A Review and Analysis of Economic Models of Prevention Benefits. A Review and Analysis of Economic Models of Prevention Benefits : Table 7


: Table 7

Abstracted informationZhuo et al. 2012 A nationwide community-based lifestyle program could delay or prevent type 2 diabetes cases and save $5.7 billion in 25 yearsKlein et al. 2011 Economic Impact of the clinical benefits of bariatric surgery in diabetes patients with BMI ≥35 kg/m2Mullen & Marr 2010 Longitudinal cost experience for gastric bypass patientsRoux et al. 2010 Cost effectiveness of community-based physical activity interventionsChatterjee et al. 2010 Screening adults pre-diabetes and diabetes may be cost-savingHuang et al. 2009 Using clinical information to project federal health care spendingHerman et al. 2005 The cost-effectiveness of lifestyle modification or metformin in preventing type 2 diabetes in adults with impaired glucose toleranceBertram et al. 2010 Assessing cost-effectiveness of drug and lifestyle intervention following opportunistic screening for pre-diabetes in primary careJohansson et al. 2009 A cost-effectiveness analysis of a community-based diabetes prevention program in Sweden
Target populationAmericansAmericansAmericansAmericansAmericansAmericansAmericansAustraliansSwedish
Study population (epidemiological)Adults aged 18-84 at high risk of developing type 2 diabetes (identified by HbA1c or fasting glucose-based diagnostic test)808 diabetes patients, who had bariatric surgery from 40 large nationwide insurers administrative claims database224 gastric bypass patients during 3 periods (preoperative, surgical, postoperative); overweight and obeseClosed cohort of US adult population aged 25-64 in 2004Individuals without known diabetesUnited States adult population ages 24 -85Members of the DPP cohort 25 years of age or older with impaired glucose ToleranceAustralian population over 45 years old without diabetes but did have risk factors for the diseaseThree municipalities in the metropolitan area of Stockholm, Sweden; aged 36-56; 2,149 men and 3,092 women
Study population (economic)Representative of the US populationSame as aboveSame as aboveSame as above1,259 adults60,000 to 100,000 representative individuals, among those who had existing diabetes and aged into the program or those who developed diabetes in this age rangeSame as above8,000 individual life histories10,000 individuals
Intervention(s)Lifestyle intervention program.   Three alternative strategies from base case: (1) All eligible people will be based on a blood sample test (2) Two year program (3) Program offered at the same intensity after the first yearBariatric surgeryBariatric surgerySeven public health interventions to promote physical activity. Interventions exemplifying each of four strategies strongly recommended by the Task Force on Community Preventive Services: (1) community-wide campaigns; (2) individually adapted health behavior change; (3) community social-support interventions; (4) the creation of or enhanced access to physical activity information and OpportunitiesStrategies: (1) GCT-pl (glucose challenge test - plasma) (2) GCT-cap (glucose challenge test - capillary) (3) RPG (random plasma glucose) (4) RCG (random capillary glucose (5) A1CPrototypical intervention to improve the treatment of type 2 diabetes similar to current well-designed disease management programsDiabetes Prevention Program. The lifestyle intervention was implemented with a 16-lesson core curriculum covering diet, exercise, and behavior modification that was taught by case managers on a one-on-one basis, followed by individual sessions (usually monthly) and group sessions with case managersScreening program followed up with 6 alternative interventions: pharmaceutical (acarbose, metformin, orlistat) or lifestyle (diet, exercise, diet and exercise) - screening inclusion criteria: age >55 years; age >45 plus high BMI, family history of type 2 diabetes or hypertension; or people from 'high-risk' groups (e.g. Indigenous Australians and women who suffered from gestational diabetesCommunity-based program promoting general population lifestyle changes to prevent diabetes: (1) develop community relations, and to educate and implement activities with local organizations; (2) to increase the aware of risk factors; (3) availability of physical activities; (4) healthy food, a nonsmoking environment; (5) professional guidance to loose weight or start exercising
Comparator(s)No interventionNo interventionPrevious health plan overweight and obese groupNo interventionNo interventionNo interventionPlacebo interventionSee aboveNo intervention
Data sourcesNational Health Examination Survey, US Census Bureau, Diabetes Prevention Program study, Medical Expenditure Panel SurveyPrivately insured administrative claims database from 40 large nationwide insurers, pharmacy claimsMidwestern metropolitan health plan administrative claims databaseUS Census Bureau, American College of Sports Medicine, CDC Behavioral Risk Factor Surveillance System, Jeffery et al. 1998, Kriska et al. 1998, Linenger et al. 1991, Lombard et al. 1995, Knowler et al. 2002, Reger et al. 2002, Young et al. 2001, Wilson et al. 1998, Wolfe et al. 2002, Brown et al. 1996, CDC National diabetes fact sheet, CDC Nation diabetes surveillance system, NCI Surveillance, epidemiology, and end results, Finkelstein et al. 2004, Katzmarzyk et al. 2004, Hu et al. 2000, National Vital Statistics Report, Lee et all. 2001, Tengs et al. 2003, Kaplan et al. 2001 & 1996, Diamond et al 2004, MEPSScreening for Impaired Glucose Tolerance (SIGT) study, Knowler et al. (2002), Diabetes Prevention Program Research Group, Trogdon et al. (2008), Nichols et al. (2005, 2008), Blake et al. (2004),  Gerstein et al. (2007), Dall et al. (2008), Medical Expenditure Panel Survey2005-06 National Health and Nutrition Examination Survey (NHANES)Diabetes Prevention Program, United Kingdom Prospective Diabetes Study (UKPDS)Australian burden of disease and injury study, Australian diabetes, obesity, lifestyle study, vital registration data from the Australian Bureau of Statistics, Australian Institute of Health and Welfare, Busselton Study, Framingham Study, NEMESIS (North East Melbourne Stroke Incidence Study)Eriksson et al. (2005, 2008), interviews with key collaborators, Caro et al. (2007), Anderson et al. (1991), Stern et al. (2002), Clarke et al. (2004), Zethraeus et al. (1991), Andersson & Kartman (1995), Ryeden-Gergsten (1999), Claesson et al. (2000), Henriksson et al. (2000), Sullivan et al. (2005), Redekop et al. (2002)
Valuation of health benefits ($, QALYs, LYS, cases averted)Type 2 diabetes cases prevent or delayed, life years gained, quality-adjusted life years (QALYs)Post-index/surgery outcomes measures: diagnostic claims for diabetes; claims for diabetes medication, average total costs of diabetes medication and suppliesNet cost-savings to health plan cost of careQuality-adjusted life years (QALYs), life years, cases of disease (coronary heart disease, ischemic stroke, type 2 diabetes, breast cancer, colorectal cancer) avertedCost-savingsCost offset (not cost-savings, but long-term reduction in major complications of diabetes including blindness, kidney failure, lower-extremity amputations, stroke, and coronary heart disease)Cumulative incidence of diabetes, microvascular and neuropathic complications, cardiovascular complications, survival, direct medical and direct nonmedical costs, quality-adjusted life-years (QALYs)Disability-adjusted life years (DALYs)Quality-adjusted life years (QALYs); life-years lost (YLS)
CostsApprox. $300 per person for the first year in the program, which includes supplies, time, and administration; $150 per person in the second year and $50 per person in the years thereafterIn-patient, ER, outpatient hospital, office visits; use of medication for weight loss, drug, medical (no further specification)Patient co-pays, co-insurance, coordination of benefits and deductibles, health plan dollarsMaterials, intervention, out-of-pocket expenses (e.g. clothing, equipment), participants' time, infrastructural components (e.g. physical activity facilities, trails)Screening, OGTT (oral glucose tolerance test), testing, true positive, false negativediabetes care, program, re-estimated costs incorporating program costs and clinical benefits, preventive medications, routine testingImpaired glucose tolerance, type 2 diabetesGP visits, medication, monitoring costs and visits to other health professional including dietitians and exercise physiologists, time, travelIn relation to CHD (coronary heart disease), AMI (acute myocardial infarction), stroke, diabetes and micro/macro complications: healthcare, pharmaceuticals, community care, patient time and travel, informal care, productivity costs
Time horizon25 years9 years7.5 yearsLifetime3 years10 and 25 yearsLifetimeLifetime or 100 years10 years
Discount rate (annual)Costs and benefits 3%Incremental savings were discounted using the mean return on a 3-month US treasury bill at 3.43%N/SCosts and benefits 3%N/SNo discounting, but cost-growth assumptions of 2.4% real growth annually for ten years and 1.7% per year thereafterCosts and benefits 3%Costs and benefits 3%Costs and QALYS 3%; YLS undiscounted
Model design (static/dynamic)Dynamic (no further specification)Static (no further specification)Static (no further specification)Dynamic (Markov, Monte Carlo/probabilistic sensitivity analysis)Static (no further specification)Dynamic (no further specification)Dynamic (Markov, probabilistic sensitivity analysis)Dynamic (Markov microsimulation, second-order/Monte Carlo simulations)Dynamic (Markov, stochastic/Monte Carlo simulation/probabilistic sensitivity analysis)
Sensitivity analysis (parameters)One-way: relative risk, cost of interventionN/SN/SOne-way & multi-way: time horizon, costs, and others (not specified)One or multi-way not specified. Screening cutoffs, testing time, disease prevalence, rates of progression to diabetes, VA testing costs, lifestyle treatmentN/SOne-way: costs, % patient adherence, discount rates, hazard of diabetes, delay from onset to diagnosis of diabetesOne or multi-way not specified: one or two OGTT (oral glucose tolerance test); risk ratios of stroke in CHD, CHD in stroke, IHD in diabetes, stroke in diabetes; 28-day case fatality rate (ischemic and haemorrhagic stroke)One-way & multi-way: disease risks, death risks, medical treatment costs, all costs, QoL weights.   One-way only: discount rate, costs in added life years, termination age
Value of informationN/SN/SN/SN/SN/SN/SN/SN/SN/S
Generalizability/scalability of findings         
Distributional or equity analysisN/SN/SN/SN/SN/SYounger population have greater clinical benefits from treatment improvement (younger can subsidize the costs of older cohorts)N/SN/SN/S
Results885,000 cases of type 2 diabetes prevented or delayed and $5.7 billion savings; or $36,024/QALYs gainedFor surgery patients, the initial investment averaged ~$25,000 for all surgeries 1999–2007, $31,000 for open surgeries 1999–2003,$29,000 for open surgeries 2004–2007, and $19,000 for laparoscopic surgeries 2004–2007. Cost savings associated with surgery started accruing at month 3. Total surgery costs were fully recovered on average after 30 months in 1999–2007 for all types of surgeries; after 29 months for open surgeries in 2004–2007;and after 26 months for laparoscopic surgeries in 2004–2007.The inflation adjusted mean per member per year total paid decreased by $1,895 in the fifth year after surgery. The mean costs for gastric bypass patients were lower within the first year after surgery than their preoperative costs. At 3.5 years after surgery, the surgical costs had been recouped for patients undergoing gastric bypass surgery, and by year 2, they had incurred fewer costs than the obese health plan population.ICERs ranged between $14,000 and $69,000 per QALY gained, relative to no intervention. Results were sensitive to intervention-related costs and effect size.Assuming 70% specificity screening cutoffs, Medicare costs for testing, retail costs for generic metformin, and costs for false negatives as 10% of reported costs associated with pre-diabetes/diabetes, health system costs over 3 years for the different screening tests would be GCT-pl $180,635; GCT-cap $182,980; RPG $182,780; RCG $186,090; and A1C $192,261; all lower than costs for no screening, which would be $205,966.   Under varying assumptions, projected health system costs for screening and treatment with metformin or lifestyle modification would be less than costs for no screening as long as disease prevalence is at least 70% of that of our population and false-negative costs are at least 10% of disease costs. Societal costs would equal or exceed costs of no screening depending on treatment type.10-year effects (2009-2018): age 24-30, $2.5B; 31-40, $1.8B; 41-50, $2.1B; 51-60, $3.1B; 61-64, $3.5B   25-year effects (2009-2033): age 24-30, $27B; 31-40, $20B; 41-50, $17B; 51-60, $15B; 61-64, $16BCompared with the placebo intervention, the cost per QALY was approximately $1,100 for the lifestyle intervention and $31,300 for the metformin intervention. From a societal perspective, the interventions cost approximately $8,800 and $29,900 per QALY, respectively. The lifestyle intervention dominated th metformin interventionThe most cost-effective intervention options are diet and exercise combined, with a cost-effectiveness ratio of AUD 22,500 per disability-adjusted life year (DALY) averted, and metformin with a cost-effectiveness ratio of AUD 21,500 per DALY averted. The incremental addition of one intervention to the other is not cost-effective.In all areas, risk factor levels increased during follow-up, leading to increased societal costs of between SEK40,000 and 90,000 (1 Euro 2004 = SEK9.13; 1 US$ = SEK7.35) and quality-adjusted life-year (QALY) losses between 0.12 and 0.48 per individual. Compared with the control area, the cost increases and QALY losses for women were more favorable in two program areas but less favorable in one, and less favorable for men in both areas (data unavailable for one municipality). The findings indicate that the program was cost-effective in only two female study groups.
LimitationsDid not consider other lifestyle intervention programs occurring at the same time (such as for hypertension); real-world setting results is unknown; limited to readily available data; only presented one of the many alternative scenariosNo data on glycosylated hemoglobin levels, blood pressure measurements, or lipid profiles; measure of surgery and clinical not available; cost-savings depend on control matching process; differences could exist in lifestyle behaviors, self-management skills, and other medicationsLack of quality-of-life metric; small final sample sizeLimited data on race/ethnicity, so assessment of cost-effectiveness on subpopulations; individuals considered well, if they do not fall into one of the 5 defined disease categories; data assumes people enter model with or without disease(s), model assumes all start 'well'; utility values not specific to subpopulation likely to choose treatmentStudy subjects were volunteers; assumed all adults are screened for pre-diabetes/diabetes; metformin may not be the best treatmentModel only looks at direct costs of type 2 diabetes; model does not include potential federal cost consequences of an intensive diabetes management effort; model does not provide a complete assessment of federal budgetary implicationsSimulation results depend on the accuracy of the underlying assumptions, including participant adherence.May have additional costs from pre-diabetes screening; may have higher benefits from other diseases; should have lower participation rates due to recruitment of motivated participantsQuestion whether all effects from the program were included in the analysis; CBA might better reflect the societal value