Retrospective analysis of real-world treatment patterns and clinical outcomes in patients with advanced non-small cell lung cancer starting first-line systemic therapy in the United Kingdom.

BACKGROUND: The treatment landscape for advanced non-small cell lung cancer (aNSCLC) has evolved rapidly since immuno-oncology (IO) therapies were introduced. This study used recent data to assess real-world treatment patterns and clinical outcomes in aNSCLC in the United Kingdom. METHODS: Electronic prescribing records of treatment-naive patients starting first-line (1 L) treatment for aNSCLC between June 2016 and March 2018 (follow-up until December 2018) in the United Kingdom were assessed retrospectively. Patient characteristics and treatment patterns were analyzed descriptively. Outcomes assessed included overall survival (OS), time to treatment discontinuation, time to next treatment, and real-world tumor response. RESULTS: In all, 1003 patients were evaluated (median age, 68 years [range, 28-93 years]; 53.9% male). Use of 1 L IO monotherapy (0-25.9%) and targeted therapy (11.8-15.9%) increased during the study period, but chemotherapy remained the most common 1 L treatment at all time points (88.2-58.2%). Median OS was 9.5 months (95% CI, 8.8-10.7 months) for all patients, 8.1 months (95% CI, 7.4-8.9 months) with chemotherapy, 14.0 months (95% CI, 10.7-20.6 months) with IO monotherapy, and 20.2 months (95% CI, 16.0-30.5 months) with targeted therapy. In the 28.6% of patients who received second-line treatment, IO monotherapy was the most common drug class (used in 51.6%). CONCLUSIONS: Although use of 1 L IO monotherapy for aNSCLC increased in the United Kingdom during the study period, most patients received 1 L chemotherapy. An OS benefit for first-line IO monotherapy vs chemotherapy was observed but was numerically smaller than that reported in clinical trials. Targeted therapy was associated with the longest OS, highlighting the need for improved treatment options for tumors lacking targetable mutations.

Projection of the future diabetes burden in the United States through 2060.

BACKGROUND: In the United States, diabetes has increased rapidly, exceeding prior predictions. Projections of the future diabetes burden need to reflect changes in incidence, mortality, and demographics. We applied the most recent data available to develop an updated projection through 2060. METHODS: A dynamic Markov model was used to project prevalence of diagnosed diabetes among US adults by age, sex, and race (white, black, other). Incidence and current prevalence were from the National Health Interview Survey (NHIS) 1985-2014. Relative mortality was from NHIS 2000-2011 follow-up data linked to the National Death Index. Future population estimates including birth, death, and migration were from the 2014 Census projection. RESULTS: The projected number and percent of adults with diagnosed diabetes would increase from 22.3 million (9.1%) in 2014 to 39.7 million (13.9%) in 2030, and to 60.6 million (17.9%) in 2060. The number of people with diabetes aged 65 years or older would increase from 9.2 million in 2014 to 21.0 million in 2030, and to 35.2 million in 2060. The percent prevalence would increase in all race-sex groups, with black women and men continuing to have the highest diabetes percent prevalence, and black women and women of other race having the largest relative increases. CONCLUSIONS: By 2060, the number of US adults with diagnosed diabetes is projected to nearly triple, and the percent prevalence double. Our estimates are essential to predict health services needs and plan public health programs aimed to reduce the future burden of diabetes.

The future burden of CKD in the United States: a simulation model for the CDC CKD Initiative.

BACKGROUND: Awareness of chronic kidney disease (CKD), defined by kidney damage or reduced glomerular filtration rate, remains low in the United States, and few estimates of its future burden exist. STUDY DESIGN: We used the CKD Health Policy Model to simulate the residual lifetime incidence of CKD and project the prevalence of CKD in 2020 and 2030. The simulation sample was based on nationally representative data from the 1999 to 2010 National Health and Nutrition Examination Surveys. SETTING & POPULATION: Current US population. MODEL, PERSPECTIVE, & TIMELINE: Simulation model following up individuals from current age through death or age 90 years. OUTCOMES: Residual lifetime incidence represents the projected percentage of persons who will develop new CKD during their lifetimes. Future prevalence is projected for 2020 and 2030. MEASUREMENTS: Development and progression of CKD are based on annual decrements in estimated glomerular filtration rates that depend on age and risk factors. RESULTS: For US adults aged 30 to 49, 50 to 64, and 65 years or older with no CKD at baseline, the residual lifetime incidences of CKD are 54%, 52%, and 42%, respectively. The prevalence of CKD in adults 30 years or older is projected to increase from 13.2% currently to 14.4% in 2020 and 16.7% in 2030. LIMITATIONS: Due to limited data, our simulation model estimates are based on assumptions about annual decrements in estimated glomerular filtration rates. CONCLUSIONS: For an individual, lifetime risk of CKD is high, with more than half the US adults aged 30 to 64 years likely to develop CKD. Knowing the lifetime incidence of CKD may raise individuals' awareness and encourage them to take steps to prevent CKD. From a national burden perspective, we estimate that the population prevalence of CKD will increase in coming decades, suggesting that development of interventions to slow CKD onset and progression should be considered.

Medical costs of CKD in the Medicare population.

Estimates of the medical costs associated with different stages of CKD are needed to assess the economic benefits of interventions that slow the progression of kidney disease. We combined laboratory data from the National Health and Nutrition Examination Survey with expenditure data from Medicare claims to estimate the Medicare program's annual costs that were attributable to CKD stage 1-4. The Medicare costs for persons who have stage 1 kidney disease were not significantly different from zero. Per person annual Medicare expenses attributable to CKD were $1700 for stage 2, $3500 for stage 3, and $12,700 for stage 4, adjusted to 2010 dollars. Our findings suggest that the medical costs attributable to CKD are substantial among Medicare beneficiaries, even during the early stages; moreover, costs increase as disease severity worsens. These cost estimates may facilitate the assessment of the net economic benefits of interventions that prevent or slow the progression of CKD.

Experimental Studies on the Combustion Characteristics of Multisource Organic Solid Waste for Collaborative Disposal Using Municipal Solid Waste Incinerators.

This study investigated the evolution of furnace conditions during the heat conversion process of multisource organic solid waste. To achieve this, combustion tests involving different sludge mixing ratios, variable load operation, and multisource organic solid waste collaborative disposal were performed on a 750 t/d new municipal solid waste incineration grate furnace. The test results revealed that as the sludge mixing ratios increased from 0 to 10 and 20%, the temperature level in the furnace decreased and the fuel-type NOx emission increased. Moreover, the sludge featured poor combustion stability under low-load conditions owing to fluctuations in its calorific value and moisture content. Field tests of multisource organic solid waste revealed that after mixing waste cloth strips and papermaking waste, the temperature level in the furnace increased. Additionally, the emissivity distribution was positively correlated with the furnace flame temperature distribution, and NOx emissions also increased. The overall results indicated the feasibility of controlling the mixing rate of different organic solid wastes in the municipal solid waste incinerator within a reasonable range for cooperative incineration.

Medicare Part D is associated with reducing the financial burden of health care services in Medicare beneficiaries with diagnosed diabetes.

BACKGROUND: Medicare Part D, implemented in 2006, provided coverage for prescription drugs to all Medicare beneficiaries. OBJECTIVE: To examine the effect of Part D on the financial burden of persons with diagnosed diabetes. RESEARCH DESIGN, SUBJECTS, AND OUTCOME MEASURES: We conducted an interrupted time-series analysis using data from the 1996 to 2008 Medical Expenditure Panel Survey (11,178 persons with diabetes who were covered by Medicare, and 8953 persons aged 45-64 y with diabetes who were not eligible for Medicare coverage). We then compared changes in 4 outcomes: (1) annual individual out-of-pocket expenditure (OOPE) for prescription drugs; (2) annual individual total OOPE for all health care services; (3) annual total family OOPE for all health care services; and (4) percentage of persons with high family financial burden (OOPE ≥10% of income). RESULTS: For Medicare beneficiaries with diabetes, Part D was associated with a 28% ($530) decrease in individual annual OOPE for prescription drugs, a 23% ($560) reduction in individual OOPE for all health care, a 23% ($863) reduction in family OOPE for all health care, and a 24% reduction in the percentage of families with high financial burden in 2006. There were similar reductions in 2007 and 2008. By 2008, the percentage of Medicare beneficiaries with diabetes living in high financial burden families was 37% lower than it would have been had Part D not been in place. CONCLUSIONS: Introduction of Part D coverage was associated with a substantial reduction in the financial burden of Medicare beneficiaries with diabetes and their families.

Cost-effectiveness of screening for microalbuminuria among African Americans.

Compared with other racial groups, African Americans have a similar prevalence of CKD but are much more likely to progress to ESRD, suggesting that the cost-effectiveness of screening strategies requires dedicated study in this population. Here, we calibrated the CKD Health Policy Model so that it accurately forecasts the higher rates for ESRD observed for African Americans. We then used the calibrated model to estimate the cost-effectiveness of screening for microalbuminuria followed by treatment with angiotensin-converting enzyme inhibitors or angiotensin II-receptor blockers. Incorporating racial differences in risk factors did not fully explain the much higher lifetime incidence of ESRD among African Americans. Thus, to calibrate the model, we applied a 20% increase in the rate of GFR decline at stage 3 and a 60% increase in the rate of GFR decline at stage 4, which resulted in a model that closely reflects lifetime ESRD incidence among African Americans. Compared with usual care, screening African Americans for microalbuminuria at 10-, 5-, 2-, and 1-year intervals had incremental cost-effectiveness ratios of $9000, $11,000, $19,000, and $35,000 per quality-adjusted life year, respectively. Incremental cost-effectiveness ratios for the same screening intervals were higher for non-African Americans: $17,000, $23,000, $44,000, and $81,000 per quality-adjusted life year, respectively. In summary, these models suggest that screening African Americans for microalbuminuria at either 5- or 10-year intervals is highly cost-effective.

Validating the UK prospective diabetes study outcome model 2 using data of 94,946 Israeli patients with type 2 diabetes.

AIMS: To externally validate the United Kingdom Prospective Diabetes Study (UKPDS) Outcome Model 2 (OM2) in contemporary Israeli patient populations. METHODS: De-identified patient data on demographics, time-varying risk factors, and clinical events of newly diagnosed type 2 diabetes patients were extracted from the Maccabi Healthcare Services (MHS) diabetes registry over years 2000-2013. Depending on the baseline risk, patients were categorized into low-risk and intermediate-risk groups. In addition to assessing discriminatory performance, the predicted and observed 15-year cumulative incidences of diabetes complications and death were compared among all patients and for the two risk-groups. RESULTS: The discriminatory capability of OM2 was moderate to good, C-statistic ranging 0.71-0.95. The model overpredicted the risk for MI, blindness and death (Predicted/Observed events (P/O: 1.32-2.31)), and underpredicted the risk of IHD (P/O: 0.5). In patients with a low baseline risk, overpredictions were even more pronounced. OM2 performed well in predicting renal failure and ulcer risk in patients with a low risk but predicted well the risk of death, stroke, CHF, and amputation in patients with an intermediate risk. CONCLUSION: OM2 demonstrated good to moderate discrimination capability for predicting diabetes complications and mortality risks in Israeli diabetes population. The prediction performance differed between patients with different baseline risks.

Selecting the optimal risk threshold of diabetes risk scores to identify high-risk individuals for diabetes prevention: a cost-effectiveness analysis.

AIMS: Although risk scores to predict type 2 diabetes exist, cost-effectiveness of risk thresholds to target prevention interventions are unknown. We applied cost-effectiveness analysis to identify optimal thresholds of predicted risk to target a low-cost community-based intervention in the USA. METHODS: We used a validated Markov-based type 2 diabetes simulation model to evaluate the lifetime cost-effectiveness of alternative thresholds of diabetes risk. Population characteristics for the model were obtained from NHANES 2001-2004 and incidence rates and performance of two noninvasive diabetes risk scores (German diabetes risk score, GDRS, and ARIC 2009 score) were determined in the ARIC and Cardiovascular Health Study (CHS). Incremental cost-effectiveness ratios (ICERs) were calculated for increasing risk score thresholds. Two scenarios were assumed: 1-stage (risk score only) and 2-stage (risk score plus fasting plasma glucose (FPG) test (threshold 100 mg/dl) in the high-risk group). RESULTS: In ARIC and CHS combined, the area under the receiver operating characteristic curve for the GDRS and the ARIC 2009 score were 0.691 (0.677-0.704) and 0.720 (0.707-0.732), respectively. The optimal threshold of predicted diabetes risk (ICER < $50,000/QALY gained in case of intervention in those above the threshold) was 7% for the GDRS and 9% for the ARIC 2009 score. In the 2-stage scenario, ICERs for all cutoffs ≥ 5% were below $50,000/QALY gained. CONCLUSIONS: Intervening in those with ≥ 7% diabetes risk based on the GDRS or ≥ 9% on the ARIC 2009 score would be cost-effective. A risk score threshold ≥ 5% together with elevated FPG would also allow targeting interventions cost-effectively.

Influence of Diabetes Complications on HbA1c Treatment Goals Among Older U.S. Adults: A Cost-effectiveness Analysis.

OBJECTIVE: Guidelines on the standard care of diabetes recommend that glycemic treatment goals for older adults consider the patient's complications and life expectancy. In this study, we examined the influence of diabetes complications and associated life expectancies on the cost-effectiveness (CE) of HbA1c treatment goals. RESEARCH DESIGN AND METHODS: We used data from the 2011-2016 National Health and Nutrition Examination Survey (NHANES) to generate nationally representative subgroups of older individuals with diabetes with various health states. We used the Centers for Disease Control and Prevention-RTI International diabetes CE model to estimate the long-term consequences of two treatment goals-a stringent control goal (HbA1c <7.5%) and a moderate control goal (HbA1c <8.5%)-on health and cost. Our simulation population represented typical patients, and all individuals in each health subgroup had average characteristics, which did not account for person-level variations. The CE study was conducted from a health system perspective and followed the study samples over a lifetime. We used $50,000 per quality-adjusted life year (QALY) as the incremental CE threshold. RESULTS: A stringent goal was, on average, cost-effective for individuals with no complications ($10,007 per QALY) or only microvascular complications (excluding renal failure; $19,621 per QALY), but it was not cost-effective for individuals with one or more macrovascular complications (all >$82,413 per QALY). Further, a stringent goal was not cost-effective when an individual had less than 7 years of life remaining. CONCLUSIONS: Our findings support the guideline recommendation that glycemic goals for older adults should consider the complexity of their complications and their life expectancy from a CE perspective.

Impact of Intensive Lifestyle Intervention on Disability-Free Life Expectancy: The Look AHEAD Study.

OBJECTIVE: The impact of weight loss intervention on disability-free life expectancy in adults with diabetes is unknown. We examined the impact of a long-term weight loss intervention on years spent with and without physical disability. RESEARCH DESIGN AND METHODS: Overweight or obese adults with type 2 diabetes age 45-76 years (n = 5,145) were randomly assigned to a 10-year intensive lifestyle intervention (ILI) or diabetes support and education (DSE). Physical function was assessed annually for 12 years using the 36-Item Short Form Health Survey. Annual incidence of physical disability, mortality, and disability remission were incorporated into a Markov model to quantify years of life spent active and physically disabled. RESULTS: Physical disability incidence was lower in the ILI group (6.0% per year) than in the DSE group (6.8% per year) (incidence rate ratio 0.88 [95% CI 0.81-0.96]), whereas rates of disability remission and mortality did not differ between groups. ILI participants had a significant delay in moderate or severe disability onset and an increase in number of nondisabled years (P < 0.05) compared with DSE participants. For a 60-year-old, this effect translates to 0.9 more disability-free years (12.0 years [95% CI 11.5-12.4] vs. 11.1 years [95% CI 10.6-11.7]) but no difference in total years of life. In stratified analyses, ILI increased disability-free years of life in women and participants without cardiovascular disease (CVD) but not in men or participants with CVD. CONCLUSIONS: Long-term lifestyle interventions among overweight or obese adults with type 2 diabetes may reduce long-term disability, leading to an effect on disability-free life expectancy but not on total life expectancy.

Annual Total Medical Expenditures Associated with Hypertension by Diabetes Status in U.S. Adults.

INTRODUCTION: Hypertension and diabetes, both independent risk factors for cardiovascular disease, often coexist. The hypertension-increased medical expenditures by diabetes status is unclear, however. This study estimated annual total medical expenditures in U.S. adults by hypertension and diabetes status. METHODS: The study population consisted of 40,746 civilian, non-institutionalized adults aged ≥18 years who participated in the 2013 or 2014 Medical Expenditure Panel Survey. The authors separately estimated hypertension-increased medical expenditures using two-part econometric and generalized linear models for the total; diabetes (n=4,396); and non-diabetes (n=36,250) populations and adjusted the results into 2014 U.S. dollars. Data were analyzed in 2017 and estimated the hypertension-increased medical expenditures by type of medical service and payment source. RESULTS: The prevalence of hypertension was 34.9%, 78.3%, and 30.1% for the total, diabetes, and non-diabetes populations, respectively. The respective mean unadjusted annual per capita medical expenditures were $5,225, $12,715, and $4,390. After controlling for potential confounders, hypertension-increased expenditures were $2,565, $4,434, and $2,276 for total, diabetes, and non-diabetes populations, respectively (all p<0.001). The hypertension-increased expenditure was highest for inpatient stays among the diabetes population ($1,730, p<0.001), and highest for medication among the non-diabetes population ($687, p<0.001). By payment source, Medicare ranked first in hypertension-increased expenditures for the diabetes ($2,753) and second for the non-diabetes ($669) populations (both p<0.001). CONCLUSIONS: Hypertension-increased medical expenditures were substantial and varied by medical service type and payment sources. These findings may be useful as inputs for cost- effectiveness evaluations of hypertension interventions by diabetes status.

Cost-effectiveness of the 2014 U.S. Preventive Services Task Force (USPSTF) Recommendations for Intensive Behavioral Counseling Interventions for Adults With Cardiovascular Risk Factors.

OBJECTIVE: 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. We assessed the long-term cost-effectiveness (CE) of implementing the recommended interventions in the U.S. RESEARCH DESIGN AND METHODS: We 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. Future QALYs and costs (reported in 2014 U.S. dollars) were discounted at 3%. RESULTS: We 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: The recommended intervention is cost effective based on the conventional CE 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.

The Cost-Effectiveness of Anemia Treatment for Persons with Chronic Kidney Disease.

BACKGROUND: Although major guidelines uniformly recommend iron supplementation and erythropoietin stimulating agents (ESAs) for managing chronic anemia in persons with chronic kidney disease (CKD), there are differences in the recommended hemoglobin (Hb) treatment target and no guidelines consider the costs or cost-effectiveness of treatment. In this study, we explored the most cost-effective Hb target for anemia treatment in persons with CKD stages 3-4. METHODS AND FINDINGS: The CKD Health Policy Model was populated with a synthetic cohort of persons over age 30 with prevalent CKD stages 3-4 (i.e., not on dialysis) and anemia created from the 1999-2010 National Health and Nutrition Examination Survey. Incremental cost-effectiveness ratios (ICERs), computed as incremental cost divided by incremental quality adjusted life years (QALYs), were assessed for Hb targets of 10 g/dl to 13 g/dl at 0.5 g/dl increments. Targeting a Hb of 10 g/dl resulted in an ICER of $32,111 compared with no treatment and targeting a Hb of 10.5 g/dl resulted in an ICER of $32,475 compared with a Hb target of 10 g/dl. QALYs increased to 4.63 for a Hb target of 10 g/dl and to 4.75 for a target of 10.5 g/dl or 11 g/dl. Any treatment target above 11 g/dl increased medical costs and decreased QALYs. CONCLUSIONS: In persons over age 30 with CKD stages 3-4, anemia treatment is most cost-effective when targeting a Hb level of 10.5 g/dl. This study provides important information for framing guidelines related to treatment of anemia in persons with CKD.

Compression of disability between two birth cohorts of US adults with diabetes, 1992-2012: a prospective longitudinal analysis.

BACKGROUND: The life expectancy of the average American with diabetes has increased, but the quality of health and functioning during those extra years are unknown. We aimed to investigate the net effect of recent trends in diabetes incidence, disability, and mortality on the average age of disability onset and the number of healthy and disabled years lived by adults with and without diabetes in the USA. We assessed whether disability expanded or was compressed in the population with diabetes and compared the findings with those for the population without diabetes in two consecutive US birth cohorts aged 50-70 years. METHODS: In this prospective longitudinal analysis, we analysed data for two cohorts of US adults aged 50-70 years from the Health and Retirement Study, including 1367 people with diabetes and 11 414 without diabetes. We assessed incident disability, remission from disability, and mortality between population-based cohort 1 (born 1931-41, follow-up 1992-2002) and cohort 2 (born 1942-47, follow up 2002-12). Disability was defined by mobility loss, difficulty with one or more instrumental activities of daily living, and difficulty with one or more activities of daily living. We entered age-specific probabilities representing the two birth cohorts into a five-state Markov model to estimate the number of years of disabled and disability-free life and life-years lost by age 70 years. FINDINGS: In people with diabetes, compared with cohort 1 (n=1067), cohort 2 (n=300) had more disability-free and total years of life, later onset of disability, and fewer disabled years. Simulations of the Markov models suggest that in men with diabetes aged 50 years, this difference between cohorts amounted to a 0·8-2·3 year delay in disability across the three metrics (mobility, 63·0 [95% CI 62·3-63·6] to 64·8 [63·6-65·7], p=0·01; instrumental activities of daily living, 63·5 [63·0-64·0] to 64·3 [63·0-65·3], p=0·24; activities of daily living, 62·7 [62·1-63·3] to 65·0 [63·5-65·9], p<0·0001) and 1·3 fewer life-years lost (ie, fewer remaining life-years up to age 70 years; from 2·8 [2·5-3·2] to 1·5 [1·3-1·9]; p<0·0001 for all three measures of disability). Among women with diabetes aged 50 years, this difference between cohorts amounted to a 1·1-2·3 year delay in disability across the three metrics (mobility, 61·3 [95% CI 60·5-62·1] to 63·2 [61·5-64·5], p=0·0416; instrumental activities of daily living, 63·0 [62·4-63·7] to 64·1 [62·7-65·2], p=0·16; activities of daily living, 62·3 [61·6-63·0] to 64·6 [63·1-65·6], p<0·0001) and 0·8 fewer life-years lost by age 70 years (1·9 [1·7-2·2] to 1·1 [0·9-1·5]; p<0·0001 for all three measures of disability). Parallel improvements were gained between cohorts of adults without diabetes (cohort 1, n=8687; cohort 2, n=2727); within both cohorts, those without diabetes had significantly more disability-free years than those with diabetes (p<0·0001 for all comparisons). INTERPRETATION: Irrespective of diabetes status, US adults saw a compression of disability and gains in disability-free life-years. The decrease in disability onset due to primary prevention of diabetes could play an important part in achieving longer disability-free life-years. FUNDING: US Department of Health & Human Services and the US Centers for Disease Control and Prevention.

Disability-Free Life-Years Lost Among Adults Aged ≥50 Years With and Without Diabetes.

OBJECTIVE: To quantify the impact of diabetes status on healthy and disabled years of life for older adults in the U.S. and provide a baseline from which to evaluate ongoing national public health efforts to prevent and control diabetes and disability. RESEARCH DESIGN AND METHODS: Adults (n = 20,008) aged 50 years and older were followed from 1998 to 2012 in the Health and Retirement Study, a prospective biannual survey of a nationally representative sample of adults. Diabetes and disability status (defined by mobility loss, difficulty with instrumental activities of daily living [IADL], and/or difficulty with activities of daily living [ADL]) were self-reported. We estimated incidence of disability, remission to nondisability, and mortality. We developed a discrete-time Markov simulation model with a 1-year transition cycle to predict and compare lifetime disability-related outcomes between people with and without diabetes. Data represent the U.S. population in 1998. RESULTS: From age 50 years, adults with diabetes died 4.6 years earlier, developed disability 6-7 years earlier, and spent about 1-2 more years in a disabled state than adults without diabetes. With increasing baseline age, diabetes was associated with significant (P < 0.05) reductions in the number of total and disability-free life-years, but the absolute difference in years between those with and without diabetes was less than at younger baseline age. Men with diabetes spent about twice as many of their remaining years disabled (20-24% of remaining life across the three disability definitions) as men without diabetes (12-16% of remaining life across the three disability definitions). Similar associations between diabetes status and disability-free and disabled years were observed among women. CONCLUSIONS: Diabetes is associated with a substantial reduction in nondisabled years, to a greater extent than the reduction of longevity.

Change in medical spending attributable to diabetes: national data from 1987 to 2011.

OBJECTIVE: Diabetes care has changed substantially in the past 2 decades. We examined the change in medical spending and use related to diabetes between 1987 and 2011. RESEARCH DESIGN AND METHODS: Using the 1987 National Medical Expenditure Survey and the Medical Expenditure Panel Surveys in 2000-2001 and 2010-2011, we compared per person medical expenditures and uses among adults ≥ 18 years of age with or without diabetes at the three time points. Types of medical services included inpatient care, emergency room (ER) visits, outpatient visits, prescription drugs, and others. We also examined the changes in unit cost, defined by the expenditure per encounter for medical services. RESULTS: The excess medical spending attributed to diabetes was $2,588 (95% CI, $2,265 to $3,104), $4,205 ($3,746 to $4,920), and $5,378 ($5,129 to $5,688) per person, respectively, in 1987, 2000-2001, and 2010-2011. Of the $2,790 increase, prescription medication accounted for 55%; inpatient visits accounted for 24%; outpatient visits accounted for 15%; and ER visits and other medical spending accounted for 6%. The growth in prescription medication spending was due to the increase in both the volume of use and unit cost, whereas the increase in outpatient expenditure was almost entirely driven by more visits. In contrast, the increase in inpatient and ER expenditures was caused by the rise of unit costs. CONCLUSIONS: In the past 2 decades, managing diabetes has become more expensive, mostly due to the higher spending on drugs. Further studies are needed to assess the cost-effectiveness of increased spending on drugs.

Medicare's intensive behavioral therapy for obesity: an exploratory cost-effectiveness analysis.

INTRODUCTION: Medicare coverage recently was expanded to include intensive behavioral therapy for obese individuals in primary care settings. PURPOSE: To examine the potential cost effectiveness of Medicare's intensive behavioral therapy for obesity, accounting for uncertainty in effectiveness and utilization. METHODS: A Markov simulation model of type 2 diabetes was used to estimate long-term health benefits and healthcare system costs of intensive behavioral therapy for obesity in the Medicare population without diabetes relative to an alternative of usual care. Cohort statistics were based on the 2005-2008 National Health and Nutrition Examination Survey. Model parameters were derived from the literature. Analyses were conducted in 2014 and reported in 2012 U.S. dollars. RESULTS: Based on assumptions for the maximal intervention effectiveness, intensive behavioral therapy is likely to be cost saving if costs per session equal the current reimbursement rate ($25.19) and will provide a cost-effectiveness ratio of $20,912 per quality-adjusted life-year if costs equal the rate for routine office visits. The intervention is less cost effective if it is less effective in primary care settings or if fewer intervention sessions are supplied by providers or used by participants. CONCLUSIONS: If the effectiveness of the intervention is similar to lifestyle interventions tested in other settings and costs per session equal the current reimbursement rate, intensive behavioral therapy for obesity offers good value. However, intervention effectiveness and the pattern of implementation and utilization strongly influence cost effectiveness. Given uncertainty regarding these factors, additional data might be collected to validate the modeling results.

Cost-effectiveness of a national population-based screening program for type 2 diabetes: the Brazil experience.

BACKGROUND: The cost-effectiveness of screening for type 2 diabetes mellitus (DM2) in developing countries remains unknown. The Brazilian government conducted a nationwide population screening program for type 2 diabetes mellitus (BNDSP) in which 22 million capillary glucose tests were performed in individuals aged 40 years and older. The objective of this study was to evaluate the life-time cost-effectiveness of a national population-based screening program for DM2 conducted in Brazil. METHODS: We used a Markov-based cost-effectiveness model to simulate the long-term costs and benefits of screening for DM2, compared to no screening program. The analysis was conducted from a public health care system perspective. Sensitivity analyses were conducted to examine the robustness of results to key model parameters. RESULTS: Brazilian National diabetes screening program will yield a large health benefit and higher costs. Compared with no screening, screen detection of undiagnosed diabetes resulted in US$ 31,147 per QALY gained. Results from sensitivity analyses found that screening targeted at hypertensive individuals would cost US$ 22,695/QALY. When benefits from early glycemic control on cardiovascular outcomes were considered, the cost per QALY gained would reduce significantly. CONCLUSIONS: In the base case analysis, not considering the intangible benefit of transferring diabetes management to primary care nor the benefit of using statin to treat eligible diabetic patients, CE ratios were not cost-effective considering thresholds proposed by the World Health Organization. However, significant uncertainty was demonstrated in sensitivity analysis. Our results indicate that policy-makers should carefully balance the benefit and cost of the program while considering using a population-based approach to screen for diabetes.