Intensive Lifestyle Counseling is Cost-effective for Some

Miriam E Tucker

June 15, 2015

BOSTON — The recent US Preventive Services Task Force (USPSTF) recommendation for intensive behavioral counseling interventions in adults at high risk of cardiovascular disease is cost-effective for individuals who are overweight or obese and have impaired fasting glucose, according to a new modeling study.

The findings, which could help target screening to those most likely to benefit, were presented at the American Diabetes Association (ADA) 2015 Scientific Sessions by Ping Zhang, PhD, senior health economist at the Centers for Disease Control and Prevention (CDC), Atlanta, Georgia.

In August 2014, the USPSTF recommended referring adult patients who are overweight or obese and who have additional cardiovascular risk factors (hypertension, dyslipidemia, impaired fasting glucose [IFG], or metabolic syndrome) for intensive behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular-disease prevention.

The recommendation was given a "B" grade, meaning that "there is high certainly that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial," said Dr Zhang, who presented the findings on behalf of the lead author Ji Lin, PhD, also with the CDC.

Based on their model, the behavior intervention is cost-saving for obese individuals with IFG and at least one additional CVD risk factor and cost-effective (based on the traditionally accepted threshold of $50,00 per quality-adjusted life-year [QALY]) for those with IFG who are either overweight or obese, but not cost-effective for those who are merely overweight and don't have IFG.

"It's good to have lifestyle intervention for everyone, but you probably don't want to [use] this program on persons at the lowest risk. You want to focus on those at highest risk," Dr Zhang noted.

Asked to comment, session moderator Erinn T Rhodes, MD, director, endocrinology healthcare research and quality at Boston Children's Hospital, Massachusetts, told Medscape Medical News, "I think clinicians should keep the recommendation in mind. This [study] gives you some sense of the economics of how it plays out in the bigger scheme. By grading it as he did, it helps you understand how, from a cost standpoint, it's more beneficial for people at the highest risk, but that doesn't mean it's not clinically beneficial for people at lower risk. That's the clinical question, which is different from the payer question."

Using $50,000 per QALY as a Yardstick

To determine whether the new USPSTF recommendation is worth the cost from a healthcare-system perspective, the investigators used 2005–2012 data from the National Health and Nutrition Examination Survey to model costs over a 25-year period, in 2014 dollars, for a 1-year intervention.

Cost assumptions used in the model — based on previously published data — were for 16 sessions at an average cost of $36/session, for a total intervention cost of $576 per person per year.

Effectiveness assumptions, again from the literature, were for reductions of 5.4 mg/dL in total cholesterol, 3.7 mg/dL in LDL cholesterol, 2.1 mm Hg in systolic blood pressure, 1.3 mm Hg in diastolic blood pressure, and a gain of 0.8 mg/dL in HDL cholesterol. The relative risk for developing diabetes was estimated to drop by 54% and the body mass index (BMI) by 1.0 kg/m2.

Based on an eligible population of 101 million US adults, over a 25-year period the incremental QALY was 0.019 and the incremental total cost $197, giving an incremental cost-effectiveness ratio (cost/QALY) of $10,500, which is far within the accepted cost-effectiveness standard.

"Given the conventional willingness to pay $50,000 per QALY, we would say it's pretty cost-effective," Dr. Zhang commented.

According to the model, the intervention would prevent 23,000 cases of cardiovascular disease and 671,000 diabetes diagnoses. However, it's not cheap: The total intervention cost worked out to $58 billion, which is "a lot," Dr Zhang noted.

Who Benefits Most? Cost Savings in Some Cases…

To determine how best to prioritize the expenditure, the investigators performed subgroup analyses. For obese individuals with BMI of 30 or greater, the only time the cost/QALY exceeded $50,000 — and therefore would not be deemed cost-effective — was for those with no other CVD risk factors (dyslipidemia, hypertension, or IFG). But even then it came close, with the cost/QALY falling just above, at $51,500.

For obese individuals who also had at least two other risk factors — IFG, hypertension, and/or dyslipidemia — the interventions were actually cost-saving, ranging from $147 to $366 per capita. And for obese individuals with IFG and no other risk factors, the cost/QALY was just $1100.

But for overweight individuals (BMI 25–29), the cost-effectiveness ratio fell below $50,000 only for those with IFG ($800–$28,700/QALY). For those without IFG, the cost/QALY exceeded the cost-effectiveness cutoff, ranging from $59,300 to $92,300.

Dr Rhodes cautioned that it's important to be familiar with what local programs offer.

"I think that's always the challenge with behavior counseling — can you translate it into actual practice? I think people need to understand exactly what intensive behavior counseling is, and make sure that what they do is actually apply it."

Dr Zhang, Dr Lin and coauthors have no relevant financial relationships. Dr Rhodes receives research funding from Merck, and her spouse has stock in Pfizer.

American Diabetes Association 2015 Scientific Sessions; June 7, 2015; Boston, MA. Abstract 265-OR

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