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  • The Cost of Type 2 Diabetes Prevention in the USAMichael M. EngelgauDivision of Diabetes TranslationCDCSymposium on Diabetes EconomicsSo Paulo, Brazil, 27 September 2004

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    Never have doctors known so much about how to prevent and control this disease, yet the epidemic keeps on raging .

    Christine GormanTime 30 November 2003

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    Today

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    How can we stop (or slow down) the diabetes?

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    Rationale for Primary Prevention

    ScientificEconomics

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    Genetic predispositionPreclinical stateNormalIGTDisabilityDeathClinical diseaseType 2 DMDisabilityDeathComplicationsComplications Primary Secondary Tertiaryprevention prevention preventionStages in the Natural History of Type 2 diabetes

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    What is the ?

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    Major Studies Da Qing IGT and Diabetes Study(China) Diabetes Prevention Study (Finland) Diabetes Prevention Program (USA)STOP NIDDM (Europe, Canada)Troglitazone in the Prevention of Diabetes (TRIPOD) (USA)

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    BenefitsStudy Reduction in risk (%)LifestyleDrugDa Qing 3146DPS 58DPP 58 31Stop NIDDM 25TRIPOD 55

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    Primary prevention works!!!!

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    Economics$$$$$$$$$

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    Medical Costs of DPP Interventions(per participant)DPP Research Group, Diabetes Care 2003.

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    Is it cost effective?Societal judgement and is not absoluteExpert panels in developed countries suggest: $100,000/QALY less attractive

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    CE of Primary Prevention DPP* (USA) Within Group LS/ DPP Generic Met Cost/QALY US$ US$

    Lifestyle vs Placebo51,600 27,100Metformin vs Placebo 99,200 35,000

    *Societal perspectiveDPP Research Group, Diabetes Care 2003.

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    Who should we target?High-Risk vs Entire Population Epidemiology PreDM (IGT/IFG) have 10 fold higher risk than NGT Only 10% have IGT/IFG but yield 40-50% new DMPathophysiology Clinical trials in populations with preDMHuman behavior Health belief model risk and benefit Narayan et al., BMJ 2002; 325:403.

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    ParticipantsEligibility Study criteria DaQing DPS DPP Stop TRIPOD NIDDMGlucose (mg/dl) Fasting none none 95-125 100-140 none 2-hr OGTT 140-199 140-199 140-199 140-199 none 5 OGTT sum >=625Age (yrs) >25 40-65 >=25 40-70 >=18BMI (kg/m2) none >=24 >=25 25-40 noneHistory GDM +

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    What are the gaps from RCTs? Isolated IFG not studiedOnly one study examined non-overweight persons with IGT

    What is the risk of developing diabetes in these groups?

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    International Diabetes Federation IGT/IFG Consensus Statement:

    Report of an Expert Consensus WorkshopCombined IGT and IFG have highest riskIsolated IFG and IGT have about the same riskIsolated IGT is more commonAbout a third who develop diabetes have normal glucose tolerance at baseline (dependent on length of follow-up)Unwin N et al., Diabetic Medicine 2002; 19: 708.

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    What are the current policy recommendations? American Diabetes AssociationPre-diabetes:Opportunistic screening for IGT or IFG:>= 45 yrsEmphasis in those with BMI >25 Consider others if are overweight with risk factorsADA Position Statement, Diabetes Care 2004; 27: S47.

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    What are the current policy recommendations? IDF IGT/IFG Consensus Statement: Report of an Expert Consensus Workshop

    IGT or IFG should receive lifestyle advice If lifestyle fails, consider drugs Target those at highest risk for DM and CVD.Unwin N et al., Diabetic Medicine 2002; 19: 708.

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    What are the current policy recommendations? Finnish National PolicyPrediction models for future riskUse fewer screening tests Tailor to the individuals level of riskLindstrom J, Diabetes Care 2003; 26: 725.

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    How do we do find the at-risk population?

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    CDC WorkshopNational and International researchersQuestionsWhat populations not studiedHealth policy for those not studiedDetection strategiesFurther studyDiabetes Therapeutics and Treatments 2004 (in press).

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    How do we detect targeted populations? Two general approaches:Measure glucose levels directlyUse clinical and demographic charaterisitics to target testDetermine current glycemic status Use individual characteristics (clinical, demographic)Predict future risk for diabetesCurrent glycemic status unknown

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    Detection Strategies:Measuring Glucose DirectlyThree approaches*Combinations of risk factors with various cutpointsStatistical models with risk factors Risk scores *NHANES (3 studies), Framingham, SAHS, AusDiab, NUDS India, INTER-99, Ely Study, Diabetes in Egypt, ARIC

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    Detection Strategies:Measuring Glucose DirectlyRisk factors DemographicsSelf-report clinical historyCurrent clinical measuresAdministrative dataLaboratory dataMetabolic syndrome criteriaCombinations

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    Detection Strategies:Measuring Glucose DirectlyPerformance Moderately effectiveAUC 0.60-0.80Sensitivity 60-80%; Specificity 70-90%

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    Detection Strategies:Prediction of Future Risk of Diabetes Method* 5-10 year risk of diabetes Risk score or clinical modelRisk factors Demographic, clinical Glucose measures not requiredResults0.60-0.85 AUCAge-dependent performance

    *Finrisk-87, JACDS-Seattle, SAHS

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    Economics$$$$$$$$$

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    Random Capillary Blood Glucose TestAll Low-risk populatione.g., age < 45RCBG positiveHigh-risk populatione.g., age 45RCBG negativeIFG or IGT or DMOGTT & FPG negativeOGTTRCBG test

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    Cost per Case of Undiagnosed Diabetes or Pre-Diabetes Identified by Random Capillary Glucose Test Zhang et al ADA 2004

    Chart1

    321.2282808909542.4944277968

    189.9282908612391.87057917

    147.9004793926425.8139311058

    125.3935215644486.7285749849

    125.1311399446557.3355665634

    127.0758114463594.2970140791

    127.9190824302643.2696235332

    129.067194593670.6779335471

    Screening for pre-diabetes & diabetes

    Screening for diabetes alone

    Cutoff value (mg/dl)

    Cost/case ($)

    Sheet1

    Version created on 3/24/2004This is based on the recommended age and BMIThe cost in each step is also calculated in this preadsheet

    sensitivity analysis with imperfact compliance rate

    The specificity and sensitivity of fasting strategy and A1c were

    base on the study population criteria

    The purposed of the following calculation is to estimate the number of people with IGT, IFG, or undiagnosed diabetes and cost of the identification using different screening strategies

    Third step

    Defined the studying population (aged 45-74, had visit to a provider)Calculating the cost of screening one person st each stepSecond step

    First stepMailling theTotal cost in first stepPat. TimePat. TimeTravelMailling theTotal cost in seco stepPat. TimePat. TimeTravelMailling theTotal cost in 3rd step

    Total population aged 45-74 in the U.S. (2000 sencus)80.34millionMD timeScreen testPati. Timetesting Res.Dir. MediDir. Non-medStaff. TimeMD timeOGTT testFGT testTravelfor testingcosttesting Res.Dir. MediDir. Non-medStaff. TimeMD timeOGTT testTravelfor testingcosttesting Res.Dir. MediDir. Non-med

    Percent of people with no BMI restriction100.00%Testing all12.75212.7521.3325.517.225.244.0020.007.001.0050.2931.00

    Percent of people with American had at least one visit toCBG>=14012.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    health care providers75%CBG>=12012.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    CBG>=11012.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    Eligible population60.255CBG>=10012.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    CBG>=9512.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    CBG>=9012.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    Table 1. Performance of each test strategyCBG>=8512.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    CBG>=8012.754.37217.1221.3325.517.225.244.0020.007.001.0050.2931.00

    Screening strategiesFSG>=100or 2-h SG>=140FSG>=126 or 2-h SG>=200FPG >=12012.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    FPG>=11512.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    FPG >=11012.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    SensitivitySpecificitySensitivitySpecificityFPG >=10512.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    CBG>=14013.0%97.0%40.0%96.0%FPG>=10012.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    CBG>=12027.0%91.0%68.0%89.0%FPG >=9512.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    CBG>=11041.0%85.0%74.0%80.0%FPG>=9012.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    CBG>=10062.0%70.0%83.0%63.0%FPG>=8512.75212.7521.3320.45.244.004.007.001.0027.9715.001.3312.7517.224.0020.007.001.0032.3031.00

    CBG>=9572.0%56.0%84.0%49.0%HbA1c>=6.3%12.7512.9821.0026.7321.3325.517.225.244.0020.007.001.0050.2931.00

    CBG>=9081.0%40.0%90.0%35.0%HbA1c>=6.0%12.7512.9821.0026.7321.3325.517.225.244.0020.007.001.0050.2931.00

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