The Cost-Effectiveness of Lifestyle Modification or Metformin in Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance

  1. William H. Herman, MD, MPH;
  2. Thomas J. Hoerger, PhD;
  3. Michael Brandle, MD, MS;
  4. Katherine Hicks, MS;
  5. Stephen Sorensen, PhD;
  6. Ping Zhang, PhD;
  7. Richard F. Hamman, MD, DrPH;
  8. Ronald T. Ackermann, MD, MPH;
  9. Michael M. Engelgau, MD, MS;
  10. Robert E. Ratner, MD; and
  11. for the Diabetes Prevention Program Research Group*
  1. From University of Michigan Health System, Ann Arbor, Michigan; RTI International, Research Triangle Park, North Carolina; Centers for Disease Control and Prevention, Atlanta, Georgia; University of Colorado Health Sciences Center, Denver, Colorado; Indiana University School of Medicine, Indianapolis, Indiana; and Medstar Research Institute, Hyattsville, Maryland.

    Abstract

    Background: The Diabetes Prevention Program (DPP) demonstrated that interventions can delay or prevent the development of type 2 diabetes.

    Objective: To estimate the lifetime cost–utility of the DPP interventions.

    Design: Markov simulation model to estimate progression of disease, costs, and quality of life.

    Data Sources: The DPP and published reports.

    Target Population: Members of the DPP cohort 25 years of age or older with impaired glucose tolerance.

    Time Horizon: Lifetime.

    Perspectives: Health system and societal.

    Interventions: Intensive lifestyle, metformin, and placebo interventions as implemented in the DPP.

    Outcome Measures: Cumulative incidence of diabetes, microvascular and neuropathic complications, cardiovascular complications, survival, direct medical and direct nonmedical costs, quality-adjusted life-years (QALYs), and cost per QALY.

    Results of Base-Case Analysis: Compared with the placebo intervention, the lifestyle and metformin interventions were estimated to delay the development of type 2 diabetes by 11 and 3 years, respectively, and to reduce the absolute incidence of diabetes by 20% and 8%, respectively. The cumulative incidence of microvascular, neuropathic, and cardiovascular complications were reduced and survival was improved by 0.5 and 0.2 years. Compared with the placebo intervention, the cost per QALY was approximately $1100 for the lifestyle intervention and $31 300 for the metformin intervention. From a societal perspective, the interventions cost approximately $8800 and $29 900 per QALY, respectively. From both perspectives, the lifestyle intervention dominated the metformin intervention.

    Results of Sensitivity Analysis: Cost-effectiveness improved when the interventions were implemented as they might be in routine clinical practice. The lifestyle intervention was cost-effective in all age groups. The metformin intervention did not represent good use of resources for persons older than 65 years of age.

    Limitations: Simulation results depend on the accuracy of the underlying assumptions, including participant adherence.

    Conclusions: Health policy should promote diabetes prevention in high-risk individuals.

    *The members of the Diabetes Prevention Program Group are listed in Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. [PMID: 11832527].

    Article and Author Information

    • Grant Support: By the Diabetes Prevention Program, National Institutes of Health through the National Institute of Diabetes and Digestive and Kidney Diseases, Office of Research on Minority Health, National Institute of Child Health and Human Development, and National Institute on Aging; Centers for Disease Control and Prevention; Indian Health Service; General Clinical Research Program; National Center for Research Resources; American Diabetes Association; Bristol-Myers Squibb; and Parke-Davis.

    • Potential Financial Conflicts of Interest: None disclosed.

    • Requests for Single Reprints: The Diabetes Prevention Program Coordinating Center, George Washington University Biostatistics Center, 6100 Executive Boulevard, Suite 750, Rockville, MD 20852; e-mail, dppmail{at}biostat.bsc.gwu.edu.

    • Current Author Addresses: Dr. Herman: University of Michigan Health System, 1500 East Medical Center Drive, 3920 Taubman Center, Box 0354, Ann Arbor, MI 48109-0354.

    • Dr. Hoerger and Ms. Hicks: RTI International, 3040 Cornwallis Road, Research Triangle Park, NC 27599-2194.

    • Dr. Brandle: Division of Endocrinology and Diabetes, Department of Internal Medicine, Kantonsspital St. Gallen, 9007 St.Gallen, Switzerland.

    • Dr. Sorensen: Division of Diabetes Translation, MS K-10, 4770 Buford Highway NE, Atlanta, GA 30341-3724.

    • Drs. Zhang and Engelgau: Division of Diabetes Translation, MS K-10, 2858 Woodcock Boulevard, Atlanta, GA 30341.

    • Dr. Hamman: Department of Preventive Medicine and Biometrics, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Box B119, Denver, CO 80262.

    • Dr. Ackermann: Indiana University School of Medicine, 250 University Boulevard, Suite 122, Indianapolis, IN 46202.

    • Dr. Ratner: Medstar Research Institute, 6495 New Hampshire Avenue, Suite 201, Hyattsville, MD 20783.

    • Author Contributions: Conception and design: W.H. Herman, T.J. Hoerger, K. Hicks, S. Sorensen, P. Zhang, R.F. Hamman, R.T. Ackermann, M.M. Engelgau, R.E. Ratner.

    • Analysis and interpretation of the data: W.H. Herman, T.J. Hoerger, M. Brandle, K. Hicks, S. Sorensen, P. Zhang, R.F. Hamman, R.T. Ackermann, M.M. Engelgau, R.E. Ratner.

    • Drafting of the article: W.H. Herman, T.J. Hoerger, M. Brandle, K. Hicks, S. Sorensen, P. Zhang, R.F. Hamman, R.T. Ackermann, M.M. Engelgau.

    • Critical revision of the article for important intellectual content: W.H. Herman, T.J. Hoerger, M. Brandle, K. Hicks, S. Sorensen, P. Zhang, R.F. Hamman, R.T. Ackermann, M.M. Engelgau, R.E. Ratner.

    • Final approval of the article: W.H. Herman, T.J. Hoerger, K. Hicks, S. Sorensen, P. Zhang, R.T. Ackermann, M.M. Engelgau, R.E. Ratner.

    • Provision of study materials or patients: P. Zhang.

    • Statistical expertise: W.H. Herman, T.J. Hoerger, K. Hicks, S. Sorensen, P. Zhang.

    • Obtaining of funding: W.H. Herman, T.J. Hoerger, K. Hicks, M.M. Engelgau. Administrative, technical, or logistic support: W.H. Herman, S. Sorensen, R.F. Hamman, M.M. Engelgau.

    • Collection and assembly of data: W.H. Herman, P. Zhang.

    Summary for Patients

    • Summaries for Patients:The Cost-Effectiveness of Strategies To Prevent Type 2 Diabetes Ann Intern Med March 1, 2005 142:I-28
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    1. Ann Intern Med March 1, 2005 vol. 142 no. 5 323-332
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