Cost-effectiveness of Implementing the Interventions for Diabetes Prevention and Control in the Community and Military Settings

Diabetes is an increasingly prevalent and costly cause of morbidity and mortality, representing not only a major clinical care concern but an immense public health challenge. In 2010, diabetes affected 25.8 million Americans – 8.3% of the US population and 26.9% of those aged 65 years or older. People with diabetes are disproportionately affected by eye and renal disease, non-traumatic amputations, and cardiovascular disease, which result in significant health-care costs of $245 billion in the US in 2012. Although many interventions can reduce health burden of diabetes, health care resources are limited. Hence, evidence is needed to inform health care practitioners and policymakers of these interventions’ costs and benefits to practices, payers, and patients, and thus aid them in prioritizing the interventions for diabetes prevention and control. Through a decision-analytic approach using computational modeling, this dissertation proposed the cost-effectiveness analysis on implementing the Chronic Care Model (CCM) for diabetes control in the community and military settings and on implementing an Online adaptation of the Diabetes Prevention Program lifestyle intervention (ODPP) for weight management in an overweight/obese primary care population with high cardiovascular risk. Our analyses showed that from a health care system and a societal perspective, the CCM compared with usual care cost$42,179-$45,495 and$42,051-$113,280 per quality-adjusted life-year (QALY) gained; the CCM compared with provider continuing medical education (PROV) cost$17,186 and $50,718 per QALY gained; and the ODPP compared with usual care cost$7,777-$14,351 and$18,263-$29,331 per QALY gained. Generally, these results were robust in sensitivity analyses. This dissertation provided supporting evidence that compared with usual care or PROV, the CCM for secondary and tertiary diabetes prevention in the community and military settings as well as the ODPP for primary diabetes prevention in the primary care setting appear to be economically reasonable interventions for diabetes management. These findings are of public health significance as the economic evaluation conducted in this dissertation is an important component of evidence-based clinical and public health practices, which is a decision making aid to help assess the relative value of alternative interventions that can enhance clinical care and public health

Cost- effectiveness of long- acting insulin analogues vs intermediate/long- acting human insulin for type 1 diabetes: A population- based cohort followed over 10 years

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154921/1/bcp14188.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154921/2/bcp14188_am.pd

Comparative cardiovascular safety of GLP-1 receptor agonists versus other glucose-lowering agents in real-world patients with type 2 diabetes: a nationwide population-based cohort study

Abstract Background Current evidence about the cardiovascular safety of glucagon-like peptide-1 receptor agonist (GLP-1ra) possesses limited generalizability to real-world patients with type 2 diabetes (T2D) in usual practice. This study aimed to investigate the comparative cardiovascular safety of GLP-1ra in comparisons with dipeptidyl peptidase-4 inhibitor (DPP-4i), sulfonylurea (SU), and insulin in a real-world population with T2D. Methods Adults with newly-diagnosed T2D were identified from Taiwan’s National Health Insurance Research Database in 2003–2014. A prevalent new-user cohort design was adopted to include a broad representation of real-world T2D patients being treated with GLP-1ra. The between-group comparability of baseline patient characteristics was achieved by matching on (1) initiation time of study drugs, (2) prior exposure to glucose-lowering agents, and (3) diabetes severity and complications, comorbidities, and concomitant cardiovascular medications using propensity scores. The primary outcome was a composite of cardiovascular disease (CVD) events and assessed up to the end of 2015. Cox modeling was employed to assess the association between study drugs and outcomes. Results A total of 3195 GLP-1ra stable users was identified in 2011-2014. 1893, 1829, and 1367 GLP-1ra stable users were 1:1 matched to DPP-4i, SU and insulin users, respectively. Compared to DPP-4i, SU and insulin, the use of GLP-1ra was associated with a lower risk of composite CVD events [hazard ratio (95% confidence interval) 0.73 (0.57–0.96), 0.76 (0.57–1.00), and 0.81 (0.62–1.07), respectively]. Subgroup analyses revealed that GLP-1ra versus DPP-4i yielded a greater cardiovascular benefit in those without established CVD versus those with established CVD. Conclusions This comparison study extends the supporting evidence for the cardiovascular safety of GLP-1ra to a broad spectrum of real-world T2D patients using GLP-1ra.http://deepblue.lib.umich.edu/bitstream/2027.42/173662/1/12933_2020_Article_1053.pd

Cost-effectiveness of GLP-1 receptor agonists versus insulin for the treatment of type 2 diabetes: a real-world study and systematic review

Abstract Background To conduct a real-word-study-based cost-effectiveness analysis of a GLP-1 receptor agonist (GLP-1RA) versus insulin among type 2 diabetes patients requiring intensified injection therapy and a systematic review of cost-effectiveness studies of GLP-1RAs versus insulin. Methods Individual-level analyses incorporating real-world effectiveness and cost data were conducted for a cohort of 1022 propensity-score-matched pairs of GLP-1RA and insulin users from Taiwan’s National Health Insurance Research Database, 2007–2016. Study outcomes included the number needed to treat (NNT) to prevent one case of clinical events, healthcare costs, and cost per case of event prevented. Costs were in 2019 US dollars. Analyses were performed from a third-party payer and healthcare sector perspectives. Structured systematic review procedures were conducted to synthesize updated evidence on the cost-effectiveness of GLP-1RAs versus insulin. Results Over a mean follow-up of 2.3 years, the NNT using a GLP-1RA versus insulin to prevent one case of all-cause mortality and hospitalized hypoglycemia was 57 and 30, respectively. Using GLP-1RAs instead of insulin cost US$54,851 and US$29,115 per case of all-cause mortality and hospitalized hypoglycemia prevented, respectively, from the payer perspective, and saved US$19,391 and US$10,293, respectively, from the healthcare sector perspective. Sensitivity analyses showed that the probability of using GLP-1RAs versus insulin being cost-effective for preventing one case of all-cause mortality or hospitalized hypoglycemia ranged from 60 to 100%. The systematic review revealed a cost-effective profile of using GLP-1RAs versus insulin. Conclusions Using GLP-1RAs versus insulin for type 2 diabetes patients requiring intensified injection therapy in clinical practice is cost-effective.http://deepblue.lib.umich.edu/bitstream/2027.42/173665/1/12933_2020_Article_1211.pd

Cost‐effectiveness of long‐acting insulin analogues vs

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154921/1/bcp14188.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154921/2/bcp14188_am.pd

Comparative predictive ability of visit-to-visit HbA1c variability measures for microvascular disease risk in type 2 diabetes

Abstract Background To assess the associations of various HbA1c measures, including a single baseline HbA1c value, overall mean, yearly updated means, standard deviation (HbA1c-SD), coefficient of variation (HbA1c-CV), and HbA1c variability score (HVS), with microvascular disease (MVD) risk in patients with type 2 diabetes. Methods Linked data between National Cheng Kung University Hospital and Taiwan’s National Health Insurance Research Database were utilized to identify the study cohort. The primary outcome was the composite MVD events (retinopathy, nephropathy, or neuropathy) occurring during the study follow-up. Cox model analyses were performed to assess the associations between HbA1c measures and MVD risk, with adjustment for patients’ baseline HbA1c, demographics, comorbidities/complications, and treatments. Results In the models without adjustment for baseline HbA1c, all HbA1c variability and mean measures were significantly associated with MVD risk, except HVS. With adjustment for baseline HbA1c, HbA1c-CV had the strongest association with MVD risk. For every unit of increase in HbA1c-CV, the MVD risk significantly increased by 3.42- and 2.81-fold based on the models without and with adjustment for baseline HbA1c, respectively. The associations of HbA1c variability and mean measures with MVD risk in patients with baseline HbA1c < 7.5% (58 mmol/mol) were stronger compared with those in patients with baseline HbA1c ≥ 7.5% (58 mmol/mol). Conclusions HbA1c variability, especially HbA1c-CV, can supplement conventional baseline HbA1c measure for explaining MVD risk. HbA1c variability may play a greater role in MVD outcomes among patients with relatively optimal baseline glycemic control compared to those with relatively poor baseline glycemic control.http://deepblue.lib.umich.edu/bitstream/2027.42/173663/1/12933_2020_Article_1082.pd

Association of Renal and Cardiovascular Safety With DPP- 4 Inhibitors vs. Sulfonylureas in Patients With Type 2 Diabetes and Advanced Chronic Kidney Disease

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/168511/1/cpt2262-sup-0001-FigS1.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168511/2/cpt2262_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168511/3/cpt2262-sup-0002-FigS2.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/168511/4/cpt2262.pd

Chronic kidney outcomes associated with GLP-1 receptor agonists versus long-acting insulins among type 2 diabetes patients requiring intensive glycemic control: a nationwide cohort study

Abstract Background Effectiveness of glucagon-like peptide-1 receptor agonists (GLP-1RAs) versus long-acting insulins (LAIs) on preventing progressive chronic kidney outcomes is uncertain for type 2 diabetes (T2D) patients requiring intensive glycemic control. This study aimed to evaluate comparative effectiveness of GLP-1RA versus LAI therapies on progressive chronic kidney outcomes among patients having poor glycemic control and requiring these injectable glucose-lowering agents (GLAs). Methods 7279 propensity-score-matched pairs of newly stable GLP-1RA and LAI users in 2013–2018 were identified from Taiwan’s National Health Insurance Research Database and followed until death or 12/31/2019 (intention-to-treat). Subdistributional hazard model was utilized to assess the comparative effectiveness on a composite renal outcome (i.e., renal insufficiency [eGFR < 15 mL/min/1.73 m2], dialysis-dependent end-stage renal disease [ESRD], or renal death) and its individual components. Sensitivity analyses with the as-treated scenario, PS weighting, high-dimensional PS techniques, using cardiovascular diseases (CVDs) as positive control outcomes, and interaction testing were performed. Results In primary analyses, subdistribution hazard ratios (95% CIs) for initiating GLP-1RAs versus LAIs for the composite renal outcome, renal insufficiency, dialysis-dependent ESRD, and renal death were 0.39 (0.30–0.51), 0.43 (0.32–0.57), 0.29 (0.20–0.43), and 0.28 (0.15–0.51), respectively. Sensitivity analysis results were consistent with the primary findings. CVD history and the medication possession ratio of prior oral GLAs possessed modification effects on GLP-1RA-associated kidney outcomes. Conclusion Using GLP-1RAs versus LAIs was associated with kidney benefits in T2D patients requiring intensive glycemic control and potentially at high risk of kidney progression. GLP-1RAs should be prioritized to patients with CVDs or adherence to prior oral GLAs to maximize kidney benefits

Association of ambient air pollution with cardiovascular disease risks in people with type 2 diabetes: a Bayesian spatial survival analysis

Abstract Background Evidence is limited on excess risks of cardiovascular diseases (CVDs) associated with ambient air pollution in diabetic populations. Survival analyses without considering the spatial structure and possible spatial correlations in health and environmental data may affect the precision of estimation of adverse environmental pollution effects. We assessed the association between air pollution and CVDs in type 2 diabetes through a Bayesian spatial survival approach. Methods Taiwan’s national-level health claims and air pollution databases were utilized. Fine individual-level latitude and longitude were used to determine pollution exposure. The exponential spatial correlation between air pollution and CVDs was analyzed in our Bayesian model compared to traditional Weibull and Cox models. Results There were 2072 diabetic patients included in analyses. PM2.5 and SO2 were significant CVD risk factors in our Bayesian model, but such associations were attenuated or underestimated in traditional models; adjusted hazard ratio (HR) and 95% credible interval (CrI) or confidence interval (CI) of CVDs for a 1 μg/m3 increase in the monthly PM2.5 concentration for our model, the Weibull and Cox models was 1.040 (1.004–1.073), 0.994 (0.984–1.004), and 0.994 (0.984–1.004), respectively. With a 1 ppb increase in the monthly SO2 concentration, adjusted HR (95% CrI or CI) was 1.886 (1.642–2.113), 1.092 (1.022–1.168), and 1.091 (1.021–1.166) for these models, respectively. Conclusions Against traditional non-spatial analyses, our Bayesian spatial survival model enhances the assessment precision for environmental research with spatial survival data to reveal significant adverse cardiovascular effects of air pollution among vulnerable diabetic patients. Graphical abstracthttp://deepblue.lib.umich.edu/bitstream/2027.42/173810/1/12940_2020_Article_664.pd