Assessing the Potential Return on Investment of the Proposed UK NHS Diabetes Prevention Programme in Different Population Subgroups: An Economic Evaluation

Objectives: To evaluate potential return on investment of the NHS Diabetes Prevention Programme (DPP) in England, and estimate which population subgroups are likely to benefit most in terms of cost-effectiveness, cost-savings and health benefits. Design: Economic Analysis using the School for Public Health Research Diabetes Prevention Model Setting: England 2015-16 Population: Adults aged 16 or over with high risk of type 2 diabetes (HbA1c 6-6.4%). Population subgroups defined by age, sex, ethnicity, socioeconomic deprivation, baseline BMI, baseline HbA1c and working status. Interventions: The proposed NHS DPP: An intensive lifestyle intervention focussing on dietary advice, physical activity and weight loss. Comparator: No diabetes prevention intervention. Main outcome measures: Incremental costs, savings and return on investment, quality adjusted life years (QALYs), diabetes cases, cardiovascular cases and net monetary benefit from an NHS perspective. Results: Intervention costs will be recouped through NHS savings within 12 years, with net NHS saving of £1.28 over 20 years for each £1 invested. Per 100,000 DPP interventions given, 3,552 QALYs are gained. The DPP is most cost-effective and cost-saving in obese individuals, those with baseline HbA1c 6.2-6.4% and those aged 40-74. QALY gains are lower in minority ethnic and low socioeconomic status subgroups. Probabilistic sensitivity analysis suggests that there is 97% probability that the DPP will be cost-effective within 20 years. NHS savings are highly sensitive to intervention cost, effectiveness and duration of effect. Conclusions: The DPP is likely to be cost-effective and cost-saving under current assumptions. Prioritising obese individuals could create the most value for money and obtain the greatest health benefits per individual targeted. Low socioeconomic status or ethnic minority groups may gain fewer QALYs per intervention, so targeting strategies should ensure the DPP does not contribute to widening health inequalities. Further evidence is needed around the differential responsiveness of population subgroups to the DPP.

The Impact of Including Costs and Outcomes of Dementia in a Health Economic Model to Evaluate Lifestyle Interventions to Prevent Diabetes and Cardiovascular Disease.

OBJECTIVES: Economic evaluations of lifestyle interventions, which aim to prevent diabetes/cardiovascular disease (CVD), have not included dementia. Lifestyle interventions decrease dementia risk and extend life expectancy, leading to competing effects on health care costs. We aim to demonstrate the feasibility of including dementia in a public health cost-effectiveness analysis and quantify the overall impacts accounting for these competing effects. METHODS: The School for Public Health Research (SPHR) diabetes prevention model describes individuals' risk of type 2 diabetes, microvascular outcomes, CVD, congestive heart failure, cancer, osteoarthritis, depression, and mortality in England. In version 3.1, we adapted the model to include dementia using published data from primary care databases, health surveys, and trials of dementia to describe dementia incidence, diagnosis, and disease progression. We estimate the impact of dementia on lifetime costs and quality-adjusted life years (QALYs) gained of the National Health Service diabetes prevention program (NHS DPP) from an NHS/personal social services perspective with 3 scenarios: 1) no dementia, 2) dementia only, and 3) reduced dementia risk. Subgroup, parameter, and probabilistic sensitivity analyses were conducted. RESULTS: The lifetime cost savings of the NHS DPP per patient were £145 in the no-dementia scenario, £121 in the dementia-only scenario, and £167 in the reduced dementia risk scenario. The QALY gains increased by 0.0006 in dementia only and 0.0134 in reduced dementia risk. Dementia did not alter the recommendation that the NHS/DPP is cost-effective. CONCLUSIONS: Including dementia into a model of lifestyle interventions was feasible but did not change policy recommendations or modify health economic outcomes. The impact on health economic outcomes was largest where a direct impact on dementia incidence was assumed, particularly in elderly populations.National Institute for Health Research (NIHR) School for Public Health Research (SPHR). Grant Reference Number PD- SPH-201

The cost-effectiveness of an updated theory-based online health behavior intervention for new university students: U@Uni2

Background: The transition to university marks a point where young people may be open to changing health behaviours such as smoking, exercise, diet and alcohol intake. This study aimed to estimate the cost-effectiveness of an updated online health behaviour intervention for new university students in the UK – “U@Uni2”, compared with both a control (measurement only) scenario and with the original intervention (“U@Uni1”). Methods: The economic analysis, based on a randomised controlled trial, comprised a detailed costing analysis, a within-trial cost-effectiveness analysis and long-term economic modelling. Cost-effectiveness of the U@Uni2 trial was estimated using 6-month data on costs and health-related quality of life. An individual patient simulation model was adapted for long-term economic analysis of U@Uni2. Probabilistic sensitivity analysis and value of information analysis accounted for uncertainty in model inputs and identified key parameters. Results: The U@Uni2 intervention costs £45.97 per person for full implementation, £10.43 per person for roll-out in a different institution and £3.03 per person for roll-out over five years. The U@Uni2 trial was not cost-effective because marginally fewer quality-adjusted life years (QALYs) were obtained in the intervention arm than control. However, modelled over a lifetime, U@Uni2 is estimated to produce more QALYs than control but fewer than U@Uni1, primarily due to the effect of the interventions on smoking. Roll-out of U@Uni2 is highly likely to be more cost-effective than doing nothing (ICER = £536 per QALY, 86% probability cost-effective). Decision uncertainty occurs primarily around the effectiveness of the U@Uni2 intervention and is worth up to £3.24m. Conclusions: The U@Uni2 intervention is highly likely to be cost-effective to roll-out compared with doing nothing. The results suggest that preventing uptake of smoking is the key driver of QALY gain and should be the primary target of such interventions. Trial Registration: Current Controlled Trials ISRCTN6768418

Stand up for recalcitrance!

This is an urgent plea for action. Action for progressive change: in services and societies that frame them. Concerted action to protest and resist hurtful orthodoxies and, more importantly, communicative action to conceive alternative, better futures and seek the change that will get us there. Some of this action is already underway. Some of it barely escapes the bounds of imagination. Too little of it involves mental health nurses, and, arguably, this must be remedied. Hence this plea. I wish to make a case for a new professional identity that embraces resistance and action for change, seeking democratised solutions for service level and societal deficiencies. Recalcitrant professionalism can seek constructive alliances with recalcitrant consumers, service users and survivors to resist and transform the forces of oppression that assail us all

What are ‘unpopular causes’ and how can they achieve fundraising success?

Recent efforts to grow and strengthen the culture of philanthropy in the UK have largely focused on two dimensions: the total amount of money donated and the effectiveness of philanthropic spending. This paper explores a third dimension: the destination and distribution of donations. A defining characteristic of charitable giving is that it is voluntary rather than coerced, and the resulting respect for donor autonomy makes people wary of promoting one cause above another or implying that any beneficiary group is more or less ‘worthy’ of support. However, the absence of much comment on, or significant research into, the destination of donations does not alter the fact that some groups succeed in attracting significant philanthropic funds whilst others struggle to secure many – or any – donations. This paper explores the concept of ‘unpopularity’ in the charity sector, especially in relation to its impact on fundraising. We unpack what this loaded phrase means, identify good practice by those seeking support and present case studies of charities that have overcome perceived unpopularity to achieve success in raising voluntary income. We suggest that by investing organisational resources and effort in fundraising, by framing the cause to maximise the arousal of sympathy and minimise concerns about beneficiary culpability, and by avoiding the unintended negative consequences of self-labelling as ‘unpopular’ no charity need assume it is their destiny to languish at the bottom of the fundraising league tables

SPHR Diabetes Prevention Model: Detailed Description of Model Background, Methods, Assumptions and Parameters

Type-2 diabetes is a complex disease with multiple risk factors and health consequences whose prevention is a major public health priority. We have developed a microsimulation model written in the R programming language that can evaluate the effectiveness and cost-effectiveness of a comprehensive range of different diabetes prevention interventions, either in the general population or in subgroups at high risk of diabetes. Within the model individual patients with different risk factors for diabetes follow metabolic trajectories (for body mass index, cholesterol, systolic blood pressure and glycaemia), develop diabetes, complications of diabetes and related disorders including cardiovascular disease and cancer, and eventually die. Lifetime costs and quality-adjusted life-years are collected for each patient. The model allows assessment of the wider social impact on employment and the equity impact of different interventions. Interventions may be population-based, community-based or individually targeted, and administered singly or layered together. The model is fully enabled for probabilistic sensitivity analysis (PSA) to provide an estimate of decision uncertainty. This discussion paper provides a detailed description of the model background, methods and assumptions, together with details of all parameters used in the model, their sources and distributions for PSA

Impact of Type 2 diabetes prevention programmes based on risk identification and lifestyle intervention intensity strategies: a cost-effectiveness analysis

Aim To develop a cost-effectiveness model to compare Type 2 diabetes prevention programmes that target different at-risk population subgroups through lifestyle interventions of varying intensity. Methods An individual patient simulation model simulated the development of diabetes in a representative sample of adults without diabetes from the UK population. The model incorporates trajectories for HbA1c, 2-h glucose, fasting plasma glucose, BMI, systolic blood pressure, total cholesterol and HDL cholesterol. In the model, patients can be diagnosed with diabetes, cardiovascular disease, microvascular complications of diabetes, cancer, osteoarthritis and depression, or can die. The model collects costs and utilities over a lifetime horizon. The perspective is the UK National Health Service and Personal Social Services. We used the model to evaluate the population-wide impact of targeting a lifestyle intervention of varying intensity to six population subgroups defined as at high risk for diabetes. Results The intervention produces 0.0020 to 0.0026 incremental quality-adjusted life-years and saves £15 to £23 per person in the general population, depending on the subgroup targeted. Cost-effectiveness increases with intervention intensity. The most cost-effective options were to target South-Asian people and those with HbA1c levels > 42 mmol/mol (6%). Conclusion The model indicates that diabetes prevention interventions are likely to be cost-saving. The criteria for selecting at-risk individuals differentially has an impact on diabetes and cardiovascular disease outcomes, and on the timing of costs and benefits. The model is not currently able to account for potential differential uptake or efficacy between subgroups. These findings have implications for deciding who should be targeted for diabetes prevention interventions.NIH

A specific group of genes respond to cold dehydration stress in cut Alstroemeria flowers whereas ambient dehydration stress accelerates developmental senescence expression patterns

Petal development and senescence entails a normally irreversible process. It starts with petal expansion and pigment production, and ends with nutrient remobilization and ultimately cell death. In many species this is accompanied by petal abscission. Post-harvest stress is an important factor in limiting petal longevity in cut flowers and accelerates some of the processes of senescence such as petal wilting and abscission. However, some of the effects of moderate stress in young flowers are reversible with appropriate treatments. Transcriptomic studies have shown that distinct gene sets are expressed during petal development and senescence. Despite this, the overlap in gene expression between developmental and stress-induced senescence in petals has not been fully investigated in any species. Here a custom-made cDNA microarray from Alstroemeria petals was used to investigate the overlap in gene expression between developmental changes (bud to first sign of senescence) and typical post-harvest stress treatments. Young flowers were stressed by cold or ambient temperatures without water followed by a recovery and rehydration period. Stressed flowers were still at the bud stage after stress treatments. Microarray analysis showed that ambient dehydration stress accelerates many of the changes in gene expression patterns that would normally occur during developmental senescence. However, a higher proportion of gene expression changes in response to cold stress were specific to this stimulus and not senescence related. The expression of 21 transcription factors was characterized, showing that overlapping sets of regulatory genes are activated during developmental senescence and by different stresses

The assessment report of the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services on pollinators, pollination and food production

The thematic assessment of pollinators, pollination and food production carried out under the auspices of the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services aims to assess animal pollination as a regulating ecosystem service underpinning food production in the context of its contribution to nature’s gifts to people and supporting a good quality of life. To achieve this, it focuses on the role of native and managed pollinators, the status and trends of pollinators and pollinator-plant networks and pollination, drivers of change, impacts on human well-being, food production in response to pollination declines and deficits and the effectiveness of responses

Cross-model validation of public health microsimulation models; comparing two models on estimated effects of a weight management intervention

Background Health economic modelling indicates that referral to a behavioural weight management programme is cost saving and generates QALY gains compared with a brief intervention. The aim of this study was to conduct a cross-model validation comparing outcomes from this cost-effectiveness analysis to those of a comparator model, to understand how differences in model structure contribute to outcomes. Methods The outcomes produced by two models, the School for Public Health Research diabetes prevention (SPHR) and Health Checks (HC) models, were compared for three weight-management programme strategies; Weight Watchers (WW) for 12 weeks, WW for 52 weeks, and a brief intervention, and a simulated no intervention scenario. Model inputs were standardised, and iterative adjustments were made to each model to identify drivers of differences in key outcomes. Results The total QALYs estimated by the HC model were higher in all treatment groups than those estimated by the SPHR model, and there was a large difference in incremental QALYs between the models. SPHR simulated greater QALY gains for 12-week WW and 52-week WW relative to the Brief Intervention. Comparisons across socioeconomic groups found a stronger socioeconomic gradient in the SPHR model. Removing the impact of treatment on HbA1c from the SPHR model, running both models only with the conditions that the models have in common and, to a lesser extent, changing the data used to estimate risk factor trajectories, resulted in more consistent model outcomes. Conclusions The key driver of difference between the models was the inclusion of extra evidence-based detail in SPHR on the impacts of treatments on HbA1c. The conclusions were less sensitive to the dataset used to inform the risk factor trajectories. These findings strengthen the original cost-effectiveness analyses of the weight management interventions and provide an increased understanding of what is structurally important in the models