Results showed that the intervention will be cost effective.
In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended behavioral counseling interventions for overweight or obese adults with the following known cardiovascular disease risk factors: impaired fasting glucose (IFG), hypertension, dyslipidemia, or metabolic syndrome. That led to accessing the long-term cost-effectiveness (CE) of implementing the recommended interventions in the U.S.
They used a disease progression model to simulate the 25-year CE of the USPSTF recommendation for eligible U.S. adults and subgroups defined by a combination of the risk factors. The baseline population was estimated using 2005–2012 National Health and Nutrition Examination Survey (NHANES). The cost and effectiveness of the intervention were obtained from systematic reviews. Incremental CE ratios (ICERs), measured in cost/quality-adjusted life-year (QALY), were used to assess the CE of the intervention compared with no intervention.
It was estimated that ∼98 million U.S. adults (44%) would be eligible for the recommended intervention. Compared with no intervention, the ICER of the intervention would be $13,900/QALY. CE varied widely among subgroups, ranging from a cost saving of $302 per capita for those who were obese with IFG, hypertension, and dyslipidemia to a cost of $103,200/QALY in overweight people without these conditions.
Conclusions from the survey recommended that intervention is cost effective based on the conventional cost effectiveness threshold. Considerable variation in CE across the recommended subpopulations suggests that prioritization based on risk level would yield larger total health gains per dollar spent.
From the results, it was estimated that under the new USPSTF recommendation on behavioral counseling for CVD prevention, 98 million Americans are eligible for the intervention, which would cost $64 billion if all were to participate. Applying the conventional “willingness-to-pay” cutoff of $50,000/QALY, the intervention is cost effective for the overall targeted population as well as for each age-group. However, CE varies substantially depending on the risk factor profile of the participants; the intervention is cost effective for overweight adults with IFG and for obese adults with at least one of three risk factors (dyslipidemia, hypertension, or IFG); these two groups account for 68% of the eligible population.
The intervention is cost saving if it was implemented in persons who are obese with IFG and hypertension, dyslipidemia, or both, 19.8 million or 20.2% of all eligible population. CE could be improved substantially by targeting these higher-risk subgroups and/or delivering the intervention in group settings. The results are consistent with those of previous studies that found intensive lifestyle interventions aimed at reducing the incidence of type 2 diabetes among people with prediabetes to be cost effective, with a median cost of approximately $14,000/QALY gained. Our risk group analysis was also consistent with a previous study of diabetes prevention interventions, in which those with higher levels of fasting plasma glucose or A1C had more favorable CE ratios than those at the lower end of the prediabetes spectrum. Applying the USPSTF recommendation to those with a relatively low risk (overweight rather than obese, and one additional risk factor rather than multiple) diminishes CE because, while the costs for implementing the intervention are the same, the number of cases of diabetes and CVD averted is smaller. Reductions in BMI and blood glucose levels have more impact on CE than reductions in blood pressure and lipid levels because of their greater risk reduction of diabetes. Previous studies have shown that behavioral counseling intervention can reduce the risk of type 2 diabetes by 38–60%. A recent study suggested that delaying or preventing type 2 diabetes for 10 years for a person at age 40 years might save more than $30,000 in lifetime medical spending. However, the effects of this intervention on other risk factors (i.e., lipid levels and blood pressure) are modest. The reductions in systolic/diastolic blood pressure reported by the USPSTF were 1–3 mmHg, and for LDL were 1.4–6 mg/dL. As expected, we found the recommended intervention to be more cost effective in the longer simulation horizon.
Chronic disease prevention typically provides more benefit over the long term than the short term. CVD events may not occur in the short term, and diabetes-related complications typically do not occur until years after diabetes onset. While policy makers and program planners are often interested in short-term results, it may be more appropriate to take a longer perspective when evaluating CVD and diabetes prevention.
- 98 million Americans are eligible for the intervention, which would cost $64 billion if all were to participate.
- The intervention in preventing diabetes is cost effective for the overall targeted population as well as for each age-group.
- The recommended intervention is cost effective based on the conventional cost effectiveness threshold.
Diabetes Care 2017 May; 40(5): 640-646. https://doi.org/10.2337/dc16-1186
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