Abstract
A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective. To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program. This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India. The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice. Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $). The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 549 (95% CI, INR 10 134-10 964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 090 (INT $14 539) per diabetes case prevented and/or delayed, and INR 196 960 (INT $14 986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 495 (INT $6505) to INR 296 681 (INT $22 574) per diabetes case prevented, and from INR 88 121 (INT $6705) to INR 305 798 (INT $23 267) per quality-adjusted life-year gained. The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.
Highlights
The health and cost burdens of diabetes are increasing worldwide.[1]
Implementing lifestyle modification and metformin was associated with Indian rupees (INR) 10 549 (INT $803 [95% CI, international dollars (INT $)771-834]) higher direct costs; INR 5194 (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2%, and an incremental gain of 0.099 quality-adjusted life-years per participant
The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added
Summary
The health and cost burdens of diabetes are increasing worldwide.[1]. India has the second largest number of individuals with diabetes worldwide, which is projected to grow in coming years.[2,3] identifying and implementing cost-effective diabetes prevention strategies is of great importance.A number of studies[4,5,6,7] have demonstrated that intensive lifestyle modification (LSM) programs and medications decrease progression to type 2 diabetes in individuals with high risk for diabetes. The health and cost burdens of diabetes are increasing worldwide.[1] India has the second largest number of individuals with diabetes worldwide, which is projected to grow in coming years.[2,3] identifying and implementing cost-effective diabetes prevention strategies is of great importance. Current expert guidelines[8] recommend a stepwise approach, ie, initiating LSM and intensifying diabetes prevention by adding metformin therapy if there is no or insufficient response to LSM during 4 to 6 months. In the Diabetes Community Lifestyle Improvement Program (D-CLIP),[9] we tested this stepped approach to diabetes prevention and demonstrated a 32% relative risk reduction in diabetes incidence that was maintained at 3 years for participants receiving the stepwise approach compared with participants receiving general lifestyle advice.[10]
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