Cost-effectiveness of a Stepwise Approach vs Standard Care for Diabetes Prevention in India.

Question Is a stepwise approach to identifying, delaying, and preventing diabetes in individuals with high risk in a low-income to middle-income country setting cost-effective? Findings In this economic evaluation study, conducted within a randomized clinical trial during a 3-year period, it would cost 145 international dollars to screen for and reduce diabetes incidence by 1 percentage point, 14 & x202f;539 international dollars per diabetes case prevented and/or delayed, and 14 & x202f;986 international dollars per quality-adjusted life-year gained. Meaning The findings of this study suggest that a stepwise approach for identification of high-risk individuals and diabetes prevention is likely cost-effective, even in a low-income to middle-income country setting. This economic evaluation estimates the cost-effectiveness of a stepwise approach to diabetes prevention among adults in India participating in the Diabetes Community Lifestyle Improvement Program. Importance A stepwise approach that includes screening and lifestyle modification followed by the addition of metformin for individuals with high risk of diabetes is recommended to delay progression to diabetes; however, there is scant evidence regarding whether this approach is cost-effective. Objective To estimate the cost-effectiveness of a stepwise approach in the Diabetes Community Lifestyle Improvement Program. Design, Setting, and Participants This economic evaluation study included 578 adults with impaired glucose tolerance, impaired fasting glucose, or both. Participants were enrolled in the Diabetes Community Lifestyle Improvement Program, a randomized clinical trial with 3-year follow-up conducted at a diabetes care and research center in Chennai, India. Interventions The intervention group underwent a 6-month lifestyle modification curriculum plus stepwise addition of metformin; the control group received standard lifestyle advice. Main Outcomes and Measures Cost, health benefits, and incremental cost-effectiveness ratios (ICERs) were estimated from multipayer (including direct medical costs) and societal (including direct medical and nonmedical costs) perspectives. Costs and ICERs were reported in 2019 Indian rupees (INR) and purchasing power parity-adjusted international dollars (INT $). Results The mean (SD) age of the 578 participants was 44.4 (9.3) years, and 364 (63.2%) were men. Mean (SD) body mass index was 27.9 (3.7), and the mean (SD) glycated hemoglobin level was 6.0% (0.5). Implementing lifestyle modification and metformin was associated with INR 10 & x202f;549 (95% CI, INR 10 & x202f;134-10 & x202f;964) (INT $803 [95% CI, INT $771-834]) higher direct costs; INR 5194 (95% CI, INR 3187-INR 7201) (INT $395; 95% CI, INT $65-147) higher direct nonmedical costs, an absolute diabetes risk reduction of 10.2% (95% CI, 1.9% to 18.5%), and an incremental gain of 0.099 (95% CI, 0.018 to 0.179) quality-adjusted life-years per participant. From a multipayer perspective (including screening costs), mean ICERs were INR 1912 (INT $145) per 1 percentage point diabetes risk reduction, INR 191 & x202f;090 (INT $14 & x202f;539) per diabetes case prevented and/or delayed, and INR 196 & x202f;960 (INT $14 & x202f;986) per quality-adjusted life-year gained. In the scenario of a 50% increase or decrease in screening and intervention costs, the mean ICERs varied from INR 855 (INT $65) to INR 2968 (INT $226) per 1 percentage point diabetes risk reduction, from INR 85 & x202f;495 (INT $6505) to INR 296 & x202f;681 (INT $22 & x202f;574) per diabetes case prevented, and from INR 88 & x202f;121 (INT $6705) to INR 305 & x202f;798 (INT $23 & x202f;267) per quality-adjusted life-year gained. Conclusions and Relevance The findings of this study suggest that a stepwise approach for diabetes prevention is likely to be cost-effective, even if screening costs for identifying high-risk individuals are added.