Diabetes Prevention Program (DPP) ROI Abstracts

Article 1:

DPP Research Group; Costs Associated With the Primary Prevention of Type 2 Diabetes Mellitus in the Diabetes Prevention Program; Diabetes Care; 26:36-47, 2003.

  1. What was the intervention/program?

Random assignment of participants into 3 groups: 1) Lifestyle Intervention 2) Medication (Metformin) Intervention 3) Placebo

The lifestyle intervention consisted of a 16 lesson curriculum including diet, exercise, and behavior modification taught by case managers on a one on one basis for the first 24 week and then monthly individual and group sessions to reinforce behavior change. The goal of the lifestyle intervention was a 7% weight reduction through decreased calories consumption, decreased dietary fat and moderate intensity physical activity. The medication intervention randomized participants to either receive metformin or a placebo at 850 mg/daily for the first month and then twice daily after. Lifestyle recommendations were given via written information and annual 20-30 minute individual sessions in addition to quarterly adherence visits.

  1. In what setting? What population?

Eligibility was determined by: IGT, 25 years or older, BMI of 24 or higher or BMI of 22 or high or Asian Americans. A total of 3,234 participants enrolled with a mean age of 51 and a mean BMI of 34. Women comprised 68% of participants and 45% were of minority groups.

  1. What type of economic analysis? (minimization, cost-benefit, cost-effectiveness, cost-utility)

Cost-benefit: Describes the costs associated with primary prevention of T2D in the DPP comparing the costs between interventions.

  1. From whose perspective? (individual, payer, societal)

Cost from a large health system (payer) perspective and societal perspective.

  1. What were the cost and types of costs?

Costs included direct medical costs, direct non-medical costs, and indirect costs of lifestyle and medication interventions compared to placebo. Large health system costs include only direct medicals coats while societal costs include direct medical and non-medical costs in addition to indirect costs. Direct medical costs include identification of individuals with IGT, implementation and maintenance of interventions, hospitalization, outpatient care, laboratory tests, medications, and costs of medical care outside of the DPP. Direct non-medical costs include the participants time spent traveling for appointments, exercising, purchase of equipment or gym memberships, shopping, and cooking. Indirect costs include loss of work, illness, or disability related to morbidity and lost productivity due to premature death/mortality.

  1. What were the benefits? (Results)

The direct medical cost of identifying each randomized participant was $139.

Placebo Intervention: Year 1 direct medical costs= $43/subject; year 2 and 3= $18/subject

Metformin Intervention: Year 1 direct medical costs= $1,019/subject($671=cost of med.); year 2=$772 ($618=cost of med); year 3= $751 ($595=cost of med)

Lifestyle Intervention: Year 1 direct medical costs= $1,399/subject ($750=staff time); year 2= $679/subject ($339=staff time); year 3=$702 ($339=staff time)

Over 3 years, direct medical costs per participant for the placebo group, metformin group, and lifestyle intervention were $79, $2,542, and $2,780 respectively. However, when comparing the direct medical costs outside of the DPP, the metformin group was $272 less and the lifestyle group $432 less compared to the placebo group. Over 3 years, direct nonmedical costs were $9 less for the metformin group and $1,445 greater for the lifestyle participants compared to the placebo. Over 3 years, indirect costs were $230 greater for the metformin participants and $174 less for lifestyle participants than for the placebo participants. From the perspective of a large health system, both the metformin and lifestyle intervention cost approximately $750 per participant per year, or $2,250 per participant over 3 years. Costs are likely to decrease with the use of generic formulas of metformin and better efficiency of utilization of staff time by using group visits.

  1. What are the key talking points?

Article 2:

DPP Research Group; Within-Trial Cost-Effectiveness of Lifestyle Intervention or Metformin for the Primary Prevention of Type 2 Diabetes; Diabetes Care; 26:2518-2523, 2003.

  1. What was the intervention/program?

Random assignment of participants into 3 groups: 1) Lifestyle Intervention 2) Medication (Metformin) Intervention 3) Placebo

The lifestyle intervention consisted of a 16 lesson curriculum including diet, exercise, and behavior modification taught by case managers on a one on one basis for the first 24 week and then monthly individual and group sessions to reinforce behavior change. The goal of the lifestyle intervention was a 7% weight reduction through decreased calories consumption, decreased dietary fat and moderate intensity physical activity. The medication intervention randomized participants to either receive metformin or a placebo at 850 mg/daily for the first month and then twice daily after. Lifestyle recommendations were given via written information and annual 20-30 minute individual sessions in addition to quarterly adherence visits.

  1. In what setting? What population?

Eligibility was determined by: IGT, 25 years or older, BMI of 24 or higher or BMI of 22 or high or Asian Americans. A total of 3,234 participants enrolled with a mean age of 51 and a mean BMI of 34. Women comprised 68% of participants and 45% were of minority groups.

  1. What type of economic analysis? (minimization, cost-benefit, cost-effectiveness, cost-utility)

Cost effectiveness in terms of diabetes prevented; cost utility in terms of measuring quality-adjusted life-years.

  1. From whose perspective? (individual, payer, societal)

Cost from a health system (payer) perspective and societal perspective.

  1. What were the cost and types of costs?

Costs included direct medical costs, direct non-medical costs, and indirect costs of lifestyle and medication interventions compared to placebo. Large health system costs include only direct medicals coats while societal costs include direct medical and non-medical costs in addition to indirect costs. Direct medical costs include identification of individuals with IGT, implementation and maintenance of interventions, hospitalization, outpatient care, laboratory tests, medications, and costs of medical care outside of the DPP. Direct non-medical costs include the participants time spent traveling for appointments, exercising, purchase of equipment or gym memberships, shopping, and cooking. Indirect costs include loss of work, illness, or disability related to morbidity and lost productivity due to premature death/mortality.

  1. What were the benefits?

Increased quality of life (measured by health utility scores) and quality-adjusted life-years (QALYs) over 3 years: For the lifestyle intervention a total of 0.072 in QALY’s were gained and 0.022 for the metformin intervention. Using number need to treat (NNT) calculation, found that 6.9 people with IGT would need to be treated with the lifestyle intervention and 14.3 with the metformin intervention to prevent 1 case of diabetes.

  1. What are the key talking points?

The intervention was DPP. From a payer perspective, the lifestyle intervention cost $15,700 per case of diabetes prevented or delayed and the metformin intervention cost $31,300; per QALY societal perspective, the lifestyle intervention cost $24,400 per case of diabetes prevented or delayed and the metformin intervention cost $34,500; per QALY gained, the lifestyle intervention cost $51,600 and metformin intervention cost $99,200.

Article 3:

DPP Research Group; The 10-Year Cost-Effectiveness of Lifestyle Intervention or Metformin for Diabetes Prevention; Diabetes Care, 35:723-730, 2012.

  1. What was the intervention/program?

The interventions were the DPP and DPPOS. The DPPOS was a follow up study to the DPP. Participants in the DPP were informed of the main results and treatment groups were revealed. Metformin and placebo participants entered a 1-2 week drug washout study. All participants were then offered a 16-session lifestyle curriculum as a bridge protocol. Lifestyle sessions were offered to all participants at 3 month intervals. For the original lifestyle participants only, 2 group classes comprising of 4 sessions per year were offered. The metformin group continued 850mg twice daily unless development of diabetes required further treatment by physician. Outcome assessment examinations continued per DPP protocol yearly and 6 monthly. The primary objectives were to assess long-term effects of DPP intervention on the development of diabetes and the complications.

  1. In what setting? What population?

3,150 surviving DPP participants were eligible, irrespective of whether they had developed diabetes. Of those eligible, 2,766 (88%) enrolled in the DPPO study. Demographics did not differ significantly by sex or ethnic origin when compared to the original DPP participants. Enrollment was lower in women with a history of gestational diabetes and was related to greater age, and in women, by lower weight and BMI.

  1. What type of economic analysis? (minimization, cost-benefit, cost-effectiveness, cost-utility)

Cost effectiveness in terms of diabetes prevented; cost utility in terms of measuring quality-adjusted life-years

  1. From whose perspective? (individual, payer, societal)

Cost from a health system (payer) perspective

  1. What were the cost and types of costs?

Total direct medical costs associated with the DPP and DPPOS interventions were calculated over each of the 10 years. Cost of lifestyle was estimated if it had been administered in a group format rather than individually as a sensitivity analysis. Direct nonmedical sots were assessed twice, once during the DPP and once during the DPPOS. The cumulative per participant costs of the lifestyle intervention (original one on one format) was $4,601, metformin intervention $2,300, and placebo $769. The cost of the lifestyle intervention dropped to $3,023 when estimating the cost in a group setting. The cumulative direct medical costs for care outside of the interventions were $24,563 for lifestyle, $25,616 for metformin, and $27,468 for place. Cumulative total direct medical costs were $29,164 for lifestyle, $27,915 or metformin, and $28,236 for placebo. The direct medical costs of nonintervention-related medical care were 34%-44% higher among diabetic participants compared to non-diabetic participants. Over 10 years, per capita nonintervention direct medical costs were $1,853 and $2.905 more for the placebo groups compared to both intervention groups.

  1. What were the benefits?

Each year after randomization, quality of life was better for the lifestyle group when compared to the other two. The lifestyle group had the greater quality of well-being score over 10 years of 6.81 while the metformin group was 6.69 and placebo 6.67. Per QALY gained was $10,037 for the lifestyle group with the metformin group having a slightly lower cost per QALY.

  1. Key points?

From the perspective of a health system (payer) the lifestyle intervention is cost-effective while the metformin intervention is slightly cost-saving when compared to the placebo.

Article 4:

Eddy DM, Schlessinger L, Kahn R; Clinical Outcomes and Cost-Effectiveness of Strategies for Managing People at High Risk for Diabetes; Ann Intern Med, 143:251-264, 2005.

  1. What was the intervention/program?

Using the Archimedes model, the investigators aimed to determine the cost-effectiveness of no prevention, DPP’s lifestyle program, lifestyle modification after developing diabetes, and metformin.

  1. In what setting? What population?

The population is derived from basic studies, epidemiologic studies, clinical trial, and Kaiser Permanente administrative data. These populations are defined at high risk for diabetes by a BMI greater than 24, fasting glucose levels between 5.3 and 6.9, and a 2-hr glucose tolerance test of 7.77 to 11 mmol/L. Measurements included are diagnosis of diabetes and complications of diabetes.

  1. What type of economic analysis? (minimization, cost-benefit, cost-effectiveness, cost-utility)

A cost-effectiveness analysis is used to determine cost associated between no prevention of diabetes, cost of treatment with diagnosed diabetes, and lifestyle and medication interventions. Cost-utility analysis is used in terms of QALYs.

  1. From whose perspective? (individual, payer, societal)

The perspective is from the healthcare system or payer. The societal cost is also analyzed for each group.

  1. What were the cost and types of costs?

Compared to no intervention, per QALY, the DPP lifestyle intervention would be $143000 from the payers perspective and $62,000 from a societal perspective. The use of metformin, per QALY, from the payers perspective would be about $35,000. Delaying intervention until diagnosis would cost $24,500 per QALY. The DPP lifestyle program’s marginal cost-effectiveness compared to delaying lifestyle modification until after diabetes diagnosis is about $201,800.

  1. What were the benefits? (Did not show “benefits”)

Over a 30 year time period, investigators found that a DPP-like lifestyle change would prevent approximately 11% of cases of diabetes, 22% of serious complications, and about 18% of related deaths for people at high risk. In terms of per person costs to a health plan, for the first 5 years it would cost approximately $60 per month for a high-risk person. For cost-effectiveness, about 100,000 members with a 10% turnover per year, the 30 year cost per QALY of a DPP like program would be about $143,000 from a health plans perspective. From a societal perspective the cost/QALY compared with no program would be about $63,000 over 30 years.

  1. Key Points?

Compared to no intervention, lifestyle modification could be cost-saving over 30 years if the annual cost of the intervention was reduced to about $100. This study using existing literature found that the DPP may be cost too expensive for health plans to handle.

Article 5:

Ackermann RT, Marrero DH, Hicks KA, Hoerger TJ, An Evaluation of Cost Sharing to Finance a Diet and Physical Activity Intervention to Prevent Diabetes; Diabetes Care, 29:1237-1241, 2006.

  1. What was the intervention/program?

Investigators used the DPP lifestyle intervention results to determine if there would be a ROI for private health insurers while still attracting participants, employers and Medicare. A Markov simulation model used DPP data to estimate direct medical costs and direct medical costs not associated with the intervention for individuals that did not develop diabetes within the 3 year period.

  1. In what setting? What population?

DPP eligibility was determined by: IGT, 25 years or older, BMI of 24 or higher or BMI of 22 or high or Asian Americans. A total of 3,234 participants enrolled with a mean age of 51 and a mean BMI of 34. Women comprised 68% of participants and 45% were of minority groups.

  1. What type of economic analysis? (minimization, cost-benefit, cost-effectiveness, cost-utility)

Cost effectiveness in terms of diabetes prevented; cost utility in terms of measuring quality-adjusted life-years.

  1. From whose perspective? (individual, payer, societal)

The article is written from a health system (payer) perspective comparing DPP lifestyle and placebo interventions.

  1. What were the cost and types of costs?

Direct medical costs were looked at while assuming that year 3 costs of the program would be incurred each year until individuals developed diabetes or died.

  1. What were the benefits?

Lifetime health economic benefits: Compared to the placebo, people starting the program before 50 years of age, diabetes risk was reduced from 87% to 65% and the cost-effectiveness ratio was $1,288 per QALY gained. For Medicare, for every 100 people in the intervention at age 50, there were about 28 fewer people living with diabetes at 65 years old. After age 65, medical costs were $2,136 lower for participants compared to the placebo. For private payers these benefits were associated with a 15-year incremental cost of $2,894 and incremental cost-effectiveness of $9,647 per QALY gained. According to the model, if a group intervention were offered with similar results, a private payer contribution would be completely recovered after 3 years. Compared to no intervention, the DPP could prevent 37% of new cases of diabetes before the age of 65 if the program was offered at age 50. This would be at a cost of $1,288 per QALY gained. In addition, the model estimates that a private payer could reimburse up to 24% of intervention costs during the first 3 years of the program and still achieve complete ROI.

  1. Key points?

Through cost sharing, the DPP intervention would be practical and provide a financial return for private payers and benefits Medicare if offered to people between the age of 50 and 64.

Article 6:

Herman WH, Hoerger TJ, Brandle M, et al. The Cost-Effectiveness of Lifestyle Modification or Metformin Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance; Ann Inn Med, 142:323-332, 2005.

  1. What was the intervention/program?

DPP lifestyle, metformin and placebo intervention protocol

  1. In what setting? What population?

DPP participants and use of a Markov simulation model

  1. What type of economic analysis? (minimization, cost-benefit, cost-effectiveness, cost-utility)

Cost effectiveness in terms of diabetes prevented; cost utility in terms of measuring quality-adjusted life-years

  1. From whose perspective? (individual, payer, societal)

Health system (payer) and societal

  1. What were the cost and types of costs? What was missing?

Costs included direct medical costs, direct non-medical costs, and indirect costs of lifestyle and medication interventions compared to placebo. Large health system costs include only direct medicals coats while societal costs include direct medical and non-medical costs in addition to indirect costs. Direct medical costs include identification of individuals with IGT, implementation and maintenance of interventions, hospitalization, outpatient care, laboratory tests, medications, and costs of medical care outside of the DPP. Direct non-medical costs include the participants time spent traveling for appointments, exercising, purchase of equipment or gym memberships, shopping, and cooking. Indirect costs include loss of work, illness, or disability related to morbidity and lost productivity due to premature death/mortality.

  1. What were the benefits? What was missing?

The cost per QALY was $1100 for the lifestyle intervention and $31,300 for the metformin intervention when compared to the placebo. From a societal perspective the lifestyle intervention costs about $8800 per QALY and $29,900 for the metformin intervention when compared to placebo. The lifestyle intervention was estimated to delay onset of diabetes by about 11 years while metformin delayed onset by about 3 years.