Last data update: Jun 03, 2024. (Total: 46935 publications since 2009)
Records 1-30 (of 30 Records) |
Query Trace: Zhuo X [original query] |
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A nested case-control study of serum polychlorinated biphenyls and papillary thyroid cancer risk among U.S. military service members
Zhuo H , Huang H , Sjodin A , Jin L , Ma S , Denic-Roberts H , Warren JL , Jones R , Davis M , Sun P , Yu H , Ward MH , Udelsman R , Zhang Y , Rusiecki J . Environ Res 2022 212 113367 BACKGROUND AND OBJECTIVES: Although polychlorinated biphenyls (PCBs) were banned decades ago, populations are continuously exposed to PCBs due to their persistence and bioaccumulation/biomagnification in the environment. Results from limited epidemiologic studies linking PCBs to thyroid cancer have been inconclusive. This study aimed to investigate the association between individual PCBs and PCB mixture and papillary thyroid cancer (PTC), the most common thyroid cancer histologic subtype. METHODS: We carried out a nested case-control study including 742 histologically confirmed PTC cases diagnosed in 2000-2013 and 742 individually matched controls from among U.S. military service members. Pre-diagnostic serum samples that were collected on average nine years before PTC diagnosis were used to measure PCB congeners by gas chromatography isotope dilution high resolution mass spectrometry (GC/ID-HRMS). Conditional logistic regression, Bayesian kernel machine regression (BKMR), and weighted quantile sum (WQS) regression were employed to estimate the association between single PCB congeners as well as their mixture and PTC. RESULTS: Four PCB congeners (PCB-74, PCB-99, PCB-105, PCB-118) had significant associations and dose-response relationships with increased risk of PTC in single congener models. When considering PCB congeners as a mixture in the BKMR model, PCB-118 showed positive trends of association with PTC. Increased exposure to the PCB mixture identified by WQS was also associated with an increased risk of PTC, with the mixture dominated by PCB-118, followed by PCB-74 and PCB-99. DISCUSSION: This study suggests that exposure to certain PCBs as well as a mixture of PCBs were associated with an increased risk of PTC. The observed association was mainly driven by PCB-118, and to a lesser extent by PCB-74 and PCB-99. The findings warrant further investigation. |
Detection and Clinical Implications of Monovalent Rotavirus Vaccine-Derived Virus Strains in Children with Gastroenteritis in Alberta, Canada.
Zhuo R , Tarr G , Xie J , Freedman SB , Payne DC , Lee BE , McWilliams C , Chui L , Ali S , Pang X . J Clin Microbiol 2021 59 (11) Jcm0115421 Background: While rotavirus vaccine programs effectively protect against severe rotavirus gastroenteritis, rotavirus vaccine strains have been identified in the stool of vaccinated children and their close contacts suffering from acute gastroenteritis. The prevalence of vaccine strains, the emergence of vaccine-derived strains and their role in acute gastroenteritis are not well studied. Methods: We developed a Locked Nucleic Acid Reverse Transcription real-time PCR assay (LNA-RTqPCR) to detect the monovalent rotavirus vaccine (RV1) Rotarix non-structural protein 2 in children with acute gastroenteritis and healthy controls and validated it using sequence confirmed RV1 strains. The association between RV1-derived strains and gastroenteritis was determined using logistic regression. Results: The new assay exhibited 100% (95%CI: 91.7%, 100%) diagnostic sensitivity and 99.4% (95%CI: 96.2%, 100%) diagnostic specificity, with a detection limit of 9.86 copies/reaction and qPCR efficiency of 99.7%. Using this assay, we identified the presence of RV1-derived NSP2 sequences in 7.7% of rotavirus gastroenteritis cases and 98.6% of rotavirus positive healthy children (94.4% had previously received the RV1). Among gastroenteritis cases, those whose stool contained RV1-derived strains had milder gastroenteritis symptoms compared to that of natural rotavirus infections. We observed no significant association between RV1-derived strains and gastroenteritis (OR 0.98; 95% CI 0.60, 1.72). Conclusion: Our study demonstrated that the new assay is suitable for monitoring RV1-derived rotavirus strain circulation and that the RV1-derived strains are not associated with development of gastroenteritis symptoms. |
Signatures of somatic mutations and gene expression from p16INK4A positive head and neck squamous cell carcinomas (HNSCC).
Saba NF , Dinasarapu AR , Magliocca KR , Dwivedi B , Seby S , Qin ZS , Patel M , Griffith CC , Wang X , El-Deiry M , Steuer CE , Kowalski J , Shin DM , Zwick ME , Chen ZG . PLoS One 2020 15 (9) e0238497 Human papilloma virus (HPV) causes a subset of head and neck squamous cell carcinomas (HNSCC) of the oropharynx. We combined targeted DNA- and genome-wide RNA-sequencing to identify genetic variants and gene expression signatures respectively from patients with HNSCC including oropharyngeal squamous cell carcinomas (OPSCC). DNA and RNA were purified from 35- formalin fixed and paraffin embedded (FFPE) HNSCC tumor samples. Immuno-histochemical evaluation of tumors was performed to determine the expression levels of p16INK4A and classified tumor samples either p16+ or p16-. Using ClearSeq Comprehensive Cancer panel, we examined the distribution of somatic mutations. Somatic single-nucleotide variants (SNV) were called using GATK-Mutect2 ("tumor-only" mode) approach. Using RNA-seq, we identified a catalog of 1,044 and 8 genes as significantly expressed between p16+ and p16-, respectively at FDR 0.05 (5%) and 0.1 (10%). The clinicopathological characteristics of the patients including anatomical site, smoking and survival were analyzed when comparing p16+ and p16- tumors. The majority of tumors (65%) were p16+. Population sequence variant databases, including gnomAD, ExAC, COSMIC and dbSNP, were used to identify the mutational landscape of somatic sequence variants within sequenced genes. Hierarchical clustering of The Cancer Genome Atlas (TCGA) samples based on HPV-status was observed using differentially expressed genes. Using RNA-seq in parallel with targeted DNA-seq, we identified mutational and gene expression signatures characteristic of p16+ and p16- HNSCC. Our gene signatures are consistent with previously published data including TCGA and support the need to further explore the biologic relevance of these alterations in HNSCC. |
Selecting the optimal risk threshold of diabetes risk scores to identify high-risk individuals for diabetes prevention: a cost-effectiveness analysis
Muhlenbruch K , Zhuo X , Bardenheier B , Shao H , Laxy M , Icks A , Zhang P , Gregg EW , Schulze MB . Acta Diabetol 2019 57 (4) 447-454 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
Shao H , Lin J , Zhuo X , Rolka DB , Gregg EW , Zhang P . Diabetes Care 2019 42 (11) 2136-2142 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 to 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. |
Projection of the future diabetes burden in the United States through 2060
Lin J , Thompson TJ , Cheng YJ , Zhuo X , Zhang P , Gregg E , Rolka DB . Popul Health Metr 2018 16 (1) 9 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. |
Impact of intensive lifestyle intervention on disability-free life expectancy: The Look AHEAD Study
Gregg EW , Lin J , Bardenheier B , Chen H , Rejeski WJ , Zhuo X , Hergenroeder AL , Kritchevsky SB , Peters AL , Wagenknecht LE , Ip EH , Espeland MA . Diabetes Care 2018 41 (5) 1040-1048 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 SF-36. 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
Wang G , Zhou X , Zhuo X , Zhang P . Am J Prev Med 2017 53 S182-s189 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
Lin J , Zhuo X , Bardenheier B , Rolka DB , Gregg WE , Hong Y , Wang G , Albright A , Zhang P . Diabetes Care 2017 40 (5) 640-646 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 Surveys. 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 approximately 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
Yarnoff BO , Hoerger TJ , Simpson SA , Pavkov ME , Burrows NR , Shrestha SS , Williams DE , Zhuo X . PLoS One 2016 11 (7) e0157323 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
Bardenheier BH , Lin J , Zhuo X , Ali MK , Thompson TJ , Cheng YJ , Gregg EW . Lancet Diabetes Endocrinol 2016 4 (8) 686-694 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. |
A crucial time for public health preparedness: Zika virus and the 2016 Olympics, Umrah, and Hajj
Elachola H , Gozzer E , Zhuo J , Memish ZA . Lancet 2016 387 (10019) 630-2 The 138th session of WHO's Executive Board on Jan 25, 2016, noted both the end of the 2014 Ebola crisis and the beginning of a global public health threat, the outbreak of Zika virus infection in the Americas.1 On Jan 15, 2016, the US Centers for Disease Control and Prevention advised pregnant women to refrain from travelling to countries affected by Zika, given a possible association between Zika virus infection with microcephaly and other neurological disorders.2 On Feb 1, 2016, WHO's International Health Regulations Emergency Committee declared the possible association between Zika virus infection and clusters of microcephaly and other neurological disorders as a Public Health Emergency of International Concern.3 With the spread of the arbovirus to more than 25 countries, Zika virus could be following the geographical spread of dengue and chikungunya, all of which are transmitted by the Aedes aegypti mosquito.1, 3 | The potential role of scheduled international mass gatherings in 2016 could exacerbate the spread of Zika virus beyond the Americas. In Brazil, the Rio Carnival on Feb 5–10 attracts more than 500 000 visitors, and on Aug 5–21 more than 1 million visitors are expected to go to the summer Olympics followed by Paralympic Games on Sep 7–18. Meanwhile, Saudi Arabia expects to host more than 7 million pilgrims from over 180 countries for the Umrah, between June and September, and the Hajj pilgrimage on Sept 8–13.4, 5 Saudi Arabia receives about 7000 pilgrims from Latin America annually. |
Disability-free life-years lost among adults aged ≥50 years, with and without diabetes
Bardenheier BH , Lin J , Zhuo X , Ali MK , Thompson TJ , Cheng YJ , Gregg EW . Diabetes Care 2015 39 (7) 1222-9 OBJECTIVE: 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, 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 much 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. |
Cost-effectiveness of a national population-based screening program for type 2 diabetes: the Brazil experience
Toscano CM , Zhuo X , Imai K , Duncan BB , Polanczyk CA , Zhang P , Engelgau M , Schmidt MI . Diabetol Metab Syndr 2015 7 95 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. |
Cost to government and society of chronic kidney disease stage 1-5: a national cohort study
Wyld ML , Lee CM , Zhuo X , White S , Shaw JE , Morton RL , Colagiuri S , Chadban SJ . Intern Med J 2015 45 (7) 741-7 BACKGROUND: Costs associated with chronic kidney disease (CKD) are not well documented. Understanding such costs is important to inform economic evaluations of prevention strategies and treatment options. AIM: To estimate the costs associated with CKD in Australia. METHODS: We used data from the 2004/2005 AusDiab study, a national longitudinal population-based study of non-institutionalised Australian adults aged ≥25 years. We included 6138 participants with CKD, diabetes and healthcare cost data. The annual age and sex-adjusted costs per person were estimated using a generalised linear model. Costs were inflated from 2005 to 2012 Australian dollars using best practice methods. RESULTS: Among 6138 study participants, there was a significant difference in the per-person annual direct healthcare costs by CKD status, increasing from $1829 (95% confidence interval (CI): $1740-1943) for those without CKD to $14 545 (95% CI: $5680-44 842) for those with stage 4 or 5 CKD (P < 0.01). Similarly, there was a significant difference in the per-person annual direct non-healthcare costs by CKD status from $524 (95% CI: $413-641) for those without CKD to $2349 (95% CI: $386-5156) for those with stage 4 or 5 CKD (P < 0.01). Diabetes is a common cause of CKD and is associated with increased health costs. Costs per person were higher for those with diabetes than those without diabetes in all CKD groups; however, this was significant only for those without CKD and those with early stage (stage 1 or 2) CKD. CONCLUSION: Individuals with CKD incur 85% higher healthcare costs and 50% higher government subsidies than individuals without CKD, and costs increase by CKD stage. Primary and secondary prevention strategies may reduce costs and warrant further consideration. |
Estimating the costs of diabetes by episodes of care: promises and challenges
Zhang P , Shrestha S . J Diabetes Complications 2015 29 (4) 463-4 Diabetes is one of the most costly chronic diseases in the United States. More than one in ten U.S. health care dollars spent in 2012 was attributed to diabetes (American Diabetes Association, 2013) and as much as one-third of Medicare’s budget for beneficiary care was incurred for those with diabetes (Centers for Medicare and Medicaid, 2005). The average person with diabetes spent a total of $13,700 on health care in 2012 and the per capita and total health care expenditures attributed to diabetes have been increasing and are expected to increase through the near future (American Diabetes Association, 2013; Zhuo et al., 2015). | The traditional fee-for-service payment system, in which each provider is paid for each individual service a patient receives during the course of treatment, has been described by some as a barrier to both high quality care and effective cost containment (Davis, 2007; Hackbarth, Reischauer, & Mutti, 2008). Experts have recognized the need for innovative payment designs that could both reduce health care costs and improve quality of care. One policy option receiving growing interest is a “bundle” payment per episode of care. |
Medicare's intensive behavioral therapy for obesity: an exploratory cost-effectiveness analysis
Hoerger TJ , Crouse WL , Zhuo X , Gregg EW , Albright AL , Zhang P . Am J Prev Med 2015 48 (4) 419-25 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. |
The effect of lifestyle intervention and metformin on preventing or delaying diabetes among women with and without gestational diabetes: the Diabetes Prevention Program Outcomes Study 10-year follow-up
Aroda VR , Christophi CA , Edelstein SL , Zhang P , Herman WH , Barrett-Connor E , Delahanty LM , Montez MG , Ackermann RT , Zhuo X , Knowler WC , Ratner RE . J Clin Endocrinol Metab 2015 100 (4) jc20143761 CONTEXT: Gestational diabetes (GDM) confers a high risk of type 2 diabetes. In the Diabetes Prevention Program (DPP), intensive lifestyle (ILS) and metformin prevented or delayed diabetes in women with a history of GDM. OBJECTIVE: The objective of the study was to evaluate the impact of ILS and metformin intervention over 10 years in women with and without a history of GDM in the DPP/Diabetes Prevention Program Outcomes Study. DESIGN: This was a randomized controlled clinical trial with an observational follow-up. SETTING: The study was conducted at 27 clinical centers. PARTICIPANTS: Three hundred fifty women with a history of GDM and 1416 women with previous live births but no history of GDM participated in the study. The participants had an elevated body mass index and fasting glucose and impaired glucose tolerance at study entry. INTERVENTIONS: Interventions included placebo, ILS, or metformin. OUTCOMES MEASURE: Outcomes measure was diabetes mellitus. RESULTS: Over 10 years, women with a history of GDM assigned to placebo had a 48% higher risk of developing diabetes compared with women without a history of GDM. In women with a history of GDM, ILS and metformin reduced progression to diabetes compared with placebo by 35% and 40%, respectively. Among women without a history of GDM, ILS reduced the progression to diabetes by 30%, and metformin did not reduce the progression to diabetes. CONCLUSIONS: Women with a history of GDM are at an increased risk of developing diabetes. In women with a history of GDM in the DPP/Diabetes Prevention Program Outcomes Study, both lifestyle and metformin were highly effective in reducing progression to diabetes during a 10-year follow-up period. Among women without a history of GDM, lifestyle but not metformin reduced progression to diabetes. |
Change in medical spending attributable to diabetes: national data from 1987 to 2011
Zhuo X , Zhang P , Kahn HS , Bardenheier BH , Li R , Gregg EW . Diabetes Care 2015 38 (4) 581-7 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 and 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 $2790 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. |
The future burden of CKD in the United States: a simulation model for the CDC CKD initiative
Hoerger TJ , Simpson SA , Yarnoff BO , Pavkov ME , Rios Burrows N , Saydah SH , Williams DE , Zhuo X . Am J Kidney Dis 2014 65 (3) 403-11 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. |
The lifetime cost of diabetes and its implications for diabetes prevention
Zhuo X , Zhang P , Barker L , Albright A , Thompson TJ , Gregg E . Diabetes Care 2014 37 (9) 2557-64 OBJECTIVE: To assess the cost implications of diabetes prevention, it is important to know the lifetime medical cost of people with diabetes relative to those without. We derived such estimates using data representative of the U.S. national population. RESEARCH DESIGN AND METHODS: We aggregated annual medical expenditures from the age of diabetes diagnosis to death to determine lifetime medical expenditure. Annual medical expenditures were estimated by sex, age at diagnosis, and diabetes duration using data from 2006-2009 Medical Expenditure Panel Surveys, which were linked to data from 2005-2008 National Health Interview Surveys. We combined survival data from published studies with the estimated annual expenditures to calculate lifetime spending. We then compared lifetime spending for people with diabetes with that for those without diabetes. Future spending was discounted at 3% annually. RESULTS: The discounted excess lifetime medical spending for people with diabetes was $124,600 ($211,400 if not discounted), $91,200 ($135,600), $53,800 ($70,200), and $35,900 ($43,900) when diagnosed with diabetes at ages 40, 50, 60, and 65 years, respectively. Younger age at diagnosis and female sex were associated with higher levels of lifetime excess medical spending attributed to diabetes. CONCLUSIONS: Having diabetes is associated with substantially higher lifetime medical expenditures despite being associated with reduced life expectancy. If prevention costs can be kept sufficiently low, diabetes prevention may lead to a reduction in long-term medical costs. |
Trends in lifetime risk and years of life lost due to diabetes in the USA, 1985-2011: a modelling study
Gregg EW , Zhuo X , Cheng YJ , Albright AL , Narayan KM , Thompson TJ . Lancet Diabetes Endocrinol 2014 2 (11) 867-74 BACKGROUND: Diabetes incidence has increased and mortality has decreased greatly in the USA, potentially leading to substantial changes in the lifetime risk of diabetes. We aimed to provide updated estimates for the lifetime risk of development of diabetes and to assess the effect of changes in incidence and mortality on lifetime risk and life-years lost to diabetes in the USA. METHODS: We incorporated data about diabetes incidence from the National Health Interview Survey, and linked data about mortality from 1985 to 2011 for 598 216 adults, into a Markov chain model to estimate remaining lifetime diabetes risk, years spent with and without diagnosed diabetes, and life-years lost due to diabetes in three cohorts: 1985-89, 1990-99, and 2000-11. Diabetes was determined by self-report and was classified as any diabetes, excluding gestational diabetes. We used logistic regression to estimate the incidence of diabetes and Poisson regression to estimate mortality. FINDINGS: On the basis of 2000-11 data, lifetime risk of diagnosed diabetes from age 20 years was 40.2% (95% CI 39.2-41.3) for men and 39.6% (38.6-40.5) for women, representing increases of 20 percentage points and 13 percentage points, respectively, since 1985-89. The highest lifetime risks were in Hispanic men and women, and non-Hispanic black women, for whom lifetime risk now exceeds 50%. The number of life-years lost to diabetes when diagnosed at age 40 years decreased from 7.7 years (95% CI 6.5-9.0) in 1990-99 to 5.8 years (4.6-7.1) in 2000-11 in men, and from 8.7 years (8.4-8.9) to 6.8 years (6.7-7.0) in women over the same period. Because of the increasing diabetes prevalence, the average number of years lost due to diabetes for the population as a whole increased by 46% in men and 44% in women. Years spent with diabetes increased by 156% in men and 70% in women. INTERPRETATION: Continued increases in the incidence of diagnosed diabetes combined with declining mortality have led to an acceleration of lifetime risk and more years spent with diabetes, but fewer years lost to the disease for the average individual with diabetes. These findings mean that there will be a continued need for health services and extensive costs to manage the disease, and emphasise the need for effective interventions to reduce incidence. FUNDING: None. |
Association of functional decline with subsequent diabetes incidence in U.S. adults aged 51 years and older: the Health and Retirement Study 1998-2010
Bardenheier BH , Gregg EW , Zhuo X , Cheng YJ , Geiss LS . Diabetes Care 2014 37 (4) 1032-8 OBJECTIVE: We assess whether functional decline and physical disability increase the subsequent risk of diabetes. RESEARCH DESIGN AND METHODS: The Health and Retirement Study, an observational study of a nationally representative survey of adults aged 51 years and older with no diabetes at baseline were followed up to 12 years (1998 to 2010). We assessed baseline disability status and incident disability with subsequent risk of diabetes, accounting for death as a competing risk and controlling for BMI, age, sex, race/ethnicity, net wealth, mother's level of education, respondents' level of education, and time of follow-up. Disability was defined as none, mild, moderate, and severe, based on a validated scale of mobility measures. Diabetes was identified by self-report of a diagnosis from a doctor. Population attributable fraction (PAF) was calculated to assess the percentage of diabetes cases that were attributable to mobility disability. RESULTS: The sample included 22,878 adults with an average of 8.7 years of follow-up; 9,649 (41.2%) reported some level of disability at baseline, and 8,175 (35.7%) additional participants developed disability during follow-up; 3,546 (15.5%) participants developed diabetes; and 5,869 (25.6%) died. Regression analyses found a statistically significant dose-response relationship of increased risk of diabetes (28-95%) among those with any level of functional decline, prevalent or incident. Among the subanalytic sample, including incident disability only, the PAF was 6.9% (CI 4.2-9.5). CONCLUSIONS: Our findings suggest those who become disabled, even mildly, are at increased risk of developing diabetes. This finding raises the possibility that approaches to prevent disability in older adults could also reduce diabetes incidence. |
Cost-effectiveness of alternative thresholds of the fasting plasma glucose test to identify the target population for type 2 diabetes prevention in adults aged ≥45 years
Zhuo X , Zhang P , Kahn HS , Gregg EW . Diabetes Care 2013 36 (12) 3992-8 OBJECTIVE: The study objective was to evaluate the cost-effectiveness of alternative fasting plasma glucose (FPG) thresholds to identify adults at high risk for type 2 diabetes for diabetes preventive intervention. RESEARCH DESIGN AND METHODS: We used a validated simulation model to examine the change in lifetime quality-adjusted life years (QALYs) and medical costs when the FPG threshold was progressively lowered in 5-mg/dL decrements from 120 to 90 mg/dL. The study sample includes nondiabetic adults aged ≥45 years in the United States using 2006-2010 data from the National Health and Nutrition Examination Survey. High-risk individuals were assumed to receive a lifestyle intervention, as that used in the Diabetes Prevention Program. We calculated cost per QALY by dividing the incremental cost by incremental QALY when lowering the threshold to the next consecutive level. Medical costs were assessed from a health care system perspective. We conducted univariate and probabilistic sensitivity analyses to assess the robustness of the results using different simulation scenarios and parameters. RESULTS: Progressively lowering the FPG threshold would monotonically increase QALYs, cost, and cost per QALY. Reducing (in 5-mg/dL decrements) the threshold from 120 to 90 mg/dL cost $30,100, $32,900, $42,300, $60,700, $81,800, and $115,800 per QALY gained, respectively. The costs per QALY gained were lower for all thresholds under a lower-cost and less-effective intervention scenario. CONCLUSIONS: Lowering the FPG threshold leads to a greater health benefit of diabetes prevention but reduces the cost-effectiveness. Using the conventional benchmark of $50,000 per QALY, a threshold of 105 mg/dL or higher would be cost effective. A lower threshold could be selected if the intervention cost could be lowered. |
Medicare part D is associated with reducing the financial burden of health care services in medicare beneficiaries with diagnosed diabetes
Li R , Gregg EW , Barker LE , Zhang P , Zhang F , Zhuo X , Williams DE , Soumerai SB . Med Care 2013 51 (10) 888-93 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. |
Implications of risk stratification for diabetes prevention: the case of hemoglobin a1c
Gregg EW , Geiss L , Zhang P , Zhuo X , Williamson DF , Albright AL . Am J Prev Med 2013 44 S375-80 Although glycated hemoglobin (HbA1c) has been widely recommended for the diagnosis of diabetes, considerable ambiguity remains about how HbA1c should be used to identify people with prediabetes or other high-risk states for preventive interventions. The current paper provides a synthesis of the epidemiologic basis and the health and economic implications of using various HbA1c-based risk-stratification approaches for diabetes prevention. HbA1c predicts diabetes and related outcomes across a wide range of HbA1c values. However, the authors estimate that, among U.S. adults, the top 15% of the nondiabetic HBA1c distribution (HbA1c of 5.7%-6.4%) accounts for 47% of diabetes cases over 5 years, and the top 30% (5.5%-6.4%) accounts for about 70% of cases. Although this clustering of eventual cases at the high end of the HbA1c risk distribution means that intervention resources will be more efficient when applied to the upper end of the distribution, no obvious threshold exists to prioritize people for preventive interventions. Thus, the choice of optimal thresholds is a tradeoff, wherein selecting a lower HbA1c cut-point will lead to a higher rate of eligibility and health benefits for more people, and a higher HbA1c cut-point will lead to fewer cases of diabetes prevented but greater "economic efficiency" in terms of diabetes cases prevented per intervention participant. Selection of optimal HbA1c thresholds also may change with the evolving science, as better evidence on the biologic effectiveness of lower-intensity interventions and effects of lifestyle interventions on additional outcomes could pave the way for a more comprehensive, tiered approach to risk stratification. |
Inhibition of DNA-dependent protein kinase catalytic subunit by small molecule inhibitor NU7026 sensitizes human leukemic K562 cells to benzene metabolite-induced apoptosis.
You H , Kong MM , Wang LP , Xiao X , Liao HL , Bi ZY , Yan H , Wang H , Wang CH , Ma Q , Liu YQ , Bi YY . J Huazhong Univ Sci Technolog Med Sci 2013 33 (1) 43-50 Benzene is an established leukotoxin and leukemogen in humans. We have previously reported that exposure of workers to benzene and to benzene metabolite hydroquinone in cultured cells induced DNA-dependent protein kinase catalytic subunit (DNA-PKcs) to mediate the cellular response to DNA double strand break (DSB) caused by DNA-damaging metabolites. In this study, we used a new, small molecule, a selective inhibitor of DNA-PKcs, 2-(morpholin-4-yl)-benzo[h]chomen-4-one (NU7026), as a probe to analyze the molecular events and pathways in hydroquinone-induced DNA DSB repair and apoptosis. Inhibition of DNA-PKcs by NU7026 markedly potentiated the apoptotic and growth inhibitory effects of hydroquinone in proerythroid leukemic K562 cells in a dose-dependent manner. Treatment with NU7026 did not alter the production of reactive oxygen species and oxidative stress by hydroquinone but repressed the protein level of DNA-PKcs and blocked the induction of the kinase mRNA and protein expression by hydroquinone. Moreover, hydroquinone increased the phosphorylation of Akt to activate Akt, whereas co-treatment with NU7026 prevented the activation of Akt by hydroquinone. Lastly, hydroquinone and NU7026 exhibited synergistic effects on promoting apoptosis by increasing the protein levels of pro-apoptotic proteins Bax and caspase-3 but decreasing the protein expression of anti-apoptotic protein Bcl-2. Taken together, the findings reveal a central role of DNA-PKcs in hydroquinone-induced hematotoxicity in which it coordinates DNA DSB repair, cell cycle progression, and apoptosis to regulate the response to hydroquinone-induced DNA damage. |
Alternative HbA1c cutoffs to identify high-risk adults for diabetes prevention: a cost-effectiveness perspective
Zhuo X , Zhang P , Selvin E , Hoerger TJ , Ackermann RT , Li R , Bullard KM , Gregg EW . Am J Prev Med 2012 42 (4) 374-81 BACKGROUND: New recommendations about the use of hemoglobin A1c (HbA1c) for diagnosing diabetes have stimulated a debate about the optimal HbA1c cutoff to identify prediabetes for preventive intervention. PURPOSE: To assess the cost effectiveness associated with the alternative HbA1c cutoffs for identifying prediabetes. METHODS: A Markov simulation model was used to examine the cost effectiveness associated with a progressive 0.1% decrease in the HbA1c cutoff from 6.4% to 5.5%. The target population was the U.S. nondiabetic population aged ≥18 years. The simulation sample was created using the data of nondiabetic American adults from the National Health and Nutritional Examination Survey (NHANES 1999-2006). People identified as having prediabetes were assumed to receive a preventive intervention, with effectiveness the same as that in the Diabetes Prevention Program study under a high-cost intervention (HCI) scenario and in the Promoting a Lifestyle of Activity and Nutrition for Working to Alter the Risk of Diabetes study under a low-cost intervention (LCI) scenario. The analysis was conducted for a lifetime horizon from a healthcare system perspective. RESULTS: Lowering the HbA1c cutoff would increase the health benefits of the preventive interventions at higher costs. For the HCI, lowering the HbA1c cutoff from 6.0% to 5.9% and from 5.9% to 5.8% would result in $27,000 and $34,000 per QALY gained, respectively. Continuing to decrease the cutoff from 5.8% to 5.7%, from 5.7% to 5.6%, and from 5.6% to 5.5% would cost $45,000, $58,000, and $96,000 per QALY gained, respectively. For the LCI, lowering the HbA1c cutoff from 6.0% to 5.9% and from 5.9% to 5.8% would result in $24,000 and $27,000 per QALY gained, respectively. Continuing to lower the cutoff from 5.8% to 5.7%, 5.7% to 5.6%, and 5.6% to 5.5% would cost $34,000, $43,000 and $70,000 per QALY gained, respectively. CONCLUSIONS: Lowering the HbA1c cutoff for prediabetes leads to less cost-effective preventive interventions. Assuming a conventional $50,000/QALY cost-effectiveness benchmark, the HbA1c cutoffs of 5.7% and higher were found to be cost effective. Lowering the cutoff from 5.7% to 5.6% also may be cost effective, however, if the costs of preventive interventions were to be lowered. |
A nationwide community-based lifestyle program could delay or prevent type 2 diabetes cases and save $5.7 billion in 25 years
Zhuo X , Zhang P , Gregg EW , Barker L , Hoerger TJ , Pearson-Clarke T , Albright A . Health Aff (Millwood) 2012 31 (1) 50-60 The increasing health and economic burden of diabetes has made preventing the disease a public health priority. But investing in such chronic disease prevention programs requires a long-term horizon because many years may be required for the downstream savings to fully offset the up-front intervention cost. Using a simulation model, we projected the costs and benefits of a nationwide community-based lifestyle intervention program for preventing type 2 diabetes. Accounting for all costs to the US health care system, our results indicate that the program would break even in fourteen years. Within twenty-five years, the program would prevent or delay about 885,000 cases of type 2 diabetes in the United States and produce savings of $5.7 billion nationwide. If restricted to people ages 65-84, the program would save $2.4 billion. Thus, implementing such a program nationwide would be an efficient use of health care resources, although it might be necessary for all health insurers to participate to share prevention costs. Our results also indicate that although a prevention program would lead to cost savings in both younger and older people, it would achieve greater health and economic gains if it were directed at people under age sixty-five. |
Evaluation of variance estimators for the concentration and health achievement indices: a Monte Carlo simulation.
Chen Z , Roy K , Gotway Crawford CA . Health Econ 2011 21 (11) 1375-81 Although the concentration index (CI) and the health achievement index (HAI) have been extensively used, previous studies have relied on bootstrapping to compute the variance of the HAI, whereas competing variance estimators exist for the CI. This paper provides methods of statistical inference for the HAI and compares the available variance estimators for both the CI and the HAI using Monte Carlo simulation. Results for both the CI and the HAI suggest that analytical methods and bootstrapping are well behaved. The convenient regression method gives standard errors close to the other methods, provided the CI is not too large (< 0.2), but otherwise tends to understate the standard errors. In our simulation setting, the improvement from the Newey-West correction over the convenient regression method has mixed evidence when the CI ≤ 0.1 and is modest when the CI > 0.1. Published 2011. This article is a US Government work and is in the public domain in the USA. |
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