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Screening for Gestational Diabetes Mellitus: Are the Criteria Proposed by the International Association of the Diabetes and Pregnancy Study Groups Cost-Effective?

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Abstract

OBJECTIVE

The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) recently recommended new criteria for diagnosing gestational diabetes mellitus (GDM). This study was undertaken to determine whether adopting the IADPSG criteria would be cost-effective, compared with the current standard of care.

RESEARCH DESIGN AND METHODS

We developed a decision analysis model comparing the cost-utility of three strategies to identify GDM: 1) no screening, 2) current screening practice (1-h 50-g glucose challenge test between 24 and 28 weeks followed by 3-h 100-g glucose tolerance test when indicated), or 3) screening practice proposed by the IADPSG. Assumptions included that 1) women diagnosed with GDM received additional prenatal monitoring, mitigating the risks of preeclampsia, shoulder dystocia, and birth injury; and 2) GDM women had opportunity for intensive postdelivery counseling and behavior modification to reduce future diabetes risks. The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS

Our model demonstrates that the IADPSG recommendations are cost-effective only when postdelivery care reduces diabetes incidence. For every 100,000 women screened, 6,178 quality-adjusted life-years (QALYs) are gained, at a cost of $125,633,826. The ICER for the IADPSG strategy compared with the current standard was$20,336 per QALY gained. When postdelivery care was not accomplished, the IADPSG strategy was no longer cost-effective. These results were robust in sensitivity analyses.

CONCLUSIONS

The IADPSG recommendation for glucose screening in pregnancy is cost-effective. The model is most sensitive to the likelihood of preventing future diabetes in patients identified with GDM using postdelivery counseling and intervention.

Most cited references22

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Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease.

Diabetes mellitus is a recognized risk factor for cardiovascular disease (CVD) and mortality. However, limited information exists on the association of diabetes with life expectancy with and without CVD. We aimed to calculate the association of diabetes after age 50 years with life expectancy and the number of years lived with and without CVD. Using data from the Framingham Heart Study, we built life tables to calculate the associations of having diabetes with life expectancy and years lived with and without CVD among populations 50 years and older. For the life table calculations, we used hazard ratios for 3 transitions (healthy to death, healthy to CVD, and CVD to death), stratifying by the presence of diabetes at baseline and adjusting for age and confounders. Having diabetes significantly increased the risk of developing CVD (hazard ratio, 2.5 for women and 2.4 for men) and of dying when CVD was present (hazard ratio, 2.2 for women and 1.7 for men). Diabetic men and women 50 years and older lived on average 7.5 (95% confidence interval, 5.5-9.5) and 8.2 (95% confidence interval, 6.1-10.4) years less than their nondiabetic equivalents. The differences in life expectancy free of CVD were 7.8 and 8.4 years, respectively. The increase in the risk of CVD and mortality from diabetes represents an important decrease in life expectancy and life expectancy free of CVD. Prevention of diabetes is a fundamental task facing today's society in the pursuit of healthy aging.
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Valuing health-related quality of life in diabetes.

(2002)
Cost-utility analyses use information on health utilities to compare medical treatments that have different clinical outcomes and impacts on survival. The purpose of this study was to describe the health utilities associated with diabetes and its treatments, complications, and comorbidities. We studied 2,048 subjects with type 1 and type 2 diabetes recruited from specialty clinics at a university medical center. We administered a questionnaire to each individual to assess demographic characteristics, type and duration of diabetes, treatments, complications, and comorbidities, and we used the Self-Administered Quality of Well Being index (QWB-SA) to calculate a health utility score. We then created regression models to fit the QWB-SA-derived health utility scores to indicator variables for type 1 and type 2 diabetes and each demographic variable, treatment, and complication. The coefficients were arranged in clinically meaningful ways to develop models to describe penalties from the health utility scores for nonobese diabetic men without additional treatments, complications, or comorbidities. The utility scores for nonobese diet-controlled men and women with type 2 diabetes and no microvascular, neuropathic, or cardiovascular complications were 0.69 and 0.65, respectively. The utility scores for men and women with type 1 diabetes and no complications were slightly lower (0.67 and 0.64, respectively). Blindness, dialysis, symptomatic neuropathy, foot ulcers, amputation, debilitating stroke, and congestive heart failure were associated with lower utility scores. Major diabetes complications are associated with worse health-related quality of life. The health utility scores provided should facilitate studies of the health burden of diabetes and the cost-utility of alternative strategies for the prevention and treatment of diabetes.
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Effects of treatment in women with gestational diabetes mellitus: systematic review and meta-analysis

(2010)
Objective To summarise the benefits and harms of treatments for women with gestational diabetes mellitus. Design Systematic review and meta-analysis of randomised controlled trials. Data sources Embase, Medline, AMED, BIOSIS, CCMed, CDMS, CDSR, CENTRAL, CINAHL, DARE, HTA, NHS EED, Heclinet, SciSearch, several publishers’ databases, and reference lists of relevant secondary literature up to October 2009. Review methods Included studies were randomised controlled trials of specific treatment for gestational diabetes compared with usual care or “intensified” compared with “less intensified” specific treatment. Results Five randomised controlled trials matched the inclusion criteria for specific versus usual treatment. All studies used a two step approach with a 50 g glucose challenge test or screening for risk factors, or both, and a subsequent 75 g or 100 g oral glucose tolerance test. Meta-analyses did not show significant differences for most single end points judged to be of direct clinical importance. In women specifically treated for gestational diabetes, shoulder dystocia was significantly less common (odds ratio 0.40, 95% confidence interval 0.21 to 0.75), and one randomised controlled trial reported a significant reduction of pre-eclampsia (2.5 v 5.5%, P=0.02). For the surrogate end point of large for gestational age infants, the odds ratio was 0.48 (0.38 to 0.62). In the 13 randomised controlled trials of different intensities of specific treatments, meta-analysis showed a significant reduction of shoulder dystocia in women with more intensive treatment (0.31, 0.14 to 0.70). Conclusions Treatment for gestational diabetes, consisting of treatment to lower blood glucose concentration alone or with special obstetric care, seems to lower the risk for some perinatal complications. Decisions regarding treatment should take into account that the evidence of benefit is derived from trials for which women were selected with a two step strategy (glucose challenge test/screening for risk factors and oral glucose tolerance test).
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Author and article information

Journal
Diabetes Care
diacare
dcare
Diabetes Care
Diabetes Care
American Diabetes Association
0149-5992
1935-5548
March 2012
10 February 2012
: 35
: 3
: 529-535
Affiliations
[1] 1Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland
[2] 2Department of Obstetrics, Gynecology, and Reproductive Science, Yale University, New Haven, Connecticut
[3] 3Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
Author notes
Corresponding author: Erika F. Werner, ewerner4@ 123456jhmi.edu .
Article
1643
10.2337/dc11-1643
3322683
22266735
c41abbe3-b01d-4c77-b932-6ab841868232
© 2012 by the American Diabetes Association.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

Categories
Original Research
Epidemiology/Health Services Research

Endocrinology & Diabetes
Endocrinology & Diabetes