Is Screening and Integrated Care for GDM Cost

Is Screening and Integrated Care for GDM Cost Effective? Anil Kapur

Hyperglycemia in Pregnancy – Why it is relevant? High risk of maternal and perinatal morbidity and mortality and poor pregnancy outcome Offspring of GDM pregnancy at high risk of metabolic problems including type 2 diabetes

Pregnancy Outcomes are linked to maternal hyperglycemia Increasing complications with rising maternal glucose • HAPO study, NEJM 2008 Atlantic DIP Study Diabetologia 2011

Hyperglycemia impacts pregnancy outcomes In 23 developing countries maternal diabetes and obesity increased the risk of macrosomia 2 to 3 fold Increased risk of birth trauma, asphyxia, and meconium aspiration Emergency caesarean section due to obstructed labour High risk of abnormal haemorrhage, uterine atony, and prolonged labour. These complications probably contributed to the excessive adverse maternal and perinatal outcomes shown in the study The Lancet 2013; 381: 476 -483

Treating GDM lowers risk of perinatal complications

GDM Assiciated with High Risk of Maternal Diabetes Post GDM Women with gestational diabetes had a 7 fold increased risk of developing type 2 diabetes (RR 7· 43, 95% CI 4· 79– 11· 51). Within 5 years of a pregnancy complicated by gestational diabetes women had a relative risk of 4. 69, which more than doubled to 9. 34 in those examined more than 5 years post partum Leanne Bellamy, Juan-Pablo Casas, Aroon D Hingorani, David Williams Lancet 2009; 373: 1773– 79

Women with GDM at high risk of premature CVD Over a median 12 y follow-up, women with GDM have a higher risk of CVD (adjusted hazard ratio 1. 66 (95% CI 1. 30, 2. 13), p < 0. 001) • Retnakaran R, Shah BR. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: a populationbased cohort study. CMAJ 2009; 181: 371 e 6. ], Over 10 y women with GDM had more non-invasive cardiac diagnostic procedures (OR 1. 8 (95% CI 1. 4 -2. 2)), simple cardiovascular events (OR 2. 7 (95% CI 2. 4 -3. 1)) and total cardiovascular hospitalizations (OR 2. 3 (95% CI 2. 0 -2. 5)) after adjusting for age, ethnicity and comorbidities such as pre-eclampsia and obesity • Kessous R, Shoham-Vardi I, Pariente G, et al. An association between gestational diabetes mellitus and long-term maternal cardiovascular morbidity. Heart 2013; 99: 1118 e 21

Post Partum Lifestyle intervention prevents Type 2 DM (and perhaps CVD) in women with GDM Both intensive lifestyle and metformin have been shown to be highly effective in delaying or preventing diabetes in women with IGT and a history of GDM • Ratner RE, Christophi CA, Metzger BE et al. Diabetes Prevention Program Research Group. Prevention of diabetes in women with a history of gestational diabetes: effects of metformin and lifestyle interventions. J Clin Endocrinol Metab. 2008 : 4774 -9. In the Diabetes Prevention Program Outcomes Study (DPPOS) over 10 y follow up in women with GDM, intensive lifestyle (ILS) and metformin reduced progression to diabetes compared with placebo by 35% and 40%, respectively. • Aroda VR et al. 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. J Clin Endocrinol Metab. 2015 Feb 23: jc 20143761 In a cohort of over 4500 women with GDM from the Nurses health study followed for 10 y, moderately intense physical activity (150 minutes/week) reduced the risk of type 2 diabetes 47% (RR, 0. 53; 95% CI, 0. 38 -0. 75); the association remained significant after additional adjustment for BMI • Bao W, Tobias DK, Bowers K, et al. Physical activity and sedentary behaviors associated with risk of progression from gestational diabetes mellitus to type 2 diabetes mellitus: a prospective cohort study. JAMA Intern Med. 2014; 174: 1047 -55

Diabetes Begets Diabetes . Evidence that treating GDM prevents Type 2 diabetes in Offspring is lacking

The Challenge ~127 Million Pregnancies/Year ~21 million /year complicated by hyperglycaemia ~3 to 4 million detected and treated ? Receive Post partum follow up and lifestyle advice

The evidence – what works? ?

The Question that is often asked Is it cost effective to screen, detect and treat GDM?

Cost Effectiveness Analysis Measures the benefits associated with an intervention relative to its cost Average Cost-effectiveness ratio (CE ratio): Benefit of intervention maybe measured as quality adjusted life year (QALY) gained or disability adjusted life year (DALY) prevented

Comparing More than One Intervention Incremental cost-effectiveness is the difference in costs between two interventions divided by the difference in QALYs gained or DALYs averted

According to the WHO CHOISE analysis any intervention in a given country is considered • highly cost-effective if its cost is less than its annual GDP per capita; • cost-effective when it is between one and three times GDP per capita; • not cost-effective when it is more than three times GDP per capita.

Perspective (in economic evaluation) • The viewpoint from which an economic evaluation is conducted. The viewpoint may be that of the patient, hospital/clinic, healthcare system or society. Discounting • Costs and benefits incurred today are usually valued more highly than costs and benefits occurring in the future. Discounting health benefits reflects society's preference for benefits to be experienced in the present rather than the future. Discounting costs reflects society's preference for costs to be experienced in the future rather than the present. Cost–benefit analysis or Cost-utility analysis • An economic evaluation that expresses both costs and outcomes of an intervention in monetary terms. Benefits are valued in monetary terms using valuations of people's observed or stated preferences, such as the willingness -to-pay approach.

Opportunity cost • The opportunity cost of investing in a healthcare intervention is the other healthcare programs that are displaced by its introduction. This may be best measured by the health benefits that could have been achieved had the money been spent on the next best alternative healthcare intervention. Dominance • An intervention is dominated if it has higher costs and worse outcomes than an alternative intervention. Extended dominance • The incremental cost-effectiveness ratio (ICER) for a given treatment alternative is higher than that of the next, more effective, alternative (that is, it is dominated by the combination of 2 alternatives and should not be used to calculate appropriate ICERs)

The Cost Effective Plane Extended Dominance Dominant

Health System Perspective Costs depend on • Technology • Criteria used • Cut off values • Prevalence Immediate MCH Perspective Costs depend on type & efficacy of interventions Treat Perinatal complications GDM CVD in mother T 2 D/NCDs in offspring NCD Perspective Savings depend on • Cost of Rx DM, CVD and their complications in future Screen & Diagnose Savings depend on • Efficacy of Rx • Type & severity of complications averted Postpartum Lifestyle Long Term (Discounted)

GDM Cost Effectiveness Model Societal Perspective S

Studies on Cost Effectiveness of GDM Screening and Treatment

Based on supportive evidence, screening for GDM is cost saving and Intensive post partum diet and education in women with GDM to prevent type 2 diabetes is cost effective • Cost-Effectiveness of Interventions to Prevent and Control Diabetes Mellitus: A Systematic Review, Diabetes Care 33: 1872– 1894, 2010

Conclusions GDM testing – when associated with good GDM care and post-partum interventions for T 2 D prevention - is highly cost -effective in both high-income (US, Israel) and low-income (India) countries according to WHO standards GDM screening could be cost-effective in some settings, even if only perinatal events are counted

Life Course Approach to Prevention

Window of Opportunity Pregnancy offers a cost effective window of opportunity to provide maternal care services to Reduce traditional maternal and perinatal morbidity and mortality indicators Cost Effectively address intergenerational prevention of NCDs, such as diabetes, hypertension, cardiovascular disease, and stroke.