–5276) as of 17 February 2021, based on the following assumptions/inputs: An estimated cost of 30 euros per dose (plus transport, storing, and administration), two doses per person, efficacy of 70% and coverage of 70% of the population. Even considering the possibility of some bias, this simplified model provides confirmation that vaccination against COVID-19 is highly cost-effective.

Health utility of type 2 diabetes patients using basal insulin in China: results from the BEYOND II study

OBJECTIVE

To derive the health utility scores of type 2 diabetes (T2D) patients using basal insulin (BI) with diverse characteristics in China.

METHODS

The study used the data of insulin-using T2D patients on BI treatment enrolled in the BEYOND II study, which is a multi-center, observational study from 78 hospitals nationwide. The 3-level EQ-5D (EQ-5D-3L) questionnaire was administered to each patient to derive their health utility scores using the EQ-5D-3L value set for China. Patients' clinical and sociodemographic information were retrieved from their electronic case report form (eCRF). Ordinary least-square models with different specifications were explored to identify the best-fitting model to predict the utility scores.

RESULTS

The sample (n = 12,583) achieved a mean (standard deviation) EQ-5D-3L utility score of 0.936 (0.120). According to the model, a Chinese male who was younger than 59 years, not underweight, diagnosed with T2D shorter than 10 years, with controlled plasma glucose and free of diabetes complications/comorbidities, would have a mean utility of 0.993. Being female, older age, underweight, and higher plasma glucose, longer diabetes duration was negatively related to EQ-5D-3L scores. Comorbidities and seven of eleven complications were associated with utility decrement. Interactions between some complications were also discovered.

CONCLUSIONS

The derived health utility scores for diabetes complications could facilitate the assessment of the cost-effectiveness of health interventions for Chinese insulin-using T2D patients.

Cost-Effectiveness of the New 2018 American College of Physicians Glycemic Control Guidance Statements Among US Adults With Type 2 Diabetes

OBJECTIVES

This study aims to estimate the national impact and cost-effectiveness of the 2018 American College of Physicians (ACP) guidance statements compared to the status quo.

METHODS

Survey data from the 2011-2016 National Health and Nutrition Examination were used to generate a national representative sample of individuals with diagnosed type 2 diabetes in the United States. Individuals with A1c <6.5% on antidiabetic medications are recommended to deintensify their A1c level to 7.0% to 8.0% (group 1); individuals with A1c 6.5% to 8.0% and a life expectancy of <10 years are recommended to deintensify their A1c level >8.0% (group 2); and individuals with A1c >8.0% and a life expectancy of >10 years are recommended to intensify their A1c level to 7.0% to 8.0% (group 3). We used a Markov-based simulation model to evaluate the lifetime cost-effectiveness of following the ACP recommended A1c level.

RESULTS

14.41 million (58.1%) persons with diagnosed type 2 diabetes would be affected by the new guidance statements. Treatment deintensification would lead to a saving of $363 600 per quality-adjusted life-year (QALY) lost for group 1 and a saving of $118 300 per QALY lost for group 2. Intensifying treatment for group 3 would lead to an additional cost of $44 600 per QALY gain. Nationally, the implementation of the guidance would add 3.2 million life-years and 1.1 million QALYs and reduce healthcare costs by $47.7 billion compared to the status quo.

CONCLUSIONS

Implementing the new ACP guidance statements would affect a large number of persons with type 2 diabetes nationally. The new guidance is cost-effective.

Predictors of Health-Related Quality of Life in Korean Adults with Diabetes Mellitus

Diabetes mellitus (DM) as a chronic disease is a major public health problem worldwide. It is important to improve the quality of life of people with DM, especially health-related aspects, which should be monitored and managed as part of diabetes management. Accordingly, this study investigated health-related quality of life (HRQoL) and identified predictors of HRQoL in Korean adults with DM using the Seventh Korea National Health and Nutrition Examination Survey (KNHANES VII) 2016–2018. This was a cross-sectional study with a stratified multistage probability sampling design that collected data from 1228 participants aged 30–80 years diagnosed with DM. HRQoL was measured using the Euro Quality of Life Five Dimension (EQ-5D) questionnaire. Analyses consisted of one-way analysis of variance, t-tests, chi-squared tests, and general linear regression analyses with complex sampling designs. Results demonstrated that low HRQoL was associated with older age (β = −0.002, 95% CI: −0.003 to −0.001), having elementary school education or less (β = −0.037, 95% CI: −0.061 to −0.014), being unmarried (β = −0.060, 95% CI: −0.078 to −0.040), poor subjective health status (β = −0.074, 95% CI: −0.094 to −0.055), perceived high stress (β = −0.047, 95% CI: −0.066 to −0.028), limited activity (β = −0.105, 95% CI: −0.131 to −0.079), being overweight (β = −0.021, 95% CI: −0.038 to −0.002), or obese (β = −0.016, 95% CI: −0.032 to −0.001), and three or more comorbidities (β = −0.044, 95% CI: −0.085 to −0.001). Comprehensive health care programs to manage these predictors should be provided to improve health-related quality of life of patients with DM.

Real-world cost-effectiveness of insulin degludec in type 1 and type 2 diabetes mellitus from a Swedish 1-year and long-term perspective

BACKGROUND AND AIMS

The ReFLeCT study demonstrated that switching to insulin degludec from other basal insulins was associated with reductions in glycated hemoglobin and hypoglycemic events in type 1 (T1D) and type 2 diabetes (T2D), and reductions in insulin doses in T1D. The aim of the present analysis was to assess the short- and long-term cost-effectiveness of switching to insulin degludec in Sweden.

METHODS

Short-term outcomes were evaluated over 1 year in a Microsoft Excel model, while long-term outcomes were projected over patient lifetimes using the IQVIA CORE Diabetes Model. Cohort characteristics and treatment effects were sourced from the ReFLeCT study. Costs (in 2018 Swedish krona [SEK]) encompassed direct medical expenditure and indirect costs from loss of workplace productivity. In the long-term analyses, patients were assumed to receive insulin degludec or continue prior insulin therapy (primarily insulin glargine U100) for 5 years, before all patients intensified to once-daily degludec and mealtime aspart.

RESULTS

Switching to insulin degludec was associated with improved quality-adjusted life expectancy of 0.04 and 0.02 quality-adjusted life years (QALYs) over 1 year, and 0.16 and 0.08 QALYs over patient lifetimes, in T1D and T2D. Combined costs in T1D and T2D were estimated to be SEK 1,249 lower and SEK 1,181 higher over the short-term, and SEK 157,258 and SEK 2,114 lower over the long-term. Benefits were due to lower insulin doses in T1D, reduced rates of hypoglycemia, and lower incidences of diabetes-related complications. Insulin degludec was associated with an incremental cost-effectiveness ratio of SEK 64,298 per QALY gained for T2D over 1 year and considered dominant for T1D and T2D in all other comparisons.

CONCLUSIONS

Insulin degludec was projected to be cost-effective or dominant versus other basal insulins for the treatment of T1D and T2D in Sweden.

Managing the multifaceted nature of type 2 diabetes using once-weekly injectable GLP-1 receptor agonist therapy

WHAT IS KNOWN AND OBJECTIVE

As a highly prevalent chronic condition associated with complications and high mortality rates, it is important for pharmacists to have a comprehensive understanding of the impact of type 2 diabetes (T2D) and available treatment options. The use of injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs) is recommended as an effective and convenient treatment regimen for improving glycaemic control in individuals with T2D, with a good safety profile; however, the wider extent of its potential benefits often are unknown to clinical pharmacists. The objective of this article is to provide an overview of the impact of T2D on individuals and to discuss the multifaceted role of once-weekly (QW) GLP-1 RAs in addressing these challenges.

METHODS

This is a narrative review of the published literature regarding the use of injectable GLP-1 RAs in managing health complications in people with T2D.

RESULTS AND DISCUSSION

Recent findings reveal additional benefits of GLP-1 RAs in managing T2D complications, including atherosclerotic cardiovascular (CV) disease, retinopathy, neuropathy, and nephropathy. Dulaglutide and semaglutide have been shown to provide additional CV benefit in patients at high risk of CV events compared with standard of care/placebo and may offer renal protection in patients with chronic kidney disease. Cost-effectiveness studies, taking into consideration these different complications, have shown that QW GLP-1 RAs were cost-effective compared with other therapies. GLP-1 RAs may also help to improve overall health-related quality of life, reducing the risk of depression and 'diabetes distress', and limiting the risk of hypoglycaemia.

WHAT IS NEW AND CONCLUSION

From the literature, this appears to be the first review of the evidence supporting the multifaceted role of QW GLP-1 RAs in T2D, with particular emphasis on their use in comorbid conditions, as well as associated potential financial and well-being benefits. The results suggest that QW GLP-1 RAs may be an attractive treatment option for improving glycaemic control in T2D, especially in individuals with (or at risk of) additional comorbidities or health complications.

Health-related quality of life and health utilities in insulin-treated type 2 diabetes: the impact of related comorbidities/complications

OBJECTIVE

To evaluate the impact of multiple comorbidities/complications on health-related quality of life (HRQoL) and health utilities in insulin-treated type 2 diabetes (T2DM).

METHODS

In a non-interventional, epidemiological study, data were collected from medical records and via interviews for 938 subjects from various geographical areas of Greece. HRQoL and health utilities were explored with the EQ-5D-5L. Univariate associations were evaluated with the Mann-Whitney and Kruskal-Wallis tests for continuous and Chi-squared tests for nominal variables, and binary logistic regressions were employed to obtain marginal effects. Employing a split sample approach, various specifications of ordinary least squares regression models were evaluated in terms of goodness of fit, model specification, shrinkage and predictive and discriminative performance, to select the best model for mapping health utilities using the whole dataset.

RESULTS

Overall, the most important factors of impaired HRQoL and health utilities were higher age, female gender, obesity, poor glycemic control and increased duration of insulin treatment. History and increasing concurrence of all complications assessed were associated with exacerbated HRQoL problems, decreased health utilities and diminished health state, although it was not always statistically significant. The highest disutilities were associated with stroke (- 0.082), diabetic retinopathy (- 0.066), diabetic neuropathy (- 0.051) and severe hypoglycemia (- 0.050).

CONCLUSIONS

The deleterious impact of comorbidities on insulin-dependent T2DM subjects' HRQoL has been confirmed and clinicians should adapt the priorities of disease management accordingly. The derived health utility estimates may be valuable for conducting economic evaluations of interventions in the area of T2DM when data are not available.

Prevalence of diabetic peripheral neuropathy in Africa: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) is a global health care problem that can impose a substantial economic burden. Diabetic peripheral neuropathy (DPN) is a common microvascular complication of DM that increases the potential for morbidity and disability due to ulceration and amputation. Though there is a significant amount of variation in the primary studies on DM regarding the prevalence of DPN in Africa. Hence, this study was aimed to estimate the overall prevalence of DPN in DM patients in Africa.

METHODS

PubMed, Scopus, Google Scholar, African Journals OnLine, WHO African Library, and the Cochrane Review were systematically searched online to retrieve related articles. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines was followed. Heterogeneity across the included studies was evaluated by the inconsistency index (I2). Publication bias was examined by funnel plot and Egger's regression test. The random-effect model was fitted to estimate the pooled prevalence of diabetic peripheral neuropathy among patients in Africa. The meta-analysis was performed using the STATA™ Version 14 software.

RESULTS

Twenty-three studies which includes 269,691 participants were included in the meta-analysis. The overall pooled prevalence of diabetic peripheral neuropathy was 46% (95% CI:36.21-55.78%). Based on the subgroup analysis, the highest prevalence of diabetic peripheral neuropathy in DM patients was reported in West Africa at 49.4% (95% CI: 32.74, 66.06).

CONCLUSION

This study revealed that the overall prevalence of diabetic peripheral neuropathy is relatively high in Africa. Hence, DPN needs situation-based interventions and preventive strategies, which are specific to the country. Further meta-analysis is needed to identify associated factors for the occurrence of diabetic peripheral neuropathy.

Selecting the optimal risk threshold of diabetes risk scores to identify high-risk individuals for diabetes prevention: a cost-effectiveness analysis

AIMS

Although risk scores to predict type 2 diabetes exist, cost-effectiveness of risk thresholds to target prevention interventions are unknown. We applied cost-effectiveness analysis to identify optimal thresholds of predicted risk to target a low-cost community-based intervention in the USA.

METHODS

We used a validated Markov-based type 2 diabetes simulation model to evaluate the lifetime cost-effectiveness of alternative thresholds of diabetes risk. Population characteristics for the model were obtained from NHANES 2001-2004 and incidence rates and performance of two noninvasive diabetes risk scores (German diabetes risk score, GDRS, and ARIC 2009 score) were determined in the ARIC and Cardiovascular Health Study (CHS). Incremental cost-effectiveness ratios (ICERs) were calculated for increasing risk score thresholds. Two scenarios were assumed: 1-stage (risk score only) and 2-stage (risk score plus fasting plasma glucose (FPG) test (threshold 100 mg/dl) in the high-risk group).

RESULTS

In ARIC and CHS combined, the area under the receiver operating characteristic curve for the GDRS and the ARIC 2009 score were 0.691 (0.677-0.704) and 0.720 (0.707-0.732), respectively. The optimal threshold of predicted diabetes risk (ICER < $50,000/QALY gained in case of intervention in those above the threshold) was 7% for the GDRS and 9% for the ARIC 2009 score. In the 2-stage scenario, ICERs for all cutoffs ≥ 5% were below $50,000/QALY gained.

CONCLUSIONS

Intervening in those with ≥ 7% diabetes risk based on the GDRS or ≥ 9% on the ARIC 2009 score would be cost-effective. A risk score threshold ≥ 5% together with elevated FPG would also allow targeting interventions cost-effectively.

Health related quality of life and healthcare utilization among adults with diabetes and kidney and eye complications in the United States

BACKGROUND

One-third of adults with diabetes in the United States have chronic kidney disease (CKD), and 19% of them have eye complications (ECs). However, little is known about the Health-related Quality of Life (HRQoL) of adults with both of these diabetes-related complications. Therefore, the purpose of this study is to examine differences in the HRQoL, mental health, and healthcare utilization of adults with diabetes who have CKD, ECs, both or neither.

METHODS

A cross-sectional study design was implemented using data from multiple panels (2009-2015) of the Medical Expenditure Panel Survey. HRQoL was measured using the SF-12 Physical and Mental Component Summary (PCS & MCS) scores. The HRQoL, mental health, and healthcare utilization of four mutually exclusive groups: 1) diabetes with both CKD and ECs; 2) diabetes with CKD only; 3) diabetes with ECs only, and 4) diabetes with neither CKD nor ECs were compared. In all analyses, adults with neither CKD nor ECs were the reference group.

RESULTS

There were 8415 adults with diabetes who met the inclusion criteria. Approximately, 75% of the study sample had neither CKD nor ECs, 13.3% had ECs only, 5.7% had CKD only, and 5.5% had both CKD and ECs. In the adjusted analyses, adults with both CKD and/or ECs complications exhibited significantly lower HRQoL compared to those with neither CKD nor ECs. Mental illness and psychological distress were higher among adults with both CKD and ECs compared to those with neither CKD nor ECs. Furthermore, adults with CKD and/or ECs had higher polypharmacy, inpatient and emergency services use compared to those with neither CKD nor ECs.

CONCLUSIONS

The results indicate that the presence of both CKD and/or ECs was negatively associated with poor HRQoL, poor mental health, higher psychological distress and healthcare utilization in adults with diabetes. The findings emphasize the need for routine assessment and treatment for diabetes-related CKD and/or ECs complications to improve the quality of care for individuals with diabetes.