Cost‐effectiveness of a multicomponent quality improvement care model for diabetes in South Asia: The CARRS randomized clinical trial

Abstract Objectives To assess the cost‐effectiveness of a multicomponent strategy versus usual care in people with type 2 diabetes in South Asia. Design Economic evaluation from healthcare system and societal perspectives. Setting Ten diverse urban clinics in India and Pakistan. Participants 1146 people with type 2 diabetes (575 in the intervention group and 571 in the usual care group) with mean age of 54.2 years, median diabetes duration: 7 years and mean HbA1c: 9.9% (85 mmol/mol) at baseline. Intervention Multicomponent strategy comprising decision‐supported electronic health records and non‐physician care coordinator. Control group received usual care. Outcome Measures Incremental cost‐effectiveness ratios (ICERs) per unit achievement in multiple risk factor control (HbA1c <7% (53 mmol/mol) and SBP <130/80 mmHg or LDLc <2.58 mmol/L (100 mg/dL)), ICERs per unit reduction in HbA1c, 5‐mmHg unit reductions in systolic BP, 10‐unit reductions in LDLc (mg/dl) (considered as clinically relevant) and ICER per quality‐adjusted life years (QALYs) gained. ICERs were reported in 2020 purchasing power parity–adjusted international dollars (INT$). The probability of ICERs being cost‐effective was considered depending on the willingness to pay (WTP) values as a share of GDP per capita for India (Int$ 7041.4) and Pakistan (Int$ 4847.6). Results Compared to usual care, the annual incremental costs per person for intervention group were Int$ 1061.9 from a health system perspective and Int$ 1093.6 from a societal perspective. The ICER was Int$ 10,874.6 per increase in multiple risk factor control, $2588.1 per one percentage point reduction in the HbA1c, and $1744.6 per 5 unit reduction in SBP (mmHg), and $1271 per 10 unit reduction in LDLc (mg/dl). The ICER per QALY gained was $33,399.6 from a societal perspective. Conclusions In a trial setting in South Asia, a multicomponent strategy for diabetes care resulted in better multiple risk factor control at higher costs and may be cost‐effective depending on the willingness to pay threshold with substantial uncertainty around cost‐effectiveness for QALYs gained in the short term (2.5 years). Future research needs to confirm the long‐term cost‐effectiveness of intensive multifactorial intervention for diabetes care in diverse healthcare settings in LMICs.