M Gillett

Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis

Objectives To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) intervention compared with usual care in people with newly diagnosed type 2 diabetes. Design We undertook a cost-utility analysis that used data from a 12 month, multicentre, cluster randomised controlled trial and, using the Sheffield type 2 diabetes model, modelled long term outcomes in terms of use of therapies, incidence of complications, mortality, and associated effect on costs and health related quality of life. A further cost-utility analysis was also conducted using current “real world” costs of delivering the intervention estimated for a hypothetical primary care trust. Setting Primary care trusts in the United Kingdom. Participants Patients with newly diagnosed type 2 diabetes. Intervention A six hour structured group education programme delivered in the community by two professional healthcare educators. Main outcome measures Incremental costs and quality adjusted life years (QALYs) gained. Results On the basis of the data in the trial, the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is £209 (95% confidence interval −£704 to £1137; €251, −€844 to €1363;

Can diabetes prevention programmes be translated effectively into real-world settings and still deliver improved outcomes? A synthesis of evidence

326, −

Assessing the cost-effectiveness of type 1 diabetes interventions: the Sheffield type 1 diabetes policy model.

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The cost-effectiveness of testing strategies for type 2 diabetes: a modelling study.

1773), the incremental gain in QALYs per person is 0.0392 (−0.0813 to 0.1786), and the mean incremental cost per QALY is £5387. Using “real world” intervention costs, the lifetime incremental cost of the DESMOND intervention is £82 (−£831 to £1010) and the mean incremental cost per QALY gained is £2092. A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of £20 000 per QALY is 66% using trial based intervention costs and 70% using “real world” costs. Results from a one way sensitivity analysis suggest that the DESMOND intervention is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year. Conclusion Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care, especially with respect to the real world cost of the intervention to primary care trusts, with reductions in weight and smoking being the main benefits delivered.

Who can prevent diabetes? Current issues in the prevention of type 2 diabetes

Randomized trials provide evidence that intensive lifestyle interventions leading to dietary and physical activity change can delay or prevent Type 2 diabetes. Translational studies have assessed the impact of interventions based on, but less intensive than, trial protocols delivered in community settings with high‐risk populations. The aim of this review was to synthesize evidence from translational studies of any design to assess the impact of interventions delivered outside large randomized trials.

Assessing the potential return on investment of the proposed UK NHS diabetes prevention programme in different population subgroups: an economic evaluation

To build a flexible and comprehensive long‐term Type 1 diabetes mellitus model incorporating the most up‐to‐date methodologies to allow a number of cost‐effectiveness evaluations.

Screening for type 2 diabetes : literature review and economic modelling

BACKGROUND An estimated 850,000 people have diabetes without knowing it and as many as 7 million more are at high risk of developing it. Within the NHS Health Checks programme, blood glucose testing can be undertaken using a fasting plasma glucose (FPG) or a glycated haemoglobin (HbA1c) test but the relative cost-effectiveness of these is unknown. OBJECTIVES To estimate and compare the cost-effectiveness of screening for type 2 diabetes using a HbA1c test versus a FPG test. In addition, to compare the use of a random capillary glucose (RCG) test versus a non-invasive risk score to prioritise individuals who should undertake a HbA1c or FPG test. DESIGN Cost-effectiveness analysis using the Sheffield Type 2 Diabetes Model to model lifetime incidence of complications, costs and health benefits of screening. SETTING England; population in the 40-74-years age range eligible for a NHS health check. DATA SOURCES The Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) data set was used to analyse prevalence and screening outcomes for a multiethnic population. Alternative prevalence rates were obtained from the literature or through personal communication. METHODS (1) Modelling of screening pathways to determine the cost per case detected followed by long-term modelling of glucose progression and complications associated with hyperglycaemia; and (2) calculation of the costs and health-related quality of life arising from complications and calculation of overall cost per quality-adjusted life-year (QALY), net monetary benefit and the likelihood of cost-effectiveness. RESULTS Based on the LEADER data set from a multiethnic population, the results indicate that screening using a HbA1c test is more cost-effective than using a FPG. For National Institute for Health and Care Excellence (NICE)-recommended screening strategies, HbA1c leads to a cost saving of £12 and a QALY gain of 0.0220 per person when a risk score is used as a prescreen. With no prescreen, the cost saving is £30 with a QALY gain of 0.0224. Probabilistic sensitivity analysis indicates that the likelihood of HbA1c being more cost-effective than FPG is 98% and 95% with and without a risk score, respectively. One-way sensitivity analyses indicate that the results based on prevalence in the LEADER data set are insensitive to a variety of alternative assumptions. However, where a region of the country has a very different joint HbA1c and FPG distribution from the LEADER data set such that a FPG test yields a much higher prevalence of high-risk cases relative to HbA1c, FPG may be more cost-effective. The degree to which the FPG-based prevalence would have to be higher depends very much on the uncertain relative uptake rates of the two tests. Using a risk score such as the Leicester Practice Database Score (LPDS) appears to be more cost-effective than using a RCG test to identify individuals with the highest risk of diabetes who should undergo blood testing. LIMITATIONS We did not include rescreening because there was an absence of required relevant evidence. CONCLUSIONS Based on the multiethnic LEADER population, among individuals currently attending NHS Health Checks, it is more cost-effective to screen for diabetes using a HbA1c test than using a FPG test. However, in some localities, the prevalence of diabetes and high risk of diabetes may be higher for FPG relative to HbA1c than in the LEADER cohort. In such cases, whether or not it still holds that HbA1c is likely to be more cost-effective than FPG depends on the relative uptake rates for HbA1c and FPG. Use of the LPDS appears to be more cost-effective than a RCG test for prescreening. FUNDING The National Institute for Health Research Health Technology Assessment programme.

'Computer modeling of diabetes and its complications: A report on the Fourth Mount Hood Challenge Meeting'

Research evidence supports the widely held view that much of the current and growing disease burden associated with diabetes in the UK is due to sedentary lifestyles and dietary trends and is therefore preventable in principle. However, prevention is dependent on the implementation of affordable and effective interventions that will encourage behaviour change, increasing physical activity levels and modifying low-fibre, calorie-dense diets. Both population-wide and individual-based intervention/prevention strategies may be feasible and costeffective, but there are a number of key outstanding uncertainties that require both further research and economic modelling to resolve. The potential for harms to outweigh benefits when implementing preventive interventions, and for health inequalities to be exacerbated when promoting behaviour change, means that guidance must consider ethics as well as effectiveness. The nature and scale of the challenge faced means that societal as well as individual and community change will be required. There are synergies between diabetes prevention strategies and wider public health priorities in relation to both chronic disease prevention and global climate change, but strong advocacy and leadership from the health sector will be required if we are to seize the opportunity to reverse current trends. DeClaration of interests No conflict of interests declared. 1E Goyder, 2R Simmons, 3M Gillett 1Section Director and Reader in Public Health Medicine, School of Health and Related Research (ScHARR), University of Sheffield; 2Career Development Fellow, MRC Epidemiology Unit, Cambridge; 3Research Fellow, ScHARR, University of Sheffield, Sheffield, UK Correspondence to E Goyder, Public Health Section, School of Health and Related Research, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK e.goyder@sheffield.ac.uk doi:10.4997/JRCPE.2010.S01 Background paper

Non-Pharmacological Interventions to Reduce the Risk of Diabetes in People with Impaired Glucose Regulation: A Systematic Review and Economic Evaluation

Objectives To evaluate potential return on investment of the National Health Service Diabetes Prevention Programme (NHS DPP) in England and estimate which population subgroups are likely to benefit most in terms of cost-effectiveness, cost-savings and health benefits. Design Economic analysis using the School for Public Health Research Diabetes Prevention Model. Setting England 2015–2016. Population Adults aged ≥16 with high risk of type 2 diabetes (HbA1c 6%–6.4%). Population subgroups defined by age, sex, ethnicity, socioeconomic deprivation, baseline body mass index, baseline HbA1c and working status. Interventions The proposed NHS DPP: an intensive lifestyle intervention focusing on dietary advice, physical activity and weight loss. Comparator: no diabetes prevention intervention. Main outcome measures Incremental costs, savings and return on investment, quality-adjusted life-years (QALYs), diabetes cases, cardiovascular cases and net monetary benefit from an NHS perspective. Results Intervention costs will be recouped through NHS savings within 12 years, with net NHS saving of £1.28 over 20 years for each £1 invested. Per 100 000 DPP interventions given, 3552 QALYs are gained. The DPP is most cost-effective and cost-saving in obese individuals, those with baseline HbA1c 6.2%–6.4% and those aged 40–74. QALY gains are lower in minority ethnic and low socioeconomic status subgroups. Probabilistic sensitivity analysis suggests that there is 97% probability that the DPP will be cost-effective within 20 years. NHS savings are highly sensitive to intervention cost, effectiveness and duration of effect. Conclusions The DPP is likely to be cost-effective and cost-saving under current assumptions. Prioritising obese individuals could create the most value for money and obtain the greatest health benefits per individual targeted. Low socioeconomic status or ethnic minority groups may gain fewer QALYs per intervention, so targeting strategies should ensure the DPP does not contribute to widening health inequalities. Further evidence is needed around the differential responsiveness of population subgroups to the DPP.