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Cost effectiveness of peer support for type 2 diabetes |
Gillespie P, O'Shea E, Paul G, O'Dowd T, Smith SM |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of a group-based peer support intervention, in general practice, for patients with type 2 diabetes. The authors concluded that the intervention led to a trend towards improvements in clinical outcomes and reductions in societal and health care costs, compared with usual care alone. The analysis had a valid and transparent framework, and the robust methods should ensure the validity of the authors’ conclusions. Type of economic evaluation Study objective This study examined the cost-effectiveness of a group-based peer support intervention, in general practice, for patients with type 2 diabetes. Interventions The intervention consisted of nine group meetings, led by peer supporters, to encourage individuals to assume responsibility for the management of their illness. This was added to and compared with the usual standardised care for patients with type 2 diabetes. Methods Analytical approach:The evaluation considered the results of a trial, followed by a model. The trial was a published cluster randomised controlled trial (RCT). The model used data from the UK Prospective Diabetes Study (UKPDS) to forecast the long-term health and economic outcomes beyond the trial data to a lifetime. The authors stated that they took the perspective of the health care system and the patient. Effectiveness data:The clinical data for the short-term analysis were from a published RCT that was carried out in Ireland and involved 20 practices and 395 patients, who were followed-up for two years. There were 192 patients (mean age 66.1 years) in the intervention group and 203 (mean age 63.2 years) in the control group. The long-term estimates were from the UKPDS. It was assumed that there was no additional intervention benefit beyond the end of the trial. Monetary benefit and utility valuations:The utility values were incorporated in the UKPDS model. Measure of benefit:Quality-adjusted life-years (QALYs) were used as the summary benefit measure and were discounted at an annual rate of 3.5%. Cost data:The economic analysis included four main cost categories: implementation of the intervention, use of primary and secondary health care services, patient expenses (time and travel), and health care for predicted diabetes complications. The intervention costs were peer supporter recruitment and training, peer support meetings, general programme implementation, practice and patient recruitment, and social events. The primary and secondary health care services were general practitioner and practice nurse consultations, hospital admissions, diabetic day care centre and out-patient consultations, dietician visits, chiropodist visits, accident and emergency visits, and diabetic treatments. The costs of peer supporter time were included. The unit costs were from national sources. All costs were in Euros (EUR). The price year was 2008 and the annual discount rate was 3.5%. Analysis of uncertainty:A one-way sensitivity analysis was carried out to investigate how robust the model outcomes were to variations in selected inputs, such as the duration of treatment, discount rate, and cost of peer supporter time. A probabilistic sensitivity analysis was performed, and the results were plotted in cost-effectiveness acceptability curves and reported as potential threshold values. Results The total lifetime costs were EUR 17,487.81 with the intervention and EUR 18,111.21 with the control. The QALYs were 6.76 with the intervention and 6.67 with the control. The intervention was dominant, as it was cheaper and more beneficial than the control, but the differences in the costs and the QALYs were not statistically significant at the 5% level. The likelihood of the intervention being cost-effective at a threshold of EUR 5,000 per QALY gained was 83%. At a threshold of EUR 15,000 it was 90%, at EUR 30,000 it was 89%, and at EUR 45,000 it was 89%. From a more restricted health system perspective, at a threshold of EUR 5,000 it was 87%, at EUR 15,000 it was 91%, at EUR 30,000 it was 92%, and at EUR 45,000 it was 91%. These results were robust in the univariate sensitivity analyses, and the intervention remained dominant in all cases. Authors' conclusions The authors concluded that the intervention led to a trend towards improvements in clinical outcomes and reductions in societal and health care costs, compared with usual care alone, for patients with type 2 diabetes. CRD commentary Interventions:The rationale for the selection of the comparators was clear. The proposed addition to usual care was compared with the conventional care alone in the authors’ setting. Effectiveness/benefits:The clinical inputs were from a recently published Irish clinical trial (Smith, et al. 2011, see 'Other Publications of Related Interest' below for bibliographic details). The main methods and characteristics of patients enrolled in the trial were reported. An intention-to-treat analysis of the clinical differences was appropriately performed. Except for patient age, which was lower in the control group, and the percentage of married or cohabiting patients, the socio-demographic and clinical characteristics of the two groups were well balanced at baseline. The observed differences were controlled for in the statistical analysis. The long-term estimates were based on validated equations and UK population data. QALYs were a valid benefit measure for capturing the impact of diabetes on the patients’ health. The survival and quality of life data were from the UKPDS. Costs:The cost categories reflected the perspective stated. Extensive details of the unit costs and resource use were provided enhancing the transparency of the analysis. Most of the data were collected alongside the clinical trial and they are likely to have been collected in detail. These data reflected the costs in Ireland, but it was unclear whether they would be the same in real-world clinical practice. The long-term costs were from validated studies. The costs were varied in the sensitivity analysis. The price year was reported and, overall, the economic part of the analysis was satisfactory. Analysis and results:The results were clearly presented for both the two-year and the lifetime horizon. An incremental approach was used to identify the best strategy, but incremental cost-utility ratios were not reported because the intervention was dominant. Valid approaches were used to investigate uncertainty, and the results were clearly presented and illustrated. Conventional discounting was applied to both the costs and benefits, but the impact of varying the discount rate was not tested in the sensitivity analysis. The authors acknowledged some limitations to their analysis, such as the use of UKPDS data that did not include some diabetes complications, but it is highly unlikely that these would have changed the cost-effectiveness conclusions. The results were specific to Ireland or the UK and might not be directly transferable to other countries. Concluding remarks:The analysis had a valid and transparent framework, and the robust methods should ensure the validity of the authors’ conclusions. Funding Funded by the Health Research Board of Ireland. Bibliographic details Gillespie P, O'Shea E, Paul G, O'Dowd T, Smith SM. Cost effectiveness of peer support for type 2 diabetes. International Journal of Technology Assessment in Health Care 2012; 28(1): 3-11 Other publications of related interest Smith SM, Paul G, Kelly A, Whitford DL, O’Shea E, O’Dowd T. Peer support for type 2 diabetes: a cluster randomized controlled trial. BMJ 2011; 342:d715. Indexing Status Subject indexing assigned by NLM MeSH Confidence Intervals; Cost-Benefit Analysis; Diabetes Mellitus, Type 2 /economics /therapy; Great Britain; Hemoglobin A, Glycosylated; Humans; Peer Group; Primary Health Care /economics; Quality-Adjusted Life Years; Risk Reduction Behavior; Social Support; Statistics as Topic; Surveys and Questionnaires AccessionNumber 22012014482 Date bibliographic record published 23/05/2012 Date abstract record published 02/01/2013 |
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