title: Enhancing the comparability of costing methods: cross-country variability in the prices of non-traded inputs to health programmes Long-term effects of a randomised trial of a 6-year lifestyle intervention in impaired glucose tolerance on diabetes-related microvascular complications: the China Da Qing Diabetes Prevention Outcome Study Economic evaluation of a lifestyle intervention in primary care to prevent type 2 diabetes mellitus and cardiovascular diseases: a randomized controlled trial Cost-effectiveness of an exercise program during pregnancy to prevent gestational diabetes: Results of an economic evaluation alongside a randomised controlled trial 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1) Cost-effectiveness of a primary care intervention to treat obesity The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study Effectiveness and cost-effectiveness of diabetes prevention among adherent participants. Long-term effects of the Diabetes Prevention Program interventions on cardiovascular risk factors: a report from the DPP Outcomes Study. Weight loss and incidence of diabetes with the Veterans Health Administration MOVE! lifestyle change programme: an observational study.
abstract: Background National and international policy makers have been increasing their focus on developing strategies to enable poor countries achieve the millennium development goals . This requires information on the costs of different types of health interventions and the re sources needed to scale them up , either singly or in combinations . Cost data also guides decisions about the most appropriate mix of interventions in different setting s , in view of the increasing , but still limited , re sources available to improve health . Many cost and cost-effectiveness studies include only the costs incurred at the point of delivery to beneficiaries , omitting those incurred at other levels of the system such as administration , media , training and overall management . The few studies that have measured them directly suggest that they can sometimes account for a substantial proportion of total costs , so that their omission can result in biased estimates of the re sources needed to run a programme or the relative cost-effectiveness of different choices . However , prices of different inputs used in the production of health interventions can vary substantially within a country . Basing cost estimates on a single price observation runs the risk that the results are based on an outlier observation rather than the typical costs of the input . Methods We first explore the determinants of the observed variation in the  prices  of selected  " non-traded " intermediate inputs to health programmes – printed matter and media advertising , and water and electricity – accounting for variation within and across countries . We then use the estimated relationship to impute average prices for countries where limited data are available with uncertainty intervals . Results Prices vary across countries with GDP per capita and a number of determinants of supply and dem and . Media and printing were inelastic with respect to GDP per capita , with a positive correlation , while the utilities had a surprisingly negative relationship . All equations had relatively good fits with the data . Conclusion While the preferred option is to derive costs from a r and om sample of prices in each setting , this option is often not available to analysts . In this case , we suggest that the approach described in this paper could represent a better option than basing policy recommendations on results that are built on the basis of a single , or a few , price observations Aims /hypothesisWe determined the effects of 6 years of lifestyle intervention in persons with impaired glucose tolerance ( IGT ) on the development of retinopathy , nephropathy and neuropathy over a 20 year period . Methods In 1986 , 577 adults with IGT from 33 clinics in Da Qing , China were r and omly assigned by clinic to a control group or one of three lifestyle intervention groups ( diet , exercise , and diet plus exercise ) . Active intervention was carried out from 1986 to 1992 . In 2006 we conducted a 20 year follow-up study of the original participants to compare the incidence of microvascular complications in the combined intervention group vs the control group . Results Follow-up information was obtained on 542 ( 94 % ) of the 577 original participants . The cumulative incidence of severe retinopathy was 9.2 % in the combined intervention group and 16.2 % in the control group ( p = 0.03 , log-rank test ) . After adjusting for clinic and age , the incidence of severe retinopathy was 47 % lower in the intervention group than the control group ( hazard rate ratio 0.53 , 95 % CI 0.29–0.99 , p = 0.048 ) . No significant differences were found in the incidence of severe nephropathy ( hazard rate ratio 1.05 , 95 % CI 0.16–7.05 , intervention vs control , p = 0.96 ) or in the prevalence of neuropathy ( 8.6 % vs 9.1 % , p = 0.89 ) among the 20 year survivors . Conclusions /interpretationLifestyle intervention for 6 years in IGT was associated with a 47 % reduction in the incidence of severe , vision-threatening retinopathy over a 20 year interval , primarily due to the reduced incidence of diabetes in the intervention group . However , similar benefits were not seen for nephropathy or neuropathy Background Cost-effectiveness studies of lifestyle interventions in people at risk for lifestyle-related diseases , addressing ‘ real-world ’ implementation , are needed . This study examines the cost-effectiveness of a primary care intervention from a societal perspective , compared with provision of health brochures , alongside a r and omized controlled trial . Methods Adults aged 30 - 50 years , at risk of type 2 diabetes ( T2DM ) and /or cardiovascular disease ( CVD ) , were recruited from twelve general practice s in The Netherl and s. They were r and omized to the intervention ( n = 314 ) or control group ( n = 308 ) . The intervention consisted of up to six face-to-face counseling sessions with a trained practice nurse , followed by three-monthly sessions by phone . Costs were collected using three-monthly retrospective question naires . Quality of life was measured with the EuroQol-5D-3L , at baseline , 6 , 12 and 24 months . Nine-year risk of developing T2DM and ten-year risk of CVD mortality were estimated using the ARIC and SCORE formulae , respectively , based on measurements at baseline and 24 months while applying a fixed age of 60 years at both time points . Results Small , statistically non-significant differences in effects were found between the intervention and control group with regard to risk scores and Quality Adjusted Life Years ( QALYs ) gained . The mean difference in costs between the intervention and control group was € -866 ( 95 % confidence interval -2372 ; 370 ) . The probability that the intervention was cost-effective varied from 93 % at € 8000/QALY to 88 % at € 80,000/QALY . Conclusion A primary care lifestyle intervention aim ed at adults at increased risk of T2DM and /or CVD  could result in cost savings over a two-year period . However , due to method ological uncertainty no advice can be given regarding the implementation of the intervention in Dutch general practice s . Trial registration Current Controlled Trials IS RCT N59358434 Background The prevalence of gestational diabetes mellitus ( GDM ) is increasing worldwide . GDM and the risks associated with GDM lead to increased health care costs and losses in productivity . The objective of this study is to evaluate whether the FitFor2 exercise program during pregnancy is cost-effective from a societal perspective as compared to st and ard care . Methods A r and omised controlled trial ( RCT ) and simultaneous economic evaluation of the FitFor2 program were conducted . Pregnant women at risk for GDM were r and omised to an exercise program to prevent high maternal blood glucose ( n = 62 ) or to  st and ard care  ( n = 59 ) . The exercise program consisted of two sessions of aerobic and strengthening exercises per week . Clinical outcome measures were maternal fasting blood glucose levels , insulin sensitivity and infant birth weight . Quality of life was measured using the EuroQol 5-D and quality -adjusted life-years ( QALYs ) were calculated . Re source utilization and sick leave data were collected by question naires . Data were analysed according to the intention-to-treat principle . Missing data were imputed using multiple imputations . Bootstrapping techniques estimated the uncertainty surrounding the cost differences and incremental cost-effectiveness ratios . Results There were no statistically significant differences in any outcome measure . During pregnancy , total health care costs and costs of productivity losses were statistically non-significant ( mean difference € 1308 ; 95%CI € -229 - € 3204 ) . The cost-effectiveness analyses showed that the exercise program was not cost-effective in comparison to the control group for blood glucose levels , insulin sensitivity , infant birth weight or QALYs . Conclusion The twice-weekly exercise program for pregnant women at risk for GDM evaluated in the present study was not cost-effective compared to st and ard care . Based on these results , implementation of this exercise program for the prevention of GDM can not be recommended . Trial registration BACKGROUND In the 2.8 years of the Diabetes Prevention Program ( DPP ) r and omised clinical trial ,  diabetes incidence  in high-risk adults was reduced by 58 % with intensive lifestyle intervention and by 31 % with metformin , compared with placebo . We investigated the persistence of these effects in the long term . METHODS All active DPP participants were eligible for continued follow-up . 2766 of 3150 ( 88 % ) enrolled for a median additional follow-up of 5.7 years ( IQR 5.5 - 5.8 ) . 910 participants were from the lifestyle , 924 from the metformin , and 932 were from the original placebo groups .  On the basis of the benefits from the intensive lifestyle intervention in the DPP , all three groups were offered group-implemented lifestyle intervention . Metformin treatment was continued in the original metformin group ( 850 mg twice daily as tolerated ) , with participants unmasked to assignment , and the original lifestyle intervention group was offered additional lifestyle support . The primary outcome was development of diabetes according to American Diabetes Association criteria . Analysis was by intention-to-treat . This study is registered with Clinical Trials.gov , number NCT00038727 . FINDINGS During the 10.0-year ( IQR 9.0 - 10.5 ) follow-up since r and omisation to DPP , the original lifestyle group lost , then partly regained weight . The modest weight loss with metformin was maintained . Diabetes incidence rates during the DPP were 4.8 cases per 100 person-years ( 95 % CI 4.1 - 5.7 ) in the intensive lifestyle intervention group , 7.8 ( 6.8 - 8.8 ) in the metformin group , and 11.0 ( 9.8 - 12.3 ) in the placebo group . Diabetes incidence rates in this follow-up study were similar between treatment groups : 5.9 per 100 person-years ( 5.1 - 6.8 ) for lifestyle , 4.9 ( 4.2 - 5.7 ) for metformin , and 5.6 ( 4.8 - 6.5 ) for placebo . Diabetes incidence in the 10 years since DPP r and omisation was reduced by 34 % ( 24 - 42 ) in the lifestyle group and 18 % ( 7 - 28 ) in the metformin group compared with placebo . INTERPRETATION During follow-up after DPP , incidences in the former placebo and metformin groups fell to equal those in the former lifestyle group , but the cumulative incidence of diabetes remained lowest in the lifestyle group . Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years . FUNDING National Institute of Diabetes and Digestive and Kidney Diseases ( NIDDK ) BACKGROUND Type 2 diabetes mellitus is increasingly common , primarily because of increases in the prevalence of a sedentary lifestyle and obesity . Whether type 2 diabetes can be prevented by interventions that affect the lifestyles of subjects at high risk for the disease is not known . METHODS We r and omly assigned 522 middle-aged , overweight subjects ( 172 men and 350 women ; mean age , 55 years ; mean body-mass index [ weight in kilograms divided by the square of the height in meters ] , 31 ) with impaired glucose tolerance to either the intervention group or the control group . Each subject in the intervention group received individualized counseling aim ed at reducing weight , total intake of fat , and intake of saturated fat and increasing intake of fiber and physical activity . An oral glucose-tolerance test was performed annually ; the diagnosis of diabetes was confirmed by a second test . The mean duration of follow-up was 3.2 years . RESULTS The mean ( + /-SD ) amount of weight lost between base line and the end of year 1 was 4.2+/-5.1 kg in the intervention group and 0.8+/-3.7 kg in the control group ; the net loss by the end of year 2 was 3.5+/-5.5 kg in the intervention group and 0.8+/-4.4 kg in the control group ( P<0.001 for both comparisons between the groups ) . The cumulative incidence of diabetes after four years was 11 percent ( 95 percent confidence interval , 6 to 15 percent ) in the intervention group and 23 percent ( 95 percent confidence interval , 17 to 29 percent ) in the control group . During the trial , the risk of diabetes was reduced by 58 percent ( P<0.001 ) in the intervention group . The reduction in the incidence of diabetes was directly associated with changes in lifestyle . CONCLUSIONS Type 2 diabetes can be prevented by changes in the lifestyles of high-risk subjects Aims /hypothesisLifestyle modification helps in the primary prevention of diabetes in multiethnic American , Finnish and Chinese population s. In a prospect i ve community-based study , we tested whether the progression to diabetes could be influenced by interventions in native Asian Indians with IGT who were younger , leaner and more insulin resistant than the above population s. Methods We r and omised 531 ( 421 men 110 women ) subjects with IGT ( mean age 45.9±5.7 years , BMI 25.8±3.5 kg/m2 ) into four groups . Group 1 was the control , Group 2 was given advice on lifestyle modification ( LSM ) , Group 3 was treated with metformin ( MET ) and Group 4 was given LSM plus MET . The primary outcome measure was type 2 diabetes as diagnosed using World Health Organization criteria . Results The median follow-up period was 30 months , and the 3-year cumulative incidences of diabetes were 55.0 % , 39.3 % , 40.5 % and 39.5 % in Groups 1–4 , respectively . The relative risk reduction was 28.5 % with LSM ( 95 % CI 20.5–37.3 , p=0.018 ) , 26.4 % with MET ( 95 % CI 19.1–35.1 , p=0.029 ) and 28.2 % with LSM + MET ( 95 % CI 20.3–37.0 , p=0.022 ) , as compared with the control group . The number needed to treat to prevent one incident case of diabetes was 6.4 for LSM , 6.9 for MET and 6.5 for LSM + MET . Conclusions /interpretationProgression of IGT to diabetes is high in native Asian Indians .  Both LSM and MET significantly reduced the incidence of diabetes  in Asian Indians with IGT ; there was no added benefit from combining them Background : Data on the cost-effectiveness of the behavioral treatment of obesity are not conclusive . The cost-effectiveness of treatment in primary care setting s is particularly relevant . Methods : We conducted a within-trial cost-effectiveness analysis of a primary care-based obesity intervention .  Study participants were r and omized to : Usual Care ( UC ; quarterly visits with their primary care provider ) ; Brief Lifestyle Counseling ( BLC ; quarterly provider visits plus monthly weight loss counseling visits ) or Enhanced Brief Lifestyle Counseling ( EBLC ; all above interventions  ,  plus choice of meal replacements or weight loss medication )  . A health-care payer perspective was used . Intervention costs were estimated from tracking data obtained prospect ively . Quality -adjusted life years ( QALYs ) were estimated with the EuroQol-5D . We estimated cost per kilogram-year of weight loss and cost per QALY . Results : Weight losses after 2 years were 1.7 , 2.9 and 4.6 kg for UC , BLC and EBLC , respectively ( P=0.003 for comparison of EBLC vs UC ) . The incremental cost per kilogram-year lost was $ 292 for EBLC compared with UC ( 95 % confidence interval ( CI ) : $ 219–$437 ) . The short-term incremental cost per QALY was $ 115 397 , but the 95 % CI were undefined . Comparison of short-term cost per kg with published estimates of longer-term cost per QALY suggested that the intervention could be cost-effective over the long term ( ⩾10 years ) . Conclusions : A primary care intervention that includes monthly counseling visits and a choice of meal replacements or weight loss medication could be a cost-effective treatment for obesity over the long term . However , additional studies are needed on the cost-effectiveness of behavioral treatment of obesity BACKGROUND Intensive lifestyle interventions can reduce the incidence of  type 2 diabetes in people with impaired glucose tolerance , but how long these benefits extend beyond the period of active intervention , and whether such interventions reduce the risk of cardiovascular disease ( CVD ) and mortality , is unclear . We aim ed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes , diabetes-related macrovascular and microvascular complications , and mortality . METHODS In 1986 , 577 adults with impaired glucose tolerance from 33 clinics in China were r and omly assigned to either the  control group or to one of three lifestyle intervention groups ( diet , exercise , or diet plus exercise ) . Active intervention took place over 6 years until 1992 . In 2006 , study participants were followed-up to assess the long-term effect of the interventions . The primary outcomes were diabetes incidence , CVD incidence and mortality , and all-cause mortality . FINDINGS Compared with control participants , those in the combined lifestyle intervention groups had a 51 % lower incidence of diabetes ( hazard rate ratio [ HRR ] 0.49 ; 95 % CI 0.33 - 0.73 ) during the active intervention period and a 43 % lower incidence ( 0.57 ; 0.41 - 0.81 ) over the 20 year period , controlled for age and clustering by clinic . The average annual incidence of diabetes was 7 % for intervention participants versus 11 % in control participants , with 20-year cumulative incidence of 80 % in the intervention groups and 93 % in the control group . Participants in the intervention group spent an average of 3.6 fewer years with diabetes than those in the control group . There was no significant difference between the intervention and control groups in the rate of first CVD events ( HRR 0.98 ; 95 % CI 0.71 - 1.37 ) , CVD mortality ( 0.83 ; 0.48 - 1.40 ) , and all-cause mortality ( 0.96 ; 0.65 - 1.41 ) , but our study had limited statistical power to detect differences for these outcomes . INTERPRETATION Group-based lifestyle interventions over 6 years can prevent or delay diabetes for up to 14 years after the active intervention . However , whether lifestyle intervention also leads to reduced CVD and mortality remains unclear OBJECTIVES We report the 10-year effectiveness and within-trial cost-effectiveness of the Diabetes Prevention Program ( DPP ) and its Outcomes Study ( DPPOS ) interventions among participants who were adherent to the interventions . STUDY DESIGN DPP was a 3-year r and omized clinical trial followed by 7 years of open-label modified intervention follow-up . METHODS Data on re source utilization , cost , and quality of life were collected prospect ively . Economic analyses were performed from health system and societal perspectives . Lifestyle adherence was defined as achieving and maintaining a 5 % reduction in initial body weight , and metformin adherence as taking metformin at 80 % of study visits . RESULTS The relative risk reduction was 49.4 % among adherent lifestyle participants and 20.8 % among adherent metformin participants compared with placebo . Over 10 years , the cumulative , undiscounted , per capita direct medical costs of the interventions , as implemented during the DPP , were greater for adherent lifestyle participants ( $ 4810 ) than adherent metformin participants ( $ 2934 ) or placebo ( $ 768 ) . Over 10 years , the cumulative , per capita non-interventionrelated direct medical costs were $ 4250 greater for placebo participants compared with adherent lifestyle participants and $ 3251 greater compared with adherent metformin participants . The cumulative quality -adjusted life-years ( QALYs ) accrued over 10 years were greater for lifestyle ( 6.80 ) than metformin ( 6.74 ) or placebo ( 6.67 ) . Without discounting , from a modified societal perspective ( excluding participant time ) and a full societal perspective ( including participant time ) , lifestyle cost < $ 5000 per QALY-gained and metformin was cost saving compared with placebo . CONCLUSIONS Over 10 years , lifestyle intervention and metformin were cost-effective or cost saving compared with placebo . These analyses confirm that lifestyle and metformin represent a good value for money AIMS Whether long-term cardiovascular risk is reduced by the Diabetes Prevention Program interventions is unknown . The aim of this study was to determine the long-term differences in cardiovascular disease risk factors and the use of lipid and blood pressure medications by the original Diabetes Prevention Program intervention group . METHODS This long-term follow-up ( median 10 years , interquartile range 9.0 - 10.5 ) of the three-arm Diabetes Prevention Program r and omized controlled clinical trial ( metformin , intensive lifestyle and placebo ) , performed on 2766 ( 88 % ) of the Diabetes Prevention Program participants ( who originally had impaired glucose tolerance ) , comprised a mean of 3.2 years of r and omized treatment , approximately 1-year transition ( during which all participants were offered intensive lifestyle intervention ) and 5 years follow-up ( Diabetes Prevention Program Outcomes Study ) . During the study , participants were followed in their original groups with their clinical care being provided by practitioners outside the research setting . The study determined lipoprotein profiles and blood pressure and medication use annually . RESULTS After 10 years ' follow-up from Diabetes Prevention Program baseline , major reductions were seen for systolic ( -2 to -3 ) and diastolic ( -6 to -6.5 mmHg ) blood pressure , and for LDL cholesterol ( -0.51 to -0.6 mmol/l ) and triglycerides ( -0.23 to -0.25 mmol/l ) in all groups , with no between-group differences . HDL cholesterol also rose significantly ( 0.14 to 0.15 mmol/l ) in all groups . Lipid ( P = 0.01 ) and blood pressure ( P = 0.09 ) medication use , however , were lower for the lifestyle group during the Diabetes Prevention Program Outcomes Study . CONCLUSION Overall , intensive lifestyle intervention achieved , with less medication , a comparable long-term effect on cardiovascular disease risk factors , to that seen in the metformin and placebo groups BACKGROUND Programmes for lifestyle change are aim ed at improving health but little is known about their effectiveness in clinical setting s. The Veterans Health Administration ( VA ) MOVE ! lifestyle change programme is the largest in the USA . We investigated whether participation in MOVE ! is associated with reduced incidence of diabetes . METHODS We did a retrospective observational analysis of data from VA data bases in overweight patients and obese patients with a weight-related disorder who had undergone at least 3 years of continuous outpatient care in 2005 - 12 . We used generalised estimating equations to assess characteristics associated with MOVE ! participation , and Cox 's proportional hazards regression to analyse the association between participation and diabetes incidence . FINDINGS Of 1·8 million eligible individuals , 238 540 ( 13 % ) participated in the MOVE ! programme . 19 367 ( 1 % overall , 8 % of participants ) met criteria for intense and sustained participation ( at least eight sessions within 6 months over at least a 4-month span ) , which was associated with greater weight loss at 3 years than low-intensity or no participation ( -2·2 % vs -0·64 % or 0·46 % ) . Compared with non-participation , incidence of diabetes was reduced by intense and sustained participation ( hazard ratio 0·67 , 95 % CI 0·61 - 0·74 ) and low-intensity participation ( 0·80 , 0·77 - 0·83 ) in MOVE!. These patterns were consistent across sex , ethnic origin , and age . Participation was most beneficial in patients with  high BMI or high r and om glucose concentrations at baseline ( both pinteraction<0·0001 ) . INTERPRETATION Participation in the MOVE ! programme  was associated with weight loss and reduced incidence of diabetes , but the rate of participation was low and , therefore , selection bias could have exaggerated these effects . FUNDING US Department of Veterans Affairs , National Institutes of Health
target: T2D prevention by physical activity or diet or both proved cost-effective according to accepted thresholds , except for five inconclusive studies , three on diabetes prevention and two on obesity control .
  This confirms that lifestyle interventions for the primary prevention of diabetes are cost-effective .
background: To summarize key findings of economic evaluations of lifestyle interventions for the primary prevention of  type 2 diabetes ( T2D ) in high-risk subjects .