Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes
Clinical outcomes and cost-effectiveness of strategies for managing people at high risk for diabetes
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DOI：
10.7326/0003-4819-143-4-200508160-00006
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发表时间：
2005-08-16
影响因子：
39.2
通讯作者：
Kahn, R
中科院分区：
文献类型：
--
作者：
Eddy, DM;Schlessinger, L;Kahn, R
背景：改变生活方式可以预防高危人群的糖尿病，但长期的成本效益尚不确定。目的：评估糖尿病预防计划（DPP）中使用的生活方式改变计划对健康和经济结果的影响。设计：使用阿基米德模型进行成本效益分析。数据来源：已发表的基础和流行病学研究、临床试验和Kaiser Permanente管理数据。目标人群：糖尿病高危成人（体重指数> 24 kg/m(2)，空腹血糖水平5.2725 ~ 6.9375 mmol/L [95 ~ 125 mg/dL] 2小时糖耐量试验结果7.77 ~ 11.0445 mmol/L [140 ~ 199 mg/dL]）。时间跨度：5至30年。视角：患者、健康计划和社会。干预措施：无预防，DPP的生活方式改变计划，生活方式改变开始后，一个人患上糖尿病，二甲双胍。测量：糖尿病的诊断和并发症。基础病例分析结果：与没有预防计划相比，DPP生活方式计划将使高风险人群30年患糖尿病的几率从72%降低到61%，严重并发症的几率从38%降低到30%，死于糖尿病并发症的几率从13.5%降低到11.2%。二甲双胍所带来的长期健康益处大约是立即改变生活方式所能达到的效果的三分之一。与不实施任何预防计划相比，从健康计划的角度来看，DIPP生活方式干预的预期30年成本/质量调整生命年（QALY）约为14.3万美元。从社会角度来看，与什么都不做相比，生活方式干预的成本/质量效益约为62 600美元。无论是使用二甲双胍还是推迟生活方式干预，直到患者患上糖尿病之后才进行干预，都将更具成本效益，与不进行干预相比，每获得一个质量aly分别要花费35400美元或24500美元。与将生活方式计划推迟到糖尿病确诊后进行相比，立即开始DPP生活方式计划的边际成本效益约为201800美元。敏感性分析结果：通过将模型结果与糖尿病及其并发症的实际临床试验结果进行比较，对模型结构引起的变异性和不确定性进行检验。最关键的不确定性因素是生活方式计划的有效性，正如DPP研究的95% CI所表达的那样。最重要的潜在可控因素是生活方式计划的成本。与没有项目相比，如果干预的年费用可以降低到100美元左右，那么高危人群的生活方式改变可以在30年内节省成本。局限性：结果取决于模型的准确性。结论：生活方式改变可能对糖尿病的发病率和死亡率有重要影响，应推荐给所有高危人群。需要更便宜的方法来达到DPP中所见的减肥程度。
Background: Lifestyle modification can forestall diabetes in high-risk people, but the long-term cost-effectiveness is uncertain.Objective: To estimate the effects of the lifestyle modification program used in the Diabetes Prevention Program (DPP) on health and economic outcomes.Design: Cost-effectiveness analysis using the Archimedes model.Data Sources: Published basic and epidemiologic studies, clinical trials, and Kaiser Permanente administrative data.Target Population: Adults at high risk for diabetes (body mass index > 24 kg/m(2), fasting plasma glucose level of 5.2725 to 6.9375 mmol/L [95 to 125 mg/dL] 2-hour glucose tolerance test result of 7.77 to 11.0445 mmol/L [140 to 199 mg/dL]).Time Horizon: 5 to 30 years. Perspective: Patient, health plan, and societal.Interventions: No prevention, DPP's lifestyle modification program, lifestyle modification begun after a person develops diabetes, and metformin.Measurements: Diagnosis and complications of diabetes.Results of Base-Case Analysis: Compared with no prevention program, the DPP lifestyle program would reduce a high-risk person's 30-year chances of getting diabetes from about 72% to 61%, the chances of a serious complication from about 38% to 30%, and the chances of dying of a complication of diabetes from about 13.5% to 11.2%. Metformin would deliver about one third the long-term health benefits achievable by immediate lifestyle modification. Compared with not implementing any prevention program, the expected 30-year cost/quality-adjusted life-year (QALY) of the DIPP lifestyle intervention from the health plan's perspective would be about $143 000. From a societal perspective, the cost/QALY of the lifestyle intervention compared with doing nothing would be about $62 600. Either using metformin or delaying the lifestyle intervention until after a person develops diabetes would be more cost-effective, costing about $35 400 or $24 500 per QALY gained, respectively, compared with no program. Compared with delaying the lifestyle program until after diabetes is diagnosed, the marginal cost-effectiveness of beginning the DPP lifestyle program immediately would be about $201 800.Results of Sensitivity Analysis: Variability and uncertainty deriving from the structure of the model were tested by comparing the model's results with the results of real clinical trials of diabetes and its complications. The most critical element of uncertainty is the effectiveness of the lifestyle program, as expressed by the 95% CI of the DPP study. The most important potentially controllable factor is the cost of the lifestyle program. Compared with no program, lifestyle modification for high-risk people can be made cost-saving over 30 years if the annual cost of the intervention can be reduced to about $100.Limitations: Results depend on the accuracy of the model.Conclusions: Lifestyle modification is likely to have important effects on the morbidity and mortality of diabetes and should be recommended to all high-risk people. The program used in the DPP study may be too expensive for health plans or a national program to implement. Less expensive methods are needed to achieve the degree of weight loss seen in the DPP.