A systematic review on costs and cost-effectiveness of screening and prevention of type 2 diabetes in women with prior gestational diabetes: Exploring uncharted territory

A Complex mHealth Coaching Intervention to Prevent Overweight, Obesity, and Diabetes in High-Risk Women in Antenatal Care: Protocol for a Hybrid Type 2 Effectiveness-Implementation Study

BACKGROUND

Women with overweight and obesity are at higher risk of developing complications in pregnancy such as gestational diabetes and longer-term chronic conditions. Research concerning health behavior change interventions during pregnancy and postpartum shows promising effects, but implementation into routine services is sparsely investigated. Most interventions focus on the antenatal or postpartum life stages, failing to meet the needs of women. IMPACT DIABETES Bump2Baby is a multicenter project across 4 high-income countries developed to test the implementation of an antenatal and postpartum evidence-based mobile health (mHealth) coaching intervention called Bump2Baby and Me (B2B&Me) designed to sit alongside usual care in the perinatal period.

OBJECTIVE

We aim to explore the feasibility and implementation of the B2B&Me intervention and investigate the effectiveness of this intervention in women at risk of gestational diabetes.

METHODS

IMPACT DIABETES Bump2Baby is a hybrid type 2 effectiveness-implementation study, which integrates an evidence-based mHealth coaching app that includes personalized health behavior change coaching provided by health care professionals alongside antenatal care from the first antenatal visit to 12 months postpartum. The mHealth app offers the possibility of synchronous calls, asynchronous contact (including coach-participant text and video messaging exchanges tailored to the participant's needs), and ongoing access to an extensive library of bespoke intervention materials. Participants will interact asynchronously with their health coach throughout the intervention via the app. This randomized controlled trial across 4 clinical sites within Ireland, the United Kingdom, Spain, and Australia will recruit 800 women in early pregnancy to evaluate the effectiveness on postpartum weight. The Exploration, Preparation, Implementation, and Sustainment implementation framework is the theoretical underpinning of the study. The implementation evaluation will be assessed at the individual, hospital staff, and broader community levels using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. Data sources for the RE-AIM evaluation will include app and platform analytics, screening and training records, participant medical records, key informant interviews, participant and partner exit interviews, cost data, study questionnaires, staff surveys, and blood sample analyses.

RESULTS

The study was approved and registered with the Australian New Zealand Clinical Trials Registry on November 19, 2020. Recruitment commenced on February 9, 2021, and data collection is ongoing. Publication of the results is expected in 2024.

CONCLUSIONS

This is the first hybrid effectiveness-implementation study of an 18-month mHealth coaching intervention in at-risk women that we are aware of. As research aims to move toward real-world implementable solutions, it is critical that hybrid studies are conducted. The data from this large multicenter study will be useful in planning the potential implementation and scale-up of evidence-based perinatal health behavior change interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620001240932; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380020&isReview=true.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51431.

Long-term cost-effectiveness of implementing a lifestyle intervention during pregnancy to reduce the incidence of gestational diabetes and type 2 diabetes

AIMS/HYPOTHESIS

The aim of this study was to determine the long-term cost-effectiveness and return on investment of implementing a structured lifestyle intervention to reduce excessive gestational weight gain and associated incidence of gestational diabetes mellitus (GDM) and type 2 diabetes mellitus.

METHODS

A decision-analytic Markov model was used to compare the health and cost-effectiveness outcomes for (1) a structured lifestyle intervention during pregnancy to prevent GDM and subsequent type 2 diabetes; and (2) current usual antenatal care. Life table modelling was used to capture type 2 diabetes morbidity, mortality and quality-adjusted life years over a lifetime horizon for all women giving birth in Australia. Costs incorporated both healthcare and societal perspectives. The intervention effect was derived from published meta-analyses. Deterministic and probabilistic sensitivity analyses were used to capture the impact of uncertainty in the model.

RESULTS

The model projected a 10% reduction in the number of women subsequently diagnosed with type 2 diabetes through implementation of the lifestyle intervention compared with current usual care. The total net incremental cost of intervention was approximately AU$70 million, and the cost savings from the reduction in costs of antenatal care for GDM, birth complications and type 2 diabetes management were approximately AU$85 million. The intervention was dominant (cost-saving) compared with usual care from a healthcare perspective, and returned AU$1.22 (95% CI 0.53, 2.13) per dollar invested. The results were robust to sensitivity analysis, and remained cost-saving or highly cost-effective in each of the scenarios explored.

CONCLUSIONS/INTERPRETATION

This study demonstrates significant cost savings from implementation of a structured lifestyle intervention during pregnancy, due to a reduction in adverse health outcomes for women during both the perinatal period and over their lifetime.

The economic evaluation of ALS care: quality and cost

Objective: The study aims to analyze the quality of studies that make economic evaluations for amyotrophic lateral sclerosis (ALS). Assessing the quality of studies can guide policy-making and planning. Methods: One of the most recognized checklists "The Consensus on Health Economic Criteria" (CHEC)-list designed by Evers et al. in 2005 aims to answer two important questions: is the methodology of the study appropriate, and are the results of the study valid? We reviewed studies focusing on ALS and its economic costs, and evaluated the studies with (CHEC)-list. Results: We examined 25 articles in terms of their cost evaluation and quality. It is seen that they mainly focus on medical costs, ignoring social care costs. When the quality of the studies is examined, it is seen that the studies overall achieve high scores in terms of their purpose and research question, but some of the studies score low in terms of ethical dimension, comprehensiveness of expenditure items, their application of sensitivity analyses and their study design. Conclusions: The main recommendation of our study for future cost evaluation studies is that they should focus on the questions in the checklist that are scored low overall by the 25 articles, and consider the social care costs as well as medical costs. Our recommendations when designing cost studies can be applied to other chronic diseases with long-term economic costs like ALS.

Economic Evaluation of Prenatal and Postpartum Care in Women With Gestational Diabetes and Hypertensive Disorders of Pregnancy: A Systematic Review

OBJECTIVES

This study aimed to summarize evidence on the economic outcomes of prenatal and postpartum interventions for the management of gestational diabetes mellitus and hypertensive disorders of pregnancy (HDP), assess the quality of each study, and identify research gaps that may inform future research.

METHODS

Electronic databases including PubMed/MEDLINE, Embase, the Cochrane Library, and Cochrane Central Register of Controlled Trials were searched from January 1, 2000, to October 1, 2021. Selected studies were included in narrative synthesis and extracted data were presented in narrative and tabular forms. The quality of each study was assessed using the Consolidated Health Economic Evaluation Reporting Standards and Consensus on Health Economic Criteria list.

RESULTS

Among the 22 studies identified through the systematic review, 19 reported favorable cost-effectiveness of the intervention. For prenatal management of HDP, home blood pressure monitoring was found to be cost-effective compared with in-person visits in improving maternal and neonatal outcomes. For postpartum care, regular screening for hypertension or metabolic syndrome followed by subsequent treatment was found to be cost-effective compared with no screening in women with a history of gestational diabetes mellitus or HDP.

CONCLUSIONS

Existing economic evaluation studies showed that prenatal home blood pressure monitoring and postpartum screening for hypertension or metabolic syndrome were cost-effective. Nevertheless, limitations in the approach of the current economic evaluations may dampen the quality of the evidence and warrant further investigation.

Gestational diabetes mellitus: a growing economic concern

Gestational diabetes mellitus (GDM) is a common pregnancy complication. Recent epidemiological data have shown that GDM prevalence has been on the increase worldwide. GDM could lead to adverse pregnancy outcomes and is usually associated with higher costs for its treatment and management. Pharmacoeconomics has become a crucial component of the healthcare systems in recent years because of the steadily rising costs. Despite this, there are few pharmacoeconomic studies evaluating the expenses of pregnancies impacted by GDM.

Cost-effectiveness of community diabetes screening: Application of Akaike information criterion in rural communities of Nigeria

Background

The prevalence of diabetes mellitus (DM) is increasing globally, and this requires several approaches to screening. There are reports of alternative indices for prediction of DM, besides fasting blood glucose (FBG) level. This study, investigated the ability of combination of biochemical and anthropometric parameters and orodental disease indicators (ODIs) to generate models for DM prediction, using Akaike information criterion (AIC) to substantiate health economics of diabetes screening.

Methods

Four hundred and thirty-three subjects were enrolled in the study in Ndokwa communities, Delta State, Nigeria, and their glycaemic status was determined, using the CardioChek analyser^® and previous data from the Prediabetes and Cardiovascular Complications Study were also used. The cost of screening for diabetes (NGN 300 = $0.72) in a not-for-profit organization/hospital was used as basis to calculate the health economics of number of individuals with DM in 1,000 participants. Data on the subjects' anthropometric, biochemical and ODI parameters were used to generate different models, using R statistical software (version 4.0.0). The different models were evaluated for their AIC values. Lowest AIC was considered as best model. Microsoft Excel software (version 2020) was used in preliminary analysis.

Result

The cost of identifying <2 new subjects with hyperglycemia, in 1,000 people was ≥NGN 300,000 ($ 716). A total of 4,125 models were generated. AIC modeling indicates FBG test as the best model (AIC = 4), and the least being combination of random blood sugar + waist circumference + hip circumference (AIC ≈ 34). Models containing ODI parameters had AIC values >34, hence considered as not recommendable.

Conclusion

The cost of general screening for diabetes in rural communities may appear high and burdensome in terms of health economics. However, the use of prediction models involving AIC is of value in terms of cost-benefit and cost-effectiveness to the healthcare consumers, which favors health economics.

Effectiveness of a Nurse-Led Web-Based Health Management in Preventing Women With Gestational Diabetes From Developing Metabolic Syndrome

BACKGROUND

Women with gestational diabetes mellitus (GDM) are more likely to develop metabolic syndrome (MS). However, the effectiveness of web-based health management in preventing women at high risk of GDM from developing MS has rarely been studied.

PURPOSE

The aim of this study was to evaluate the longitudinal effects of nurse-led web-based health management on maternal anthropometric, metabolic measures, and neonatal outcomes.

METHODS

A randomized controlled trial was conducted from February 2017 to February 2018, in accordance with the Consolidated Standards of Reporting Trials guidelines. Data were collected from 112 pregnant women at high risk of GDM who had been screened from 984 potential participants in northern Taiwan. Participants were randomly assigned to the intervention group (n = 56) or the control group (n = 56). The intervention group received a 6-month nurse-led, web-based health management program as well as consultations conducted via the LINE mobile app. Anthropometric and metabolic measures were assessed at baseline (Time 0, prior to 28 weeks of gestation), Time 1 (36-40 weeks of gestation), and Time 2 (6-12 weeks of postpartum). Maternal and neonatal outcomes were assessed at delivery. Clinical trial was registered.

RESULTS

Analysis using the general estimating equation models found that anthropometric and metabolic measures were significantly better in the intervention group than the control group and varied with time. At Time 1, the levels of diastolic pressure (β = -4.981, p = .025) and triglyceride (TG; β = -33.69, p = .020) were significantly lower in the intervention group than the control group, and at Time 2, the incidence of MS in the intervention group was lower than that in the control group (χ2 = 6.022, p = .014). The number of newborns with low birth weight in the intervention group was lower than that in the control group (χ2 = 6.729, p = .012).

CONCLUSION/IMPLICATIONS FOR PRACTICE

This nurse-led, web-based health management was shown to be effective in improving MS outcomes and may play an important role and show feasible clinical value in changing the current pregnancy care model.

Gestational diabetes mellitus prediction model: A risk factors analysis of pregnant women with gestational diabetes mellitus but have normal oral glucose tolerance test results in the second trimester of pregnancy

BACKGROUND:

Oral glucose tolerance test (OGTT) is a standard for the diagnosis of gestational diabetes mellitus (GDM). However, clinically, some cases with normal results were diagnosed as GDM in the third trimester.

OBJECTIVE:

To establish a risk model based on energy metabolism, epidemiology, and biochemistry that could predict the GDM pregnant women with normal OGTT results in the second trimester.

METHODS:

Qualitative and quantitative data were analyzed to find out the risk factors, and the binary logistic backward LR regression was used to establish the prediction model of each factor and comprehensive factor, respectively.

RESULTS:

The risk factors including the rest energy expenditure per kilogram of body weight, oxygen consumption per kilogram of body weight, if more than the weight gain criteria of the Institute of Medicine, the increase of body mass index between the second trimester and pre-pregnancy, and fasting blood glucose. By comparison, the comprehensive model had the best prediction performance, indicating that 85% of high-risk individuals were correctly classified.

CONCLUSION:

Energy metabolism, epidemiology, and biochemistry had better recognition ability for the GDM pregnant women with normal OGTT results in the second trimester. The addition of metabolic factors in the second trimester also improved the overall prediction performance.

Economic Evaluations of Gestational Diabetes Mellitus Screening: A Systematic Review

BACKGROUND

This study aims to find evidence of the cost-effectiveness of gestational diabetes mellitus (GDM) screening and assess the quality of current economic evaluations, which have shown different conclusions with a variation in screening methods, data sources, outcome indicators, and implementation in diverse organizational contexts.

METHODS

Embase, Medline, Web of Science, Health Technology Assessment, database, and National Health Service Economic Evaluation Database databases were searched through June 2019. Studies on economic evaluation reporting both cost and health outcomes of GDM screening programs in English language were selected, and the quality of the studies was assessed using Drummond's checklist. The general characteristics, main assumptions, and results of the economic evaluations were summarized.

RESULTS

Our search yielded 10 eligible economic evaluations with different screening strategies compared in different settings and perspectives. The selected papers scored 81% (68-97%) on the items in Drummond's checklist on average. In general, a screening program is cost-effective or even dominant over no screening. The one-step screening, with more cases detected, is more likely to be cost-effective than the two-step screening. Universal screening is more likely to be cost-effective than screening targeting the high-risk population. Parameters affecting cost-effectiveness include: diagnosis criteria, epidemiological characteristics of the population, efficacy of screening and treatment, and costs.

CONCLUSIONS

Most studies found GDM screening to be cost-effective, though uncertainties remain due to many factors. The quality assessment identified weaknesses in the economic evaluations in terms of integrating existing data, measuring costs and consequences, analyzing perspectives, and adjusting for uncertainties.

Healthcare Professionals' Perspectives on the Cross-Sectoral Treatment Pathway for Women with Gestational Diabetes during and after Pregnancy-A Qualitative Study

Gestational diabetes mellitus (GDM) increases the risk of adverse outcomes during and after pregnancy, including a long-term risk of type 2 diabetes. Women with GDM are treated by numerous healthcare professionals during pregnancy and describe a lack of preventive care after pregnancy. We aim to investigate healthcare professionals’ perspectives on the cross-sectoral treatment pathway for women with GDM—during and after pregnancy. A qualitative study was conducted using systematic text condensation. Nine healthcare professionals (two general practitioners, four midwives, two obstetricians and one diabetes nurse) were interviewed and eight health visitors participated in two focus group discussions., Three major themes emerged: (1) “professional identities”, which were identified across healthcare professionals and shaped care practices; (2) ”unclear guidelines on type 2 diabetes prevention after GDM”, which contributed to uncertainty about tasks and responsibilities during and after pregnancy; and (3) “cross-sectoral collaboration”, which relied heavily on knowledge transfers between hospitals, general practice and the local municipality. The findings implicate that clear, transparent guidelines for all sectors should be prioritized to strengthen cross-sectoral care to women with GDM during and after pregnancy. As a result, strong cross-sectoral care throughout the GDM care pathway may improve maternal health by supporting healthy behaviors, facilitate weight loss and reduce the risk of subsequent GDM and early onset diabetes.

A quality improvement collaborative increased preventive education and screening rates for women at high-risk for type 2 diabetes mellitus in primary care settings

AIMS

Type 2 diabetes mellitus (T2DM) rates continue to increase across women of reproductive age in the United States. The Ohio Type 2 Diabetes Learning Collaborative aimed to improve education and screening for T2DM among women aged 18-44years at high risk for developing T2DM.

METHODS

Fifteen primary care practices across Ohio participated in a 12-month quality improvement (QI) collaborative, which included monthly calls to share best practices, one-on-one QI coaching, and Plan-Do-Study-Act cycles. Monthly, practices submitted data on three outcome measures on preventive education and three measures on clinical screening for T2DM.

RESULTS

Increases across each of the three preventive education rates (range of percent increase: 53.6% - 60.0%) and each of the three screening rates for T2DM (15.0% - 19.4%) were observed. Specifically, screening rates for high-risk women with two or more risk factors for T2DM (excluding gestational diabetes mellitus (GDM)) increased by 16.8% (60.5%-77.3%) while rates for T2DM among women with a history of GDM increased by 15.0% (75.0 - 90.0).

CONCLUSIONS

A quality improvement collaborative increased preventive education and screening rates for women at high-risk for T2DM in primary care settings.

Cost-utility analysis of lifestyle interventions to prevent type 2 diabetes in women with prior gestational diabetes

BACKGROUND

To compare estimated costs and health outcomes of lifestyle interventions for the prevention of type 2 diabetes mellitus in women who had gestational diabetes.

METHODS

An age-specific Markov model was applied comparing costs and quality-adjusted life years (QALYs) of three alternatives: 'doing nothing'; an annual reminder system (ARS) with an awareness campaign ('ARS-awareness'); and an ARS with an intensive lifestyle intervention ('ARS-ILS'). A healthcare payer perspective was adopted, the time horizon was 30 years and the setting was Flanders (Belgium). Sensitivity analyses were performed.

RESULTS

'ARS-awareness' was extendedly dominated. Per 10 000 participants, 'ARS-ILS' cost €13 210 256 more and gained 496 QALYs compared with 'doing nothing' (26 632 €/QALY), with a 63% probability of being cost effective, given a cost effectiveness threshold of 35 000 €/QALY. A scenario analysis showed that 'ARS-ILS' for 15 years only offered to women with prediabetes (compared with 'doing nothing') has an 89.5% likelihood of being dominant.

CONCLUSIONS

'ARS-ILS' may be the preferred intervention. However, the probability of being cost effective was low. Based on further scenario analyses, we recommend healthcare decision makers to consider the application of a more intensive alternative, focused on the highest risk profiles and with a shorter intervention duration.

Systematic review of effectiveness and cost-effectiveness of lifestyle interventions to improve clinical diabetes outcome measures in women with a history of GDM

OBJECTIVE

Lifestyle interventions have been shown to be both effective and cost-effective in reducing diabetes and metabolic risk in high-risk populations. We systematically reviewed the effectiveness and cost-effectiveness of lifestyle interventions on anthropometric, glycemic and cardiovascular outcomes in women with previous gestational diabetes mellitus (GDM).

METHOD

Relevant randomized control trials (RCT) were identified by searching multiple electronic databases through 20th June 2018. Data were pooled using random-effects models. The review protocol was registered on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42018108870).

RESULTS

Twenty-one studies met the inclusion criteria and 16 studies with outcome data were analyzed in the meta-analysis. No RCT studies included cost-effectiveness data on lifestyle interventions. The pooled estimate for postpartum weight showed a significant mean reduction in the intervention arm (-1.8 kg [95% CI: -2.9, -0.6; p = 0.002; I² = 92.2%; p < 0.05]). Further, the effect of lifestyle intervention on weight change was significantly greater in studies of longer duration. Most of the other endpoints had modest improvements but only anthropometric endpoints were statistically significant. However, there was high heterogeneity between the studies.

CONCLUSIONS

Lifestyle interventions showed statistically and clinically significant improvements in anthropometric outcomes. However, more research is needed to explore lifestyle effects on glycemic and cardiovascular risk factors and to establish cost-effectiveness. Methodologically sound, large scale studies on diverse ethnicities and with longer follow-up would establish the real effect of lifestyle interventions to reduce diabetes risk in women with previous GDM.

Prediction of Glucose Intolerance in Early Postpartum in Women with Gestational Diabetes Mellitus Based on the 2013 WHO Criteria

Predictors for glucose intolerance postpartum were evaluated in women with gestational diabetes mellitus (GDM) based on the 2013 World Health Organization (WHO) criteria. 1841 women were tested for GDM in a prospective cohort study. A postpartum 75g oral glucose tolerance test (OGTT) was performed in women with GDM at 14 ± 4.1 weeks. Of all 231 mothers with GDM, 83.1% (192) had a postpartum OGTT of which 18.2% (35) had glucose intolerance. Women with glucose intolerance were more often of Asian origin [15.1% vs. 3.7%, OR 4.64 (1.26–17.12)], had more often a recurrent history of GDM [41.7% vs. 26.7%, OR 3.68 (1.37–9.87)], higher fasting glycaemia (FPG) [5.1 (4.5–5.3) vs. 4.6 (4.3–5.1) mmol/L, OR 1.05 (1.01–1.09)], higher HbA1c [33 (31–36) vs. 32 (30–33) mmol/mol, OR 4.89 (1.61–14.82)], and higher triglycerides [2.2 (1.9–2.8) vs. 2.0 (1.6–2.5) mmol/L, OR 1.00 (1.00–1.01)]. Sensitivity of glucose challenge test (GCT) ≥7.2 mmol/l for glucose intolerance postpartum was 80% (63.1%–91.6%). The area under the curve to predict glucose intolerance was 0.76 (0.65–0.87) for FPG, 0.54 (0.43–0.65) for HbA1c and 0.75 (0.64–0.86) for both combined. In conclusion, nearly one-fifth of women with GDM have glucose intolerance postpartum. A GCT ≥7.2 mmol/L identifies a high risk population for glucose intolerance postpartum.